Increased reporting of medication errors in a Healthcare Area

Virginia Greciano, of the Area 2 of Madrid, presented an interesting oral communication on medication error reporting, which is summarized below.

Given the necessity to extend definitively the culture of reporting medication errors (ME) and facing an increasing number of targets by the organization, the Functional Unit for Health Risks Management (FUHRM) proposed the Pharmacy Department to develop strategies to promote reporting.

Managers designed a training session on ME for healthcare centers in the Area 2. This session was directed at doctors, pediatricians and nursing, and other non-healthcare professionals. The main objective was to deepen the concept of ME and its differentiation from other adverse events. The content was also aimed at promoting reporting by simple steps, as well as illustrating the session with useful information and examples.

There were a few support messages based on 4 basic principles:

1. Curiosity: about any circumstance that cause surprise about a drug or pharmaceutical product at any time.

2. No doubt: "at the dilemma of whether it is an ME, an adverse reaction or other event, report it. An excess of notification does not hurt anybody and do so could get a risk to the patient ".

3. No blame: the ME is a part of the sanitary work. Reporting is anonymous, encourages a culture of risk and helps us grow as healthcare professionals.

4. Avoid bureaucracy: do not let papers paralyze you. To report a ME, just publicize it and ask for collaboration.

The results of the sessions were very interesting in terms of number of people attending and the number of notifications that have been received later. In less than six months reported a number of EM sufficient to achieve the goal of the year, reaching 42% report a higher than agreed. At the end of 2009, we were the third AP Management goal percentage and fourth in number of notifications.

Having identified the improvement areas and made the balance in the FUHRM, various measures have been proposed to maintain this line of work in the future.

To view the full presentation click here


Posted by Fernando Palacio
English version by Erika Céspedes