By using confidential peer interview of house officers during morning rounds at a major teaching hospital in Boston, researchers were able to flag many adverse events, medical errors, and potential adverse events that would have been unidentified. They say we need to have mandatory reporting for egregious errors, but we also need to have a voluntary system that will allow us to actually learn enough to make some improvements. It's likely that Medicare hospitals will see mandatory reporting requirements soon. Shows percentages of errors in ordering, transcription, dispensing, and administration of medication orders. Participants do not necessarily define medical errors in the same way.
Errors can include problems in practice, products, procedures, or systems.
More information nneds to be made availale on safety and quality for both consumers and health care purchasers. The authors describe how they used root cause analysis to investigate and remediate patient safety issues following a well-publicized sentinel event involving a medication overdose. Building a Safer Health System. HIV care requires close, frequent monitoring of patients for progression of illness, response to treatment, and drug side effects related to complex treatment regimens. In addition, this frequent monitoring requires the implementation of systems to track patients and their treatment adherence, referrals, medications, and laboratory reports to ensure the safety and efficacy of HIV care.