The official and popular reaction was swift. He ordered Congress to monitor progress in efforts to prevent harm to the patient, and the healthcare industry set significant goals, such as reducing medical errors by 50% within five years. The media closely reported the actions. A remedy for a long-term problem appeared on the horizon.
However, in 2019, medical errors were as frequent as in 1999. ‘Human Errors’ was an embarrassing reading; as well as the September 2019 report on patient safety from the World Health Organization. Among the findings of the World Health Organization: Globally, hospital-acquired injuries affect about 10% of hospitalized patients. Medical errors harm 40% of patients in primary and outpatient care. Diagnostic errors and medications hurt millions and cost billions of dollars each year.
So, after two decades, why is this chronic condition at risk in medical care?
The chain reaction to the 1999 report spent its energy quickly. Contrary to what is required in the expert report from outside the medical profession, patient safety was assumed by clinical managers and other health care officials whose interests were hardly addressed by a comprehensive study of the crisis that would have shaken the status quo. These institutional leaders also ignored the experts (psychologists, sociologists, organizational behaviorists, and others) who had long provided innovative ideas to improve safety and reduce accidents in medical care.
Medical directors also had ideas, but this served as local (and weak) prescriptions such as safety checklists, manual sterilization stations, posters promoting a “safety culture” and programs that invited low-level employees to talk. Minds of their supervisors. Innovations aimed at larger categories of risks are missed outside the scope of multi-hospital systems, such as problem-solving such as similar medicines, similar to sound or confusing and error-stimulating technological interfaces.
Sound-like drugs are drugs that have spelling similarities or are visually similar in physical appearance or packaging. For example, disruption of epinephrine and ephedrine drugs caused significant harm to the patient. The names of the drugs are similar and sometimes they are stored near each other. But each drug has a different purpose and can have serious and fatal side effects if taken incorrectly. Error-interfaced technology interfaces occur when simple technology connectors are compatible with multiple pipes, outputs, or machines, increasing the likelihood of incorrect connections. For example, when the feeding tube is mistakenly coupled to a tube that enters the vein, or the IV tube is inadvertently connected to the nasal oxygen.