By David Bui
A new study published in the BMJ Quality & Safety Journal, conducted in Nova Scotia with members from four community hospitals, found that reporter burden—the added work and difficulty in using reporting forms—may be a key barrier in medication error reporting.
“Extra time required in reporting, cumbersome report forms, hesitancy about “telling” on someone, and the perceived severity of the error,” were the four barriers to reporting most frequently identified by the focus group participants said Dr. Nicole Hartnell, the first author on the study.
On the other hand, “the most frequently mentioned incentive for reporting a medication error was to improve care and improve patient safety,” said Dr. Hartnell. “Reporting for protection or immunity was also mentioned at each of the study hospitals.”
Medication errors have an enormous impact on patient safety and care, but despite efforts to reduce these errors, it has been estimated that up to 20% of all medication doses administered are done in error. Even more worrisome—50-96% of errors are estimated to be underreported. These errors have been associated with increased hospital stays and wasted medical expenditures. In 2006, it was estimated that medication errors accounted for$3.5 billion in medical expenses. That figure rises to $177.4 billion when accounting for all drug related deaths and complications.
“In theory reporting compliance would translate into better practice because people could learn from the mistakes of others, thus hopefully preventing the same mistakes from happening time and time again,” said Dr. Hartnell.
The study also identified potential interventions to facilitate medication error reporting, suggesting a focus on reducing reporter burden—making the process easier and clearer—could increase reporter compliance. Dr. Hartnell suggested that “these facilitators could improve reporting because they were identified as such by the people doing the actual reporting. These were things that the front line health professionals thought would encourage them to report errors more often.”
In addition to increasing feedback, efforts to improve education around reporting—how to report, why to report and how reports were being used—was identified as an important factor to help providers feel more confident about reporting and to feel that they were helping to improve patient safety. Education is an important factor since many skeptics aren’t completely convinced that error reporting would improve patient safety.
“Improved communication and improved education were the two changes participants seemed to want the most,” Dr. Hartnell noted. “Better communication or organization specific feedback was requested by participants at each of the four study hospitals. Many participants voiced frustration over the feeling that they did not receive feedback about error reports that had been submitted.”
And of course, no one solution exists to improve error reporting.
“Error reporting is a multi-factorial and complex issue, and that band aid solutions are not available,” Dr. Hartnell said. “Each hospital will have unique factors at play that will influence the reporting environment within that organization. While vast improvements will not occur overnight, this study suggests that some small changes could make a positive difference in error reporting, and are worth considering.”
TUCSON, Ariz. – Howard J. Eng, MS, DrPH, RPh, professor in Public Health and Pharmacy Practice and director of the Southwest Border Rural Health Research Center at the Center for Rural Health, was named Pan Asian Man of the Year by the Pan Asian Community Alliance (PACA). PACA is a non-profit organization that promotes and develops education and community services for Asian and Pacific Islanders.
Dr. Eng was honored “For Championing Cultural Diversity and for Philanthropic Services and Achievements in the Tucson Community.” The award recognizes his involvement in founding the Southern Arizona Asian and Pacific Islander Health Coalition.
Formed in August 2010, the coalition seeks to improve the health of Asian and Pacific Islander (API) communities in Arizona. The coalition includes partnerships with API community organizations, businesses, several colleges, and health professionals.
“The main goals [of the coalition] are to increase access to health care, but at the same time to improve the health status of API communities,” says Dr. Eng. The coalition seeks to be an interface between the API community members and healthcare centers, while empowering the community to be their own health advocates. “We want to develop the infrastructure within the community to let them address their own health concerns…a platform to let the community take their health concerns to the next level.”
The award was presented to Dr. Eng during the 17th Annual Asian Lunar New Year Celebration February 11 in Tucson. “There were a number of very deserving people who could have been recognized,” Dr. Eng said. “I’m humbled and honored to be recognized with a group of excellent past recipients."
The Center for Rural Health at the University of Arizona Mel and Enid Zuckerman College of Public Health will join the National Organization of State Offices of Rural Health (NOSORH) in celebrating the first-ever National Rural Health Day on Thursday, November 17, 2011.
