Medication errors process-improvement approach

Thus, the process-improvement approach to the safety of the medication-use cycle goes beyond the celebrated cases and first stories to scientifically investigate the system as a whole. Data on near-misses and uncelebrated errors should be analyzed to find hidden flaws and strengths, and to better understand the dynamics of our medication-use system. Scientific investigation of the whole cycle— peeling away the layers of the onion—will reveal latent points of failure and facilitate a redesign that substantially reduces the occurrence of harmful outcomes. 

All the objectives presented in Box 11.1 can be described as quality improvement in the structure and process to support improvement in each patient s health outcome. This support the patient medication care process presented in Fig. 3.1. Various problems and tools and models for improvement have been described in this book. Another approach to prevent medication errors and to improve care is to be open and continuously learn from mistakes. The basis for this is not to punish health care providers who make errors, as this may lead to less reporting of errors. In Britain, the government has taken steps away from this blame-culture (Wise 2001). In a declaration it is stated that honest failure should not be responded to primarily by blame and retribution, but by learning and by a drive to reduce risk for future patients. 

Research supports a systems approach to error prevention as well as investigation of errors [8-11]. This means that all aspects of the medication use process, including characteristics of the products themselves should be explored for ways to improve safety in use. 

The Institute for Healthcare Improvement (IHI) has pioneered quality improvement in healthcare, drawing together ideas and practical experience from healthcare and many other sources. We will use their approach to reducing medication error as an overall framework to illustrate the potential of process improvement, addressing the particular role of technology in a later section. 

An effective patient safety program cannot exist withont optimal reporting of medical or healthcare errors and occnrrences. The organization should adopt a no punitive approach in its management of errors and occurrences. Personnel must be able to report suspected or identified medical or healthcare errors without the fear of reprisal in relationship to their anployment. Organizations must support the concept that errors occur due to a breakdown in systems and processes. Improvement will be achieved by focusing on systems and processes rather than disciplining those involved in adverse events. 

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