Patient education errors

Because no individual knows everything, and because everyone has occasional slips or lapses in performance, everyone makes errors. Medication use is a complex process that consists of subprocesses such as the ordering, preparing, dispensing, administration, and the provision of patient education. 

The patient is the last individual in the medication use process. The pharmacist-patient interface can play a significant role in capturing medication errors before they occur. Unfortunately, many health care organizations do not take advantage of this key interaction. Three important factors play a role in any patient interface and often determine the outcome of error-prevention efforts. These include direct patient education, health care literacy, and patient compliance. 

Hospital work areas and staff asked to complete the survey When the Hospital SOPS was developed, it was not specifically designed and tested for use with non-clinical staff like those in honsekeeping, facilities, or human resources. Yet once the snrvey was released, it became very clear that hospitals wanted to survey all staff from all units and departments, with the understanding that every staff member plays an important role in ensuring patient safety. By being attentive and aware of patient safety risks, in an environment that encourages open communication and learning, even non-clinical staff can help prevent medication errors, patient identification errors and many other types of errors. Since one of the uses of the survey is as an education and awareness tool, it makes sense for hospitals to conduct the survey in a broad way across units and staff positions. 

The nature of interactions between patients and outpatient providers can also contribute to adverse events. Circnmstances can limit face-to-face interaction between a provider and a patient. Patients then shonld assume a much greater role in and responsibility for managing their own health. This elevates the importance of patient education to ensure that patients understand their illnesses and treatments. Medication errors can occur due to a patient s understanding of the indication, dosing schedule, proper administration, and potential side effects of a drug. Low health literacy and poor patient education contribute to increased error risks. Patients should understand how and when to contact their caregivers outside of routine appointments. 

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 Council recommends that healthcare organizations develop and implement (or provide access to) education and training programs for healthcare professionals, technical support personnel, patients, and caregivers that address methods for reducing and preventing medication errors. 

AHRQ will develop research and build partnerships with heath care practitioners and healthcare systems, and establish a permanent program of Centers for Education and Research in Therapeutics (CERTs). These initiatives will help address concerns raised in a 1999 report by the Institute of Medicine (lOM) that estimates as many as 98,000 patients die as a result of medical errors in hospitals each year. " ... 

To develop recommendations and effective strategies for preventing medication errors and reducing adverse drug events and to educate healthcare professionals and patients to ensure that these recommendations and practices are implemented appropriately. 

The edueation and dissemination of information is another primary objective of ISMP—Spain If everyone understands the nature and causes of medication errors, there is a much greater possibility of improving patient safety. In this sense, ISMP—Spain makes educational presentations and holds conferences at healthcare professional meetings to provide information about adverse drug events. ISMP—Spain also publishes opinion articles and practical articles in Spanish healthcare journals in an effort to broadly disseminate a culture of safety and error prevention. 

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