Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit

ObjectiveThis study analyses patterns in reporting rates of medication errors, rates of medication errors with harm, and responses to the Safety Attitudes Questionnaire (SAQ), all in the context of four cultural and three system-level interventions for medication safety in an intensive care unit.MethodsOver a period of 2.5 years (May 2007 to November 2009), seven overlapping interventions to improve medication safety and reporting were implemented: a poster tracking ‘days since last medication error resulting in harm’, a continuous slideshow showing performance metrics in the staff lounge, multiple didactic curricula, unit-wide emails summarising medication errors, computerised physician order entry, introduction of unit-based pharmacy technicians for medication delivery, and patient safety report form streamlining. The reporting rate of medication errors and errors with harm were analysed over time using statistical process control. SAQ responses were collected annually.ResultsSubsequent to the interventions, the reporting rate of medication errors increased 25%, from an average of 3.16 to 3.95 per 10 000 doses dispensed (p