A hospital pharmacy implemented a voluntary medication error reporting system to improve patient safety. Two months later, the medication error rate had increased by 33%. Which of the following is most likely to be the reason for this increase?
A.
Culture change resulted in increased error reporting
B.
Culture change resulted in a punitive environment
C.
Focus on errors led to decreased focus on dispensing
D.
Focus on compliance with culture stimulated false reporting
When a voluntary, nonpunitive medication error reporting system is introduced and safety culture improves, organizations commonly see an initial rise in reported errors. This does not necessarily mean more errors are occurring; rather, more errors are being reported due to increased staff comfort and encouragement to report. Punitive cultures (B) reduce reporting, not increase it. Distraction from dispensing (C) or false reporting (D) are not recognized primary drivers of such patterns in patient safety literature.
References (Pharmacy Technician documents / Study Guides):
• ISMP and AHRQ patient safety culture principles: nonpunitive, learning-focused reporting increases the number of reported events initially.
• NCC MERP recommendations on error reporting and safety culture.
• Pharmacy safety and quality improvement modules in PTCB/ExCPT study guides: trends in reporting after implementing voluntary systems.
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