TABLE 5-2 Medication Error Detection Methods: Inpatient Setting

Detection Method


Source of Data

Chart review

Data sources are screened for evidence that an error occurred

Medical record


Observer records medications administered and compares with orders, or observer shadows physician (Rothschild et al., 2005)

Personnel actions

Self-report, voluntary

Providers submit data about events

Patients, medical record

Self-report, prompted

Providers are interviewed to see whether any incidents have occurred


can create a learning system whereby errors and recommended preventive measures are reported and used as a tool for learning. Second, they can make a commitment to learning about error problems, monitoring national trends and reports, and implementing plans designed to prevent similar errors from occurring at their site. When errors and ADEs are identified, reporting should be encouraged. For example, the Institute for Safe Medication Practices’ (ISMP) Medication Safety Alert newsletter, United States Pharmacopeia (USP) MedMARx reports, and case studies from AHRQ’s Web M&M ( should be required reading for health care practitioners, including community pharmacists, who can learn about errors that have occurred and take action to avoid them. Recommended preventive actions, based on expert review, are included in the ISMP newsletter.

As noted, voluntary reporting is valuable for identifying large problems and providing a stimulus for change, but has recognized limitations for evaluating the true frequency of medication errors and ADEs. In a comparison of voluntary reports against observation in 36 health care facilities, observation detected 456 times more errors (Flynn et al., 2002).

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