Category: Professional Posters
Purpose: Incident reporting systems are standard for most health systems and can aid in enhancing just culture when use is optimized. Utilizing data from these reporting systems is essential to identify opportunities and trend outcomes of process changes. The Agency for Healthcare Quality and Research reports medications events as one of the highest reported event types within voluntary reporting systems. The purpose of this project is to streamline taxonomy options available during event entry to aid in providing consistent data extraction, tracking, and trending.
Methods: The Ascension National Medication Safety Team, comprised of six pharmacists with medication safety training, reviewed the current medication event classifications offered by the subscription service Ascension utilizes for incident reporting. The team compared the taxonomy classification to nationally recognized medication event taxonomy published by the National Coordinating Council for Medication Error Reporting, which has been adopted and implemented in the Institute for Safe Medication Practices error reporting system and the Pennsylvania Patient Safety Reporting System taxonomy. The team identified an opportunity to reduce the current taxonomy structure from 88 unique event classifications to 24 unique event classifications. The recommendations were guided by the reduction of contributory factors that were used as an event type and to align with nationally recognized taxonomy structure to better identify patient safety opportunities. This proposal went through an extensive review process approval process including multidisciplinary clinical, operational, and quality committees. Feedback on the recommendations included from clinical pharmacy leaders, retail pharmacy leaders, other medical clinicians as well as quality leaders within the Ascension Healthcare System. Once agreed upon, the proposal was recommended and approved for incorporation into the subscription incident reporting service.
Results: The subscription service amended several recommendations and provided a taxonomy classification of 48 unique events. Ascension was provided the opportunity to suppress medication event classifications for the Ascension Healthcare System subscribers. After approval and agreement from the subscription service on final taxonomy structure, the taxonomy structure was implemented in the subscription service to a total of 28 unique events. Education was sent out to users of the incident reporting system to notify of changes and rationale for aligning with nationally recognized taxonomy.
Conclusion: Medication event taxonomy can be a complex classification system for safety event reporting. Alignment with nationally recognized taxonomy structures may be beneficial and can be difficult to adopt in external subscription services. More research is needed to determine if aligning taxonomy classification for incident reporting can improve patient outcomes. As data systems migrate and increase bi-directional language it will be necessary for event taxonomy to be consistent from source to source and allow for better sharing of information to increase patient safety.