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After completing this chapter, the reader will be able to

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  • Define and compare the terms medication errors, adverse drug events, and adverse drug reactions.
  • Discuss the role of Patient Safety Organizations (PSOs) in health care.
  • Assign an event severity rating to reported errors and events.
  • Describe reporting systems for medication errors and adverse drug events.
  • Discuss two methods of analyzing medication errors and adverse drug events that are utilized to develop action plans for prevention of recurrence.
  • Describe examples of skill-based, rule-based, and knowledge-based errors.
  • Explain a systems approach to error.
  • Determine strategies health care practitioners and health systems can implement to reduce medication errors.
  • Reflect on the need for interprofessional education and training on quality and safety principles.
  • Compare a Just Culture with a culture of shame and blame.

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  • Image not available. The terms medication error, adverse drug event, and adverse drug reaction are similar and often confused. They are interrelated yet distinct occurrences.
  • Image not available. Several methods of identifying errors are recommended to gain a more global understanding of the risks and errors occurring within an institution.
  • Image not available. Classification of error types is a common method to identify common themes and causes of events. The Common Formats associated with Patient Safety Organizations (PSOs) may become the new standard classification scheme.
  • Image not available. Thorough analysis of safety events through root cause analysis (RCA), failure mode and effects analysis (FMEA), or other methods is a key activity to support learning from our mistakes in an effort to prevent recurrence.
  • Image not available. Human beings (including health care professionals of all types) have a propensity to commit errors in all aspects of their lives. To err is human.
  • Image not available. Understanding human error types (skill-based, rule-based, and knowledge-based errors) is very important to understanding errors and events, and in developing appropriate strategies to reduce the risks of recurrence.
  • Image not available. Poorly designed health care systems and processes are a significant contributor to individual human error and subsequent patient harm.
  • Image not available. A Just Culture is one in which discipline is applied in a consistent manner based on the intentions of the individual and the situation in which the individual was placed, not on the outcome.
  • Image not available. All health professionals should be trained to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.
  • Image not available. There are many resources available that identify best-practice error prevention strategies.
  • Image not available. Designing with human factor principles in mind is a great way to improve the safety of any process.

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Much attention has been focused on adverse outcomes in health care in the past decade. Although pockets of research in medical errors were developing prior to 2000, the Institute of Medicine's report, To Err Is Human: Building a Safer Health System,1 released in late 1999, served as a catalyst for additional research in the causes and methods to prevent adverse outcomes in health care. The mortality estimates documented in this report (an estimated 44,000 to 98,000 people die each year as a result of medical errors) ...

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