Patient safety learning from error

The Medication Error Reporting Program (MERP) is a voluntary program administered by the U.S. Pharmacopeia (USP) in conjxmction with the ISMP. This confidential reporting system improves patient safety by alerting practitioners and the industry to potential or actual problems. Practitioners are asked to report errors and near misses to this program so that others learn from errors and prevent similar errors in the future. 

HIT can enhance patient safety in three ways it can help prevent medical errors and adverse events it can initiate rapid responses to any event and it can enable the tracking of events, if they occur, and provide feedback on them to learn from [30]. But it is the first of these which is of most interest when it comes to proactively reducing the risk of harm. If we can identify the conditions in which dangerous scenarios occur we have a vital window of opportunity to intervene in the natural history of a hazard (see Sect. 2.6). 

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 NPSA idenhfies patient safety-associated deficiencies with the aid of input from pahents and clinical experts, develops appropriate solutions, and monitors results of correchve measures within the NHS. Its initiatives and alerts include items such as hand hygiene, information for doctors and patients on steps to decrease risk of error, vaccine safety, and disclosure of error to all injured patients. Finally, the National Reporting and Learning System (NRLS) allows all NHS employees to provide the NPSA with reports on an anonymous basis. 

Gearge, B., Polly, C., Everlyn, S., Implementation of a Patient Safety Collaborative Forum Facilitates Organizational Learning from Medical Error, Proceedings of the Human Factors and Ergonomics Society Conference, 2006, pp. 944-948. 

We used to think that studying medical accidents could create harm-free care. We learned instead that risks, near misses, hazards, and the wisdom of front-line workers teach equally important lessons about improving safety, without aU the emotion and trauma of accidents. Recovery from error and resilience in a system are as important as prevention in creating safety for patients. 

Fortunately, an occasional leader has recognized the gravity of the situation and the need to take responsibility for changing this type of culture. The authors of this book not only found support from such individuals but also knew what to do with it. They had two very different experiences, as chronicled in the Introduction, but both authors made impressive changes in the cultures of their institutions. Each has been on the front line, and each has experience in implementing the techniques recommended in this volume. The lessons they learned from their experiences form the core around which this remarkable book is constructed. This book is not the outcome of a theoretical exercise. Its skeleton comes from the Harvard Executive Session on Medical Error and Patient Safety manifesto for leaders, but the knowledge and advice it offers come from practical, frontline experience. 

The devastating problem of medical error has forever changed the lives of too many patients and providers. Creating a culture of safety, a culture of harm-free care delivery, is the only course of action for the health care leaders of today and tomorrow. Its achievement rests on a profound change, and its creation is the duty of today s health care leaders. As leaders, we have learned and continue to learn from those we have served and failed and from providers who were giving care when systems failed them. 

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