Reducing Medication Errors in Hospitals: A Peer Review Organization Collaboration

Motivated by published reports of the incidence, costs, causes, and nature of adverse drug events (ADEs) in hospitalized patients, in 1997 the Medicare peer review organization for Nevada and Utah initiated a voluntary project of medication error reduction for Utah hospitals. Through project activities, hospital teams were encouraged to make changes to their medication processes based on direct evaluation of medication systems characteristics, informed by ergonomic principles and published studies of medication errors. Assessment of project effects included an evaluation of the changes implemented and results from an anonymous medication errors survey of clinical staff from participating organizations. Thirteen of the 39 acute care hospitals in Utah participated in 1997–1998 in the collaborative project. Participants reported substantive medication system changes that were expected to result in improved patient safety. Baseline and follow-up survey data were available for 8 of the participating hospitals. Analysis of 560 responses showed a 26.9% decrease in overall error frequency, a 12.5% increase in error detection and prevention, and a 24.1% increase in formal written reporting of errors that reached the patient. This project demonstrated community interest in a proactive and collaborative approach to improving patient safety. The improvement efforts were substantive and sustainable. Survey results suggest that the changes implemented in participating organizations may have reduced medication errors and improved capacity for error detection and prevention. Decreases in reported medication errors were consistent with improvements in the reliability of medication systems in participating organizations.