SafetyDog

Back to the Future…

In Behavior change, High Reliability Orgs, Resiliency, Root cause analysis on January 28, 2012 at 8:08 am

ISMP newsletter, 1998

“Currently, there is no consistent process among healthcare organizations for detecting and reporting errors. Since many medication errors cause no harm to patients, they remain undetected or unreported. Still, organizations frequently depend on spontaneous voluntary error reports alone to determine a medication error rate. The inherent variability of determining an error rate in this way invalidates the measurement, or benchmark. A high error rate may suggest either unsafe medication practices or an organizational culture that promotes error reporting. Conversely, a low error rate may suggest either successful error prevention strategies or a punitive culture that inhibits error reporting. Also, the definition of a medication error may not be consistent among organizations or even between individual practitioners in the same organization. Thus, spontaneous error reporting is a poor method of gathering “benchmarks;”it is not designed to measure medication error rates.” Read the full newletter here

Hey McFly, why have we made so little progress?

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