demonstrated a rate in hospitals of 16 errors/100 doses of medication (Barker & McConnell,1962). Because of this report, there have been ongoing initiatives to investigate medication errors and the commencement of setting forth important principles for the conduct of the research of medication errors. By the 1970s, medication error research extended into non-acute-care settings such as nursing homes, outpatient pharmacies, and special patient environments. Early work in the 1970s and 1980s included more effective monitoring of dispensing systems to reduce error. Commentaries were written on the exact nature of medication errors sparking increased public policy attention into the late 1980s. Interest in patient safety and medication errors continued to grow in the 1990s. In addition to evaluating occurrences of medical errors, a work was published regarding a meta-analysis of drug-related hospital admissions. In 1995, there was a startling economic estimate of adverse drug events set at about $76 billion annually (Kohn et al., 2000). Medical errors are not a new concern. However, this topic gained attention in the 1990s when government sponsored research about the problem was undertaken by physicians Lucian Leape and David Bates. The 1999 release of To Err Is Human and its subsequent publication in book form has been credited with galvanizing national action to improve patient safety (Kohn et al., 2000). Research related to patient safety has been part of healthcare literature for more than four decades. The Agency for Healthcare Research and Quality (AHRQ) funded a series of research studies examining the frequency and causes of medical errors. Based on these studies, the Institute of Medicine (IOM) estimated that as many as 44,000 to 98,000 Americans die in hospitals each year as a result of medical errors (Kohn et al., 2000). In light of these studies, healthcare leaders have rallied to shrink that alarming figure. enables accurate transfer of patient information can enhance patient safety but can also present risks to patient safety. Errors can happen when the patient’s sociodemographic and health data are entered. Other patient safety issues can be related to the software and upgrades to the computer hardware. Implementation of an infrastructure to monitor and learn from near misses is extremely important to reduce errors (Meeks et al., 2014). Human factors Human factors, such as fatigue, illness, drug use, and apathy, can all contribute to medical errors. These factors can affect the ability of healthcare providers to follow policies, guidelines, and best practice protocols (Rodziewicz et al., 2023). For example, researchers of an international study performed in 12 countries found that nurses working shifts longer than 12 hours, and those who worked overtime hours, reported increased incidents of poor quality and safety, along with care activities that were not able to be completed (Griffiths et al., 2014). Patient-related factors Patient-related issues can include inadequate identification, incomplete patient assessments, incomplete patient information, and inadequate patient education (Rodziewicz et al., 2023). The Joint Commission’s National Patient Safety Goals (NPSGs) program for hospital accreditation went into effect on January 1, 2003. Currently, the Joint Commission (2023a) lists Goal 1 as “to identify patients correctly.” Included in the action steps is the use of at least
In 2015, the National Patient Safety Foundation (NPSF) convened a panel of experts to discuss the current state of patient safety. The publication, Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human identifies that despite progress in the past nearly 20 years, patient safety remains an important public health issue. Preventable harm remains unacceptably frequent—in all settings of care and among all patient populations. Studies suggest that the overall toll exacted by safety problems has remained high (Classen et al., 2011; James, 2013; Landrigan et al., 2010; Makary & Daniel, 2016). Harms caused during care carry significant mortality, morbidity, and quality-of life implications, no less than obesity, airplane or motor vehicle crashes, and breast cancer. Despite increased focus and some indications of improvement, about 1 in 10 patients develop an adverse event, such as a healthcare-acquired infection, pressure ulcer, preventable adverse drug event, or a fall, during hospitalization (AHRQ, 2014; Bates et al. 2023). The World Health Organization (WHO, 2023) has reported that 1 in 10 patients who are hospitalized experience some type of harm due to care provided, and greater than 50% of these cases are preventable. Ten percent of surgical procedures performed each year globally have an occurrence of harm (WHO, 2023). About 50% of errors in healthcare are due to medications (WHO, 2023). Between 5% and 20% of doctor- patient encounters experience a diagnostic error (WHO, 2023). Globally, there are 421 million hospitalizations and approximately 42.7 million adverse events each year (WHO, 2019). History of medical errors issue One of the earliest studies of a medical error was a 1954 analysis of causes of death during anesthesia administration (Beecher & Todd, 1954). Early studies indicated that medication errors accounted for a significant proportion of adverse patient care events. Influential research relating to medication errors includes a report in 1962 which Contributing causes of medical errors Multiple factors are attributed to medical errors, and the contributing causes can be grouped into eight categories (AHRQ, 2003). This section summarizes these factors. Communication factors Miscommunication represents the most common cause of errors impacting the patient (Rodziewicz et al., 2023). Lack of clear oral and written communication among teams and between care providers and patients jeopardizes patient care. Miscommunication can occur across and within healthcare settings and among anyone involved in the care of patients. All members of the interprofessional team need to be knowledgeable about effective communication techniques that focus on patient safety (Interprofessional Inadequate information flow can affect the availability of critical information that is needed to influence patient care decisions. Patient transitions or movement across and within acute care settings, community settings, and the patients’ homes are times when patients are at increased risk of harm. For example, confusing and incomplete information and/or decreased sharing of information about the patient throughout the care continuum could lead to adverse events (Finkelman, 2016). A decentralized and fragmented healthcare system can result in poorly documented or lost information on laboratory tests, diagnostic tests, or medical information, further contributing to medical errors. Investing in health information technology (HIT) to have a system that Education Collaborative, 2016). Inadequate information flow
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