PROMOTING A CULTURE OF SAFETY
A culture of fear stifles creativity and innovation, and it impedes continuous improvement by enabling defects to remain undetected—or unreported. Fear fosters gaps between “what we know” and “what we do.” To close this gap, it is imperative to promote and to support a culture in which staff members can search [...]
In October 2006, several nurses, pharmacists and providers commented that the medication error-reporting process at the Veterans Affairs-New York Harbor Healthcare System (VA-NYHHS) was lengthy and cumbersome and did not promote the reporting of all medication close calls and adverse events. The staff’s concerns were validated by the medication error-reporting data.
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, [...]
Enlist the help of local pharmacists and encourage patients to ask pharmacists about their medications and ADR
Physicians should remember that they have a good source of drug information in local pharmacists. Patients as well as physicians should actively interact with pharmacy personnel to obtain drug information. Physicians should work with local pharmacists to minimize medication [...]
Take a drug history/document drug allergy
A poor drug history may lead to a failure to detect unintended drug effects. A drug history should include the use of alternative medicines or herbal medications, supplements and other over-the-counter (OTC) medications. A recent study indicated that review and documentation of nonprescription substances are uncommon in primary practice. Of [...]
Update knowledge of therapeutics
Three key factors were listed by the IOM that contribute to prescribing error: 1) using the wrong drug name, 2) incorrect dosage calculations, and 3) atypical or unusual and critical dosage frequency. It is very easy to use the wrong drug name when prescribing, because so many new drugs enter the market [...]
INTRODUCTION
In the United States, an estimated 44,000 to 98,000 deaths annually may be caused by medical errors. These figures were provided in a report by the Institute of Medicine (IOM). The report documents the fact that medication errors are a major problem in our hospitals and that adverse drug reactions (ADR) remain an important cause [...]
