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Nursing Excellence

The Online Newsletter for Children's Nurses
e-Edition, Volume 1, Issue 3 

Susan Wisniewski
Magnet Logo Decreasing Medication Errors Through Reporting of Unusual Occurrences

By Susan Wisniewski, CPHQ
Manager Accreditation and Regulatory Compliance



The medication management process is complex. There is a correlation between the number of steps in a process and the probability of error. The Institute of Medicine reported that there were an estimated 1.5 million people harmed as a result of medication errors and studies indicate that 400,000 preventable drug-related injuries occur each year in hospitals(1). 

The implementation of technology and redundant safeguards doesn’t guarantee the elimination of medication errors although it may reduce them. For instance, the use of Bedside Medication Verification (BMV) may improve the accuracy of medication administration, but doesn’t replace the critical thinking necessary to ensure that the right medication is being given. Technology and systems address safety features but come with their own set of challenges. No technology can replace critical thinking skills.

The Children’s Hospital unusual occurrence reporting process has evolved over time to become a reporting system that is representative of a Just Culture. It is based on good judgment, staff accountability, and the recognition that humans sometimes make mistakes and systems sometimes need repair. The Hospital’s Patient Safety Committee oversees the patient safety program and has been instrumental in promoting the development of a Culture of Safety by creating goals that include: 1) making patient safety the responsibility of all employees; 2) taking proactive steps to identify potential patient safety issues; 3) emphasizing education; 4) promoting fear-free reporting; and most importantly, 5) keeping children free from the risk of harm. All of our unusual occurrences are reported and evaluated; adverse drug events and potential adverse drug events receive additional scrutiny.

Our process for reporting and evaluating medication errors

  • The individual discovering the error immediately reports the issue to a supervisor and the attending physician and makes sure the patient is safe;
  • The individual discovering the error completes an unusual occurrence report within 24 hours for review by a supervisor;
  • The supervisor reviews the report and forwards it to the Clinical Risk Management Department where it is logged into a database;
  • An interdisciplinary committee meets weekly to review medication errors with a focus on level 3 and 4 drug events;
  • Investigation is completed in the department where the error occurred and recommended operational changes are implemented;
  • A Root Cause Analysis may be performed on significant errors;
  • Findings are reported through the Patient Safety Committee.

Root Cause Analysis is performed for significant medication errors. Participants include an interdisciplinary review team comprised of physicians, subject experts and the individual(s) directly involved with the error. There are candid discussions about the error and every participant’s input is valued. Employees recognize that changes are implemented based on their input, reinforcing the Hospital’s commitment to patient safety.

During the recent Medication Error Reduction Plan survey, Children’s Hospital presented data associated with the significant reduction in medication errors related to the use of technology, staff education and adverse drug events reporting and investigation. The surveyors asked about our unusual occurrence reporting process. Medication error reporting, especially self reporting is a challenge for most hospitals. The evolution of our culture was validated when virtually all staff easily responded to questions about medication error reporting. Every individual questioned clearly explained the importance of reporting medication errors; the importance of causing no harm to the kids. The surveyors were impressed with the staff’s commitment to reporting unusual occurrences.

Efforts to support ongoing improvement in patient safety through the reporting and evaluation process include:

1. A hospital-wide non-punitive approach to medication error reporting and adopting a “just culture” philosophy where staff are held accountable for decisions they make.

2. A robust reporting system that encourages staff to report medication errors which are then reviewed and analyzed by an interdisciplinary team. The team also provides regular feedback to both management and staff.

3. In-depth investigations that include senior leaders, content experts, physicians and those involved in the error. Committing valuable resources sends a powerful message about the importance of eliminating or preventing medication errors and enhances patient safety.

4. Appointing a champion who is given sufficient resources to implement the recommendations of the interdisciplinary team.

5. A focused commitment by staff, leadership and medical staff toward quality and safety in delivering patient care.


Reference (1) Committee on Identifying and Preventing Medication Errors, P. Aspden, J. Wolcott, J. Bootman, L. Cronenwett, Editors, 2007, Preventing Medication Errors: Quality Chasm Series, The National Academies Press.



In This Issue
Seasons of Change
Change and Transition
Career Path to Success
Decreasing Medication Errors Through Reporting of Unusual Occurrences
Demystifying Simulation
Breastfeeding: Improving the Health of Baby and Mom
Addressing Parent’s Fear of the MMR Vaccine
NICU Nursing in Nepal