Patient safety/medical errors, effects

To enhance the quality, appropriateness, and effectiveness of health care services, and access to these services the federal government in the Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239) established the AHCPR. The act, sometimes referred to as the Patient Outcome Research Act, called for the establishment of a broad-based, patient-centered outcomes research program. In addition to the traditional measures of survival, clinical endpoints and disease- and treatment-specific symptoms and problems, the law mandated measures of functional status and well-being and patient satisfaction. In 1999, then President Clinton signed the Healthcare Research and Quality Act, reauthorizing AHCPR as the AHRQ until the end of fiscal year 2005. Presently, its mission is to improve the outcomes and quality of health care, reduce its costs, address patient safety and medical errors, broaden access to effective services, and improve the quality of health care services. 

According to the JCAHO medication error is one of the most important patient safety risk factors. The medical literature describes different models of risk assessment that can be used to identify the causes of medication errors. This is important because without such knowledge no actions would be effective, and furthermore identifying the wrong cause would result in an inappropriate or suboptimal action plan (Weinberg, 2001). 

Chapter 10 is devoted to medical device usability. It covers topics such as medical device users and use environments, medical device user interfaces, an approach to develop medical devices effective user interfaces, guidelines to reduce medical device user interface-related errors, guidelines for designing hand-operated devices with respect to cumulative trauma disorder, and useful documents for improving usability of medical devices. Chapter 11 presents three important topics relating to patient safety patient safety organizations, data sources, and mathematical models for performing probabilistic patient safety analysis. 

JCAHO has been instrumental in getting safety on the radar screens of all the facilities it surveys. Using information collected about serious medical errors and sentinel events, as well as consensus panels of safety experts, JCAHO has cod-ifled six patient safety goals into standards that became effective in January 2003. The goals, expressed as specific tactics in aJCAHO press release of July 24, 2002, are as follows ... 

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. 

Simulation-based education (SBE) has been introduced as an efFective method for training healthcare workers [1]. SBE can improve patient safety in healthcare facilities in different ways, particularly if used in individual skills [2]. As a result of the proven efficacy of SBE, there has been an increased number of simulation centers worldwide. These centers have various visions, purposes, and functionahties. Most of them are tailored to deliver education to particular healthcare giver categories or undergraduate trainees, with the end result being better training, reduced medical errors, and thus improved patient safety and quality of care in many medical domains. 

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