To Err is Human: Building a Safer Health System

There is a great publication, delivered by Institute of Medicine (US) Committee on Quality of Health Care in America about medication errors. Here are three key takeway:

1. High Incidence of Adverse Events: Studies indicate that 2.9% to 3.7% of hospital admissions result in an adverse event, with over half being preventable errors.

2. Leading Cause of Death: Extrapolating the data to national levels implies that at least 44,000 to 98,000 Americans die annually in hospitals due to preventable adverse events, surpassing many other leading causes of death.

3. Comparison to Other Causes: Deaths from preventable adverse events in hospitals exceed those from motor vehicle accidents, breast cancer, and AIDS.

Why do Errors happen:

1. System Complexity and Human Error: Healthcare services are complex systems inherently prone to accidents, often due to human error. However, these errors are typically induced by underlying system failures rather than individual culpability.

2. Latent Errors Pose the Greatest Threat: These errors are built into the system, often invisible to operators, and can lead to active errors. Current strategies often focus on active errors, neglecting these latent failures that compound over time.

3. Cross-Industry Learning: Lessons from other industries, where human factors have been successfully employed to reduce errors, should be applied to healthcare to improve reliability and safety.

How does UnitBox (ADC) can help to overcome those issue:

1. Reducing Adverse Events and Preventable Errors: ADC systems areused to monitor medication error and medication administration. This allows for immediate intervention when abnormal patterns are detected, reducing the incidence of preventable errors.

2. Addressing System Complexity and Human Error: ADC simplify complex workflows by automating routine tasks, thereby reducing the scope for human error. It also provides healthcare staff with real-time insights, helping them make better-informed decisions.

3. Identifying and Mitigating Latent Errors: ADC systems monitor for inconsistencies or abnormalities over time, helping identify latent errors that might be built into the healthcare system. By capturing and analyzing data continuously, these systems can help in proactively addressing risks before they escalate.

   
   

4. Monitoring and Reporting for Continuous Improvement: With robust data collection and analytics, ADC provides a basi for ongoing evaluation of healthcare processes. This leads to more effective policies aimed at reducing the number of preventable adverse events, thereby improving patient safety.

Base on: https://pubmed.ncbi.nlm.nih.gov/25077248/