Standardizing Medication Error Event Reporting in the U.S. Department of Defense

Soon after the 1999 Institute of Medicine report, To Err Is Human, was released, the Department of Defense (DoD) began an aggressive examination of medical errors and the strategies for minimizing them. A primary goal was the creation of a standardized medication event reporting system, including a central registry for the compilation of reported data. This paper describes important experiences gleaned from the DoD’s transition to a standardized medication error reporting system. MEDMARX, an Internet-based commercial reporting application, was selected by the DoD leadership as the standard tool for medication event reporting. MEDMARX was implemented initially at five military hospitals in fall 2000 as part of a patient safety pilot project, and was later made available to all 143 military treatment facilities worldwide. Medication errors represent approximately 50 percent of all patient safety events reported by military health care facilities. Although the challenges associated with the implementation of a standardized error reporting system were considerable in number and scope, the long-term benefits to the DoD are significant.