Conclusions

There are many lessons to learn from the four cases and the circumstances surrounding them that contributed to error. The actions of a health care provider can directly cause an error; however, the source of such actions is the reasonable target for remediation. There are a multitude of circumstances and system issues including the complexity of prescribing, dispensing, administering, and monitoring medication that contribute to medication errors. To reduce errors, those circumstances and issues must be identified and addressed.

The stories presented in this chapter represent only a small portion of the situations in which health care providers and patients interact. Nonetheless, those stories provide a glimpse of the difficulties that face practitioners like Dr. Yoder, Nurse Paula Peters, and Pharmacist Ron White on a day-to-day basis in a variety of settings. The inability to prevent harm to patients like Mark, Mr. Jones, and Mrs. Bledsoe, reflected in these stories, has less to do with the capabilities of the practitioners and more to do with the systems factors that they constantly encounter. Although the majority of health care interactions involving medication are safe and effective, error-provoking systems factors lead to incidents. It is beyond human ability, particularly the ability of a stressed and fatigued health care provider, to anticipate and compensate for all such factors; to reduce error, the factors must be changed.

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