Nonpunitive,Voice-Mail-Based Medication Error Reporting System

Abstract

By eliminating paperwork, Summa Health System has increased health care providers’ compliance in reporting medication errors, potential errors, and near misses. Nurses, pharmacists, pharmacy technicians, physicians, and respiratory therapists call errors or potential errors into a voice mail system. The voice mails are screened by a Medication Safety Coordinator (a pharmacist), who enters the data into the MEDMARx database and provides reports and feedback to the various departments. The system has resulted in a significant increase in reporting and several process improvements that can be tied directly back to the reports. Although the number of significant medication errors reaching the patient has not increased, the number of reported near misses or potential errors has gone up significantly. The Medication Safety Coordinator has been able to identify process issues and corroborate the existence of perceived problems that were previously unquantified. The new information is being used to educate personnel, improve computer shortcuts, change the appearance of medication administration records and labels, and facilitate formulary decisions. The data will also be used as input in decision making for the computerized physician order entry system in development at Summa Health System.