Improving the Reporting of Medication Errors
INTRODUCTION
According to the Institute of Medicine’s (IOM’s) 1999 report, To Err Is Human: Building a Safer Health System, between 44,000 and 98,000 patients die each year in hospitals as a result of medical errors, thereby making these misadventures the eighth leading cause of death. With an estimated cost of $17 to $29 billion each year, 38% of these mistakes are errors in drug administration, and only 2% of these errors are intercepted. These findings have spurred the nation to make patient safety a key issue and to move toward improvement. Since realizing that medical errors have been underreported, the IOM has recommended establishing error-reporting systems that can help identify errors and allow hospitals to learn from these mistakes.
Generally, two types of incidents are reported: close calls and adverse events.
The Veterans Affairs National Center for Patient Safety defines an adverse event as an “untoward incident, therapeutic misadventure, iatrogenic injury, or other adverse occurrence directly associated with care or services provided within the jurisdiction of a medical center, outpatient clinic, or other Veterans Health Administration (VHA) facility.”
A close call is an “event or situation that could have resulted in an adverse event but did not, either by chance or through timely intervention.” Such events have also been referred to as “near-miss” incidents. An example of a close call would be a surgical procedure that is almost performed on the wrong patient because of a lack of patient identification but that is caught at the last minute. Close calls are opportunities for learning, and they afford the chance to develop preventive strategies and actions before a patient has been harmed. However, because close calls are not always detected, and because they sometimes appear in the patient’s medication record as an adverse event, they are often underreported. canadian pharmacy viagra
An incident reporting system or “culture of safety” that focuses on a nonpunitive approach allows individuals to report errors without fear of blame. This type of error-reporting system is confidential and impartial, it offers incentives for report ing close calls and adverse events, and it ensures that there is no retribution for those reporting. Therefore, encouragement, rewards, staff education, open communication, and department recognition can increase medical-error reporting.
