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Preventing medication errors in long-term care: results and evaluation of a large scale web-based error reporting system
  1. Stephanie Pierson1,
  2. Richard Hansen2,
  3. Sandra Greene1,
  4. Charlotte Williams1,
  5. Roger Akers1,
  6. Mattias Jonsson1,
  7. Timothy Carey1
  1. 1Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  2. 2School of Pharmacy, Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  1. Correspondence to:
 Stephanie Pierson
 University of North Carolina at Chapel Hill, Cecil G Sheps Center for Health Services Research, 725 Martin Luther King Jr Blvd, Campus Box #7590, Chapel Hill, North Carolina 27599-7590, USA; pierson{at}


Objective: To describe the implementation and evaluation of a web-based medication error reporting system.

Design: Evaluation study.

Setting: Long-term care.

Participants: 25 nursing homes in the US state of North Carolina.

Intervention: Detailed information about all medication errors occurring in a facility during a 1 year period was entered into a web-based reporting system. An evaluation survey was conducted to assess usability and the potential for the system to prevent errors.

Main outcome measures: Number and specific characteristics of medication errors reported. A survey evaluating ease of use of the system and whether the participants thought it would help improve medication safety.

Results: 23 (92%) sites entered 631 error reports for 2731 discrete error instances when weighted by the number of times the errors were repeated. 51 (8%) errors were classified as having a serious patient impact requiring monitoring/intervention or worse. The most common errors were dose omission (203, 32%), overdose (91, 14%), underdose (43, 7%), wrong patient (38, 6%), wrong product (38, 6%), and wrong strength (38, 6%). Errors most commonly occurred during medication administration (296, 47%) and were attributed to basic human error (402, 48%). Seven drugs were implicated in a third (175, 28%) of all errors: lorazepam, oxycodone, warfarin, furosemide, hydrocodone, insulin and fentanyl. 20 sites (86% of respondents) completed the evaluation survey and participants found the system easy to use and thought it would increase accuracy of reporting and improve patient safety.

Conclusions: The web-based medication error reporting system was easy to use, with strong indications that it would be a valuable tool for preventing future errors.

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  • This work was funded by the North Carolina Division of Facility Services, a US state organisation responsible for licensing nursing homes.

  • Competing interests: All authors declare that they have no competing interests and therefore nothing to declare.

  • This study was determined to be exempt from review by the UNC-Chapel Hill Internal Review Board. The IRB project number is 03-2169.

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