⌚ Causes Of Medication Errors
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Fear of punishment makes healthcare professionals reluctant to report errors. Unfortunately, failing to report contributes to the likelihood of serious patient harm. Many healthcare institutions have rigid policies in place that also create an adversarial environment. This can cause staff to hesitate to report an error, minimize the problem, or even fail to document the issue. These actions or lack thereof can contribute to an evolving cycle of medical errors. When these errors come to light, they can tarnish the reputation of the healthcare institution and the workers.
A professional whose confidence and morale has been damaged as a result of an error may work less effectively and may abandon a career in medicine. However, adverse patient outcomes may occur because of errors; to delete the term obscures the goal of preventing and managing its causes and effects. Errors, no matter the nomenclature, typically occur from the convergence of multiple contributing factors.
Public and legislative intolerance for medical errors typically illustrates a lack of understanding that some errors may not, in fact, be preventable with current technology or the resources available to the practitioner. Human factors are always a problem, and identifying errors permits improvement strategies to be undertaken. In particular, blaming or punishing individuals for errors due to systemic causes does not address the causes nor prevent a repetition of the error. Errors represent an opportunity for constructive changes and improved education in health care delivery. Governmental, legal, and medical institutions must work collaboratively to remove the culture of blame while retaining accountability.
When this challenge is met, health care institutions will not be constrained from measuring targets for process improvement, including all errors, even with adverse outcomes. Healthcare providers want to improve outcomes while reducing the risk of patient harm. Despite provider best efforts, medical error rates remain high with significant disability and death. Preventable medical errors contribute substantially to healthcare costs, including higher health insurance costs per person expenses. Only by health professionals working together will the cost and injury associated with medical errors be mitigated. The Joint Commission has introduced several patient safety goals to assist institutions and healthcare practitioners in creating a safer practice environment for patients and providers.
The Joint Commission Goals include:. Identify patient safety dangers and risks. Prevent infection by hand-cleaning, post-op infection antibiotics, catheter changes, and central line precautions. Prevent mistakes in surgery by making sure the correct surgery is done on the correct body part; pause before surgery to double-check. Use medications correctly and safely, double-checking labeling and correctly passing on patient medicines to the next provider. Label all medications, even those in a syringe.
This should preferably be done in the area where the medications are prepared. Take extra time with patients who have been prescribed anticoagulants and chemotherapeutic agents. To prevent nosocomial infections, hand washing should be routine before and after visiting each patient. While it is true that individual providers should be held accountable for their decisions, there is a growing realization that the majority of errors are out of the clinician's control. This being said, it remains difficult to change a culture of non-reporting. The potential for errors in healthcare is very high. Due to cost control measures, are individuals accountable, or are increased workload and staff fatigue the reason for errors?
Why report? Failure to report errors may subject clinicians to disciplinary action and increased risk for legal liability. Beneficence and nonmaleficence are ethical concepts that are violated when an error is not reported. Practitioners often fear they will gain a reputation for committing mistakes and may not self-report. They know that mistakes and written warnings are often recorded in personnel files. Does the system need modification to decrease the penalty and encourage reporting?
Punishment may, in fact, reduce reporting errors because of the discipline and humiliation that is associated with repeated errors. Nevertheless, not addressing the problem increases the potential for more adverse events which places more patients at risk. Rather than placing blame, administrators and review boards need to move toward eliminating the blame-shame-discipline structure and move toward a prevention and education structure. This culture incorporates both learning and improvement efforts that target system redesign and a reporting culture whereby all providers feel safe from retribution and, therefore, report issues about safety that help to constantly improve patient care and improve the safety of the system.
Patient safety has typically been outcome-dependent and the focus has been on preventing patients from experiencing adverse outcomes when receiving medical care. Multiple similar definitions are available for each of these terms from various sources; the health practitioner should be aware of the general principles and probable meaning. Active errors are those taking place between a person and an aspect of a larger system at the point of contact. Active errors are made by people on the front line such as clinicians and nurses.
For example, operating on the wrong eye or amputating the wrong leg are classic examples of an active error. An adverse event is a type of injury that most frequently is due to an error in medical or surgical treatment rather than the underlying medical condition of the patient. Adverse events may be preventable when there is a failure to follow accepted practice at a system or individual level. Not all adverse outcomes are the result of an error; hence, only preventable adverse events are attributed to medical error. Adverse events can include unintended injury, prolonged hospitalization, or physical disability that results from medical or surgical patient management.
Adverse events can also include complications resulting from prolonged hospitalization or by factors inherent in the healthcare system. These are errors in system or process design, faulty installation or maintenance of equipment, or ineffective organizational structure. When a latent error occurs in combination with an active human error, some type of event manifests in the patient. The active human error triggers the hidden latent error, resulting in an adverse event.
Latent errors are basically "accidents waiting to happen. The failure to complete the intended plan of action or implementing the wrong plan to achieve an aim. When planning or executing a procedure, the act of omission or commission that contributes or may contribute to an unintended consequence. Failure to meet the reasonably expected standard of care of an average, qualified healthcare worker looking after a patient in question within similar circumstances. For example, the healthcare worker may not check up on the pathology report which led to a missed cancer or the surgeon may have injured a nerve by mistaking it for an artery.
A subcategory of preventable , adverse events that satisfy the legal criteria used in determining negligence. Any event that could have had an adverse patient consequence but did not. Potential adverse events that could have caused harm but did not, either by chance or because someone or something intervened. Near misses provide opportunities for developing preventive strategies and actions and should receive the same level of scrutiny as adverse events.
Never events are errors that should not ever have happened. A classic example of a never event is the development of pressure ulcers or wrong-site surgery. Asking questions is essential, but it isn't enough. Your health care providers can follow a process called medication reconciliation to significantly decrease your risk of medication errors. Medication reconciliation is a safety strategy that involves comparing the list of medications your health care provider currently has with the list of medications you are currently taking.
This process is done to avoid medication errors such as:. Medication reconciliation should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting such as being admitted or discharged from the hospital , health care provider or level of care. Sharing your most up-to-date information with your health care providers gives the clearest picture of your condition and helps avoid medication mistakes.
Don't hesitate to ask questions or to tell your health care providers if anything seems amiss. Remember, you're the final line of defense against medication errors. If despite your efforts you have problems with a medication, talk with your doctor or pharmacist about whether to report it to MedWatch — the Food and Drug Administration safety and adverse event reporting program. Reporting to MedWatch is easy, confidential and secure — and it can help save others from being harmed by medication errors.
This content does not have an English version. This content does not have an Arabic version. See more conditions. Healthy Lifestyle Consumer health. Products and services. Free E-newsletter Subscribe to Housecall Our general interest e-newsletter keeps you up to date on a wide variety of health topics. Sign up now. Medication errors: Cut your risk with these tips Medication errors are preventable. By Mayo Clinic Staff. Show references Medication safety basics. Centers for Disease Control and Prevention. Accessed July 25, Agency for Healthcare Research and Quality. Medication errors related to drugs. Food and Drug Administration. Accessed July 29, Ferri FF. Pediatric medication errors. In: Ferri's Clinical Advisor Philadelphia, Pa. Medicines: Use them safely.
National Institute of Aging. Medication errors. Agency of Healthcare Research and Quality. How to report product problems and complaints to the FDA. Accessed July 30, Mekonnen AB, et al. Pharmacy-led medication reconciliation programmes at hospital transitions: A systematic review and meta-analysis. Journal of Clinical Pharmacy and Therapeutics. DeCourcey DD, et al. Medication reconciliation failures in children and young adults with chronic disease during intensive and intermediate care.
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