Medication Errors in Family Practice, in Hospitals and after Discharge from the Hospital: An Ethical Analysis

2004 ◽  
Vol 32 (2) ◽  
pp. 349-357 ◽  
Author(s):  
Peter A. Clark
Keyword(s):  
Patient Safety ◽  
Health System ◽  
Vietnam War ◽  
Medication Errors ◽  
Family Practice ◽  
Medical Errors ◽  
Ethical Analysis ◽  
Institute Of Medicine ◽  
Surgery Patient

The issue of death due to medical errors is not new. We have all heard horror stories about patients dying in the hospital because of a drug mix-up or a surgery patient having the wrong limb amputated. Most people believed these stories were the exception to the rule until November 1999, when the Institute of Medicine (IOM) issued a report entitled To Err Is Human: Building A Safer Health System. This report focused on medical errors and patient safety in U.S. hospitals. The report indicated that as many as 44,000 to 98,000 people die each year in hospitals as a result of medical errors. These numbers suggest that more Americans are killed in U.S.hospitals every 6 months than died in the entire Vietnam War, and some have compared the alleged rate to fully loaded jumbo jets crashing every other day. This report was not without its critics.

Reducing Medical Errors and Increasing Patient Safety

2017 ◽  
pp. 87-115
Keyword(s):  
Patient Safety ◽  
Medical Errors ◽  
Motor Vehicle ◽  
Motor Vehicle Accidents ◽  
Healthcare Sector ◽  
Institute Of Medicine ◽  
Vehicle Accidents ◽  
Functional Quality ◽  
Atmosphere Interaction ◽  
Quality Dimensions

This chapter will describe the interrelationship between ICT, total relationship medicine approach, 5 Q and reducing medical errors and increasing patient safety. Medical errors are one of the Nation's leading causes of death and injury. A report published in 2000 by the Institute of Medicine (IOM) estimates that as many as 44,000 to 98,000 people die in U.S. hospitals each year as the result of medical errors. By 2004 the result was 195000 die and 1 000 000 excess injures by the medical errors. This means that more people die from medical errors than from motor vehicle accidents, breast cancer, or AIDS. Few studies have been conducted to investigate the link between technological, technical and functional quality dimensions and the level of patient's safety, medical errors and patient satisfaction in the healthcare sector. None of the identified studies have empirically examined how the atmosphere, interaction and infrastructure which focuses on availability of technology might prevent the medical errors and impact overall patient's quality perception and satisfaction.

scholarly journals Leveraging IT to Improve Patient Safety

2003 ◽  
Vol 12 (01) ◽  
pp. 153-158
Author(s):  
D.E. Garets ◽  
T.J. Handler ◽  
M.J. Ball
Keyword(s):  
Patient Safety ◽  
Medical Errors ◽  
Improve Patient Safety ◽  
Quality Care ◽  
Quality Of Healthcare ◽  
The United States ◽  
Institute Of Medicine ◽  
The Media ◽  
The Military ◽  
Improve Patient

Abstract:Medical errors and issues of patient safety are hardly new phenomena. Even during the dawn of medicine, Hippocrates counselled new physicians “to above all else do no harm.” In the United States, efforts to improve the quality of healthcare can be seen in almost every decade of the last century. In the early 1900s, Dr. Ernest Codman failed in his efforts to get fellow surgeons to look at the outcomes of their cases. In the 1970s, there was an outcry that the military allowed an almost blind surgeon to continue to practice and even transferred him to the prestigious Walter Reed Hospital. More recently, two reports by the Institute of Medicine caught the attention of the media, the American public, and the healthcare industry. To Err Is Human highlights the need to reduce medical errors and improve patient safety, and Crossing The Quality Chasm calls for a new health system to provide quality care for the 21st century.

scholarly journals Patient Safety in Pediatrics

2020 ◽  
pp. 299-308
Author(s):  
Sara Albolino ◽  
Marco De Luca ◽  
Antonino Morabito
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Health System ◽  
Pediatric Patient ◽  
Medication Errors ◽  
Surgical Complications ◽  
Hospitalized Children ◽  
Intravenous Line ◽  
Hospital Acquired Infections ◽  
Hospital Acquired

AbstractSince the publication of the 1999 IOM report “To Err Is Human: Building a Safer Health System,” much has been learned about pediatric patient safety. However, adverse events still affect one-third of all hospitalized children [1]. The main areas of adverse events are hospital-acquired infections, intravenous line complications, surgical complications, and medication errors [2].

Setting the Stage

2019 ◽  
pp. 3-14
Author(s):  
Robert L. Wears ◽  
Kathleen M. Sutcliffe
Keyword(s):  
Patient Safety ◽  
Medical Errors ◽  
Institute Of Medicine ◽  
Reform Effort ◽  
The Public ◽  
Public Agenda ◽  
Celebrity Status ◽  
A Charge

The Institute of Medicine report, To Err Is Human, which led the news in late 1999 with a charge that “medical errors” were killing 44,000 to 120,000 Americans each year, gave patient safety “celebrity status.” But the emergence of patient safety as a major concern on the public agenda was not a given. In this chapter, the authors raise questions about why it developed at this time even though the problem of medical harm had long been known, why it was understood as “error” as opposed to “risk” or “hazard,” and, finally, who gained control of the reform effort and to what end.

