Improving medication error reporting and learning in primary care
The Health Quality & Safety Commission and the New Zealand Pharmacovigilance Centre (NZPhvC) are encouraging wider reporting and learning from medication errors and near-miss events in primary care.
The NZPhvC successfully piloted a web-based, voluntary and anonymised medication error reporting programme (MERP) designed to reduce patient harm by gaining a better understanding of the causes and likely prevention strategies for medication errors in primary care. The MERP will now be rolled out in stages to expand and promote use in primary care.
The pilot findings were recently published in the New Zealand Medical Journal (abstract available at https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2014/vol-127-no-1401/6275) and demonstrate how use of a common platform for capturing information about errors can identify weaknesses in the system. These weaknesses can be used to identify error reduction strategies.
The roll out to primary care will take the following staged approach:
- reactivation of pilot sites
- promotion of reporting by community pharmacists and general practitioners
- promotion to other primary care clinicians.
Analysis of reports will be used to inform initiatives for improving patient safety. The Commission encourages primary care reporting of medication and vaccine errors to MERP through the electronic form https://nzphvc.otago.ac.nz/merp/report/ or by phone (03) 479 5915.
Funding support has been provided by the Preferred Medicines Centre Inc (PreMeC) – an organisation which pioneered national prescribing quality initiatives in general practice in the 1990s. PreMeC as an organisation no longer exists, but their residual funds will be expressly used for the promotion of MERP in primary care.
The Commission will be the custodian of funds and anonymised findings from MERP, which will be shared with the Commission’s Medication Safety Expert Advisory Group (MSEAG) for the purposes of wider learning and prevention.