50-275 / Report and learning system on medication errors

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Ministry of Health, Social Services and Equality (MSSSI)
Institute for Safe Medication Practices ISMP-Spain


Incident reporting and learning system
Program on quality and safety

GOP Description
Implementation level
Clinical settings
All. The system collects information from events taken place in any clinical setting
1. Analyze, classify and assess medication errors reported by any healthcare professional
2. Identify the patient safety problems associated to these medication errors, elaborate technical proposals to prevent them and support their implementation.
All healthcare professionals, Pharmaceutical companies, Pharmacists associations, Spanish Agency of Medicines and Medical Devices
-ISMP Spain receives notifications on medication errors from different sources: on-line form, e-mail, ordinary mail, phone call, specific local (hospitals and primary care) learning and report system on medication errors, regional report system from Andalucía (since 2010), national patient safety report and learning system -SiNASP- (since 2012).
-These notifications are classified and analyzed according to the Spanish classification for medication errors and taking into account: severity, medicines involved, error types and processes, causes and contributing factors. Once analyzed, all information coming from other sources is stored in the same database implemented for the local-national report and learning system.
-Based on the analysis, recommendations and reports are elaborated and addressed to the Spanish Agency of Medicines and Medical Devices, the Pharmaceutical companies or the Pharmacists associations. Also specific alerts and bulletins are prepared and disseminated for all healthcare professionals and the public.
Timeframe implementation
One year
Implementation tools available
ISMP web
Local report and learning system on medication errors
Implementation cost
Around 30,000 € per year to mantain the Web page and Newsletters and expert collaboration
Method used to measure the results
Annual report including the number of analysis carried out, the alerts and bulletins disseminated and the actions known to have been implemented or initiated by the pharmaceutical industry or the national Agency.
Around 850 notifications are analyzed each year. The number of bulletins and alerts disseminated depends on the results of the analysis (usually 2 bulletins/year).
Analysis of the results
The results obtained have allowed to change the presentation of some medications and to establish national recommendations.
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
There is no specified text here
Describe the strategies used to overcome the barriers (If needed)
There is no specified text here
Other information
Other information about the GOP that you would like to add (Link or attached document)
LInk to ISMP Spain web: http://www.ismp-espana.org/