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03-11-2011 | Legal medicine | Article

A ‘culture of safety’ improves medication error reporting, reduces harm


Free abstract

MedWire News: Implementing system-level interventions to stimulate a culture of medical safety in intensive care units (ICU) increases the reporting rate of medical errors, while reducing the number of such events that lead to harm, study findings show.

However, these mechanisms - including putting up posters in the ICU to track adverse events, and sending "medication error emails" to staff - may be ineffective by themselves in the face of a poor safety culture, say the researchers.

"It is difficult to determine which individual interventions had what attributable impact - only that overall trends in medication safety improved with concomitant improvements in staff attitudes towards patient safety and error reporting," say Katherine Abstoss (University of Michigan, Ann Arbor, USA) and co-researchers in the BMJ Quality and Safety.

Improving patient safety has become an imperative in recent years, they remark, adding that medical errors are traditionally underreported for reasons including fear of reprisal.

To encourage a free and open environment of information flow, Abstoss and colleagues analyzed the impact of both system-level and safety-culture strategies in their pediatric ICU on medication error reporting and harm. A total of seven interventions were implemented from May 2007 through November 2009.

Errors and harm were graded according to the National Coordinating Council for Medication Error Reporting and Prevention. In addition, the team administered the Safety Attitudes Questionnaire (SAQ) to the unit, which captures attitudes and perspectives of staff on specific safety issues.

In addition to the poster and the error emails, culture interventions included a quality improvement "channel" running on a television in the ICU, and a quality improvement curriculum, which involved a "mini-symposia."

System interventions comprised a computerized physician order entry system, a pediatric ICU medication manager program, and a revision of existing patient safety report forms.

Overall, reported errors resulting in harm decreased from an average of 0.56 to 0.16 events per 10,000 doses, say Abstoss et al, giving a statistically significant reduction of 71%.

By contrast, the overall error reporting rate increased, from an average 3.16 to 3.95 reports per 10,000 doses; a significant increase of 25%.

For comparison, the research team used data from the whole hospital, excluding the ICU, and found that safety reports filed for medication-related harm remained stable across the study period.

Analysis of the SAQ responses showed that after 2007, teamwork climate increased from 52.8% to 71.8% agreement (significant), and safety climate increased from 54.6% to 63.4% agreement (borderline significant).

"System-level mechanisms to promote medication safety are likely important factors that enable positive safety culture to translate into better outcomes, but may be ineffective by themselves in the face of poor safety culture," suggest the researchers.

The methods tested in the current study could be adapted to suit other units or hospital settings, they conclude.

By Sarah Guy

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