Use of severity-indexed medication error reports to improve quality.

A severity-indexed medication error reporting system using data from voluntary incident reports has provided enough information to target opportunities for quality improvement. Reports are ranked by severity and categorized by error type, system breakdown, drug category, and nursing unit. Specific reports are generated for review by different quality improvement committees in the hospital. Based on these data and the actions of these quality improvement committees, four problem areas in medication use have been identified. Recommendations for improvements have been made to solve problems with late IV antibiotic doses, narcotic errors, anticoagulant errors and transcription errors. Two of these initiatives have resulted in objective improvement. Two others are being actively pursued to resolve medication related problems.