Engaging Pharmacists in Adverse Medication Incident Reporting: Pilot of a Streamlined Reporting Application

Garrett, Tim; Reeves, Diane; Went, David
December 2010
Journal of Pharmacy Practice & Research;Dec2010, Vol. 40 Issue 4, p269
Academic Journal
Background: Medication-related harm is a major cause of morbidity in hospitalised patients. Incident reporting is a core initiative in improving this safety risk. Aim: To describe the impact of a purpose-built incident reporting application; and to investigate the influence of clinical duties/pharmacists' characteristics on incident reporting at an area health service. Method: Following implementation of the incident reporting application at the area health service, data (volume and severity on incidents by therapeutic group, error type, medication) were extracted for a 12-month period. Pharmacists concurrently completed a data collection form to record 'time in clinical areas' and profile their clinical activities. Results: Post-implementation, 2887 incident reports were recorded by 29 pharmacists; a 20-fold increase from baseline. The 2887 incident reports included 4106 error types for 43 therapeutic groups comprising 388 different medications. 'Prescribing errors on admission' (n = 562), incidents relating to 'anticoagulants, antithrombotics' (n = 457) and 23 medications were most commonly reported (p < 0.05). No significant differences emerged for the severity of incident by error type, therapeutic group or medication. There was no difference between 'high' and 'low' reporting pharmacists for most characteristics, such as time in clinical areas, profile of clinical activities, grade and years of experience. Conclusion: Streamlining incident reporting and actively engaging pharmacists can reduce safety risk as well as highlight the professional role of pharmacists in improving patient safety. Workplace safety culture and individual beliefs in the reporting process need to be explored further.


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