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International Journal for Quality in Health Care Advance Access originally published online on April 22, 2008
International Journal for Quality in Health Care 2008 20(4):238-245; doi:10.1093/intqhc/mzn015
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© The Author 2008. Published by Oxford University Press on behalf of International Society for Quality in Health Care (ISQua); All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
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Using nurses and office staff to report prescribing errors in primary care

Amanda G. Kennedy1, Benjamin Littenberg2 and John W. Senders3

1 Research Assistant Professor of Medicine, Division of General Internal Medicine, University of Vermont College of Medicine, 371 Pearl Street, Burlington, VT 05401, USA
2 Henry and Carleen Tufo Professor of Medicine, Division of General Internal Medicine, University of Vermont College of Medicine
3 Principal Scientific Consultant to the Institute for Safe Medication Practices (ISMP)

Objective. To implement a prescribing-error reporting system in primary care offices and analyze the reports.

Design. Descriptive analysis of a voluntary prescribing-error-reporting system

Setting. Seven primary care offices in Vermont, USA.

Participants. One hundred and three prescribers, managers, nurses and office staff.

Intervention. Nurses and office staff were asked to report all communications with community pharmacists regarding prescription problems.

Main Outcome Measures. All reports were classified by severity category, setting, error mode, prescription domain and error-producing conditions.

Results. All practices submitted reports, although reporting decreased by 3.6 reports per month (95% CI, –2.7 to –4.4, P < 0.001, by linear regression analysis). Two hundred and sixteen reports were submitted. Nearly 90% (142/165) of errors were severity Category B (errors that did not reach the patient) according to the National Coordinating Council for Medication Error Reporting and Prevention Index for Categorizing Medication Errors. Nineteen errors reached the patient without causing harm (Category C); and 4 errors caused temporary harm requiring intervention (Category E). Errors involving strength were found in 30% of reports, including 23 prescriptions written for strengths not commercially available. Antidepressants, narcotics and antihypertensives were the most frequent drug classes reported. Participants completed an exit survey with a response rate of 84.5% (87/103). Nearly 90% (77/87) of respondents were willing to continue reporting after the study ended, however none of the participants currently submit reports.

Conclusions. Nurses and office staff are a valuable resource for reporting prescribing errors. However, without ongoing reminders, the reporting system is not sustainable.

Keywords: medication errors/statistics and numerical data, medical errors/statistics and numerical data, adverse drug reaction reporting systems/classification, primary health care/methods/standards, community pharmacy services

Address reprint requests to: Amanda Kennedy; Research Assistant Professor of Medicine Division of General Internal Medicine, University of Vermont College of Medicine, 371 Pearl Street, Burlington, VT 05401, USA. Tel: (802) 847-8268; Fax: (802) 847-0319; E-mail: amanda.kennedy{at}vtmednet.org

Accepted for publication March 28, 2008.


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