Relationships between organisations and health professionals

Improving reporting systems in hospitals ▸

A paper by Crawford et al in the Journal of Medical Systems analyses medication errors that “result from process breakdowns in organizational systems” and that “should be preventable with effective organizational processes and systems controls”. The study sought to identify systems factors related to higher levels of error reporting. It investigated a range of hospital systems factors—the “multifactorial and interdisciplinary problems and sources” of medication errors.

Hospital policies, procedures and practices were surveyed in 201 hospitals. Based on a review of the literature, a number of independent variables were tested. These included:

• existence of formal committees for the review and evaluation of error reports;

• staffing ratios of pharmacists and registered nurses per occupied bed;

• baseline screening or testing of nurses on proper medication use and preparation;

• use of computerised medication administrative records;

• 24 hour pharmacy service;

• use of patient focused care models.

There was an 84% response rate (169 questionnaires) based on 156 hospitals. A total of 951 serious medication errors were reported for the previous year, nine of which resulted in patient death and 12 caused permanent impairment of body function. The hospitals were divided into two groups—low and high reporters. The first group reported no more than two incidents (39%) and the second reported 6–32 incidents (38.5%). A middle group was excluded from the analysis. The study found that the reasons behind “increased reporting of medication errors warrants serious evaluation, but does not …