All Mixed Up

Reporting of physicians' medication mix-ups can help prevent them

/ Author:  / Reviewed by: Joseph V. Madia, MD

(RxWiki News) Communication problems and lack of knowledge create the most medication mix-ups in busy primary-care practice offices and these mix-ups lead to adverse drugs events

This is according to the study of a prototype web-based reporting system known as MEADERS (Medication Error and Adverse Drug Event Reporting System), developed by investigators from the Regenstrief Institute and Indiana University School of Medicine.

"We found this first generation reporting system to be popular with physicians and others in their offices, in spite of time pressures and a culture that does not support admitting mistakes," said William M. Tierney, M.D., president and CEO of the Regenstrief Institute and co-developer of MEADERS.

In the study, facilities in California, Connecticut, Oregon and Texas used MEADERS for 10 weeks. Each submitted 507 confidential event reports with the average time spent to report lasting a little over four minutes. Seventy percent of reports included medication mistakes, while 2 percent included both medication errors and adverse drug events.

Medications for cardiovascular disorders and diseases, pain killers and other central-nervous-system medications, endocrine-disease medication (mostly for diabetes), and antibiotics were most often associated with the events reported. No harm was reported for most of the affected patients, but adverse effects were recorded in about 11 percent.

Tierney said the the real challenge is to demonstrate that event reporting is "sustainable and that the data from event reporting can be used in an ongoing way to identify and to correct systems problems to reduce medication errors, adverse drug events, hospital admissions and patient harm."

Reviewed by: 
Review Date: 
December 5, 2010
Last Updated:
December 6, 2010