A new survey says few pharmacy errors reported

Many pharmacy errors are not reported in a way that helps prevent the repeat of such errors in the future, according to the results of a recent survey by the Institute for Safe Medication Practices (ISMP).

The ISMP, a nonprofit group in Huntingdon Valley, PA, surveyed health care providers about how medical errors are detected and what is done with that information. The 417 responses indicate "it’s clear that we need to pay greater attention to the processes involved and the environment in which these functions take place," the ISMP reports. The survey results were reported recently on the ISMP Web site at www.ismp.org.

The group found that spontaneous reports from staff are the most common method used to identify errors, with 97% reporting they use that method. Other methods of error detection, which the ISMP say may be more effective and productive, have not been widely adopted. For instance, the ISMP found that only 19% of respondents use a telephone hotline or other method to simplify error reporting. Sixty percent of the survey respondents said they reviewed medication records or patients’ charts to uncover errors, but only 32% reviewed drug or laboratory triggers or markers that may signal an error.

The ISMP also found that only 17% used medical record external cause codes, or E codes, to identify adverse drug events.

"Although access to valuable error-related data may be easy to obtain, it may not actually be used to improve medication safety," the ISMP writes. "For example, more than a quarter of respondents (29%) said they had not collected and used information about pharmacy interventions to correct prescribing errors. As a result, about half of them said these intercepted errors are unlikely to be reported. More importantly, they are most likely to be repeated."

Providers also reported that only 40% of dispensing errors and 46% of transcription errors were likely to be reported, saying it is more likely for staff to report errors that actually reach the patient and cause harm. Even for that type of error, however, only 76% of respondents said they were fully confident that they would be reported in their facility.

"Potentially hazardous situations that could lead to an error were the least likely to be reported, which demonstrates how reactive, rather than proactive, healthcare continues to be today," the ISMP reports.

The survey results also suggest that providers are inconsistent in punishing and rewarding people. Respondents reported that nurses received more frequent and harsh punishment for serious errors, but nurses also were more frequently rewarded for reporting serious errors and provided with psychological counseling after an error. Physicians receive the least punishment for serious errors, according to the survey, but they rarely are rewarded for reporting an error or are provided with psychological counseling.