Irruption onto the World Stage

2019 ◽  
pp. 119-140
Author(s):  
Robert L. Wears ◽  
Kathleen M. Sutcliffe
Keyword(s):  
Patient Safety ◽  
United Kingdom ◽  
Small Group ◽  
Federal Government ◽  
Medical Errors ◽  
Healthcare Research ◽  
Institute Of Medicine ◽  
Safety Program ◽  
The United Kingdom ◽  
The World

The Institute of Medicine (IOM) report To Err Is Human created a media firestorm. Prior to this, interest in patient safety might be described as a cult—a small group of passionate believers—but the IOM report and its aftermath moved patient safety to a prominent place on the broad public agenda, creating pressure for quick action. The federal government announced a safety program at the Agency for Healthcare Research and Quality; President Clinton committed to a “50% reduction in medical errors in five years”; similar events occurred in the United Kingdom. Programmatic efforts in patient safety began to crowd out safety scientists. The litany of fear-provoking incidents of patient harm continued.

Hospital Nurses’ Intention to Report Near Misses, Patient Safety Culture and Professional Seniority

2021 ◽  
Author(s):  
Orly Toren ◽  
Dokhi Mohanad ◽  
Freda DeKeyser Ganz
Keyword(s):  
Patient Safety ◽  
Safety Culture ◽  
Medical Errors ◽  
Improve Patient Safety ◽  
Patient Safety Culture ◽  
Team Work ◽  
Near Miss ◽  
Institute Of Medicine ◽  
Near Misses ◽  
The Relationship

Abstract Background Preventable medical errors are the third cause of death after cancer and heart disease. The first step in coping with medical errors in the healthcare system is to develop a culture of patient safety. Reporting medical errors, especially near misses, is one of the chosen methods of dealing with patient safety issues, recommended by the Institute of Medicine. Despite this recommendation, few studies examined the relationship between reporting near misses and improvements in patient safety culture. Intention to report a near miss event is another means to understand the phenomena of reporting, but no studies were found that included this variable and its relationship to safety culture. The aims of this study were to determine the extent nurses reported near miss events; to describe the relationship between patient safety culture, professional seniority and intention to report near misses; and to determine predictors of intention to report near miss events. Methods This was a descriptive cross-sectional study, based on the Hospital Survey on Patient Safety (HSOPS). The target population was ICU and inpatient ward nurses working in general hospitals. The sampling method was cluster convenience sampling. Statistical analysis included descriptive and predictive analyses. Results The sample included 227 nurses. Most nurses rated the patient safety culture components as moderately positive. Approximately 80% stated their intention to report a near miss, however 52.4% indicated that they did not report a near miss event in the past year. A positive correlation was found between all components of the patient safety culture and the intention to report a near miss event. Professional seniority was not related to any safety culture components or intention to report a near-miss event. Three variables predicted intention to report: team work, feedback and communication about errors, and the amount of near misses reported in the last year. Conclusions There is a discrepancy between what nurses describe as their intent to report a near miss event and their actual reporting of an event. Components of safety culture, especially communication openness, teamwork and reported near misses in the last year are significant predictors of the intent to report. Therefore, reinforcement of these components should be encouraged at the policy level to enable nurses to report near misses and thus improve patient safety.

scholarly journals Patient safety issues in rehabilitation for person with locomotor disabilities: a review

2019 ◽  
Vol 7 (4) ◽  
pp. 1388
Author(s):  
Kuldeep Deka ◽  
Pranjal Gogoi
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Health System ◽  
Cause Of Death ◽  
Institute Of Medicine ◽  
Safety Issues ◽  
Rehabilitation Professionals ◽  
Analysis Of Error

Since the publication of the Institute of medicine report, To Err Is Human: Building a safer health system, notes that errors in health care are a significant cause of death and injury and the emphasis on patient safety has steadily increased. The rehabilitation professionals engaged for the management of patient with locomotor disabilities should incorporate elements of patient safety into their practices and also to stimulate research associated with prevalence of analysis of error/harm which occurs during the rehabilitation phase and also to develop and validate certain specific measuring tools and instruments for patient safety issues.

scholarly journals Segurança do paciente: desafios para a prática e a investigação em Enfermagem

