Medication Error Reporting by Community Pharmacists in Vermont
Objective: To document community pharmacists' awareness and use of the United States Pharmacopeia Medication Errors Reporting (USP MER) program.
Design: Telephone survey.
Setting: Community pharmacies in Vermont.
Participants: One self-identified community pharmacist from each community pharmacy.
Intervention: Each operating community pharmacy in Vermont was contacted by telephone between June 2002 and February 2003. The first individual to self-identify himself or herself as a pharmacist was asked to participate. The telephone surveys were conducted using a standard script.
Main Outcome Measure: Survey responses to questions about awareness and use of USP MER.
Results: A pharmacist was contacted in 98% (122/124) of all operating community pharmacies in Vermont. Nine (7%) pharmacists refused to participate, leaving 113 pharmacists who responded to the survey. Although more than one half of all respondents (70/113; 62%) had heard of USP MER, less than one quarter (24/113; 21%) had ever submitted a report. Significantly more pharmacists employed by independent pharmacies had submitted a report, compared with pharmacists from other pharmacy types (chain, supermarket, mass merchandiser; P = .03). Submitting reports through a corporate hierarchy or to a corporate program was the reason most frequently cited by pharmacists for not submitting reports directly to USP MER (37%). Whether corporate reports were forwarded to USP MER is unknown.
Conclusion: The majority of Vermont community pharmacists were aware of USP MER. However, use was low. Barriers to reporting to a common system such as USP MER may differ depending on pharmacy type. Further research to document the barriers to submitting reports is warranted.

An estimated 1 of every 131 outpatient deaths can be attributed to medication errors. Additionally, in the United States, the cost of outpatient medication-related morbidity and mortality is estimated to exceed $177 billion per year. Because of both the serious health care and economic consequences of medication errors, preventing them has been recently targeted as 1 of 20 national quality improvement priorities.

Reporting and analyzing medication errors enhances our understanding of the environment that allows them to occur. Voluntary reporting systems encourage quality improvement and identification of potentially harmful medication errors before a serious event occurs. The United States Pharmacopeia (USP), presented in cooperation with the Institute for Safe Medication Practices (ISMP), monitors medication errors through a voluntary reporting system called the Medication Errors Reporting (MER) program. Unlike USP's MEDMARX program, an anonymous, Internet-based, subscription reporting program for hospitals and health systems, the MER program can be used freely by practitioners in any practice setting for voluntary medication error reporting. Reports may be completed on paper, by telephone or fax, or via the Internet. Additionally, a paper copy of the report is included in every issue of the Journal of the American Pharmacists Association.

Since many actual and potential errors occur in the outpatient setting, community pharmacists are in a position to contribute substantially to the USP MER database. However, data published in 1994 indicated that community pharmacists submitted only 10% of total reports during a 2-year period. A conversation with USP (November 12, 2003) confirmed this statistic is still accurate. In contrast, hospital pharmacists submitted 47% of all reports (various other health care professionals submitted the remaining 43% of reports). While underreporting in all settings is a known problem, we are unaware of research targeted at community pharmacists to better document the barriers that deter them from reporting medication errors.