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Qual Saf Health Care. 2010 Jun;19(3):218-22. doi: 10.1136/qshc.2008.031260. Epub 2010 Feb 1.

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

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  • 1Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7590, USA.



Legislation enacted in the US State of North Carolina in 2003 requires all licenced nursing homes to report all medication errors. In 2007, nursing homes were encouraged to voluntarily convert from aggregate reporting to a new online system where they reported each individual error.


A new optional web-based reporting tool was made available to all 393 North Carolina nursing homes to submit error reports for each distinct medication error as they occurred during the year.


A total of 5823 medication error reports were submitted by 203 sites (52%) using the new system during the reporting year, a median of 18 error reports per site. Of the 5823 error reports, 612 (10.5%) were categorised as serious. Serious errors were more likely to be caused by drugs given to the wrong patient (RR 4.39, CI 3.7 to 5.2), lab-work error (RR 2.40, CI 1.4 to 4.0), wrong product given (RR 2.22, CI 1.8 to 2.8) and medication overdoses (RR 1.49, 1.2 to 1.8). Serious errors were more likely to occur on second shift (RR 1.32, 1.1 to 1.5). Common medications that are involved in the most serious errors include warfarin (RR 2.58, CI 2.09 to 3.18) and insulin (RR 2.35, CI 1.86 to 2.97), and oxycodone combinations (RR 1.48, CI 1.07 to 2.06).


Data collected from a nursing home medication error system can provide helpful information on serious errors that can be used to focus patient safety efforts to reduce harm. This improved information will be useful in nursing homes for continuous quality improvement efforts.

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