CMAJ: Drug mishap reporting system created for consumers

NEWS
July 7, 2010 View PDF

Drug mishap reporting system created for consumers

The SafeMedicationUse.ca website offers Canadians a simplified form to report any medication incident involving the use of prescription and non-prescription drugs, natural health products, imported products, or devices used to administer medicine.

Photo credit: SafeMedicationUse.ca

Canadians can now directly flag the medication mix-ups they experience at home or while receiving health care.

The Institute for Safe Medication Practices Canada and the nonprofit advocacy group Patients for Patient Safety Canada have created a website, SafeMedicationUse.ca, to provide consumers with a simple mechanism for reporting medication incidents (mistakes with medicine or problems that could cause mistakes with medicine). It aims to reduce harm from medication errors by empowering patients to play a more active role in health care decision-making.

The new national medication incident reporting system is the first of its kind to directly engage Canadian consumers (http://safemedicationuse.ca/report/index.html).

“Healthcare practitioners and hospitals have been reporting medication incidents using similar tools for years, but there’s never been a formal mechanism to collect incident reports from consumers,” says Bonnie Salsman, project lead for the website, which was developed with support from Health Canada.

In the past, if a consumer wanted to report a medication mistake, they had to use a tool designed for health care workers, or else ask a medical practitioner to report the incident on their behalf.

“It wasn’t a consumer-friendly process. It was really difficult for people to get their concerns heard without doing a considerable amount of footwork first,” says Salsman. “That there were still patients who took the initiative to report incidents using the practitioner reporting system showed us how helpful a consumer tool would be.”

The website offers Canadians a simplified form to report any medication incident involving the use of prescription and nonprescription drugs, natural health products, imported products, or devices used to administer medicine. Consumers can report incidents that occur at any stage in the prescribing, dispensing, administration, or monitoring of a medication. They can also offer their own suggestions on how to avoid similar mishaps in future.

The information collected through the website will be used strictly for research and educational purposes, Salsman says. The institute uses the data to further their ongoing research in patient safety, as well as to create educational materials and recommendations for consumers, including steps that patients can take to improve the safety of their care.

“Punitive measures might fix a symptom, but they seldom fix the causes of medication errors,” she says. “While only a small percentage of medication errors are due to negligence or lack of competency, the majority are actually caused by systemic issues that lead otherwise competent practitioners and patients to make mistakes.”

The institute has already published several newsletters on the website sharing lessons learned from some of the first incident reports submitted by consumers.

“Since our formal launch, we’ve seen traffic on the site take a surge, and have collected almost 20 incident reports,” Salsman says. “A lot of the reports we’re getting are about incidents that occurred in the consumers’ homes. It’s often very simple things, like misunderstanding medication directions or labelling, but it’s surprising the number of things that can go wrong.”

According to the 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults, 1 in 10 Canadians with health problems have reported receiving the wrong medication or doses when filling a prescription or when hospitalized in the last two years, while nearly 1 in 7 said they had experienced a medication error in the past two years.

The Institute for Safe Medication Practices Canada will continue to monitor the success of the website’s pilot phase in the coming months, and expects to report preliminary results to Health Canada this fall.


DOI:10.1503/cmaj.109-3314— Lauren Vogel, CMAJ
CMAJ: Drug mishap reporting system created for consumers