A Reporting Culture Detects Harm and Potential Harm Due to Errors
Expand the buttons below for tools and objectives.
Objectives: Explain the role of voluntary reporting systems in a program of patient safety
- Identify the characteristics of successful reporting systems
- Identify information necessary for systematic data collection in a medication error reporting program
- Understand how the NCC MERP Taxonomy of error severity provides a language to describe errors in the context of a system process Map Template for Medication Administration
Creating a flowchart or process map makes your process or system visible and ensures that everybody has the same mental model of the system.
A process map will:
- Identify unexpected complexity and redundancy of steps
- Compare and contrast the current process with the evidence-based process from guidelines and identify priorities for change
- Identify needed areas for further data collection and prioritization of change
- Serve as a communication tool in training or a root cause analysis
Objectives: List three benefits for documenting a process using a process map
- Identify barriers and gaps in a process
- Determine evidence-based practices to improve the process to eliminate failures
- Describe three tools for documenting processes
Process mapping allows you to identify productivity opportunities, best practices, root causes of problems, create workflow consistency, and determine who owns an action item within the process and who is accountable for the process.
MEDMARX - Medication Error Reporting System
MEDMARX is an anonymous medication error reporting program that subscribing hospitals and health systems participate in as part of their ongoing quality improvement initiatives. Nationally, data from MEDMARX contributes to knowledge about the causes and prevention of medication errors. Over 870 hospitals and health systems have submitted more than 1.3 million medication error records to MEDMARX. Analyses of voluntary medication error reports from large patient safety databases, such as MEDMARX, can identify system sources of error and lead to the establishment of safe medication practices.
MEDMARX Data Entry Workshop Slides
Using MEDMARX for Reporting and Benchmarking Workshop Slides
Excel Quarterly Report Template for MEDMARX Data
Use the Near-Miss Reporting Form to encourage reporting of Category A and Category B errors.
Implementing a Program of Patient Safety in Small Rural Hospitals: Findings and Trends in Medication Error Reporting from 25 Critical Access Hospitals
This report summarizes the medication error reports voluntarily submitted to MEDMARX in calendar year 2005 by the 25 Critical Access Hospitals in our project.
Hospital Survey on Patient Safety Culture
Survey items to assess a Reporting Culture:
- When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported?
- When a mistake is made, but has no potential to harm the patient, how often is this reported?
- When a mistake is made that could harm the patient, but does not, how often is this reported?
- In the past 12 months, how many event reports have you filled out and submitted?
Survey items to assess a Just Culture:
- Staff feel like their mistakes are held against them.
- When an event is reported, it feels like the person is being written up, not the problem.
- Staff worry that mistakes they make are kept in their personnel file.
Survey items to assess a Flexible Culture:
- People support one another in this department.
- When a lot of work needs to be done quickly, we work together as a team to get the work done.
- In this department, people treat each other with respect.
- When one area in this department gets really busy, others help out.
Survey items to assess a Learning Culture:
- We are actively doing things to improve patient safety.
- Mistakes have led to positive changes here.
- After we make changes to improve patient safety, we evaluate their effectiveness.
- We are given feedback about changes put into place based on event reports.