Farmleigh House, Dublin, June 29-30, 2006 Experience with Medication Error Reporting Systems in an Irish Hospital Tim Delaney, FPSI Head of Pharmacy AMNCH Tallaght, Dublin 24, Ireland First OECD Health Care Quality Indicators Seminar on Improving Patient Safety Data Systems. Farmleigh House, Dublin, June 29-30, 2006

Indicators - starting point for change

Medication Error Reports as Indicators OECD Health Technical Papers No. 19 (2004), p.29

Drugs involved in harmful incidents (Kirke C. AnalyzErr Pilot Study 2006)

Irish Experience: Errors by stage of the Medication Use Process (all reports) (Kirke C. AnalyzErr Pilot Study 2006)

Stage involved in harmful incidents (Kirke C. AnalyzErr Pilot 2006)

5 Principles for Creating an Environment for Safety 1. Culture: There should be a non-punitive culture for reporting healthcare errors that focuses on preventing and correcting systems failures and not on individual or organisation culpability. 2. Data Analysis: Information submitted to reporting systems must be comprehensively analysed to identify actions that would minimise the risk that reported events recur. General Principles for Patient Safety Reporting Systems, (NCCMERP 2003)

5 Principles for Creating an Environment for Safety 3. Confidentiality. Confidentiality protections for patients, healthcare professionals, and healthcare organizations are essential to the ability of any reporting system to learn about errors and effect their reduction. 4. Information Sharing. Reporting systems should facilitate the sharing of patient safety information among healthcare organizations and foster confidential collaboration with other healthcare reporting systems General Principles for Patient Safety Reporting Systems, (NCCMERP 2003)

5 Principles for Creating an Environment for Safety 5. Legal Status of Reporting System Information. The absence of legal protection for information submitted to patient safety reporting systems discourages the use of such systems, which reduces the opportunity to identify trends and implement corrective measures. Information developed in connection with reporting systems should be privileged for purposes of state judicial proceedings in civil matters, and for purposes of state administrative proceedings, including with respect to discovery, subpoenas, testimony, or any other form of disclosure General Principles for Patient Safety Reporting Systems, (NCCMERP 2003)

Legal protection and reporting In Ireland, incident report and analysis may be protected under the Freedom of Information Act but are still discoverable in the event of civil litigation This is a significant deterrent to the production of RCA reports.

Factors to Consider when Comparing Reporting Rates Reporting Culture Differences in the types of reporting and detection system Differences in the patient populations served Definition of error

1. Culture Differences in culture among health care organisations can lead to significant differences in the level of reporting of medication errors.

Culture - sense-making in a community of practice Fellenz. M. (Trinity College Dublin / Irish Management Institute, 2006)

Drive out fear! Great loss is associated with fear, when workers are afraid to ask a question of to take a position. A secure worker will report faults and point to conditions that impair quality W. Edwards Deming : “Out of the Crisis” (1986)

AMNCH – A culture of safety? Staff Values (1998) Reporting Culture (2000) Respect Caring Openness Partnership & teamwork Fairness & equity Blame Punishment Secrecy Adversity Cynicism Unfairness & inequity

Reporting culture varies between professions at AMNCH 160 100% 140 97% 100% 99% 80% 120 83% 100 60% No. Reports (Oct-Dec 2004) 80 49% Cumulative % Reports 40% 60 40 20% 20 0% Pharmacists Nurses Pharmacy Doctors Dieticians technicians Frequency Cumul %

2. Populations Served Differences in the patient populations served by various health care organisations can lead to significant differences in the number and severity of medication errors occurring among organisations.

3. Definition of error Differences in the definition of a medication error among health care organisations can lead to significant differences in the reporting and classification of medication errors.

Definition – what’s in a name? Source: AMNCH Tallaght: Medication Safety Incident Reporting Policy DTC4/2002

OECD uses JCAHO operational definition OECD Health Technical Papers No. 19 (2004), p.29

NCC MERP Definition “Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labelling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use." NCCMERP (1998)

4% of reported incidents involved patient harm (AMNCH data 2004) (Kirke C. AMNCH Data Oct-Dec 2004)

7% of reported incidents involved patient harm (5 Irish Hospitals Pooled Data, 2006) (Kirke C. AnalyzErr Pilot Study 2006)

Issues with definitions OECD definition is equivalent to NCC MERP Categories G and I Covers only 2 of 5 NCC MERP sub-categories of errors causing harm Excludes a major harm category -errors where emergency intervention was needed to sustain life

4. Reporting Systems Differences in the types of reporting and detection systems for medication errors among health care organizations can lead to significant differences in the number of medication errors recorded

Monthly Medication Safety Incident Reporting at AMNCH 2001-2005

AMNCH Tallaght Dispensary Errors 2004/2005 Errors detected in Pharmacy 2004 2,125 Errors detected on Ward 81 Errors reaching patient 41 Detection in Pharmacy per 100,000 items 709 Detection in Ward per 100,000 items 27 Not detected (given to patient) per 100,000 items 14 Errors detected in Pharmacy 2005 2,795 Errors detected on Ward 77 Errors reaching patient 21 Detection in Pharmacy per 100,000 items 1067 Detection in Ward per 100,000 items 29 Not detected (given to patient) per 100,000 items 8

Limitations of passive reporting OECD Health Technical Papers No. 19 (2004), p.30

“ Mistakes are the portals of discovery.” James Joyce