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Medication Error Reporting & Prevention Tool

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Context

The Making it Safer Together (MiST) Collaborators identified this tool as a useful solution to providing a simple, accurate repeatable measure of the harm that arises from medication incidents.

Aims

To provide a universal system suitable to measure the impact of prescribing and administration quality improvement projects.

Description

The (US) National Coordinating Council for Medication Error Reporting & Prevention classification tool provides a 9 point classifcation system (Cat A-I). It grades the harm that occurs from A (circumstances or events that have capacity to cause error), through (B-D) which are no harm incidents, but reflect increasing proximity/impact to the patient, through (E-H) where increasing harm occurs & finally I where the error causes a death.Medication incidents can be easily classified using the simple algorithm provided on the website here 

Implementation

This classification system has been sucessfully incorporated into the reporting systems at Royal Manchester Children's Hopsital and Birmingham Children's Hospital. A number of other hospitals in the MiST collaborative are also in the process of incorporating into their IT systems.The scores from this classification can be used directly on a run chart to provide evidence of the effect of local interventions.

Suggestions for further implementation

If you deploy this tool please consider joining the MiST Collaborative and submitting your data so that joint learning projects can be developed though discussions & a more detailed analysis of the data. 

Challenges and learning

Key to success is incorporation into existing reporting systems.

Quality assurance/MHRA registration

Nationally recognised reporting tool in USA. Endorsed and advocated by USA National Coordinating Council for Medication Error Reporting and Prevention.