Quantitative and Qualitative Analysis of Medication Errors: The New York Experience

摘要

Objectives: In June 2000, the New York State Department of Health (NYSDOH) expanded its New York Patient Occurrence Reporting and Tracking System (NYPORTS) mandatory adverse event reporting system to include the reporting of medication errors. The errors included were those that resulted in a severity of patient harm that met the National Coordinating Council Medication Error Reporting Program (NCC MERP) criteria for categories G (resulting in permanent patient harm), H (resulting in a near-death event) and I (resulting in patient death). Root cause analyses (RCA) that examine systems issues and identify mechanisms for future prevention of these events were studied. Methods: A panel of 11 multidisciplinary professionals performed a quantitative and qualitative analysis of 24 months of medication errors reports submitted to the NYPORTS system. NYPORTS requires that the 249 hospitals in New York State (NYS) electronically notify the NYSDOH of reportable errors within 24 hours of occurrence detection and that a RCA for that occurrence be submitted within 30 days. Results: Qualitative analysis of the RCAs included findings related to lessons learned, emergent themes, and use of system fixes instead of punitive fixes or inappropriate/incomplete system fixes. The quantitative analysis examined several variables. These included where in the process the error occurred, what disciplines were involved, the error distribution, the occurrence type, the medication or medication classes involved, and the breakdown by patient outcome. Conclusions: Mandatory medication error reporting can provide useful information about systems contributing to errors, strategies for prevention, and evidence-based information about patient safety concepts. This information is important for hospitals to consider both when analyzing medication errors and when implementing systems to improve safety.