Using nurses and office staff to report prescribing errors in primary care

Amanda G Kennedy, Benjamin Littenberg, John W Senders, Amanda G Kennedy, Benjamin Littenberg, John W Senders

Abstract

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.

Figures

Figure 1
Figure 1
Linear regression of reporting over time

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