The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data

This paper examines the impact of an Internet-based method on the collection of medication error occurrence reports. Data for this study was collected for two time periods. The first data collection effort used a paper-based method and produced our baseline data (January 1994 to December 2000). A second dataset was created with information collected from January to December 2003, using a Web-based software application. Four priority areas were developed from the baseline data: (1) increase the overall number of reported medication errors; (2) increase the number of intercepted medication errors; (3) increase the documented number of physician-attributed medication errors; and (4) improve data quality and specificity. Findings from the Web-based method of collecting data show significant improvements across all four areas. The number of documented medication errors increased from an average of 414 between 1994 and 2000, to 959 in 2003. In this same time period, intercepted errors increased from an average of 17.3 percent to 58.2 percent, and physician-attributed errors increased from an average of 4.8 percent to 27.2 percent. Finally, the missing or unspecified data from the cause-of-error variable decreased from 18.6 percent to 2.1 percent. The electronic system’s deliberate anonymity and ease of use, coupled with its ability to expedite reported medication error investigations and the educational efforts directed at the creation of an open reporting environment, are the most likely explanations for the positive impact of the Web-based reporting system. Introduction Medication error (ME) is a significant problem within our health care system, in terms of patient harm and cost. In July 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) cited the need to reduce medication errors as a top priority. Several studies suggest that medical error is the third-leading cause of death in the United States, closely trailing heart disease and cancer. 2 In fact, at least 7,000 inpatient deaths occur annually as a direct result of medication errors in hospitals and 106,000 deaths occur each year, due to adverse effects of medications. 2 Kohn reported that 44,000 to 98,000 Americans die annually as a result of medication errors. It has been estimated that medication-related problems cost the U.S. health care system $132–$182 billion annually, at a price of approximately $1.5 million per hospital. 4 It has been Report Documentation Page Form Approved OMB No. 0704-0188 Public reporting burden for the collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to a penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.