Chapter 16: Medication Misadventures II: Medication and Patient Safety

Learning Objectives

After completing this chapter, the reader will be able to

• Define and compare the terms medication errors, adverse drug events, and adverse drug reactions.

• Describe methods to identify medication errors and adverse drug events.

• Discuss the role of Patient Safety Organizations (PSOs) in health care.

• Assign an event severity rating to reported errors and 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.

• Compare a Just Culture with a culture of shame and blame.

• 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.

Key Concepts

1. The terms medication error, adverse drug event, and adverse drug reaction are similar and often confused. They are interrelated, yet distinct occurrences.

2. Several methods of identifying errors are recommended to gain a more global understanding of the risks and errors occurring within an institution.

3. Classification of errors by type is a common method to identify common themes and causes of events.

4. 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 errors in an effort to prevent recurrence.

5. 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.

6. Understanding the three modes of human performance (skill based, rule based, and knowledge based) is very important to understanding errors and events, and in developing appropriate strategies to reduce the risks of recurrence.

7. Poorly designed health care systems and processes are a significant contributor to individual human error and subsequent patient harm.

8. 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 they were placed, not on the outcome.

9. 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.

10. There are many resources available that identify best-practice error prevention strategies.

11. Researching, recognizing, and designing with human factors principles in mind is a great way to improve the safety of any process.

Introduction

Much attention has been focused on adverse outcomes in health care in the past 15 years. While 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 ...