Authors

1. Al Qubaisi, Mai MPharm
2. Stewart, Derek PgCert, BSc, MSc, PhD, MRPharmS, FFRPS
3. Tonna, Antonella BSc, MSc, PhD, MRPharmS
4. Strath, Alison BSc, FRPharmS

Abstract

Review objective: The objective of this review is to critically appraise, synthesize and present the available evidence on health professionals' beliefs, attitudes and experiences of medication error reporting.

Review questions: More specifically, this review seeks to answer the following questions.

In relation to health professionals (i.e. doctors, nurses and pharmacists):

1. What are their beliefs and attitudes towards medication error reporting?

2. What are their experiences of medication error reporting? (E.g. nature of feedback obtained, any subsequent changes in their practice, ease of use of the reporting system, any improvements required to optimize medication error reporting.)

3. What are the reasons given or factors which are associated with under-reporting of medication errors? (E.g. lack of awareness or understanding of the reporting system, fear of possible consequences of reporting, and forgetting to report.)

Background: Promoting patient safety through minimizing medication errors is a key global healthcare objective. The most widely used and accepted definition of the term "medication error" is that of the United States (US) National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP), which defines "medication error" as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the health care professional, patient or consumer".1 The United Kingdom (UK) National Patient Safety Agency (NPSA) proposes a similar definition of "any incident where there has been an error in the process of prescribing, dispensing, preparing, administering, monitoring, or providing medicines advice, regardless of whether any harm occurred or was possible".2 In a philosophical discussion on the construction of the term, Ferner and Aronson suggest a definition of "failures in the treatment process that lead to, or have the potential to lead to harm to the patient".3^(p.1013) All definitions emphasize harm and prevention.

There is some overlap and often confusion between the terms "medication error" and "adverse drug reaction". The UK Medicines and Healthcare Products Regulatory Agency (MHRA) defines an "adverse drug reaction" as "a harmful and unintended reaction that occurs at a dose normally used for the prophylaxis, diagnosis or treatment of disease or the modification of physiological functions".4 Those adverse drug reactions which are deemed preventable are also considered to be medication errors.5

The National Coordinating Council for Medication Error Reporting and Prevention highlights that medication errors "may be related to professional practice, health care products, procedures and systems, including prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use".1 It proposes a classification system of severity of error ranging from no error: circumstances or events that have the capacity to cause error, error no harm, error harm and error death.1

Most of the published literature on medication errors appears to relate to "prescribing errors". Aronson and Ferner distinguish between "prescription" and "prescribing". While "prescription" is the "act of writing the prescription", "prescribing" relates more to associated cognitive decision-making processes.6^(p.602) Aronson later proposes a definition of "prescribing error" as a "failure in the prescribing process that leads to, or has the potential to lead to harm to the patient".6^(p.602)

Whatever the classification of medication error, it is clear that these greatly impact patient care. Indeed, medication errors are common. According to a report published by the US Institute of Medicine in 2006, medication errors accounted for 1.5 million injuries annually at a cost of up to $1.35 billion in the form of lost productivity, wages and additional medical expenses.7 Data from the United Kingdom, collated and reported by the NPSA for the period from October 2010 to September 2011, illustrates that medication errors are the second most common cause of patient safety issues (following patient accidents) during hospital stay, contributing to 11% of all incidents, affecting 134,684 patients.8

Several recent systematic reviews have focused on prescribing errors. Lewis et al. reported the prevalence, incidence and nature of prescribing errors in hospital in-patients.9 They reported that prescribing errors were common, affecting 7% of all medication orders, 2% of patient days and 50% of hospital admissions, from studies largely conducted in the US and UK. They also noted that reporting rates varied widely due to inconsistent and often absent study definitions in the term, "prescribing error", and differences in study methodologies, specifically the research outcome measures. In the same year, Ross et al. reported on the scale of prescribing errors committed by junior doctors, reporting error rates of two to 514 per 1000 items prescribed and 4.2-82% of patients or charts reviewed.10

Dornan et al. further reported primary data on prescribing errors in the hospital setting, highlighting that errors are often multi-factorial, with several active failures and error-provoking conditions (e.g. lack of training or experience, fatigue, stress, high workload for the prescriber and inadequate communication between healthcare professionals) often acting together to cause them.11 More recently, similar findings were reported by Ross et al.,12 Ryan et al.,13 and Duncan et al.,14 as part of the Prescribing Outcomes for Trainee doctors Engaged in Clinical Training (PROTECT) study of prescribing errors committed by junior doctors in Scottish hospitals.

The NCCMERP in the US and the NPSA in the UK have similar mission statements in terms of promoting safe medication use and increasing awareness of medication errors through communication, reporting and promotion of medication error prevention strategies.1,2 Indeed the vision of NCCMERP is that "no patient will be harmed by a medication error".2 Cohen notes that while most health professionals are familiar with the "five rights" of safe medication use (right patient, drug, time, dose, route of administration), there is a gulf between theory and practice, which can lead to error.15

Both the NCCMERP and the NPSA place much of their focus on medication error reporting. Goals of NCCMERP include stimulating the "development and use of reporting and evaluation systems by individual health care organizations" and stimulating "reporting to a national system for review, analysis and development of recommendations to reduce and ultimately prevent medication errors".1 Similarly, the NPSA describes "tools and guidance to help organizations improve their reporting levels".2 These include: ensuring quality reports, engaging frontline staff and management, reporting regularly, reporting serious incidents quickly, making reporting matter and ensuring consistency. Adopting these tools and guidance into practice should increase reporting system efficiency with subsequent impact on the incidence, prevalence, nature and severity of medication errors, thus improving patient safety and care.

While several systematic reviews have reported error prevalence and associated causes of errors, the authors did not describe the current quantitative or qualitative data regarding medication error reporting and impact factors relevant to the reporting systems. Furthermore, a preliminary search of the JBI Database of Systematic Reviews and Implementation Reports and the Cochrane Library has revealed that there is not currently a systematic review either published or underway on this topic. There is therefore a major gap in the literature in terms of the beliefs, attitudes and experiences of health professionals in relation to medication error reporting. For error reporting systems to operate efficiently and optimize their positive contribution to medication errors and thus patient safety, it is vital that all health professionals understand the reporting processes, that appropriate errors are reported and that feedback on reports at the individual practitioner and organizational level allow reflection of practice to further improve patient safety. The systematic review will focus on these aspects and synthesize the available literature on issues of beliefs, attitudes and experiences, with specific attention to issues around under-reporting of medication errors by health professionals. At this stage, any studies, which focus on patient reporting of medication errors, will be excluded.