May 2010 Volume 36 Number 5 195 Matthew C. Grissinger, R.Ph.; Rodney W. Hicks, Ph.D., A.R.N.P.; Mark A. Keroack, M.D., M.P.H.; William M. Marella, M.B.A.; Allen J. Vaida, Pharm.D. S ince the release of the Institute of Medicine’s report To Err Is Human 1 in 1999, the competing interests of health care organizations, professional responsibilities, and the potential impact on liability exposure have spurred the use of patient safety reporting programs to identify actual and potential fail- ures. The external reporting of medical errors and adverse events has become an important health policy topic in the United States and in other industrialized countries. 2–7 Patient safety reporting programs enable us to learn from the errors of others in the pursuit of systems-level improvements that can prevent future errors. 4 By September 2005, 24 states in the United States had passed legislation to create or improve report- ing systems for hospital-based adverse events. 8 Lucian Leape has summarized the characteristics of success- ful reporting systems: a nonpunitive approach, confidentiality, independence, expert analysis, timeliness, a systems-level orien- tation, and responsiveness. 4 The variation in reporting pro- grams presents both a challenge and an opportunity as the U.S. Agency for Healthcare Research and Quality (AHRQ) estab- lishes the National Network of Patient Safety Databases under the Patient Safety and Quality Improvement Act of 2005. This network will permit aggregating data from multiple reporting programs, which may enable identification of otherwise unrec- ognized hazards and provide more compelling evidence for the significance of known problems. 9 The law assumes that there will be value in aggregating data from many diverse systems using common formats, a proposition that the study reported in this article attempted to explore. Anticoagulants are among the most frequently cited product classes involved in harmful medication errors. 10–13 They are con- sidered “high-alert” medications by the Institute for Safe Medication Practices (ISMP) because they bear a heightened risk of significant harm, including death, when used in error. 14 In 2007 The Joint Commission established a National Patient Safety Goal, now known as NPSG.03.05.01, “Reduce the like- lihood of patient harm associated with the use of anticoagulant Reporting Systems Harmful Medication Errors Involving Unfractionated and Low-Molecular-Weight Heparin in Three Patient Safety Reporting Programs The Joint Commission Journal on Quality and Patient Safety Article-at-a-Glance Background: External reporting of medical errors and adverse events enables learning from the errors of others in the pursuit of systems-level improvements that can prevent future errors. It is logical to presume that medication errors involving the use of anticoagulants, among the most fre- quently cited product classes involved in harmful medica- tion errors, would be captured in a variety of patient safety reporting programs. Methods: Data on reported errors involving the anticoag- ulant heparin were reviewed, compared, and aggregated from the databases of three large patient safety reporting programs—MEDMARX ® , the Pennsylvania Patient Safety Authority’s Patient Safety Reporting System, and the University Health System Consortium, together represent- ing more than 1,000 reporting organizations for 2005. Results: Approximately 300,000 medication errors and near misses were reported to the programs, and 10,359—a mean of 3.6% (range, 3.1%–5.5%)—involved heparin products. The proportion of heparin-related reports that involved patient harm ranged from 1.4% to 4.9%. The phase of the medication use process cited most frequently in harmful events was the administration phase (56% of errors leading to harm), followed by the prescribing phase (19% of errors leading to harm). Discussion: This study represents the first attempt by these three large reporting systems to combine data on a sin- gle clinical process. The consistent patterns evident in the reports, such as the percentage of all medication errors that involved heparin, suggests that reporting programs, at least for common events such as medication errors, may reach a point of diminishing returns in which aggregating more reports of a certain type yields no additional insight once a large volume of similar events is captured and analyzed. Copyright 2010 Joint Commission on Accreditation of Healthcare Organizations