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Nurses and office staff can help report prescribing errors in primary care offices

Research Activities, March 2009, No. 343

A set of procedures that involves nurses and office staff from primary care practices can bring success in reporting prescribing errors. Researchers at the University of Vermont's College of Medicine and the Institute for Safe Medication Practices developed a voluntary prescribing-error reporting system that was used at seven primary care practices. Nurses and office staff were asked to report whenever a pharmacist called to either get additional information or notify them about a problem with a prescription. Prescribers were also encouraged to report their own errors. None of the practices used electronic medical records.

Of the 103 people from the practices who participated in the study, there were 31 physicians, 8 nurse practitioners, 2 physician assistants, 26 nonprescribing nurses, 10 medical assistants, 20 office staff, and 6 nonphysician office managers. Prescribers submitted 7 of the 216 reports (3.5 percent). Total error reports varied from 10 to 62 per practice (with a median of 32 reports). The most frequent drug classes involved in reports were antidepressants (38 reports), narcotics (32 reports), and drugs to lower blood pressure (24 reports). A fifth of the near-misses or errors involved drugs considered "high-alert," that is, with a high risk of causing injury when misused.

In addition to 49 reports of near misses, there were 165 errors. Almost 90 percent of these errors did not reach the patient, 19 reached the patient without causing harm, and 4 errors caused temporary harm that required intervention. None of the errors resulted in hospitalization, permanent harm, or death. The majority of study participants did not find the reporting system burdensome and indicated that they would be willing to participate beyond the study period. However, none of the practices continued to submit reports after the study ended. The study was funded in part by the Agency for Healthcare Research and Quality (HS13891).

More details are in "Using nurses and office staff to report prescribing errors in primary care," by Amanda G. Kennedy, Pharm.D., B.C.P.S., Benjamin Littenberg, M.D., and John W. Senders, Ph.D., in the August 2008 International Journal for Quality in Health Care 20(4), pp. 238-245.

Current as of March 2009
Internet Citation: Nurses and office staff can help report prescribing errors in primary care offices: Research Activities, March 2009, No. 343. March 2009. Agency for Healthcare Research and Quality, Rockville, MD.