Strategies to improve reporting of medication and other safety incidents.
Patients, consumers and healthcare professionals are critical stakeholders for successful learning from medication errors, acting as primary source and providing first-hand information on the case when reporting medication errors spontaneously to a competent authority, marketing authorisation holder or other organisation (e.g. regional pharmacovigilance centre, poison control centre) as unsolicited communication (1).
Junior doctors, pharmacists and other healthcare professionals should all feel 'psychologically' safe when they raise concerns about the safety of medicines use and other healthcare processes. In the past, dysfunctional responses to error characterized by ''naming, blaming, and shaming'' individuals (2) have been identified.
This type of response prevents the sharing of knowledge that would serve to prevent safety incidents from being repeated.
Hierarchies tend to favour those at the top of the hierarchy.
Those at the bottom or the lower levels may need to have a structured approach for raising concerns.
Issues in relation to non reporting in primary and secondary care will be different.
Hierarchies and challenges to medication safety will vary in both settings.
Data in relation to medication safety incidents and other processes is available in many secondary care locations. The safety of medication use and other healthcare processes in primary care is less well known.
The culture of the healthcare environment and the perceived value of raising concerns will be some of the factors that influence reporting.. Many healthcare staff agree with and understand the value of reporting of concerns they may have. However, there are many reasons for not reporting.
Strategies to Improve Incident Reporting (3):
Promote and sustain a culture of learning from mistakes.
Make incident reporting an individual performance expectation.
Have clear definitions for reportable events that everyone understands.
Make it easy to report and provide several different reporting methods.
Allow for anonymous error reporting.
Maintain a confidential incident reporting system.
Use reports to identify common error-producing factors, not just to create incident counts.
Share the learning derived from incident analyses with physicians and staff.
Communicate and celebrate improvements that result from analyzing reported events.
Rapid Response:
Strategies to improve reporting of medication and other safety incidents.
Patients, consumers and healthcare professionals are critical stakeholders for successful learning from medication errors, acting as primary source and providing first-hand information on the case when reporting medication errors spontaneously to a competent authority, marketing authorisation holder or other organisation (e.g. regional pharmacovigilance centre, poison control centre) as unsolicited communication (1).
Junior doctors, pharmacists and other healthcare professionals should all feel 'psychologically' safe when they raise concerns about the safety of medicines use and other healthcare processes. In the past, dysfunctional responses to error characterized by ''naming, blaming, and shaming'' individuals (2) have been identified.
This type of response prevents the sharing of knowledge that would serve to prevent safety incidents from being repeated.
Hierarchies tend to favour those at the top of the hierarchy.
Those at the bottom or the lower levels may need to have a structured approach for raising concerns.
Issues in relation to non reporting in primary and secondary care will be different.
Hierarchies and challenges to medication safety will vary in both settings.
Data in relation to medication safety incidents and other processes is available in many secondary care locations. The safety of medication use and other healthcare processes in primary care is less well known.
The culture of the healthcare environment and the perceived value of raising concerns will be some of the factors that influence reporting.. Many healthcare staff agree with and understand the value of reporting of concerns they may have. However, there are many reasons for not reporting.
Strategies to Improve Incident Reporting (3):
Promote and sustain a culture of learning from mistakes.
Make incident reporting an individual performance expectation.
Have clear definitions for reportable events that everyone understands.
Make it easy to report and provide several different reporting methods.
Allow for anonymous error reporting.
Maintain a confidential incident reporting system.
Use reports to identify common error-producing factors, not just to create incident counts.
Share the learning derived from incident analyses with physicians and staff.
Communicate and celebrate improvements that result from analyzing reported events.
Reference:
1. https://www.ema.europa.eu/en/documents/regulatory-procedural-guideline/g...
2. Bosk CL. Forgive and Remember: Managing Medical Failure. 2nd ed. Chicago, IL: University of Chicago Press; 2003.
3. Failure to Report. March 2007 https://psnet.ahrq.gov/webmm/case/146/Failure-to-Report
Competing interests: No competing interests