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Variability in Threshold for Medication Error Reporting Between Physicians, Nurses, Pharmacists, and Families

[ Vol. 12 , Issue. 3 ]


Patricia Keefer*, Kelley Kidwell, Candice Lengyel, Kavita Warrier and Deborah Wagner   Pages 187 - 192 ( 6 )


Background: Voluntary medication error reporting is an imperfect resource used to improve the quality of medication administration. It requires judgment by front-line staff to determine how to report enough to identify opportunities to improve patients’ safety but not jeopardize that safety by creating a culture of “report fatigue.”

Objective: This study aims to provide information on interpretability of medication error and the variability between the subgroups of caregivers in the hospital setting.

Methods: Survey participants included nursing, physician (trainee and graduated), patient/families, pharmacist across a large academic health system, including an attached free-standing pediatric hospital. Demographics and survey questions were collected and analyzed using Fischer’s exact testing with SAS v9.3.

Results: Statistically significant variability existed between the four groups for a majority of the questions. This included all cases designated as administration errors and many, but not all, cases of prescribing events. Commentary provided in the free-text portion of the survey was sub-analyzed and found to be associated with medication allergy reporting and lack of education surrounding report characteristics.

Conclusion: There is significant variability in the threshold to report specific medication errors in the hospital setting. More work needs to be done to further improve the education surrounding error reporting in hospitals for all noted subgroups.


Medication safety, voluntary safety reporting, patient safety, medication error, variability, threshold.


1540 E Hospital Drive, 12-525H, Ann Arbor, MI 48109, University of Michigan School of Public Health, Ann Arbor, MI, Randall Children's Hospital, Portland, Oregon, IHA Canton, Canton, MI, University of Michigan College of Pharmacy, University of Michigan Medical School, Department of Anesthesiology, Ann Arbor, MI

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