Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center.
Approach to Improving Safety
Setting of Care
Hospital incident reporting systems are ubiquitous, but many events remain unreported. This pre-post study sought to determine the impact of a reengineered medication error reporting approach. Researchers implemented a Web-based electronic medication error reporting system in concert with a novel work process in which clinical managers perform the first review of the report. The intervention led to increased error reporting, with the majority of errors being near-misses. This finding suggests that under-reporting of medication errors via standard incident reporting mechanisms can be addressed using human factors engineering approaches, which apply to and enhance both the error reporting tool and clinicians' workflow. A past AHRQ WebM&M perspective discusses how human factors engineering can be used to uncover problems with device design and work processes.