ISMP Survey on Internal and External Medication Error Reporting

Please take a few minutes to complete the following survey regarding the frequency, motivation, and promotion of medication error and medication safety reporting to both internal and external reporting programs (multiple responses from individuals at the same practice site are encouraged). Submit your responses through our website, www.ismp.org (or fax to 215 914 1492) by December 15, 2002. Thank you!

1. Please place a checkmark in the appropriate box to estimate the number of times during the past year that you have voluntarily reported a medication error or safety issue to your internal reporting program or to the ISMP-USP, FDA, or other external reporting programs

Type of Error or Other Medication Safety Issue	Internal System-Wide Reporting	External	Reporting	Programs
	Program	ISMP/USP Reporting Program	FDA MEDWATCH	Other: (list)
	0 | 1-5 | >5	0 | 1-5 | >5	0 | 1-5 | >5	0 | 1-5 | >5
a. Adverse drug reaction
b. A hazardous condition that could lead to error
c. An error that did not reach the patient
d. Error that reached a patient but caused no harm
e. Error that caused patient harm
f. Other:

2. Please mark your response in the appropriate box to indicate the motivational factors that have stimulated you during the past year to report medication errors or other medication safety issues to your internal reporting program or the ISMP-USP, FDA, or other external reporting programs. Please note: If you have not reported any medication errors or medication safety issues to your internal reporting program or an external reporting program during the past year, please mark NA (not applicable) for the entire column.

Motivational Factors	Internal System-Wide Reporting	External	Reporting	Programs
	Program	ISMP/USP Reporting Program	FDA MEDWATCH	Other: (list)
	Yes | No | NA	Yes | No | NA	Yes | No | NA	Yes | No | NA
a. My superior mandates that I report
b. I'm granted amnesty if I report an error
c. I feel rewarded for reporting
d. The information is used to enhance safety
e. I want others to know about the problem so needless tragedies can be prevented
f. The reporting program is easy to use
g. I trust that my name will be kept confidential
h. Other:

3. Please indicate how often during the past year you've witnessed various people or organizations promoting the value of voluntarily reporting medication errors/medication safety issues to your internal reporting program and the ISMP-USP, FDA, or other external reporting programs. Please note: F = Frequently; S = Sometimes; N = Never.

People, Organizations, and Other Healthcare Stakeholders	Internal System-Wide Reporting	External	Reporting	Programs
	Program	ISMP/USP Reporting Program	FDA MEDWATCH	Other: (list)
	F | S | N	F | S | N	F | S | N	F | S | N
a. Trustees/Senior Leaders
b. Middle Managers
c. Risk Manager
d. Quality Improvement Professional
e. Patient/Medication Safety Officer
f. Staff Educators
g. Professional Licensing Bodies
h. Professional Organizations
i. Professional Journals/Newsletters
j. Local/Federal Government
k. Accrediting Bodies (e.g., JC)
l. Academic Educators
m. Drug/Medical Product Vendors
n. Other:

4. Please indicate the categories that best describe your profession and level of service within your practice site:

Profession: Nurse Pharmacist Physician Technician Other:

Level: Administrator Middle Manager Staff Other: