Medication Management Transactions and Errors in Family Medicine Offices: A Pilot Study

Objective: The objective of this study was to determine the feasibility of detecting medication errors by self-observation of office transactions related to medication management. Methods: Primary care physicians (N = 14) and office staff (N = 18) reported all their medication management transactions during the 4-hour study period. A study coordinator abstracted additional information from patients’ charts. Results: Participants documented 440 medication management transactions for 246 encounters: 98 office visits, 70 patient refill requests, 34 pharmacy refill requests, 16 nonvisit patient phone questions, 13 encounters initiated by laboratory results, and 15 others. Errors were identified in 84 of the cases (34.1 percent). Error types included medication not listed on the chronic medication list (59); medication not listed anywhere in the chart (7); wrong dose prescribed (6); prescription incorrectly written (5); failure to implement medication across care settings (3); contraindicated medication prescribed (1); and other (3). None of these errors would have been detected by chart review alone. Conclusion: Self-reporting followed by chart review is feasible in primary care practices and discovers medication errors that might not have been detected by either method alone.