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Medication error reporting in nursing homes: identifying targets for patient safety improvement
  1. S B Greene1,
  2. C E Williams1,
  3. S Pierson1,
  4. R A Hansen2,
  5. T S Carey1
  1. 1Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  2. 2UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  1. Correspondence to Sandra B Greene, Cecil G. Sheps Center for Health Services Research, 725 Martin Luther King Jr Boulevard, Campus Box 7590, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7590, USA; sandrab_greene{at}


Background Legislation enacted in the US State of North Carolina in 2003 requires all licenced nursing homes to report all medication errors. In 2007, nursing homes were encouraged to voluntarily convert from aggregate reporting to a new online system where they reported each individual error.

Methods A new optional web-based reporting tool was made available to all 393 North Carolina nursing homes to submit error reports for each distinct medication error as they occurred during the year.

Results A total of 5823 medication error reports were submitted by 203 sites (52%) using the new system during the reporting year, a median of 18 error reports per site. Of the 5823 error reports, 612 (10.5%) were categorised as serious. Serious errors were more likely to be caused by drugs given to the wrong patient (RR 4.39, CI 3.7 to 5.2), lab-work error (RR 2.40, CI 1.4 to 4.0), wrong product given (RR 2.22, CI 1.8 to 2.8) and medication overdoses (RR 1.49, 1.2 to 1.8). Serious errors were more likely to occur on second shift (RR 1.32, 1.1 to 1.5). Common medications that are involved in the most serious errors include warfarin (RR 2.58, CI 2.09 to 3.18) and insulin (RR 2.35, CI 1.86 to 2.97), and oxycodone combinations (RR 1.48, CI 1.07 to 2.06).

Conclusions Data collected from a nursing home medication error system can provide helpful information on serious errors that can be used to focus patient safety efforts to reduce harm. This improved information will be useful in nursing homes for continuous quality improvement efforts.

  • Nursing homes
  • long-term care
  • medication error
  • adverse drug reaction reporting systems
  • quality of healthcare
  • safety
  • warfarin
  • quality of care
  • incident reporting

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  • Funding This project was funded by the Division of Health Service Regulation, Department of Health and Human Services, North Carolina. Contract #27900010. Other funders: State Government.

  • Competing interests None.

  • Ethics approval This study was reviewed by the institutional review board at the University of North Carolina at Chapel Hill and determined to be exempt.

  • Provenance and peer review Not commissioned; externally peer reviewed.