Medical errors are a serious public health problem and a leading
cause of death in the United States. It is a difficult problem as
it is challenging to uncover a consistent cause of errors and, even
if found, to provide a consistent viable solution that minimizes
the chances of a recurrent event. By recognizing untoward events
occur, learning from them, and working toward preventing them,
patient safety can be improved.
- poor teamwork—such as incomplete communication
and failing to use available expertise—increases the risk of
medical error and decreases quality of care
- During the years there has been considerable concern about the
insufficient drug dose calculation skills among nursing students
and registered nurses
- Medication errors are the most common types of medical errors
in hospitals and leading cause of morbidity and mortality among
patients.
- Medication errors due to illegible handwritten prescriptions,
overlooked allergies and drug interactions, and incorrect dosages
often result in ADEs. Consequently, technology-based interventions
have been recommended as a key mechanism for reducing the
likelihood of medication errors and ADEs.
- Take, for example, the allergy detection
process used in our hospital several years ago, which was similar
to that used in most hospitals at the time. Physicians, medical
students, and nurses all asked patients what their allergies were.
This information was recorded at several sites in the medical
record, though there was no one central location. The information
was also required to be written at the top of every order sheet,
although in practice this was rarely done. The pharmacy recorded
the information in its computerised database, but it found out
about allergies only if the information was entered into the
orders, and often it was not. Checking by physicians and pharmacy
and nursing staff was all manual. This information was not retained
between the inpatient and outpatient settings, or from admission to
admission. Not surprisingly, about one in three orders for drugs to
which a patient had a known allergy slipped through.