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.
At any of these places, an error can occur. Dr. Bill Weeks, from the VA Regional and Medical Office Center in White River Junction, described efforts the VA is advancing to improve patient safety. Most projects were in the area of medications, as a majority of problems occur with medications. These positive results are possible when a culture of safety exists, Weeks said. The entire organization must make a commitment to ensuring mistakes do not happen.