Errors in the field of medicine can be dangerous and deadly. It is important for health organizations to take responsibility for mistakes done while treating patients, medical procedures, and therapies. Significant incidents, such as the Three Mile Island or the Challenger crash, catch the attention of people and make newspapers the front page. Since they typically only involve one person at a time, errors in healthcare are less noticeable and severe than those in other industries. They are scarcely noted, except for celebrated cases such as Betsy Lehman (the Boston Globe reporter who died from an overdose during chemotherapy) or Willie King (who had amputated the wrong leg). Accidents, however, show what the system lacks as they represent places where the system failed and damage resulted from the failure. 

 A Report from the Institute of Medicine

On December 1, 1999, To Err is Human: Creating a Safer Health System was published by the Institute of Medicine (IOM), which reported that an estimated 44,000 to 98,000 individuals die annually from medical errors. According to the study, “more people die as a result of medical errors in a given year than in motor vehicle accidents (43,458), breast cancer (42,297), or AIDS” (16,516). The study also reports that the overall national costs of preventable adverse events, including lost sales, lost household production, impairment, and health care costs, are projected to be between $17 and $29 billion per year, 50 percent of which are direct health care costs. 

Deaths that occurred in hospitals (both in and out) exceed those that occur as a result of workplace injuries. It was also noted that the majority of these medical errors were due to structural flaws in the hospital systems rather than individual recklessness. In order to avoid errors and improve patient safety, a systematic approach is required in order to change the factors that lead to errors. The Healthcare sector has the most trained and committed workers than any other sector. The issue is not bad individuals; the problem is that it is important to make the system safer. 

What can the healthcare system do to avoid medical errors?

• Legibly write chart notes, directives, and prescriptions. The use of hand-held computers or computerized charting stations to record drugs and dosage instructions by hospitals and large outpatient clinics was the top recommendation to mitigate the issue of illegible writing as cited in the IOM Study.
• Ensure that patients are fully aware of what medicine they are taking, what the tablets look like, and what the drug is treating to boost compliance with them.
• Promoting a system-based approach to error resolution, reiterating drug protection at staff meetings, developing non-punitive environments and error and injury reporting processes, minimizing memory reliance, promoting memory reliance, Protocol standardization, and the use of checklists (Committee on Health Care Quality in America, 1999).
• Promote the distinctive storage of medicines that are to be diluted before being given to minimize the risk of errors, the Henry Ford Health System, cited in the IOM Study, stores non-diluted drugs in double canisters, for example.
• Be proactive. Bring good ideas to the supervisors that you will learn about, such as color-coded wrist placement when they are admitted, bands on babies. The colored bands are coded to the weight of the infant, thereby helping rapidly with the measurement of dosages of medication.
• Redesigning the default devices to a protected mode
• Reducing the difficulties of concurrently using several devices
• Minimize the number of models of equipment purchased
• Implement specific procedures prior to beginning surgery to review equipment, materials, etc.
• Orient and train new hires with the team(s) they will work with.
• Provide a safe atmosphere for the detection and communication of organizational learning mistakes and improvements to eliminate errors.

Human error is one of the biggest contributors to injuries in any sector, including health care. Saying, however, that an accident is due to human error is not the same as assigning blame because machine failures trigger most human errors. For a number of documented and complex causes, humans commit mistakes. In other sectors, the implementation of human factors has effectively decreased errors. Health care must accept medical error not as a special case of medicine, but as a special case of error, and apply the theory and techniques already used in other fields to minimize errors and increase reliability.