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incidents at least quarterly as well as an annual report of all adverse incidents (Florida Statutes, 2015a). In addition, a separate section of state law requires the Florida Agency for Healthcare Administration to collect data on hospital-acquired infections (Florida Statues, 2015a). Florida became the first state to publish a hospital-specific report on hospital-acquired infections (HAIs) in 2005. However, a March 2010 review by the Committee to Reduce Infection Deaths noted that the Florida reports were disappointing due to weaknesses in data collection, detail, and methodology (RID, 2011). In 2011 the Florida Department of Health announced it received funding from the American Recovery and Reinvestment Act to develop a Healthcare-Associated Infection Prevention Program intended to help monitor and prevent these infections. Its status on infection rates as compared to the national baseline is accessible from the CDC (CDC, 2015a). Florida’s Progress Combating HAIs image: florida hai progress Source: CDC, 2015. Click here or on the image to view the full-size graphic. Types of Medical Errors Error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Institute of Medicine, 1999 To Err is Human: Building a Safer Health System There are many ways that medical care can go wrong. Errors can be related to the administration of medications, laboratory testing, infections occurring within the healthcare setting, surgery, or an environment contributing to a patient fall. A number of healthcare organizations and government agencies have lists of medical errors on which they focus, but the seven we will discuss appear as hot-button indictors across most oversight organizations and are the ones most commonly encountered: Medication events (including adverse drug events/reactions) Healthcare-associated infections Surgical errors Laboratory errors Patient Falls Pressure sores Documentation/computer errors (NQF, 2011; AHRQ, 2015; CMS, 2014; Joint Commission, 2015; NHSN, 2015; CDC, 2014) Medication Events According to Preventing Medication Errors, the final report of a joint project involving the Institute of Medicine and others, there are 1.5 million preventable adverse medication events in the United States each year costing as much as $3.5 billion annually, making medication errors the most common of all medical errors.The report notes a comprehensive study found an administration error rate of 11%. With a typical hospital patient receiving an average of 10 doses of medication each day, he or she could be subjected to at least one administration error per day (IOM, 2007). Some of the most common causes of medication errors are: Incomplete patient information, with the healthcare professional not knowing about allergies and other medications the patient is using Miscommunication between physicians, pharmacists, and other healthcare professionals. For example, drug orders can be communicated incorrectly because of poor handwriting. Name confusion from drug names that look or sound alike Confusing drug labeling Identical or similar packaging for different doses Drug abbreviations that can be misinterpreted (FDA, 2012) Adverse drug events (ADEs) cause an estimated 700,000 emergency department visits each year, and the CDC notes that the numbers of ADEs will likely grow due to: development of new medications, discovery of new uses for older medications, an aging American population, increase in the use of medications for disease prevention, and increased coverage for prescription medications (CDC, 2012). Medication Errors In 2011 the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) urged medication error researchers, software developers, and institutions to use this standard definition to identify errors: A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice, healthcare products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use (NCCMERP, 2014). Not all medication errors result in harm to the patient. For example, if the dosage or route were prescribed incorrectly but the error was caught prior to administration (often called a “near miss”), there was no patient harm. That said, any type of medication error must be tracked so preventions can be developed, regardless of whether a patient was harmed or not. Adverse Drug Events (ADEs) An adverse drug event (ADE) is “an injury resulting from the use of a drug.” However, not all adverse drug events are the result of errors. According to the VA, “adverse drug events may result from medication errors but most do not” (USDVA, 2006). ADEs are a serious public health problem, and are a leading cause of injury and death. ADEs account for an estimated one-third of hospital adverse events and approximately 280,000 hospital admissions annually (ODPHP, 2014). According to the federal Office of Disease Prevention and Health Promotion, ADEs are responsible for a staggering number of harmful patient impacts. In inpatient settings, ADEs: Account for an estimated 1 in 3 of all hospital adverse events Affect about 2 million hospital stays each year Prolong hospital stays by 1.7 to 4.6 days In outpatient settings, ADEs account annually for: Over 3.5 million physician office visits An estimated 1 million emergency department visits Approximately 125,000 hospital admissions (ODPHP, 2014) In addition, the Centers for Disease Control and Prevention (CDC) said ADEs are responsible for $3.5 billion in extra medical expenses as well as 40% of preventable ambulatory care costs (CDC, 2012). Adverse Drug Reactions (ADRs) Adverse drug reactions (ADRs) are unintended negative responses or harm caused during the normal use of a medication. ADRs can be an allergic response, such as hives after taking antibiotics, or a side effect such as stomach upset with aspirin (USDVA, 2006). While all adverse drug reactions are adverse drug events, not all adverse drug events are adverse drug reactions. A patient given the wrong medication is an adverse drug event but not an adverse drug reaction because the medication in question was not used as it was intended. The figure below helps to clarify how the medication-related errors differ and relate to one another. Adverse Drug Events vs. Reactions Source: ODPHP, 2014. Adverse drug reactions are a leading cause of injury and death; it is estimated they cause 100,000 deaths annually in the United States (FDA, 2014). According to the Institute of Medicine, more than 2 million serious ADRs occur each year, 350,000 in nursing homes alone. In recent years the number of medications prescribed to patients has increased dramatically and, not surprisingly, adverse drug reactions have also increased. “Whereas a patient admitted to the hospital typically undergoes one—or even no—surgical procedure, virtually everyone gets bombarded with an array of medications the whole time they’re there” (FDA, 2014; Wachter & Shojania, 2004). There are three main causes for adverse reactions: As many as two-thirds of all patient visits to a doctor result in a prescription, and there are more drugs and combinations of drugs being used than ever before. More than 4 billion prescriptions were filled in 2014 at retail pharmacies alone, nearly 10 prescriptions per person in the United States. The rate of ADRs increases exponentially when a patient is taking four or more medications (FDA, 2014; KFF, 2014). The drug approval process may also play a role in the increase of adverse drug reactions. A drug that is tested in only a few thousand people may have an excellent safety profile in those patients, but some drugs require many more