Medication Error Rates

As hospital pharmacy professionals, we have all likely been asked about our medication error rates at one time or another. Administrators, committee chairpersons, and surveyors may inquire about the rate, or a benchmark, or how we stack up compared to others; sometimes the question is whether we’ve ‘improved’.  In this era of metrics and abundant quality data it’s not surprising that this information is requested.  The issue is that it’s not useful or valuable to benchmark medication error data across organizations. The data must be understood and used appropriately in the context of each individual organization.

The use of a medication error rate as a benchmark has been widely discouraged by leading bodies in the realm of medication safety. The Institute for Safe Medication Practices (ISMP) and the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) have both issued statements on this topic.  The full text is available on their websites.  Excerpts are as follows:

• “The National Coordinating Council for Medication Error Reporting and Prevention believes there is no acceptable incidence rate for medication errors. Use of medication error rates to compare health care organizations is of no value.¹

• “A national or other regional medication error rate does not exist. It is not possible to establish a national medication error rate or set a benchmark for medication error rates. Each hospital or organization is different. The rates that are tracked are a measure of the number of reports at a given institution not the actual number of events or the quality of the care given. Most systems for measuring medication errors rely on voluntary reporting of errors and near-miss events. Studies have shown that even in good systems, voluntary reporting only captures the 'tip of the iceberg.' For this reason, counting reported errors yields limited information about how safe a medication-use process actually is. It is very possible that an institution with a good reporting system, and thus what appears to be a high error 'rate,' may have a safer system.” ²

Perhaps your facility measures a rate based on reports, but the actual rate of medication errors is likely higher. To increase medication safety and enhance patient care, all staff must be encouraged to report errors and ‘near miss’ events; this will inflate the numbers, and that’s okay.  If we truly want to optimize patient safety, we need to know about all events so that we may learn from them.   

Sources

2. http://www.ismp.org/faq.asp#Question_1