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Outpatient Prescription Errors: Detection, Analysis, and Impact on Safety

NCT ID: NCT00256568

Last Updated: 2011-12-15

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

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Recruitment Status

COMPLETED

Total Enrollment

103 participants

Study Classification

OBSERVATIONAL

Study Start Date

2003-09-30

Study Completion Date

2008-08-31

Brief Summary

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The purpose of this study is to better understand outpatient prescribing errors through clinic and pharmacy-based error reporting systems.

Detailed Description

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Medication errors cause substantial morbidity and mortality in the United States. However, relatively little is known about medication errors in the outpatient setting. The broad goal of this proposal is to improve outpatient safety. Specifically, this research plan promotes the understanding of the causes of outpatient prescription errors. The specific aims of this project are:

1. To develop and evaluate a novel reporting system in physicians' offices for detecting prescription errors
2. To develop and evaluate a novel improvement system in community pharmacies to increase prescription error reporting by pharmacists
3. To analyze reports of outpatient prescription errors and understand their root causes

To achieve these specific aims, statewide research will be conducted utilizing qualitative and quantitative methods including root cause analysis, failure mode and effects analysis, and surveys. This research plan will promote patient safety by furthering the understanding of the causes of outpatient prescription errors in all outpatient populations, including rural, women, children, elderly, low income, and the chronically ill.

Conditions

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Medication Errors

Keywords

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Medical Errors Medication Errors Prescriptions, Drug Pharmacies Ambulatory Care Facilities

Study Design

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Observational Model Type

COHORT

Study Time Perspective

PROSPECTIVE

Study Groups

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Primary Care Practices

One hundred and three prescribers, managers, nurses and office staff at seven primary care practices in Vermont

reporting system

Intervention Type BEHAVIORAL

Nurses and office staff were asked to report all communications with community pharmacists regarding prescription problems

Interventions

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reporting system

Nurses and office staff were asked to report all communications with community pharmacists regarding prescription problems

Intervention Type BEHAVIORAL

Eligibility Criteria

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Inclusion Criteria

* Employed in a physician's office or community pharmacy

Exclusion Criteria

* Not employed in a physician's office or community pharmacy
Minimum Eligible Age

18 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

Yes

Sponsors

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Agency for Healthcare Research and Quality (AHRQ)

FED

Sponsor Role collaborator

Vermont Program for Quality in Health Care

OTHER

Sponsor Role collaborator

University of Vermont

OTHER

Sponsor Role lead

Responsible Party

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Amanda Kennedy

Assistant Professor of Medicine

Responsibility Role PRINCIPAL_INVESTIGATOR

Principal Investigators

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Amanda G Kennedy, PharmD

Role: PRINCIPAL_INVESTIGATOR

University of Vermont

Locations

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University of Vermont, Division of General Internal Medicine

Burlington, Vermont, United States

Site Status

Countries

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United States

References

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Kennedy AG, Littenberg B. Medication error reporting by community pharmacists in Vermont. J Am Pharm Assoc (2003). 2004 Jul-Aug;44(4):434-8. doi: 10.1331/1544345041475724.

Reference Type BACKGROUND
PMID: 15372863 (View on PubMed)

Kennedy AG, Littenberg B, Vezina LC. Vioxx-Viagra confusion. Am J Health Syst Pharm. 2002 Nov 1;59(21):2112. doi: 10.1093/ajhp/59.21.2112a. No abstract available.

Reference Type BACKGROUND
PMID: 12434730 (View on PubMed)

Kennedy AG, Littenberg B, Senders JW. Using nurses and office staff to report prescribing errors in primary care. Int J Qual Health Care. 2008 Aug;20(4):238-45. doi: 10.1093/intqhc/mzn015. Epub 2008 Apr 22.

Reference Type RESULT
PMID: 18430748 (View on PubMed)

Other Identifiers

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K08HS013891

Identifier Type: AHRQ

Identifier Source: org_study_id

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