Medication Error History
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(now published by Thomas Land Publishers). 1981 First printing of Medication Errors: Causes and Prevention, a comprehensive book on the causes and prevention types of medication errors of drug mistakes, written by Michael Cohen and Neil Davis, ISMP cofounders. examples of medication errors 1987 ISMP convenes national meeting that influences the United States Pharmacopeia (USP) and U.S. Food and Drug Administration worst medical mistakes in history (FDA) to require that potassium chloride concentrate for injection have black caps, closures, and warning statements to prevent mix-ups with other parenteral drugs. First ISMP list of dangerous medical abbreviations
Medication Errors Statistics
published in Nursing ’87 magazine. 1991 National, confidential, voluntary medication error reporting program (MERP) created by ISMP to provide expert analysis of the system causes of medication errors, in coordination with The United States Pharmacopeia (USP). ISMP promotes changing vincristine labeling to reduce the likelihood of inadvertent intrathecal injection; this advocacy leads to an updated USP standard. 1992 ISMP convenes medication error definition national meeting to discuss elimination of cardiac lidocaine in 1 and 2 g concentrate prefilled syringes, due to reports of deaths from mix-ups with 100 mg prefilled syringes. Products are subsequently pulled off the market by their manufacturers. ISMP President appears on the premier segment of the Dateline show on NBC, which discussed fatal medication errors, including a vincristine overdose that killed a small child. First scholarly publication in the medical literature about the dangers of free-flow infusion pumps appears with ISMP-authored article in Hospital Pharmacy. 1994 Institute officially incorporates as nonprofit organization and runs on volunteer efforts. First article on the use of failure mode and effects analysis to examine medication errors is published by ISMP in the medical literature (Hospital Pharmacy). First ISMP Global Conference on Medication Error Reporting Programs held. Administration of error reporting program is transferred to USP; becomes the ISMP MERP. 1995 National forum on preventing medication errors in cancer chemotherapy is sponsored; recommendations are later published in the American Journal of Hospital Pharmacy. ISMP’s website (www.ismp.org) goes live, providing free safety information electronical
error reduction program in place. Learn More Health care quality and safety represents a constantly recurring theme in U.S. health policy. In radiation oncology, recently published incidents involving medical events have received increased public attention medication error stories and Congressional scrutiny. The practice and business of radiation oncology is rapidly changing as
Preventing Medication Errors
pressure increases to reduction medical errors and increase patient safety. The History of Medical Errors and Patient Safety is a snapshot of past,
Ismp Medication Safety Alert
current, and future initiatives taken by state and federal governments to improve quality of care and patient safety. Introduction Patient safety is defined as freedom from accidental injury due to medical care, or absence of medical http://www.ismp.org/about/timeline.aspx errors, or absence of misuse of services.1,2,3,4 An error is described as the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning).5 In radiation oncology, a variety of injuries and errors can occur in the diagniostic imaging and therapeutic treatment delivery process. Various descriptors of the term “error” found in radiation oncology are unintended http://www.radphysics.com/history-of-medical-errors deviation, incident, accident, mistake, unusual occurrence, recordable event, adverse event, misadministration, medical event, and sentinel event. History The Institute of Medicine (IOM) report in 1999 focused a great deal of attention on the issue of medical errors and patient safety. The report stated that 44,000 to 98,000 deaths occur per year in U.S. hospitals as a result of medical errors.6 In addition, 10,000 deaths per year occur in Canadian hospitals. Deaths in the U.S. alone exceed annual death rates from road accidents, breast cancer, and AIDS combined. The IOM estimated costs due to medical errors in the U.S. of approximately $37.6 billion per year.7 Of the $37.6 billion, about $17 billion are associated with preventable errors. Of that $17 billion, about $8 to $9 billion are for direct health care costs. Updated estimates place costs for errors in hospitals nationwide to be between $17 billion and $29 billion each year.8 The Healthcare Research and Quality Act of 1999 required the Agency for Healthcare Research (ARHQ) to support research and build private-public partnerships. The purpose was to identify causes of preventable health care errors and patient injury; develop, demonstrate, and evaluate strategies for reducing errors and patient injury; and disseminate such strategies.9 Federal initiatives taken by former President Clinton on February 22, 2000 were based on IOM recommendations. These initiatives in
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article, discuss the issue on the talk page, or create a new article, as appropriate. (December 2010) (Learn how and when to remove this template message) A medical error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment. Globally, it is estimated that 142,000 people died in 2013 from adverse effects of medical treatment; this is an increase from 94,000 in 1990.[1] However, a 2016 study of the number of deaths that were a result of medical error in the U.S. placed the yearly death rate in the U.S. alone at 251,454 deaths, which suggests that the 2013 global estimation may not be accurate.[2][3] Contents 1 Definitions 2 Impact 2.1 Difficulties in measuring frequency of errors 3 Causes 3.1 Healthcare complexity 3.2 System and process design 3.3 Competency, education, and training 3.4 Human factors and ergonomics 4 Examples 4.1 Errors in diagnosis 4.2 Misdiagnosis of psychological disorders 4.3 Most common misdiagnoses 4.4 Outpatient vs. inpatient 5 After an error has occurred 5.1 Recognizing that mistakes are not isolated events 5.2 Placing the practice of medicine in perspective 5.3 Disclosing mistakes 5.3.1 To oneself 5.3.2 To patients 5.3.3 To non-physicians 5.3.4 To other physicians 5.3.5 To the physician's institution 5.3.6 Use of rationalization to cover up medical errors 5.3.7 By presence of to the patient 5.4 Cause-specific preventive measures 5.5 In specific specialties 5.6 Legal procedure 6 Prevention 6.1 Reporting requirements 7 Misconceptions 8 See also 9 References 10 Further reading 11 External links Definitions[edit] The word error in medicine is used as a label for nearly all of the problems harming patients. Medical errors are often described as human errors in healthcare.[4] Whether the label is medical error or human error, one definition used for it in medicine says that it occurs when a healthcare provider chooses an inappropriate method of care or improperly executes an appropriate method of care. It has been said that the definition should be the subject of more debate. For instance, studies of hand hygiene compliance of physicians in an ICU show that