Med error reporting gets shot in the arm
MedMARx now in 300 hospitals
The U.S. Pharmacopeia (USP) has signed an agreement with the U.S. Department of Defense (DOD) to implement the USP’s MedMARx program. MedMARx is an Internet-accessible, anonymous, national medication error reporting and prevention program for hospitals in the United States. The system allows hospitals to anonymously report, document, track, and analyze medication errors. The information generated by the MedMARx database identifies hospital system problems and helps form strategies for the prevention of medication errors.
The "Summary of 1999 Information Submitted to MedMARx: A National Database for Hospital Medication Error Reporting," appears on the USP’s web site at www.usp.org. This report summarizes data submitted to MedMARx from 56 member hospitals.
In addition to other hospitals that have joined MedMARx since the 1999 report, the DOD agreement brings the total number of hospitals in the MedMARx program to more than 300. "MedMARx can be used in hospitals and other institutions to identify drugs and drug classes that are prone to medication errors," says Diane Cousins, RPh, vice president of USP’s Practitioner and Product Experience Division.
Internal review of medication error data can help hospitals identify high-risk medications so that new employee orientation and staff competency programs can be designed to highlight those medications of concern. "It helps hospitals identify the source of medication error problems and develop strategies to prevent their recurrence," Cousins tells Drug Utilization Review. MedMARx participants can utilize national data about product error trends when making drug formulary selection decisions, in developing protocols, and in developing proactive safety measures for problematic products. "With MedMARx, hospitals have access to cutting-edge technology for reporting, tracking, and comparing medication errors. They also learn valuable lessons in medication error prevention and reduction from the strategies and recommendations of other hospitals nationwide," Cousins says.
MedMARx is strengthened by the USP’s long history of experience in operating voluntary reporting programs for health care professionals. The USP launched MedMARx in 1998 to serve voluntary reporting needs of health care professionals. Since the first version was released, USP has continued to improve the software program with input from subscribing hospitals. MedMARx not only documents medication errors, but also focuses upon risk management solutions that ultimately will protect patients and consumers of health care services provided by the nation’s 6,200 hospitals.
The USP demonstrated its MedMARx system at a congressional hearing on Feb. 9. Members of the House Commerce Committee and Veterans Affairs Committee were present. They heard Cousins testify on the importance of MedMARx as a national voluntary reporting system. The testimony included a background of USP’s experience in promoting the quality and appropriate use of medicines.
Distracted pharmacists = more errors
"The response to the presentation was very favorable," Cousins says. "The data reported last December from 1999 MedMARx reports has been even more convincing. With this report, they’re able to see what they’ve only been hearing about previously. For example, they can now see documentation that shows that distraction of pharmacists from their work load increases the numbers of medication errors. Congress also noted that if this is the kind of reporting that is generated without legal protection, just imagine what’s possible with legal protection." That type of legal protection would have to come at the federal level, since state policies vary too much, Cousins added.
"There are no patient identifiers in the database," Cousins says. "Where applicable, patient age is requested, but not the date of birth. Information is presented in aggregate form." This privacy and anonymity applies to the reporter and professionals involved in the medication error, too. "Those involved are identified only with information regarding their level of staff."
The USP has helped develop legislation to support the confidentiality of information submitted to national medication error reporting systems.
The absence of protection poses a major barrier to the reporting of medical errors. The Medication Error Prevention Act of 2000 was introduced by Rep. Connie Morella (R-MD) to provide for voluntary reporting of medication error information by health care providers by protecting this information. Morella prepared the legislation with the USP’s assistance.
The USP continues to monitor congressional activity and meet with Senate and House staff members, administration officials, and national professional organizations to build support for the legislation and for MedMARx as the national voluntary reporting system. Features of MedMARx as described on the USP web site include:
- Internet accessibility, which reduces the need for technical support;
- "point and click" technology and predefined drop-down boxes or pick lists with full on-line help for ease of use in creating individual medication error incident reports;
- the ability to hold reports for up to 60 days, at the facility’s discretion, to facilitate the investigative process and/or update information;
- a hard copy of the medication error reporting form, which will make reporting easier and give increased access to health care professionals within the facility;
- a root-cause analysis (RCA) database update based on the latest Joint Commission on Accreditation of Healthcare Organizations’ RCA framework;
- new user security access levels with a "write only" level added to give staff on patient units the ability to enter new medication error reports directly without accessing the entire database;
- a hyperlink from Notices to Update mode by clicking on record number, which allows faster access to reports that are about to be released.
When a user receives an electronic alert message from USP that a record will be released to the general database, the user can 1) click on the record number; 2) automatically hyperlink to the record in the update mode; and then, 3) check its accuracy and completeness prior to release.
"Reports generated by individual hospitals are visible only to the institution that generates them for the first 60 days they are in the system. This allows the hospital to make changes or updates to the report. You can think of it as being on a clipboard at this point," Cousins explains. "On the 60th day, the report is automatically transferred to the general database where other institutions can then access the report and include it in their searches.
"Recent enhancements to MedMARx have been primarily in infrastructure. In anticipation of becoming the national database for reporting medication errors, we have made changes to improve speed and capability," says Cousins.
Results of the data from the year 2000 will be published around the middle of 2001. During 1999, 6,224 medication errors were reported to MedMARx. Three percent (187) of these resulted in patient harm. Of these, 181 resulted in temporary harm, five in permanent harm, and one in death. The data do not compare the number of errors to the volume of medications dispensed; therefore the incidence is not known. The total volume of medication used per hospital is not captured by the MedMARx program.
The three drugs most frequently involved in medication errors were insulin (151), warfarin (155), and heparin (129). Cousins states that the frequency of errors reported for these agents is likely due to the protocols in which they are used. "Any deviation from these stringent protocols is considered an error and is therefore reported," she says.
Those interested in MedMARx can learn more about the program by calling (877) MedMARx. A free feature demo disk is available upon request, and a free on-line demo is available at www.usp.org/medmarx.
Source
• Diane Cousins, RPh, Vice President, Practitioner and Product Experience, U.S. Pharmacopeia, 12601 Twinbrook Parkway, Rockville, MD 20852. Telephone: (800) 227-8772.
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