Health Care Human Error Reporting Systems

10 Health Care Human Error Reporting Systems 

Human error data play an important role in making various types of decisions in the health care sector. The effectiveness of such decisions depends on the error data quality (i.e., poor-quality data will result in ineffective decisions). There are many human-error-related systems currently in use in the area of health care [2,5], some of which are described below [2,5]  

Food and Drug Administration (FDA) Surveillance System. This was developed and is managed by the FDA. As part of this system, all adverse events reports concerning medical products after their formal approval are submitted to the FDA. In the case of medical devices, the device manufacturers report information on items such as deaths, serious injuries, and malfunctions. Furthermore, the device user facilities such as hospitals and nursing homes are required to report deaths to both the FDA and manufacturers and also serious injuries to device manufacturers. In regard to drug-related adverse events, reporting is mandatory for all manufacturers, but it is voluntary for physicians, consumers, and so on [2]. 

Medication Errors Reporting System. This system was developed by the Institute for Safe Medication Practice (ISMP) in 1975 and is a voluntary medication error reporting system. The system receives reports from frontline practitioners and shares its information with the pharmaceutical companies and the FDA, and is managed by U.S. Pharmacopoeia (USP). 

Med Marx System. This Internet-based system is established for hospitals to report medication errors anonymously on a voluntary basis. The system was developed by the USP in 1998 and the information contained in the system is not shared with the FDA. 

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The 1999 report entitled To Err is Human Building a Safer Health Care System emphasized that medication errors were an important contributor to morbidity and mortality. Yet this committee also noted that the elimination of such errors will require a comprehen-... 

In recent years patient safety has become an important issue because of a staggering number of deafhs and injuries due to patient safety-related problems. For example, as per an Institute of Medicine report around 100,000 Americans die each year due to human errors in the health care system [1], Today there are many patient safety organizations in various parts of the world that advocate improvement in patient safety. A patient safety organization may be described as a group, association, or institution that improves medical care by reducing the occurrence of medical errors. 

It appears that the modern patient safety movement started in 1991 with the publication of the results of the Harvard Medical Practice Study in the New England Journal of Medicine [2-4], In the study, the medical records of 30,000 patients hospitalized in acute care hospitals in New York State in 1984 were examined. In 1996, the American Medical Association announced the formation of the National Patient Safety Foundation [2], In 1999, the National Academy of Sciences Institute of Medicine released its report entitled "To Err Is Human Building a Safer Health System" [5]. The report stated that medical errors are causing 44,000-98,000 preventable deaths annually in the United States. In 2001, the United States Congress appropriated 50 million per year for patient safety research to the Agency for Healthcare Research and Quality (AHRQ) [2],... 

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