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Voluntary Medication Error Reporting Program in a Japanese National University Hospital

Associate Director, Department of Pharmacy, Staff of Department of Medical Informatics, Staff of Department of Medical Safety Management, Kanazawa University Hospital, Kanazawa, Japan

Hisashi Bunko, MD

Director, Department of Medical Informatics; Associate Director of Department of Medical Safety Management, Kanazawa University Hospital

Fumito Tsuchiya, BS

Director, Department of Pharmacy of Dental Hospital, Tokyo Medical and Dental University, Tokyo, Japan

Ken-ichi Miyamoto, PhD

Director, Department of Pharmacy, Kanazawa University Hospital

Reprints: Hiroyuki Furukawa MS, Department of Pharmacy, Kanazawa University Hospital, 13-1, Takara-machi, Kanazawa, 920-8641 Japan, FAX 81-076-234-4309, sambista-knz{at}umin.ac.jp

BACKGROUND: In Japan, as in other countries, medical accidents arising from human error can seriously damage public confidence in medical services, as well as being intrinsically undesirable.

OBJECTIVE: Errors voluntarily reported by the healthcare practitioners in our institution (Kanazawa University Hospital) were considered to assess the contributory factors by using the accumulated error database in the hospital information system.

METHODS: Medical errors in our institution during the period from July 1, 2000, to June 30, 2002, were counted using the error reporting system database and were classified.

RESULTS: The number of errors reported during the investigation period was 1378, of which 78% were reported by nursing staff. Medication errors involving administration of injectable or oral drugs to inpatients, dispensing, and prescription accounted for about 50% of that number. Among dispensing errors, 53% were detected by patients or their families and 36% by nurses.

CONCLUSIONS: The best method of error prevention is to learn from previous errors. For this purpose, the error reporting program is effective. In patient safety management, it is important to take into account the potential risks of future errors, as well as to capture information about errors that have already happened. For safety management, adoption of appropriate information technology (e.g., implementation of a prescription order entry system) is effective in reducing medication errors. However, it is important to note that serious errors can also arise in computer-based systems.

Key Words: database, information technology, medication error, reporting program

Published Online, September 18, 2003. www.theannals.com, DOI 10.1345/aph.1C330

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