Largest database of medication errors created

Communication problems and lack of knowledge are the most frequent causes of medication errors and adverse drug events in primary care practice offices, according to a study of a prototype Web-based medication error and adverse drug event reporting system.

The study researched the use of an electronic system called MEADERS (Medication Error and Adverse Drug Event Reporting System), which was developed by investigators from the Regenstrief Institute and Indiana University School of Medicine, led by Atif Zafar, MD. The study appeared in the November/December 2010 issue of the Annals of Family Medicine.

Urban, suburban and rural primary care practices in California, Connecticut, Oregon and Texas used MEADERS for 10 weeks, submitting 507 confidential event reports. The average time spent reporting an event was a little over four minutes. Seventy percent of reports included medication errors only; only 2 percent included both medication errors and adverse drug events.

"We as physicians have a responsibility to make good decisions and to translate those decisions into safe and effective care," said William M. Tierney, MD, president and CEO of the Regenstrief Institute. "If we make a mistake, we need to learn from the mistake and prevent it from reoccurring. We found this first generation reporting system to be popular with physicians and others in their offices, in spite of time pressures and a culture that does not support admitting mistakes."

Tierney, who is also associate dean for clinical effectiveness research at the IU School of Medicine, is a co-developer of MEADERS and the senior author of the Annals of Family Medicine study.

The study found that medications used for cardiovascular, central nervous system (including pain killers), endocrine diseases (mainly diabetes) and antibiotics were most often associated with the events reported in MEADERS.