How do medical errors happen? And what can be done?

Millions of people suffer every year from mistakes in health care. In a presentation from the IHI Open School, Lucian Leape explains why those mistakes happen — and how to prevent them.

The INQRI program is committed to understanding and preventing medication errors. Several of our teams are focused on this important work:

• "Examining the Impact of Nursing Structures and Processes on Medication Errors"
  The Institute of Medicine noted that a hospital patient on average is subject to at least one medication error per day, making medication errors the most common cause of preventable adverse events. This interdisciplinary study, directed by Linda Flynn and Dong Suh from Rutgers University has been designed to disentangle the effects of nursing structures and care processes on non-intercepted medication errors in acute care hospitals. Click here to read a profile on Linda and her work.

• "Nursing-Pharmacy Collaboration on Medication Reconciliation: A Novel Approach to Information Management"
  Deficits in communication across the continuum of care in regards to medication use can place patients at serious risk for harm. This interdisciplinary team, directed by Linda Costa and Bob Feroli at Johns Hopkins Hospital is examining how to economically support direct care providers in medication reconciliation in order to facilitate safe transition to and from hospital and community. The team has evaluated the effectiveness of a nurse-pharmacist clinical information coordination team in improving drug information management on admission and discharge, quantify potential harm due to reconciliation failures, and determine cost-benefit related to averted harm. Click here to read “Nurse-Led Interdisciplinary Teams: Challenges and Rewards,” a piece co-authored by Linda and Stephanie Poe which ran last fall in the Journal of Nursing Care Quality’s Focus on Patient Safety column.

• "Empowering Home Care Nurses to Efficiently Resolve Medication Discrepancies"
  To contribute to a better understanding of the potential for home care nurses to lead in the identification and resolution of medication discrepancies during transitions between hospital and home care providers, this team at Washingon State University is conducting a clinical trial that investigates a new nurse-led, informatics-based intervention. They hypothesize that with this improvement in their environment, home care nurses already on staff can enhance patients' outcomes, reduce healthcare costs, and eliminate the need for duplicative services by external consultants or specialty providers. This team is co-led by Cynthia Corbett and Stephen Setter. Click here to read more about their project.

Recently, Drs. Flynn and Costa presented their work at the Funders Forum, co-sponsored by INQRI and the Donaghue Foundation. Click here to download their presentations.

For other programs from the IHI Open School, click here.