We successfully implemented a prescribing-error-reporting system in busy outpatient primary care practices using existing office systems. This approach required minimal provider and staff effort. The system was easily transferable from practice to practice, despite operational differences in handling pharmacist communications. Providers, nurses, office staff and managers overwhelmingly accepted the system, with most willing to continue their involvement. However, none of the practices have continued to send reports.
It is unclear why the reporting system failed to work beyond the study. Although there was disagreement among the survey respondents about the need for more reminders and feedback, it is likely that some intervention is required to keep participants active. Given the decrease in submitted reports over time during the study, it is likely that our reminders and feedback were insufficient to create a sustainable system.
Errors in strength, dosage form [28
] and decimal point or calculations [29
] have been reported in the literature for more than 30 years. Why should these types of errors still be reported? First, reporting is important for local surveillance and education. Our data suggest feedback to providers about prescribing bupropion and strengths not commercially available would be useful for local quality improvement efforts. Second, reporting promotes a discussion of error. Since the majority of reports concerned circumstances or errors that did not reach the patient, prescribers discussed the errors without fear of litigation. Third, reporting is hypothesis-generating for strategies that may then undergo rigorous testing. For example, error reports stimulated us to develop and test a modified prescribing form [30
]. Reports may be used to stimulate other ‘basic science’ research into the understudied nature of error [31
]. Lastly, reporting can help evaluate new technology after implementation. Although computerized technology is widely promoted as a means of reducing prescribing errors, these systems do not prevent all types of prescribing errors, have induced new errors and have questionable generalizability [32
]. Reporting systems detect unanticipated errors and can guide revisions of new technology.
The strengths of this reporting system include simple design, outpatient focus, easy translation to multiple primary care offices and minimal disruption of the office. The system allows for local surveillance of prescribing errors, promotes a discussion of errors among prescribers, nurses and office staff, and generates ideas for future research.
The limitations of this study include low reporting rates, inability to capture many important errors, small sample size, geographic restriction to one state and limited follow-up analysis with participants. We did not have patient information or the prescribers' perspectives on the circumstances surrounding the error. A more detailed survey or semi-structured interviews would have enhanced our understanding of the strengths and weaknesses of our system. It is unknown if this system would transfer well to specialty practices. We do not know if any of the practices have made changes or conducted quality improvement projects based on the feedback received from the reporting system. Finally, since none of the practices in this study use electronic prescribing technology, it is unknown if the detected errors would be similar or different.
Nurses and office staff may not have fully understood the complexities of the prescriptions and pharmacology of the medications well enough to submit complete reports. Additionally since the nurses and office staff were often intermediate parties, many of the reports did not contain the resolution of the problem. These limitations are recognized, however there was still interesting and useful information contained in the submitted reports.
As with all voluntary reporting systems, the true error rate is unknown, the ability to capture important errors is unpredictable and the reporting rates are consistently low. We only have data that participants deemed ‘reportable’. For example, participants may have felt a heightened awareness around narcotics compared with other classes of drugs, contributing to higher reporting. However, errors involving another class of drugs may have been more frequent or more dangerous. Additionally many medication errors, such as administration errors or errors corrected with the patient at the pharmacy before dispensing are not detected by this system and are therefore never reported.
These data are not rich enough to further specify errors mechanisms. For example, one report described a prescription for 120 tablets of oxycodone, but the pharmacist dispensed 180 tablets. With more data, we may be able to determine if this error was a substitution of 180 for 120 or a repetition of a count of 60. This insight is important as different solutions are required depending on the mechanism of the error.
Nurses and office staff are a valuable resource for reporting prescribing errors in primary care practices. However, without ongoing reminders, the reporting system is not sustainable. Important information about outpatient prescribing errors is available using existing office systems. Simple taxonomies for outpatient prescription errors may be useful to primary care practices who wish to conduct local quality improvement efforts, although further study is required to explore the effectiveness of these efforts and applicability to practices with electronic prescribing systems.