Medication error rates should never be used to benchmark institutional performance or patient safety at a particular hospital or health system, according to leading patient safety experts—but some payors, evaluators and accrediting bodies are apparently still doing so.
“Due to differences in culture, definitions, patient populations, resources, and the types of reporting and error-detection systems, medication error rates should never be used to compare one organization to another,” said Matthew Grissinger, BSPharm, FISMP, the director of education at the Institute for Safe Medication Practices. He noted that both ISMP and the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) recommend against this practice.
A September 2023 updated NCC MERP statement on medication error rates outlined a better overall approach to ensuring safe medication use. The authors cited, as an example, institutions that encourage medication error reporting with nonpunitive, continuous quality improvement. By taking such an approach, they are likely to receive more reports of medication errors than institutions that view medication error rates as a source of criticism or punishment.
And that’s not necessarily a bad outcome, Mr. Grissinger stressed. In fact, “the easiest way to improve your error rate is to stop reporting, which is the opposite of what we want,” he said. “We already know that people aren’t reporting inside the hospital for a million reasons: ‘It’s too difficult to do; it takes too much time; I’m afraid I’ll get in trouble if I report this error.’”
The Danger Zone of Concealed Information
Connecting error rates to regulatory evaluation, accreditation or financial reimbursement also may lead a health system into the danger zone of concealing information, warned Divya Varkey, PharmD, MS, a clinical associate professor of pharmacy practice at the University of Houston College of Pharmacy. “You may be encouraging healthcare workers to avoid reporting because what is reported will have a financial or regulatory outcome. Incentivizing decreasing reported error rates will never be the story of a safer system,” she said.
Yet ISMP still receives frequent inquiries about benchmarking medication error rates. According to a November 2023 article in ISMP’s Medication Safety Alert! newsletter, which can be accessed as a stand-alone open-access article, such queries are very common. “Organizations often want to know if there is a national standard (benchmark) for medication error rates or reported errors to ‘make sure the organization has less than the benchmark,’” the article noted. “Others want to know statistics on ‘medication error rates per practitioner,’ or ‘what is the average safe number of medication orders to verify or compound in an hour.’”
Yet URAC, a leading accreditor, continues to include dispensing accuracy in its performance measurements. Dispensing accuracy is assessed in six parts—incorrect drug and/or product dispensed, incorrect recipient, incorrect strength, incorrect dosage form, incorrect instructions, and incorrect quantity—with a lower reporting rate considered to represent better performance.
With some frustration, Mr. Grissinger pointed out that ISMP’s first newsletter article criticizing the use of medication error rates in benchmarking came out in 1998, with the aforementioned updated ISMP/ECRI article published in 2023. “We’ve been saying why it’s not good to do this for a quarter century, and yet we still see these practices and have to have this discussion,” he said.
Instead of using medication error reports for quantitative comparisons and benchmarking, use your reporting program to learn, Mr. Grissinger urged. “It’s not about the number of error reports you receive; it’s about what you do with that information. Are you doing investigations? Are you going out and observing workflows? If you want to measure something, measure how many process improvements you put in place to prevent errors from happening.”
The NCC MERP statement recommended multiple strategies for identifying and analyzing medication error risk, including:
- proactive risk assessments;
- direct observation of processes;
- root cause analyses;
- trigger assessments;
- retrospective chart reviews;
- focus groups with front-line staff;
- review of data from tools such as smart pumps and barcode medication administration; and
- ongoing review of external sources of information.
“The sheer number of error reports is less important than the quality of the information collected in the reports, the health care organization’s analysis of the information, and the strength of its corrective actions to improve the system to prevent harm to patients,” the statement said.
ISMP’s recommendations for safe medication practices encourage self-reporting and striving for increases in actionable reports, such as those focusing on “close calls,” to benefit from the resultant lessons learned. The group also recommends:
- monitoring and sharing performance improvement;
- building organizational targets into a medication safety dashboard; and
- highlighting the system changes that have been made as a result of increasing information shared through error reporting.
Dr. Varkey agreed with this overall approach. “It’s appropriate to measure how adherent we are to our own policies, procedures and safety protocols. If there are processes that we know lead to better outcomes, we have to determine how consistently we are following those processes.”
The sources reported no relevant financial disclosures.
This article is from the June 2025 print issue.