Protecting the Patient: Medical Errors and Safety

Mistakes happen. But it’s one thing when your best friend accidentally scratches your car and another when patient safety is involved. It’s impossible to be perfect, but what are best practices? Third-year College of Medicine students getting ready for their fall 2018 clerkships began a second week of preparation July 23 with a session designed to teach them about medical errors and safety.

NEOMED’s focus on interprofessional learning kicked in, with the medicine students being taught by two pharmacy faculty members: Kathleen Cubera, R.Ph., clinical associate professor of pharmacy practice; and Susanna Petiya, Pharm. D., clinical associate professor of pharmacy practice.            

Vigilance is crucial

Dr. Petiya said medication errors happen from flaws in the medication use system—in other words, flaws in the way that a medication is prescribed, transcribed, dispensed or administered. New residents need to be vigilant, even about details that it might seem they could trust to be right. Take those little plastic dosing cups that patients might get to measure their cough medicine. A supply of them was manufactured a few years back and distributed for patients to use, despite leaving out the 10 mL mark and instead repeating the 5 mL mark in its place—opening a dangerous potential for harm.

Health care providers can keep themselves up to the minute, too, with Institute for Safe Medication Practice safety alerts that are issued every two weeks, said Dr. Petiya. A recent alert noted that bar code scanners have trouble reading information that’s printed horizontally on the curved surface of a pill container.

In the rare and unfortunate circumstance that an error occurs and a patient becomes ill or even dies, health care providers need to recognize that those involved may become second ''victims'' who are in anguish about the results of the error. As one student in the class noted, directing ''second victims'' to counseling is one immediate way to help.

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