Page 23
any given week four out of every five U.S. adults will use prescription medicines, over-the-counter drugs, or dietary supplements, and nearly one-third of adults will take five or more different medications (IOM, 2006). Some of the harm done by medications can be anticipated, as they are the potential side effects that may be caused by the medications. The potential benefit of using the medication is determined by the patient and prescriber to be worth the risk of the side effects which may be possible with the use of a particular medication. However, some adverse drug events (ADEs) occur as injuries that happened because of an error in prescribing, dispensing or administering a medication. Such errors can be prevented. Some of the harm done by medications can be anticipated, as they are the potential side effects that may be caused by the medications. The potential benefit of using the medication is determined by the patient and prescriber to be worth the risk of the side effects which may be possible with the use of a particular medication. However, some adverse drug events (ADEs) occur as injuries that happened because of an error in prescribing, dispensing or administering a medication. Such errors can be prevented. In 2008 the actor Dennis Quaid and his wife became celebrity spokespersons regarding medication errors after their twin infants, in November, 2007, were given 1,000 times the dosage of heparin than was ordered-twice! In that situation, according to their 60 Minutes interview (March 16, 2008), the error occurred because a pharmacy technician stored the higher heparin doses in the wrong place and a nurse who administered the drug to the babies failed to verify the amount. Additionally, the Quaids then also sued Baxter Healthcare Corp., accusing the company of negligence in packaging different doses of Heparin in similar vials with blue backgrounds. The findings of the IOM study are that medication errors are quite common - and that they are very costly to the population. At least 1.5 million preventable ADEs occur in the U. S. each year. The true number may be much higher. A hospitalized patient in the US can expect to be subjected to more than one medication error per day! 10 In the state of Florida, medical errors have improved, as per the above Third Annual Patient Safety in American Hospitals Study. Florida was among the16 states that performed statistically significantly better than expected. Florida health officials have been collecting data on medical mistakes from hospitals and walk-in surgery centers since 2001. The reports do not include hospital names; they identify aggregate data only. Despite the improvement noted above, data collected by Florida officials indicate that more than 1,000 patients died in Florida hospitals from adverse events between January 2001 and June 2004. Additionally, nearly 400 patients have needed surgery to remove a sponge or other object left inside them in a prior operation (Gaul, Washington Post, 2005). Defining Medical Errors The National Patient Safety Foundation (NPSF), in 2003, defined patient safety and healthcare error (NPSF, 2005): Patient safety is the prevention of healthcare errors, and the elimination or mitigation of patient injury caused by healthcare errors. A healthcare error is an unintended healthcare outcome caused by a defect in the delivery of care to a patient. Healthcare errors may be errors of commission (doing the wrong thing), omission (not doing the right thing), or execution (doing the right thing incorrectly). Errors may be made by any member of the healthcare team in any healthcare setting. There is no universal definition of medical errors. The many healthcare organizations that are currently focused on healthcare errors do not all define medical errors in the same way. Sometimes medical errors are called something other than an "error". Other terms or words used to identify a medical error include (Kirker, 2003): · Adverse event, adverse outcome; · Medical mishap, unintended consequences; · Unplanned clinical occurrence; unexpected occurrence; untoward incident; · Therapeutic misadventure; bad call; · Peri-