I was appalled when I read this, but let us all face it. The medical community is filled with human beings who will make errors. It’s never did you make an error, it’s when did you make an error. Then I think, did the error harm or have major potential to harm? Then lastly, what happened to cause the error? It is very easy to point the finger, though I can say I would have to point the finger at a nurse who threw away an organ; most of the time it is the process. This case would be termed a “Never Event” as in it should never happen.
So, when you have an error at the pharmacy, what are the steps taken to make sure it is corrected? Do you have meetings where you discuss the error openly and try to figure out how to correct it? Or, do you automatically assume that the pharmacist is lazy or needs education? Do you assume that he/she is incompetent? Whatever your group does it is so important to step outside of your group and realize that human beings will always err. Processes must change to create a scenario that has taken into account all of the possible things that could have happened wrong.
Have you ever seen the same type of error or even the same identical error twice from two different medical professionals? This is a huge red flag that process should be addressed.
The term “Never Event” was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable. The NQF initially defined 27 such events in 2002. The list has been revised since then, most recently in 2011, and now consists of 29 events grouped into 6 categories: surgical, product or device, patient protection, care management, environmental, radiologic, and criminal.
Source: Sentinel Event Statistics. September 30, 2009. The Joint Commission Web site.
Source: Adverse Health Events in Minnesota. Fifth Annual Public Report. St. Paul, MN: Minnesota Department of Health; January 2009. Available at: http://www.health.state.mn.us/patientsafety/publications/
consumerguide.pdf. Accessed December 30, 2009.
|Table. Never Events, 2011|
The National Quality Forum’s Health Care “Never Events” (2011 Revision)
|Surgery or other invasive procedure performed on the wrong body part|
|Surgery or other invasive procedure performed on the wrong patient|
|Wrong surgical or other invasive procedure performed on a patient|
|Unintended retention of a foreign object in a patient after surgery or other procedure|
|Intraoperative or immediately postoperative/postprocedure death in an American Society of Anesthesiologists Class I patient|
|Product or device events|
|Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the health care setting|
|Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used for functions other than as intended|
|Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a health care setting|
|Patient protection events|
|Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person|
|Patient death or serious disability associated with patient elopement (disappearance)|
|Patient suicide, attempted suicide, or self-harm resulting in serious disability, while being cared for in a health care facility|
|Care management events|
|Patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)|
|Patient death or serious injury associated with unsafe administration of blood products|
|Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a health care setting|
|Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy|
|Artificial insemination with the wrong donor sperm or wrong egg|
|Patient death or serious injury associated with a fall while being cared for in a health care setting|
|Any stage 3, stage 4, or unstageable pressure ulcers acquired after admission/presentation to a health care facility|
|Patient death or serious disability resulting from the irretrievable loss of an irreplaceable biological specimen|
|Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results|
|Patient or staff death or serious disability associated with an electric shock in the course of a patient care process in a health care setting|
|Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances|
|Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a health care setting|
|Patient death or serious injury associated with the use of restraints or bedrails while being cared for in a health care setting|
|Death or serious injury of a patient or staff associated with introduction of a metallic object into the MRI area|
|Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider|
|Abduction of a patient/resident of any age|
|Sexual abuse/assault on a patient within or on the grounds of a health care setting|
|Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a health care setting|
I do think the answer lies in evaluating all errors and making time to do so. Just sending a report of an error doesn’t evaluate why or how it happened.