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J Patient Saf. 2012 Dec;8(4):165-76. doi: 10.1097/PTS.0b013e3182676cf3.

National and local medication error reporting systems: a survey of practices in 16 countries.

Author information

  • 1Division of Social Pharmacy, University of Helsinki, Finland. anna-riia.holmstrom@helsinki.fi



To explore the existence and characteristics of national and local medication error reporting (MER) systems and to describe national medication safety experts' perceptions of a good and effective MER system and barriers to reporting.


In a descriptive cross-sectional study, 32 medication safety experts were identified through member organizations of the International Pharmaceutical Federation in 88 countries and other professional organizations in 3 additional countries. These experts were invited to participate in an online survey.


Sixteen national medication safety experts from different countries participated in the study (response rate, 50%). A national (n = 5) or local (n = 6) MER system existed in 11 of these countries. In 5 countries, no MER system existed. The most common features of the MER systems were confidentiality of the reported information and providing feedback to those involved in reporting. Most experts perceived that a good and effective MER system was characterized by the opportunity to learn from errors by those involved in reporting, having a nonpunitive approach to reporting, and ease of use. They also perceived that a blame culture, lack of time, training, and coordination of reporting were the main barriers to reporting.


Blame culture, a lack of time, training and coordination of reporting continue to be the major barriers to reporting. Learning from errors and having a nonpunitive approach to reporting were thought to be the most critical features of a MER system. Difficulties in identifying national medication safety experts indicates a need for promoting international networking of medication safety experts and bodies for sharing information and learning from others.

[PubMed - indexed for MEDLINE]
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