Improving medication administration error reporting systems. Why do errors occur?

Abstract

Monitoring medication administration errors (MAE) is often included as part of the hospital's risk management program. While observation of actual medication administration is the most accurate way to identify errors, hospitals typically rely on voluntary incident reporting processes. Although incident reporting systems are more economical than other methods of error detection, incident reporting can also be a time-consuming process depending on the complexity or "user-friendliness" of the reporting system. Accurate incident reporting systems are also dependent on the ability of the practitioner to: 1) recognize an error has actually occurred; 2) believe the error is significant enough to warrant reporting; and 3) overcome the embarrassment of having committed a MAE and the fear of punishment for reporting a mistake (either one's own or another's mistake).