Providers can lose their jobs and face significant lawsuits if implicated. So countless great opportunities to learn from mistakes and institute systems to prevent further errors are lost. But to effectively put in place systems which screen out errors before they occur requires that health systems create learning environments with open communication about what works and what does not. Human beings make mistakes, said John Combes, M.D. Senior Advisor to the Hospital and Health Systems of Pennsylvania, because they are in a hurry, are tired, are repeating something they do often, they are bored or they are anxious. In such environments, systems that detect and correct potential errors are essential, he said.
Errors happen after a whole series of things have gone wrong.
The person closest to the patient usually is blamed, but many latent errors will have to occur first, he said. A nurse or doctor may administer an incorrect medication, but the order and the drug itself will be handled by numerous people on its way to the patient. A new medication, for instance, may be packaged almost identically to another that is used for a completely different symptom. Sometimes the names of drugs are similar. Physician handwriting can be subject to interpretation.