Error and Harm in Health Care

Chapter Two provides a historical overview of the patient safety movement. 

There are two parts to this. One is the epidemiologic error studies that have dominated the medical literature. The second part describes the early organized efforts in patient safety. Researchers and theorists in the safety field have moved beyond a limited conceptualization of safety that focuses solely on counting errors. It is now understood that a focus on hazard and harm is more meaningful. This focus will be introduced in Chapter Three. 

ERROR IS BEST VIEWED AS A SYMPTOM OF A LARGER PROBLEM—A BROKEN HEALTH CARE SYSTEM. 

This approach is beginning to make some inroads into the traditions of blame and denial that burden the health care culture. Medical accidents are stiU laden with seemingly intractable connotations of fault finding, mistake making, or carelessness, and the associated responses of shame and blame. However, research now reveals recurring elements in accidents and near misses culture- and system-based failures in teamwork, communication, and transitions. 

ERRORS WILL ALWAYS EXIST AND ARE USEFUL ONLY AS A DATA SOURCE TO HELP US AVOID HARM. 

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Chapter Two, Error and Harm in Health Care, departs momentarily from the patient safety manifesto, as already mentioned, to provide background knowledge on current research in patient safety, the patient safety movement to date, and the reasons why today s health care system is so error-prone. Chapter Three, Understanding the Basics of Patient Safety, provides an overview of basic concepts and terms in the science of patient safety. These concepts and terms fe>rm the foundational touchpoints of the book. 

In 2003 the National Quality Forum in the United States endorsed a total of 30 patient safety-related safer practices that should be implemented throughout clinical care settings to lower the risk of error and resultant harm to patients in general [20,21]. The first safer practice (i.e.. Create and sustain a health care culture of safety) was composed of the following four basic components [20,21] ... 

The idea of eliminating harm rather than stamping out error is a relatively new concept in health care. Not long ago, when error was attributed to the carelessness of individuals or to human mistakes, and blame and punishment were thought to be... 

The chapters in this book are structured around the patient safety manifesto developed at the Harvard Executive Session on Medical Error and Patient Safety. The Executive Session brought together senior leaders in health care from aroimd the nation to examine the failures in current health care models and to develop models of health care delivery that do no harm (see the Introduction and Chapter Nine for further information on the Harvard Executive Session). Leaders emerged with a seven-point manifesto for creating a system of harm-free care. With the exception of Chapters Two and Three, which provide basic information about the science of patient safety, and Chapter Ten, which recaps the lessons offered by the book as a whole, the titles of the chapters are the same as the seven commitments of the manifesto ... 

The prototypical form of error in the health care system that could be reduced by a systems approach is medication error. The kind of error identified in the literature—overdose of chemotherapy, injection of the wrong drug, etc.—sometimes leads to either injury or death, the kinds of harm that are the central concern of after-the-fact medical liability adjudication. Phar-macogenomics introduces not only another conception of harm—genetic risks—but also new ways of developing and prescribing drugs. 

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including prescribing order communication product labeling, packaging, and nomenclature compounding dispensing distribution administration education monitoring and use. 

Hospitals and other health care organizations work to reduce medication errors by using technology, improving processes, zeroing in on errors that cause harm, and building a culture of safety. Here are a couple of examples. 

A HIT system designed to assist in this process may bring with it some idiosyncrasies. These behaviours are likely to be less familiar, poorly characterised and less well understood by its users. Without effective management the overall risk picture could deteriorate, at least in the short term. The Committee on Quality of Health Care in America concludes that health care orgaiusations should expect any new technology to introduce new sources of error and should adopt the custom of automating cautiously, alert to the possibility of uiuntended harm [5]. 

Patient safety is a relatively new health care discipline that clearly emphasizes the reporting, analysis, and prevention of all types of medical errors that frequently result in adverse health care events. The Institute of Medicine in the United States defines patient safety as "the prevention of harm to patients" [1,2]. 

Each year a vast sum of money is spent on health care around the globe, and patient safety has become a serious global public health issue because it results in millions of deaths costing billions of dollars to the world economy each year. As per the World Health Organization, in developed countries alone as many as 1 in 10 patients is harmed while receiving hospital care due to a range of errors or adverse events. 

Understanding the Consumer s View. In 1997, the National Patient Safety Foundation commissioned a survey of how the public perceives risk when interacting with the health care system. Of those who responded, 42 percent reported that either they or someone they knew had experienced an injury when visiting a physician s office (Louis Harris and Associates, 1997). Studies by the Kaiser Family Foundation and the Commonwealth Fund support these results. A 2002 Kaiser Family Foundation survey found that one-third of U.S. physicians reported that they or a family member had been harmed by medical error (Blendon and others, 2002). The Commonwealth Fund found that one in ten consumers reported... 

Making Health Care Safer II An Updated Critical Analysis of the Evidence for Patient Safety Practices is the result of a panel of patient safety experts who assessed the evidence behind 41 patient safety strategies and identified 10 strategies that health systems should adopt now. The strategies can help prevent harmful events such as med errors, bed sores, and healthcare-associated infections. Making Health Care Safer II updates Evidence-based Practice Center report ( 43), which was published in 2001 and provided the first systematic assessment of patient safety practices. 

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