Most hospital errors go unreported

A report cited by a recent New York Times article says that only one out of every seven errors, accidents and other harmful events are report by hospital employees. In fact, errors occur more frequently than many are willing to admit. According to the now infamous “To Err Is Human: Building a Safer Health System“ report in November 1999, between 45,000 and 98,000 patients die each year in healthcare systems secondary to medical error. Such numbers may appear out of place on the surface, but one must look at the complex nature of the healthcare system and the treatment patients receive to understand the difficulty in differentiating an error or harmful event from a change in patient status.

While practically every hospital has a system in place to identify and report medical errors, the fact remains that a majority of them go undetected because their effects may be indiscernible from acute changes in the patient’s condition. It may be difficult to comprehend such a thing, but the problem is really quite simple: humans make mistakes and adverse events are hard to spot.

Regardless of the policies and procedures in place, we’re all human, and as such are prone to error. As unsettling as this may be, for many it is reality. However, improvements in automation and technology are beginning to change the landscape of many pharmacy operations. Adoption of bar code medication administration (BCMA), computerized provider order entry (CPOE), Smart Pump technology, and so on are helping drive down the number of errors seen in hospitals. As the adoption of these technologies increase, healthcare systems will see error rates drop. In addition to advances in pharmacy technology, the use of advanced computer models will aid in predicting, tracking and alerting healthcare providers of potential medical errors. While this may seem like science fiction, systems like IBM’s Watson and advanced mathematical modeling with supercomputers are already making it a reality.

As I alluded to above, errors are often hard to spot. According to a New York Times article “the problem is that hospital employees do not recognize “what constitutes patient harm” or do not realize that particular events harmed patients and should be reported.“ The complex nature of patient care contributes to the confusion. It is often difficult to determine the difference between harm caused by a medical error and a natural change in a patient’s condition. This is especially true with medication errors, as many healthcare professionals outside of pharmacists don’t think of drugs as a potential cause of a patient’s worsening condition. Fortunately programs such as the Pharmacy Practice Model Initiative (PPMI) from ASHP and other advanced practice models throughout the United States are already changing the way pharmacy is practiced. The future will bring professionals trained in the art of spotting adverse drug reactions, i.e pharmacists, to the patient bedside.

A lot has changed since the To Err Is Human report in 1999. Unfortunately medical errors remain problematic. While efforts to reduce medical errors have failed to pay dividends in recent years I believe advancement in technology and a drive to change how pharmacists practice have created an atmosphere of positive patient care that will include a decrease in the number of errors found in healthcare. It’s only a matter of time.

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