Who Is Responsible for Reporting Medication Errors?
All healthcare professionals—including physicians, nurses, and pharmacists—are responsible for reporting medication errors, with each professional having specific roles in detecting and reporting different types of errors throughout the medication process. 1
Shared Responsibility Across All Healthcare Professionals
The responsibility for medication error reporting is explicitly distributed among all members of the healthcare team:
- Physicians (medical staff) must immediately notify errors related to potential harm from prescriptions, drug-drug interactions, and adverse drug reactions 1
- Nurses are responsible for reporting errors related to incorrect writing, administration errors, and monitoring during drug administration 1
- Pharmacists must report potential harm deriving from prescriptions and are particularly effective at detecting medication errors compared to other professionals 1
Why This Multidisciplinary Approach Matters
Feedback control systems require immediate notification of errors by all healthcare professionals to create an effective safety net throughout the medication process 1. The evidence demonstrates that:
- Approximately 35% of all medication errors occur at the administration stage (primarily involving nurses), while errors also occur during prescribing (physicians) and dispensing (pharmacists) 1
- Nurses are less effective at detecting medication errors than pharmacists, highlighting the need for complementary reporting from different professionals 1
- Physicians, nurses, and patients were responsible for 49.1%, 48.2%, and 2.7% of medication errors respectively in one study, demonstrating that errors originate from multiple sources 2
Reporting Systems and Mechanisms
Healthcare systems should utilize:
- Spontaneous reporting schemes such as the National Reporting and Learning System (UK) and the Medication Errors Reporting Program (USA) that accept reports from all healthcare professionals 1
- Institutional reporting to both local and national incident reporting systems 3
- Continuous quality improvement systems that support all healthcare workers in identifying and responding to errors 3
Common Pitfall to Avoid
A critical barrier exists where different healthcare professionals have varying attitudes toward reporting: doctors are often unlikely to report less-serious medication errors, while nurses and pharmacists are more likely to report both minor and serious errors despite fears of disciplinary action 4. Training for all healthcare professionals in medication error recognition and reporting is essential to overcome this inconsistency 1.