2010 ◽  
Vol 12 (3) ◽  
pp. 422-4 ◽  
Author(s):  
Ana Elisa Bauer de Camargo Silva
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Health System ◽  
World Health Organization ◽  
World Health ◽  
Institute Of Medicine ◽  
News Releases ◽  
Health Organization ◽  
Related Harm

doi: 10.5216/ree.v12i3.11885A preocupação com qualidade do cuidado e com a segurança do paciente nas instituições de saúde tem surgido em âmbito global. O movimento em prol da segurança do paciente teve seu início na última década do século XX, após a publicação do relatório do Institute of Medicine dos EUA que apresentou os resultados de vários estudos que revelaram a crítica situação de assistência à saúde daquele país. Dados apontaram que de 33,6 milhões de internações 44.000 a 98.000 pacientes, aproximadamente, morreram em consequência de eventos adversos(1). Desde então a Organização Mundial de Saúde (OMS) tem demonstrado sua preocupação com a segurança do paciente e adotou esta questão como tema de alta prioridade na agenda de políticas dos seus países membros a partir do ano 2000. Em 2004, criou a Aliança Mundial para Segurança do Paciente, visando a socialização dos conhecimentos e das soluções encontradas. Esta aliança tem também o objetivo de conscientizar e conquistar o compromisso político, lançando programas, gerando alertas sobre aspectos sistêmicos e técnicos e realizando campanhas internacionais que reúnem recomendações destinadas a garantir a segurança dos pacientes ao redor do mundo(2) . Em maio de 2007 foram publicadas as nove soluções para prevenção de evento adverso no cuidado à saúde(3). Os atuais desafios globais incluem "Cuidado Limpo é Cuidado Seguro" visando garantir a melhoria da higienização das mãos dos profissionais que atuam no cuidado, "Cirurgias Seguras Salvam Vidas", visando melhorar a segurança do tratamento cirúrgico em todos os contextos de cuidados de saúde e "Enfrentar a Resistência Antimicrobiana" como uma prioridade e o foco do Dia Mundial da Saúde de 2011(4). O maior desafio dos especialistas em segurança do paciente, que buscam a redução dos eventos nas instituições de saúde tem sido a assimilação, por parte dos dirigentes, de que a causa dos erros e eventos adversos é multifatorial e que os profissionais de saúde estão suscetíveis a cometer eventos adversos quando os processos técnicos e organizacionais são complexos e mal planejados. Os sistemas fracassam em todo o mundo e desde que a assistência seja prestada por seres humanos há a possibilidade de promoção de riscos e danos aos pacientes, embora o que seja de fato importante neste momento é que esta realidade não seja mais ignorada. A compreensão de que sistemas falham e permitem que as falhas dos profissionais se propaguem, atingindo os pacientes e causando eventos adversos, permite à organização hospitalar rever os seus processos, estudar e reforçar suas barreiras de defesa e as falhas latentes, que estão presentes nos locais de trabalho e que tornam o sistema frágil e suscetível a erros. Como resultado dos movimentos globais acerca dessa problemática, investigações científicas tem sido conduzidas para identificação e compreensão dos erros e eventos adversos, adoção de medidas corretivas e pró-ativas, análise das falhas sistêmicas e dos fatores causais, desenvolvimento de estratégias que garantam a prática segura melhorando a qualidade da assistência e, consequentemente, fornecendo maior segurança ao paciente. Um grave problema encontrado tem sido a falta de informações sobre os eventos adversos que ocorrem e sobre seus fatores causais, impedindo o conhecimento, avaliação e a discussão sobre as consequências destes eventos para os profissionais, usuários e familiares. Esta lacuna prejudica a ação dos gestores para realização do planejamento e desenvolvimento de estratégias organizacionais voltadas para a adoção de práticas seguras, minimização dos eventos e melhoria da assistência, colocando em risco a segurança dos pacientes. Entre os desafios para a enfermagem quando se trata do assunto estão: a criação de Comitês de Segurança do Paciente nas instituições de saúde constituída por equipe multidisciplinar, visando desenvolver uma cultura de segurança dentro das instituições e o fortalecimento da Rede de Enfermagem e Segurança do Paciente (Internacional, Nacional e Regional) promovendo a comunicação rápida e efetiva das evidências, experiências e recomendações destinadas a garantir a segurança dos pacientes ao redor do mundo. Outro desafio, não menos importante, está o desenvolvimento de pesquisas científicas que visem minimizar a reconhecida distância que existe entre o que se sabe em teoria e o que se aplica na prática (know-do gap). A enfermagem necessita transformar o discurso da pesquisa sobre segurança existente hoje, em um caminho sólido em direção a uma assistência mais segura no amanhã. As investigações sobre a segurança do paciente devem subsidiar as tomadas de decisão e as intervenções da gestão modificando a prática do cuidado.  As ações adotadas precisam gerar resultados como práticas confiáveis que façam a diferença na segurança dos pacientes, minimizando os riscos e alterando o quadro atual de eventos indesejáveis.   REFERÊNCIAS 1. Kohn LT, Corrignan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington: National Academy Press; 2001. 2. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29]. World Alliance for Patient Safety. Available from: http://www.who.int/patientsafety/worldalliance/en/. 3. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29]. WHO launches. Nine patient safety solutions. Solutions to prevent health care-related harm. Available from: http://www.who.int/mediacentre/news/releases/2007/pr22/en/index.html 4. World Health Organization [Internet]. Geneva: World Health Organization (SW) [cited 2010 sep 29]. Campaings. WHO Patient Safety campaigns. Available from: http://www.who.int/patientsafety/campaigns/en/. 

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