Journal of the American Medical Directors Association
Original studyIdentifying Modifiable Barriers to Medication Error Reporting in the Nursing Home Setting
Section snippets
Study Participants and Settings
The participants in our study were health care professionals who worked at 1 of 4 independently owned, nonprofit nursing homes affiliated with the University of Pittsburgh. One nursing home is in an urban setting, and the others are in suburban settings. The average number of beds in these nursing homes was 150 (range, 126 to 180), and the total number of regular full-time and part-time health care professionals who were classified as physicians, pharmacists, advanced practitioners, and nurses
Nominal Group Technique Sessions
The nominal group sessions involved a total of 28 participants (Table 1). The majority of participants were women (67.9%), were full-time employees (89%), and had worked for an average of 11.2 years in nursing homes. In each of the 4 individual sessions, participants discussed an average of 19.3 barriers to medication error reporting.
Survey
Of 154 surveys distributed, 104 (67.5%) were returned. Facility response rates ranged from 55.8% to 92.9%. Pharmacists had the highest response rate (100%), and
Discussion
Our study provides a broad-based account of barriers to medication error reporting in nursing homes, as viewed from multiple clinical perspectives. To our knowledge, this is the first study that has focused on this topic in the nursing home setting. We found that about two thirds of the modifiable factors requiring immediate action were organizational factors. This finding is consistent with recommendations made by various organizations, including the Institute of Medicine, the Joint Commission
Conclusion
The study results provide a broad-based perspective of the barriers to medication error reporting in the nursing home setting. Our findings suggest that efforts to improve medication error reporting should focus on organizational rather than individual-level interventions. Further research is needed to determine if such organizational interventions would increase the frequency of medication error reporting and ultimately improve medication safety.
Acknowledgment
For their assistance throughout the study, we thank the staff of Asbury Health Center, Baptist Homes of Western Pennsylvania, RxPartners-LTC, UPMC Senior Living Seneca Place, and UPMC Senior Living Heritage Shadyside.
References (45)
- et al.
Detecting adverse events for patient safety research: a review of current methodologies
J Biomed Inform
(2003) Medication errors and adverse drug events in nursing homes: Problems, causes, regulations, and proposed solutions
J Am Med Dir Assoc
(2001)- et al.
Medication error reporting in long-term care
Am J Geriatr Pharmacother
(2004) - et al.
Reporting near-miss events in nursing homes
Nurs Outlook
(2006) - et al.
Using a modified nominal group technique to elicit director of nursing input for an osteoporosis intervention
J Am Med Dir Assoc
(2006) - et al.
Using focus groups to understand physicians’ and nurses’ perspectives on error reporting in hospitals
Jt Comm J Qual Saf
(2004) - et al.
Response rates to mail surveys published in medical journals
J Clin Epidemiol
(1997) - et al.
Types of medication errors in North Carolina nursing homes: a target for quality improvement
Am J Geriatr Pharmacother
(2006) - et al.
Epidemiology of medication-related adverse events in nursing homes
Am J Geriatr Pharmacother
(2006) - National Coordinating Council for Medication Error Reporting and Prevention. What is a Medication Error? Available at:...
Preventing Medication Errors
To Err Is Human: Building a Safer Health System
Medication errors observed in 36 health care facilities
Arch Intern Med
The health care cost of drug-related morbidity and mortality in nursing facilities
Arch Intern Med
Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities
Am J Health Syst Pharm
Reporting of adverse events
N Engl J Med
Group Techniques for Program Planning: A guide to nominal group and delphi processses
Barriers to delivering asthma care: A qualitative study of general practitioners
Med J Aust
Barriers to detecting and treating hypercholesterolaemia in patients with ischaemic heart disease: Primary care perceptions
Br J Gen Pract
Clinical Global Impression of Change in Physical Frailty: Development of a measure based on clinical judgment
J Am Geriatr Soc
The nominal group technique: A research tool for general practice?
Fam Pract
Cited by (63)
Methodological options of the nominal group technique for survey item elicitation in health research: A scoping review
2021, Journal of Clinical EpidemiologyPerceptions of nurses about reporting medication administration errors in Jordanian hospitals: A qualitative study
2021, Applied Nursing ResearchDrug safety in United Arab Emirates
2020, Drug Safety in Developing Countries: Achievements and ChallengesDrug safety in Palestine
2020, Drug Safety in Developing Countries: Achievements and ChallengesMedication errors
2020, Drug Safety in Developing Countries: Achievements and ChallengesDrug safety in Yemen
2020, Drug Safety in Developing Countries: Achievements and Challenges
This study was supported in part by an American Medical Directors Association Foundation/Pfizer Quality Improvement Award, by a Merck/AFAR Junior Investigator Award in Geriatric Clinical Pharmacology, and by NIH grants 1K12HD049109–01, 5T32AG021885, P30-AG024827, and AG027017.