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J Am Med Dir Assoc. 2007 Nov;8(9):568-74. Epub 2007 Oct 22.

Identifying modifiable barriers to medication error reporting in the nursing home setting.

Author information

1
Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA. handlersm@upmc.edu

Abstract

OBJECTIVES:

To have health care professionals in nursing homes identify organizational-level and individual-level modifiable barriers to medication error reporting.

DESIGN:

Nominal group technique sessions to identify potential barriers, followed by development and administration of a 20-item cross-sectional mailed survey.

PARTICIPANTS AND SETTING:

Representatives of 4 professions (physicians, pharmacists, advanced practitioners, and nurses) from 4 independently owned, nonprofit nursing homes that had an average bed size of 150, were affiliated with an academic medical center, and were located in urban and suburban areas.

MEASUREMENTS:

Barriers identified in the nominal group technique sessions were used to design a 20-item survey. Survey respondents used 5-point Likert scales to score factors in terms of their likelihood of posing a barrier ("very unlikely" to "very likely") and their modifiability ("not modifiable" to "very modifiable"). Immediate action factors were identified as factors with mean scores of <3.0 on the likelihood and modifiability scales, and represent barriers that should be addressed to increase medication error reporting frequency.

RESULTS:

In 4 nominal group technique sessions, 28 professionals identified factors to include in the survey. The survey was mailed to all 154 professionals in the 4 nursing homes, and 104 (67.5%) responded. Response rates by facility ranged from 55.8% to 92.9%, and rates by profession ranged from 52.0% for physicians to 100.0% for pharmacists. Most respondents (75.0%) were women. Respondents had worked for a mean of 9.8 years in nursing homes and 5.4 years in their current facility. Of 20 survey items, 14 (70%) had scores that categorized them as immediate action factors, 9 (64%) of which were organizational barriers. Of these factors, the 3 considered most modifiable were (1) lack of a readily available medication error reporting system or forms, (2) lack of information on how to report a medication error, and (3) lack of feedback to the reporter or rest of the facility on medication errors that have been reported.

CONCLUSIONS:

The study results provide a broad-based perspective of the barriers to medication error reporting in the nursing home setting. Efforts to improve medication error reporting frequency should focus on organizational-level rather than individual-level interventions.

PMID:
17998112
PMCID:
PMC2151929
DOI:
10.1016/j.jamda.2007.06.009
[Indexed for MEDLINE]
Free PMC Article
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