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Medication errors: analysis not blame
Kimberly M Horns1, Donna Lee Loper
1Neonatal Nurse Practitioner Program, College of Nursing, University of Utah, Salt Lake City 84112, USA. kimberly.horns@nurs.utah.edu
Abstract:
This article summarizes current knowledge regarding neonatal medication errors and explicates the key concepts of human error and system error. A case report illustrates the sources of error. Medication error analysis must go beyond the blaming of individuals for active errors and explore the latent errors that exist in a complex health care environment. Using correct language to describe and define medication error may facilitate the development of a nonpunitive culture and enable effective evaluation of the causes of error.
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