Events patient harm

Each time a patient moves from one setting to another, clinicians should compare previous medication orders with new orders and plans for care and reconcile any differences. If this process does not occur in a standardised manner designed to ensure complete reconciliation, medication errors may lead to adverse events and harm (IHI MedReconcilliation 2008). Several national organisations round the world have now produced help to reduce errors with medication reconciliation. Some examples are given below. 

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. 

Ernst (2) projected that costs of 177 billion a year are attributable to medication misuse. Adverse drug events (ADEs) are instances when patient harm results from the use of medication. This includes both adverse drug reactions/ which were discussed in Chapter 25/... 

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while medication is in the control of a healthcare professional/ patient/ or consumer (6). Not all medication errors reach the patient. These are often referred to as "near misses." They are not usually considered to be ADEs only because no harm was done. Preventable ADEs are a subset of medication errors that cause harm to a patient (7). Figure 26.1 depicts the relationship between ADES/ medication errorS/ and adverse drug reactions (8). Because adverse drug reactions are generally unexpected/ they are not presently considered to be a reflection of medication use quality in a classic sense. However/ as genetic variances become a more prominent consideration in drug selection and monitoring/ it may be possible to predict and avoid some of the reactions that have been previously unexpected. This offers an opportunity to improve the quality of medication use. 

A true hazard can only exist if it is possible to define a tangible and credible impact which results from the hazard being realised. The primary purpose of estabUshing the impact is to set the rationale for the estimation of severity - one of the two components of clinical risk. As we have previously discussed, the impact of a hazard should be expressed in terms of the harm it may cause on the patient rather than harm done to the system, its hardware or users. By focussing on the patient this ensures that the hazard and its impacts work together to describe a comprehensible and contextualised story from the trigger event to harm. 

We found that 23 % of hospital admissions in eight specialties were associated with patient safety incidents and 11% with adverse events. This is similar to rates found in studies using similar methods in the United Kingdom and internationally. The routine reporting system as implemented in this large hospital missed most patient safety incidents that were identified by case note review and detected only 5% of those incidents that resulted in patient harm. This suggests that the routine reporting system considerably under-reports the scale and severity of patient safety incidents. 

Event reporting Event reporting is important for hospitals to understand patient safety risks and enable them to take steps to prevent and mitigate harm to patients. However, the status of event reporting in the US still shows considerable nnderreporting. A 2012 report from the Office of the Inspector General found that US hospital incident reporting systems captured only an estimated 14 percent of the patient harm events experienced by Medicare beneficiaries (Department of HHS 2012). 

The occurrence, frequency, and magnitude of avoidable adverse patient-related events were not well known until the 1990s, when a number of countries reported staggering numbers of patient harm and deaths due to human errors. For example, the United States lost more American lives to patient safety-associated adverse events every 6 months than it did during the entire Vietnam War [3]. 

A medication error is an example of a preventable cause of an adverse drug event and is defined as any preventable event that may result in incorrect medication use or patient harm while the medication is in the control of a consumer, a healfh care professional, or a patient [4,5]. Medication-related errors result in deaths or serious injuries infrequently, but a sizable number of people each year are affecfed due to the widespread use of various types of drugs bofh oufside and wifhin the hospital environments [6]. 

Among the significant contributions from human factors research to the field of patient safety is the notion that fallibility is part of the human condition. Therefore creating safety requires changing the conditions in which human beings work. Although individual failures and system vulnerabilities are inevitable, adverse events and harm resulting from them need not be. 

Autolysis of the pancreas can occur when zymogens are activated in the pancreas before being released into the duodenum. Acute pancreatitis can result from the initial injury to the zymogen-producing cells, which is followed by neutrophil invasion of the pancreas, and that ends in further activation of enzymes within the pancreas. This cascade of events can be destructive to the pancreas and harmful to the patient. 

These events are significant because they may result in significant harm and even death to a patient and can also pose serious detriments to pharmacists, such as feelings of guilt and stress, the potential for litigation from patients and their families, the threat... 

In writing on human error, Senders and Moray (1991, p. 128) conclude Human error rates can be reduced to as low a level as desired, at some unknown cost. The occurrence of a particular error at a particular instant, however, cannot absolutely be prevented. Even if the patient suffers no permanent harm, a service failure or mistake in a pharmacy is a significant event. The consequences of a service failure or mistake in a pharmacy include a deterioration of trust in the pharmacist and the system, the spread of negative word-of-mouth advertising, the possibility of legal action, possible board of pharmacy involvement, the erosion of customer patronage, and a diminished level of profit (see Chapters 7, 28, and 30 on minimizing the occurrence of prescription errors). 

---