Health care system medication errors

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. 

Increased awareness of medication errors and methods of prevention throughout the health care system... 

Health care systems should approach medication errors as system failures and seek system solutions in preventing them. 

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-... 

Each day thousands of patients throughout the United States are warded into intensive care units where they receive various types of medical services. Just as in the performance of any other services in the health care system, the performance of services in intensive care units is subjected to human error. Some of the facts and figures concerned with the occurrence of human error in intensive care units are presented below ... 

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. 

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... 

Patients and citizens have also been surveyed about their experiences with the safety of medical care. In the Commonwealth Fund s 2010 International Survey of the General Public s Views of their Health Care System s Performance , citizens of 11 countries were asked to report about medical errors [11]. Across... 

Policy makers, practitioners, and scholars from a variety of disciplines have recently embraced a new approach to risk reduction in health care—a "systems approach"—without proposing any specific reforms of medical liability law. The Institute of Medicine (IOM) placed its imprimatur on this approach in its recent reports (Kohn et al., 2000 IOM, 2001). In its simplest form, a systems approach to risk reduction in health care posits that an injury to a patient is often the manifestation of a latent error in the system of providing care. In other words, a medical mishap is the proverbial "accident waiting to happen" because the injury-preventing tools currently deployed, including medical liability law, are aimed at finding the individuals at fault rather than the systemic causes of error. Coexistence of a systems approach to error reduction and medical liability law as a conceptual framework for policy makers implies that the latter is likely to evolve in an incremental fashion as the former makes more visible different aspects of the medical error problem. 

Detecting the incidence and type of adverse drug events (ADEs) and medication errors is important for improving the quality of health care delivery. Problems include missing dose, wrong dose, frequency, and route errors. The consequence (ADE) of the errors depends on medication and patient factors as described previously. Some of these problems are organisational and related to chart order system and prescribing. 

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. 

The Couneil recommends the establishment of a systems approach to reporting, understanding, and prevention of medication errors in health care organizations. The organization s leaders should foster a culture and systems that include the following key elements ... 

Bates, D.W., Preventing Medication Errors. In Medication Use A Systems Approach to Reducing Errors (D.D. Cousins, ed.). Joint Commission on Accreditation of Health Care Organizations, Oakbrook Terrace, IL, 1999, pp. 57-73. 

Creation of Committee on the Quality of Health Care in America To Err Is Human Building a Safer Health System Crossing the Quality Chasm A New System for the 21st Century Created opportunities for pharmacists to provide guidance on system to decrease medical errors Created opportunities for pharmacy organizations to include medical errors on research agendas... 

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