Errors and Adverse Events

A physician failed to use an indicated diagnostic test or misinterpreted test. Emergency room personnel could not use a defibrillator with dead batteries. Patient developed a postsurgical wound infection resulting in a longer stay. A patient received the wrong blood type during a transfusion. 

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The lOM report concludes that most of these errors are the result of systemic problems rather than poor performance by individual providers. Pharmacists play a key role in helping prevent and eliminate medication errors by providing information on the proper use of medications. Pharmacists provide the link between prescribers and patients, as shown in Figure 27.1, and can monitor for medication errors and adverse events. 

There is continued focus on adverse drug events and medication errors. Processes must respond to actual or potential adverse drug events and medication errors and properly report them internally and externally (e.g., to the FDA, ISMP, or USP). Other standards address how adverse drug events and medication errors should be addressed to improve systems, support staff education and training, and minimize the risk of medication-related errors and adverse events. 

The United States Pharmacopeia (USP) collects medication error and adverse event data from hospitals and health systems through MEDMARX, <>. Hospitals and health systems participate on a voluntary basis, with anon3onous submissions. Subscribers have the ability to share data amongst hospitals and health systems. 

Which program collects data from health systems and hospitals on medication errors and adverse events ... 

HIT can enhance patient safety in three ways it can help prevent medical errors and adverse events it can initiate rapid responses to any event and it can enable the tracking of events, if they occur, and provide feedback on them to learn from [30]. But it is the first of these which is of most interest when it comes to proactively reducing the risk of harm. If we can identify the conditions in which dangerous scenarios occur we have a vital window of opportunity to intervene in the natural history of a hazard (see Sect. 2.6). 

Tables 4.1 and 4.2 summarize the main types of studies of errors and adverse events, and their respective advantages and limitations. Thomas and Petersen s original source version has been separated into two separate tables and the content has been adjusted in particular, a section on case analysis has been added. Case analyses, usually referred to as root cause analysis or systems analysis, share some of the features of morbidity and mortality meetings, but are generally more focused and follow a particular method of analysis (Vincent, 2003) (Chapter 8).

Thomas, B.J. and Brennan, T. (2001) Errors and adverse events in medidne an overview, in Clinical Risk Management. Enhancing Patient Safety, 2nd edn (ed. C.A. Vincent), BMJ Publications, London, pp. 31-44. 

Thomas, B.J. and Petersen, L.A. (2003) Measuring errors and adverse events in healthcare. Journal of General Internal Medicine, 18(1), 61-67. 

What is the difference between human error and adverse event ... 

Promotion of a nonpunitive culture for sharing information and lessons learned Routine organizationwide assessment of the risk of error and adverse events in the care delivery process... 

Staff noncompliance and failures to follow protocols and procedures are the main sources of errors and adverse events. 

Axley B, Speranza-Reid J, Williams H Venous needle dislodgement in patients on hemodialysis. Nephrol Nurs J 2012 39 435-445. Holley JL A descriptive report of errors and adverse events in chronic hemodialysis units. Nephrol News Issues 2006 20 57-63. 

To prevent medical errors and adverse events, small events and their precursors must be taken as seriously as large ones. 

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