NOSORH created National Rural Health Day as a way to showcase rural America; increase awareness of rural health-related issues; and promote the efforts of NOSORH, State Offices of Rural Health and others in addressing those issues. Plans call for National Rural Health Day to become an annual celebration on the third Thursday of each November. Read more
Neil MacKinnon has been named director of the Rural Health Center at the University of Arizona College of Public Health.
MacKinnon, a Canadian, took the position this summer and immediately set to work absorbing information on the rural populations of Arizona and their health needs.
"Certainly it is a complex issue," MacKinnon says in an Arizona Illustrated interview. "Arizona actually has a lot of special challenges. For example, it has the second highest child poverty rate in rural areas of any state in the U.S., just after Mississippi. So about one-third of rural children in Arizona are in poverty."
Denver, Colorado (September 8, 2011) – Alison Hughes, recently retired interim director of the Arizona Rural Health Office, has received the 2011 James D. Bernstein Mentoring Award from the National Organization of State Offices of Rural Health (NOSORH). Hughes received her award today during the organization’s annual conference in Denver, Colorado.
NOSORH was created in 1995 to serve as an influential voice for rural health concerns and promote a healthy rural America through state and community leadership. Each year, the organization presents its James D. Bernstein Mentoring Award to an experienced, long-time rural health leader who has gone “above and beyond the call of duty” to mentor emerging rural health leaders. Because of his or her sincere interest in the emerging leaders’ professional growth, the award recipient has played a key role in developing future leaders within the national rural health movement.
The award is named in memory of Jim Bernstein, who during his 35-year career formed the first state office of rural health in the United States (in North Carolina) and served as president of the National Rural Health Association. Jim was also a model mentor who advised and inspired hundreds of emerging rural health professionals.
Hughes has filled many roles at the University of Arizona throughout a career spanning a quarter century – associate director, director, flex program director and interim director of the Arizona Rural Health Office; co-founder and associate director of the Arizona Telemedicine Program; and a faculty member in Mel and Enid Zuckerman College of Public Health.
Alison has also served on numerous national boards and committees as well, including the National Advisory Committee on Rural Health; the Universal Services Administration Company; the National Rural Health Association Policy Board; the Medical Care Section of the American Public Health Association; and the Arizona Arts Commission. She has also served as NOSORH president in 2007 and played a key role in developing the organization’s education exchange (mentoring) program.
Neil J MacKinnon, PhD joined the Center for Rural Health in August 2011 as the Center Director, Professor of Public Health, and the Walter H. Pearce Endowed Chair.
Neil grew up in the small towns of Truro and Bridgewater, Nova Scotia, Canada. He completed a Bachelors of Science in Pharmacy degree at Dalhousie University in Halifax, Nova Scotia. He then completed a Master’s degree in Hospital Pharmacy and an administrative hospital pharmacy residency at the University of Wisconsin Hospital and Clinics. Next, he attended the University of Florida where he completed a PhD in Pharmacy Health Care Administration and a fellowship. Finally, in 2007-08, Neil was a Harkness Fellow in International Health Care Policy with the Commonwealth Fund in New York City.
Prior to joining the UA, Dr. MacKinnon was professor and associate director of research at Dalhousie University College of Pharmacy with cross appointments to the Faculty of Medicine and School of Health Administration.
Neil has considerable healthcare experience providing direct patient care as a community and hospital pharmacist. He also served as a member of his local community health board in Nova Scotia and on the drug formulary committee of a large private payer in Canada. In 2010-11, MacKinnon served as President of the Canadian Society of Hospital Pharmacists.
He enjoys teaching and won two teaching awards while a faculty member at Dalhousie University. He has supervised and mentored Master’s and PhD students, fellows and residents in a variety of disciplines including health administration, community health and epidemiology, applied health services research, medicine, pharmacy, nursing, occupational therapy, interdisciplinary studies and public health.
Neil’s research projects have included a broad range of topics in addition to rural health, including the quality and safety of the medication-use system, drug policy and the role of health professionals. Neil edited two textbooks and he is the co-author of the Canadian bestsellingbook Take as Directed: Your Prescription for Safe Health Care in Canada (Sept. 2010).
Neil’s wife Leanne is an Arizona native and they have three young daughters, Breagh, Ashlynn and Kaylee. Neil is also known to wear a kilt on special occasions.