Medication Errors in Nursing Homes

Objectives: North Carolina legislation enacted in 2003 requires all nursing homes to report medication errors. A statewide mandatory nursing home medication error reporting system for reporting errors annually on an aggregate basis for all 385 licensed nursing homes in North Carolina, exclusive of hospital-based facilities, was implemented. Methods: A Web-based reporting tool was developed for nursing home staff to report retrospective year-end summary data of all medication errors occurring during a nine-month period. A voluntary follow-up survey was used at the end of the data collection period to evaluate the reporting process. Results: North Carolina is the first state to implement mandatory reporting of all medication errors in nursing homes, including near misses and potential errors. One hundred percent of nursing homes submitted a medication error report. A total of 10,920 errors, including near misses, dose omissions and potential errors were reported statewide for the first annual report, which included nine months of experience. Most of errors, 91.1% did not reach nor harm the patient. Twenty-five percent of sites completed a follow-up survey. Reporting was a positive experience for most sites. Conclusions: Mandatory reporting of medication errors by nursing home personnel on an annual basis is feasible on a statewide basis. Data are limited due to the summary nature, and there is significant potential for under-reporting. With education, however, data should improve over time. The reporting requirement encourages nursing homes to consistently record and review medication error incidents and influences patient safety processes.