Compounding the problem is the fact that changes in our health system are forcing many long-term care facilities to adopt treatment methods that were formerly reserved for hospitalized patients. Even when consultant pharmacists try to solve the drug problems they've uncovered, they are often stymied by several factors. The problem may be nearly impossible to correct because of the complexity of the systems with which the pharmacist and the facility are working. Or, the same problem might be highly unlikely to occur again, because so many system failures would have to occur simultaneously for that error to ever reach another patient. Or, the medication error itself may be relatively benign.
Most people working in long-term care are skilled and careful professionals.
Pharmacists or other members of the care team who have made an error are often devastated. And even though whoever came up with the name for amlodipine had no idea it would be confused so often with Navane, it's possible this could have been revealed through more thorough testing by the drug company. Despite the fact that all of this may be true, the fault really doesn't matter at this point. What matters is that we need to do something to make sure this critical error doesn't recur. Systems Failures, Not People Problems Since ISMP began working in this field in 1975, it has made it a point to look at medication errors as systems failures, rather than as people problems.