As the primary goal of healthcare is “do no harm” [1]
As the primary goal of healthcare is “do no harm” 1, healthcare quality and patient safety have emerged as major targets for improvement during past decades 2. Health System shocked the nation with its frank discussion of the extent of preventable medical errors 3. Medication errors and drug-related adverse events have important implications from increased length of hospitalization, costs, disability and increased mortality 4. There has been a tremendous movement to identify and implement ways to improve the safety of health care delivery systems on many levels 3. Medical-error reporting helps to understand why errors occur, to prioritize opportunities for error prevention and to generate long term improvements in patient safety 5. Also reporting systems can provide guidance not only for the work that remains but also to evaluate the effectiveness of changes implemented 3. One of the most surprising findings was that even some of the most serious, egregious adverse events were not reported 2.
An error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems 6. Although not all errors lead to quality problems—only those errors that decrease the likelihood of desired health outcomes do so, the frequency and adverse impact of serious errors in medicine may be rising 7. Medical errors have been reported by various authors. Medical errors are defined by researchers as those in which the physicians concurred that they had made errors and tabulated those that had the potential to do severe, serious, or significant harm. The rate of such errors increased 122% between 1987 and 1994(7). A quarter of Medicare beneficiaries admitted to a hospital are victims of medical harm 8. A published report estimated the errors caused between 40,000 to 80,000 avoidable deaths annually. These errors include diagnostic errors, errors of omission, errors of context, and communication errors 6. In the overall, more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month 2. Medical errors have also economic implications as reported in 2013 in US to be $ 17 to 30 billion 6. WHO an annual cost ranging between $ 6 and 29 billion 10.Medication errors are among the most common medical errors, harming about 1.5 million people every year. These errors may occur during any phase of the drug delivery process from prescription to drug administration and at anywhere medications are administered 5. Physicians were the main source of reported medication errors 4. Medication errors, perhaps the most common misuse problem, caused preventable injuries to hospitalized patients at a rate of about ten per week in each of two large urban teaching hospitals and one-fifth were life-threatening 7. A pre-test and post-test study conducted on inpatients of a 177 bed hospital revealed that Medication errors were higher during ordering/prescription stage (38.1%) 5. Same result in a retrospective study, 1550 medication errors were collected and analyzed from government hospital in Abu-Dhabi for 2 years by using patient safety net 4. Patient safety is one of the greatest concerns in health care today. Preventing medical errors requires an understanding of how errors happen and requires honest, accurate disclosure 3. Error reporting and cause analysis are important tools to identify the major causes of medication errors 5. The Institute of Occupational Medicine recommends a two-tier error reporting system: a nationwide, state-based system that includes mandatory reporting of mistakes that result in death or serious injury, and a voluntary reporting system for other medical mistakes 6. Voluntary reporting can provide useful information about systems contributing to errors, strategies for prevention, and evidence-based information about patient safety concepts 4. Currently, several databases exist that collect information on specific types of errors 6, unfortunately, all of these systems have been limited by underreporting of adverse events 10. This lead to an inability to combine sufficient patient safety event data for analysis 6. One of the reasons of underreporting that the person who is responsible for the error may not report it, possibly out of fear of punitive action or because they do not understand an error has been committed 8. Also reporting of errors in the medical setting usually take place in a verbal, informal, non-official manner among medical professionals 11.Errors should be identified through an active management and effective reporting system, so they could be removed before they can reach or cause harm to patients 5. It is the responsibility of the bedside nurse, unit leadership, administration, and the organization to report errors 8.
