In several recent Tuesday Tips we have been focusing on the issue of medication errors. First looking at how to define a medication error, and last week examining how to respond to medication error. This prompted a response from some Tuesday Tip subscribers emphasizing the need for clear reporting policies within individual assisted living and residential care communities.
After addressing any urgent needs related to the error, it is a good practice to report medication errors to at least the following individuals/agencies:
- The direct supervisor: The individual discovering the error should report it to his/her supervisor. Typically it is the supervisor that will handle further reporting/notifications to the other individuals on this list
- The resident’s physician
- The resident’s responsible party/family
- Your state licensing/regulatory agency (if/when required)
- Internal quality review teams
Any report of a medication error-particularly those to responsible parties and state licensing agencies-should include how the error was handled and the condition of the resident. Families will not be happy to hear about a medication error, but they will respond much better if the report includes news that error was handled and how the resident is doing.
It is also important to follow normal reporting and documentation practices when reporting medication errors. Most importantly: stick to the facts! Do not share opinions and judgments about the error, simply report what happened, when it happened, your response, etc.
Lastly, your medication error reporting policy should include a clear “no reprisal” statement. All staff members who handle medications in your community should feel confident that they can report an error to his/her supervisor without fear of being punished for the error. If staff feel that they may be “written up” or terminated because of an error, they are highly unlikely to report it.