Under reporting medication errors

Originally posted 10-18-2010:
A series of sad news has come out of Seattle in the last month, as three different medication errors led to patient deaths at Seattle Children's.  The errors seemed to range from overdoses to wrong medications. Until the proper investigation is done, it is hard to speculate what factors could have caused these errors.  The only way to truly understand what happened is to do the root cause analysis and find where the system broke down. 

Reading about what happened led me to this article about under reporting of medication errors in the state of Washington.  According to the article, the medication error reporting law "has loopholes", making it "difficult to gauge exactly how many cases other hospitals have withheld from the health department".  This lack of reporting could be one of the flaws in the medication system that caused the errors. As Dr. Vaida states in the article, "One of the most important things is to make sure we share information about and learn from errors that happen." The culture in the state needs to be supportive of reporting medication errors without fearing punishment. Even issues in the healthcare system at this high a level can have an impact on patient care.

It is good to see legislation is being proposed to increase funding to improve the error reporting system.  Hopefully this leads to the cultural changes needed to support the sort of reporting that will allow caregivers and healthcare administrators to find ways to improve patient safety.

One other thought on this.  I hope one of the improvements is an easier to use reporting system. It is often the case that software put in place to report such errors is not very easy to use, causing it to be a hindrance to reporting.  Through some of the research I have done, I have heard many health care professionals talk about systems full of long forms that take too much time to fill out.  The technology has to fit in the process in a way that it will not lead to more under reporting.