Introduction and Blame and Shame (03:18)

FREE PREVIEW

In 2000 the Institute of Medicine published "To Err is Human." Medical errors are one of the leading causes of death in the United States. The Institute of Medicine recommended a paradigm shift from blaming the individual to determining what system failed.

System-Wide Approaches to Preventing Medication Errors (12:32)

The Institute of Medicine proposed electronic medical records in 1991; The Health Information Technology Economic Clinical Health Act mandated that health care providers adopt and use the technology. Learn how automated medication dispensing cabinets, smart pumps, including a pharmacist on rounds, barcodes, and patient profiling improve patient safety.

Staff Issues (02:48)

Mitigate noise and fatigue. In California, nurse-to-patient ratios are one to five on medical and surgical units. The Accreditation Counsel for Graduate Medical Education mandates that residents only work 80 hours per week.

Reporting System and Conclusion (02:29)

Report medication errors immediately, supplying what happened, where it occurred, who was involved, who was notified, patient response, and actions initiated. Nurses, doctors, and staff are not infallible. Safety equipment such as smart pumps, barcodes, and automated medication dispensing cabinets improve patient safety.

Credits: Preventing Medication Errors Part 1: General Recommendations for System-wide Change (00:54)

Credits: Preventing Medication Errors Part 1: General Recommendations for System-wide Change