Catastrophic medication error

Catastrophic medication errors, particularly when someone dies, are a newsworthy event. Health care is not immune. Such errors are not likely to remain secret. As a result of the adverse public exposure, reputations will be diminished, with potentially significant consequences for individual practitioners and institutions. The only means available, at least initially, to rehabilitate individual and institutional reputations is an appropriate message and response through the media. 

As a practical matter, a successful response to a catastrophic medication error proceeds through the following stages ... 

Signal detection. Catastrophic medication errors should not be a surprise. Routine and noncatas-trophic errors foreshadow the inevitable. 

Preparation and prevention. The best organizations do all they can to prevent catastrophic medication errors while recognizing that they must prepare and plan for their inevitable occurrence. 

System versus isolated event. An accident does not just happen. An accident evolves from latent failures or weaknesses in a system. These failures or weaknesses are cumulative and interactive. Nearly always, a single error is insufficient to create an accident, but the same error combined with others will be cumulatively successful in creating an accident. Research has revealed that at least four errors must align to produce an accident. A recent analysis of a catastrophic medical accident revealed over fifty latent system failures contributing to the... 

Richard M.J. Bohmer is a physician and an Assistant Professor of Business Administration at Harvard University. His research focuses on the management of clinical processes and the way in which health-care teams learn to improve outcomes, prevent error, and reduce adverse events. He has studied catastrophic failures in health care, the adoption of new technologies into medical practice, and more recently the way in which health-care delivery organizations deal with custom and standard operations concurrently. He holds a medical degree from the University of Auckland, New Zealand, and an MPH from the Harvard School of Public Health. 

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