Increasing staff reporting of pharmacy occurrences

Internal system opens safety discussion at all levels

A pilot study at Dartmouth-Hitchcock Medical Center, a rural 353-bed tertiary care academic center in New Hampshire, found that a pharmacy internal occurrence reporting system increased staff reporting and identified areas for improvement within the medication distribution process that may not have been recorded by a hospital-based reporting system.

The research conducted by Geoffrey Rickrode, PharmD, and colleagues was published in the American Journal of Health-System Pharmacy. The researchers note that most hospitals depend on hospital-based error reporting systems to evaluate the human steps of the medication distribution process.

In response to focusing on systems issues, Dartmouth-Hitchcock uses a voluntary on-line non-punitive occurrence reporting program, the main purpose of which is to identify any system-related problems that contribute to an error, whether it is in prescribing, dispensing, transcribing, or administering medication. But Rickrode says these types of reporting programs can create a lengthy time commitment for reporting and significant delays between the actual report and follow-up of the incident, ultimately deterring hospital staff from reporting an occurrence at all.

In 2004, Dartmouth-Hitchcock received 1,756 reported events through the hospital's occurrence reporting system, with 21% of them classified as dispensing errors, an occurrence rate that is said to be comparable to other health care institutions. "Pharmacy administration believed that these reports were not providing an accurate assessment of the medication distribution process at our institution because of incomplete reporting and an inability to observe trends from the few reports that were submitted," the researchers say.

"As a result, we developed an internal reporting system to gain a better understanding of which points within our medication distribution process could contribute to errors and be improved to increase medication safety. This internal reporting method is a technique that few studies have used to capture medication errors….Unlike other reporting systems that record dispensing errors and near-misses at the patient's bedside, this internal reporting method was designed to catch near-misses that did not leave the pharmacy department. All events that occurred outside of the pharmacy were to be reported in the hospital-based reporting system."

The Dartmouth-Hitchcock pharmacy includes a central pharmacy, an I.V. room for all inpatient sterile products and chemotherapy, a robot packaging center, a compounding room, and a satellite I.V. room for preparing investigational products and outpatient chemotherapy in the institution's cancer center. Some 1.5 million doses are dispensed from the pharmacy annually, with 20% of them manually removed from stock by pharmacy technicians, and the rest pulled using robot technology.

Potential to cause an error

For the study, a near-miss reported to the internal reporting system was considered any event having the potential to cause an error as defined by the institution but never leaving a pharmacy staff member's possession. An error was defined by the hospital as the failure of a planned action to be completed as intended (failure of execution) or use of a wrong plan to achieve an aim (error in planning).

The pharmacy staff was asked to complete a survey about the department's current occurrence-reporting process and what the staff desired in an occurrence-reporting system. The staff also was surveyed on which steps of the pharmacy's medication distribution process could contribute the most to errors.

Some 48 of the 57 employees who responded had used the hospital-based reporting system. On a five-point scale, 98% of those who used that system rated it a 3 or less for documenting occurrences. The researchers say the main reasons for this unsatisfactory rating were that the system was confusing, too detailed, and time-consuming.

When the employees were asked about the best method to record events in a new reporting system, e-mail (49%), paper (35%), and intranet (30%) ranked highest. Some 72% of the staff wanted to be able to report an event in three minutes or less.

Looking at which steps of the medication distribution process needed the most improvement, the staff cited manual picking of medications (42%), pharmacist order entry (33%), and I.V. product preparation (12%). When the staff was asked for comments or suggestions, the most common suggestion was to make the reporting process easier than the intranet-based hospital reporting program. Also, many employees wanted better feedback on when they were involved in an error.

After the internal error reporting system was implemented, pharmacy leadership created the excellence and quality improvement in pharmacy (EQuIP) team to review both hospital-reported errors and pharmacy-reported events and identify areas for improvement in the medication distribution process. Once problem areas were identified, system changes were recommended and facilitated by the EQuIP team members to improve the medication distribution process.

Problem areas seen

Notably, the researchers say, the most frequently reported occurrences per day were in the areas of manual picking of medications and pharmacist order entry, averaging 2.73 and 1.40 events per day. Among the 659 manual pick events reported, the type that occurred most was wrong drug (22%), followed by wrong dose (19.6%), expired drugs (13.4%), and wrong dosage form (10.8%). Orders entered incorrectly and medication orders missed and not entered at all comprised the majority of the 258 reported pharmacist order entry events (33% and 29.5%, respectively).

The study says that before the evaluation period, pharmacy administration had data from the hospital's occurrence-reporting system to determine where problems existed in the medication distribution system. But, the researchers say, the hospital's system provided very limited in-process details for the administration to use. A major reason, they say, was the design of the hospital's reporting system, a voluntary system that is very comprehensive but also very time-consuming. When a near-miss would occur within the pharmacy department, staff members would correct the mistake and move forward rather than spend extensive time reporting the incident on the hospital's system.

Rickrode says the internal system has been used to establish open discussions with all levels of the pharmacy staff about medication safety. "If the event can be used as a learning tool to prevent future occurrences, the staff member is asked to present the topic at the monthly pharmacy morbidity and mortality conference, a mandatory department-wide educational meeting for pharmacy staff that reviews pharmacy dispensing errors and the improvements that the department can make to prevent those errors from reoccurring," he explains.

Address accountability as needed

Pharmacy administrators also are able to use the new reporting system to address accountability when appropriate. If a staff member's performance needs to improve in a certain aspect of the medication distribution process, he or she is assigned an individual preceptor. The preceptor and staff members use the internal reporting form to monitor accuracy in the area being assessed. The staff member's supervisor routinely meets with the preceptor and the employee to review the information and revise the performance improvement plan as necessary.

While every institution has its own method of processing orders and taking care of problems, he says, the work that was done at Dartmouth-Hitchcock can be replicated. "The most important thing is that employees are on board with what you are doing," he says.

Rickrode tells DFR he carried out the project while he was a pharmacy resident at the facility and found it hard to make a lot of progress. He says it would help any facility trying to replicate the work to have someone assigned to work on it full-time. Because the hospital has had a lot of changes, he says, the pharmacy internal system is still in place but is not being used. The hospital-based system is still being used, he says, and the pharmacy system could again be operational if the administration wanted to use it and there was someone to run it.

(Editor's note: Contact Dr. Rickrode at (603) 650-5590 or e-mail