Institutes of Medicine’s Conclusion on Medication Errors
The Institute of Medicine’s focus is to develop a strategy to improve the quality of American health care. They have compiled and analyzed a massive collection of data and reports by researchers in their endeavor. One such endeavor is to recommend measures in an effort to decrease the amount of preventable medication errors in hospitals. A report cited remarkable progress in using system approaches to enhance safety, reduce errors and maximize quality in industry, but that health care “is decades behind in terms of creating safer systems.” Another report stated that “most adverse events are preventable, particularly those due to error or negligence.” A study focused on the pharmacy’s order entry process since most errors were known to occur there. Order entry errors among pharmacy employees ranged from 0 to 112 over 2 months. Errors were often the result of misunderstandings, distractions and interruptions and the illegibility of handwritten scripts. As a result it was recommended to institute computerized physician order management and the education and supervision of pharmacy technicians among other steps. The simple step of discussing each medication prescribed with a patient informing them of potential side effects and drug interactions eliminated the instance of many medication errors. The Institute of Medicine's recommendation for quality improvement is based on many years of data observation, collection, and analysis. This work was performed by practitioner-researchers and efficiency consultants from many disciplines. The resulting recommendations are striking in their straightforward practicality and in their insistence that process factors determine output
