When you hear somebody use the term error, you should always make sure you understand what they mean by the word. Because there's no uniformly agreed upon definition of error. The one on your screen, I like in particular, and it's by actually the Institute of Medicine. They've defined an error as the failure of a planned action to be completed as intended, an error of execution, or the use of a wrong plan to achieve an aim, an error of planning. That's actually based on James reasons work. But this is, I think the nicest definition, most comprehensive definition I've come across. There's a number of different ways in which error is used. The first one I'll talk about is a close call or a near miss, and that actually is used two different ways. One is the error didn't reach a patient. As an example, a pharmacy technician makes the wrong medicine and a pharmacist spots that, that error was made and stops it from being dispensed out to the floor so that can't be administered to a patient. That was an error, but it didn't reach the patient. Another near mess is when an error reaches the patient with the potential of causing significant harm and doesn't. That too would be categorized as a near mess. Now, there's also two other different ways of thinking about error, and those are errors of commission and errors of omission. The first, errors of commission, those are a mistake that consists of doing something wrong. Well, for instance, I intend to give him medicine to one patient, but accidentally give it to another patient. Here's some examples. I gave the wrong drug, I gave the medicine to the wrong patient, or I performed the wrong procedure on a particular patient, those would be errors of commission. Interestingly, when you're reading about errors and error rates, typically, this is the error that they're talking about. Generally, they don't talk about errors of omission, but errors of omission can be just as significant as an error of commission. An error of omission is a mistake that consists of not doing something that should have been done. Here's some examples. Failing to order prophylactic therapy to prevent venous thromboembolism when it was indicated, that would be an error of omission. Another example of an error omission would be failing to assess for pregnancy before administering a abdominal x-ray to a woman. I now want to compare this concept of error and harm. Really important to remember that not all errors cause harm and not all harm is caused by errors. In this then diagram, let's first look at those population of errors that didn't cause harm. In the center, these errors caused preventable harm. It's preventable because it was secondary to an error, and then other harm that's not associated with an error is considered unavoidable. What we should do is target preventable harm. That really should be our key goal in our safety projects and our performance improvement projects is to prevent preventable harm. Now, obviously, we want to decrease the number of errors that are made. But humans will always make error because after all, to error is human. Our main goal should be to avoid preventable harm. Now, take a look at the following scenario from a hospital setting. A patient starts off with troubled breathing. The nurse comes in to check on her. See if you can identify the multiple steps along the way where there are patient safety issues leading to a medication error. What's wrong? I can't breathe. I can see that. Anything else bothering you? I am in a lot of pain. She has been lying just all morning. I'm sorry. Let me go check your chart and I'll be right back with some medications for you. Okay? Okay. This is ridiculous. Mrs. Walker, let me see what is due for her,40 milligrams of Lasix. Morning, Laura. Hey, how are you? Hi. Hi. Just wondering everybody's ordering lunch today. Did you want anything from the deli? Yeah. What's everybody getting? Everybody's ordering powerhouse. They want one, that's the one with the cheese and some veges. Two milligrams of morphine, cheese, and veg. Yeah, that sounds good. I'll have one of those. Thanks. All right. I will get you one. Thanks. Morphine two milligram. Yeah, okay. Hello, Laura. Yes. Yeah, I forgot to ask you, do you want it with chips? Yeah. I like Barbecue chips and a sprite, please. All right, you'll get the sprite. Okay. All right. Okay, here I am. This is a pill you can take by mouth, Mrs. Walker, all right? Yes. Okay. When is the doctor coming? Hi, Laura. Hi. Just checking with you. One of our nurse pulled out today, is there a way that you could do another shift today? I did a double two days ago and I really I'm tired. I really don't want to do another one. No, I can't. I'm sorry. All right. Okay, thank you. When is the doctor coming? I gave you your medication. The doctor, they should be here any minute. Okay. They have not been here all day. Don't worry. They will be back. Don't forget to take your medication. This should make you feel better. I'll see you later. Okay. Jane, Jane, Jane, wake up, Jane. Help. Can I get some help over here? I can't wake her up. Help. Jane, wake up.
