Field test results of a new ambulatory care medication error and adverse drug event reporting system-MEADERS

John Hickner, Atif Zafar, Grace M. Kuo, Lyle Fagnan, Samuel N. Forjuoh, Lyndee M. Knox, John T. Lynch, Brian Kelly Stevens, Wilson D. Pace, Benjamin N. Hamlin, Hilary Scherer, Brenda L. Hudson, Caitlin Carroll Oppenheimer, William M. Tierney

Research output: Contribution to journalArticle

28 Citations (Scopus)

Abstract

PURPOSE: In this study, we developed and field tested the Medication Error and Adverse Drug Event Reporting System (MEADERS)-an easy-to-use, Web-based reporting system designed for busy office practices. METHODS: We conducted a 10-week field test of MEADERS in which 220 physicians and office stafffrom 24 practices reported medication errors and adverse drug events they observed during usual clinical care. The main outcomes were (1) use and acceptability of MEADERS measured with a postreporting survey and interviews with office managers and lead physicians, and (2) distributions of characteristics of the medication event reports. RESULTS: A total of 507 anonymous event reports were submitted. The mean reporting time was 4.3 minutes. Of these reports, 357 (70%) included medication errors only, 138 (27%) involved adverse drug events only, and 12 (2.4%) included both. Medication errors were roughly equally divided among ordering medications, implementing prescription orders, errors by patients receiving the medications, and documentation errors. The most frequent contributors to the medication err ors and adverse drug events were communication problems (41%) and knowledge deficits (22%). Eight (1.6%) of the reported events led to hospitalization. Reporting raised staffand physician awareness of the kinds of errors that occur in office medication management; however, 36% agreed or strongly agreed that the event reporting "has increased the fear of repercussion in the practice." Time pressure was the main barrier to reporting. CONCLUSIONS: It is feasible for primary care clinicians and office staffto report medication errors and adverse drug events to a Web-based reporting system. Time pressures and a punitive culture are barriers to event reporting that must be overcome. Further testing of MEADERS as a quality improvement tool is warranted.

Original languageEnglish (US)
Pages (from-to)517-525
Number of pages9
JournalAnnals of Family Medicine
Volume8
Issue number6
DOIs
StatePublished - Nov 2010

Fingerprint

Medication Errors
Ambulatory Care
Drug-Related Side Effects and Adverse Reactions
Office Management
Physicians
Physicians' Offices
Quality Improvement
Documentation
Fear
Prescriptions
Primary Health Care
Hospitalization
Communication
Interviews

Keywords

  • Adverse drug event
  • Adverse drug reaction reporting systems
  • Event reporting
  • Medication error
  • Online systems
  • Practice-based research
  • Primary care

ASJC Scopus subject areas

  • Family Practice

Cite this

Field test results of a new ambulatory care medication error and adverse drug event reporting system-MEADERS. / Hickner, John; Zafar, Atif; Kuo, Grace M.; Fagnan, Lyle; Forjuoh, Samuel N.; Knox, Lyndee M.; Lynch, John T.; Stevens, Brian Kelly; Pace, Wilson D.; Hamlin, Benjamin N.; Scherer, Hilary; Hudson, Brenda L.; Oppenheimer, Caitlin Carroll; Tierney, William M.

In: Annals of Family Medicine, Vol. 8, No. 6, 11.2010, p. 517-525.

Research output: Contribution to journalArticle

Hickner, J, Zafar, A, Kuo, GM, Fagnan, L, Forjuoh, SN, Knox, LM, Lynch, JT, Stevens, BK, Pace, WD, Hamlin, BN, Scherer, H, Hudson, BL, Oppenheimer, CC & Tierney, WM 2010, 'Field test results of a new ambulatory care medication error and adverse drug event reporting system-MEADERS', Annals of Family Medicine, vol. 8, no. 6, pp. 517-525. https://doi.org/10.1370/afm.1169
Hickner, John ; Zafar, Atif ; Kuo, Grace M. ; Fagnan, Lyle ; Forjuoh, Samuel N. ; Knox, Lyndee M. ; Lynch, John T. ; Stevens, Brian Kelly ; Pace, Wilson D. ; Hamlin, Benjamin N. ; Scherer, Hilary ; Hudson, Brenda L. ; Oppenheimer, Caitlin Carroll ; Tierney, William M. / Field test results of a new ambulatory care medication error and adverse drug event reporting system-MEADERS. In: Annals of Family Medicine. 2010 ; Vol. 8, No. 6. pp. 517-525.
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AU - Knox, Lyndee M.

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