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[Medication errors: who is responsible?].

Mário Borges Rosa1, Edson Perini

  • 1Fundação Hospitalar do Estado de Minas Gerais e na Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil. mariobr@uai.com.br

Revista Da Associacao Medica Brasileira (1992)
|December 11, 2003
PubMed
Summary

Healthcare errors, especially medication errors, are a serious public health issue. A systemic approach, rather than an individualistic one, can identify process failures and improve patient safety.

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Area of Science:

  • Medical error analysis
  • Health systems research
  • Patient safety science

Context:

  • Increasing complexity and cost of healthcare.
  • Growing public scrutiny of medical errors.
  • Inadequate training for healthcare workers in error management.

Purpose:

  • To advocate for a paradigm shift in addressing medical errors.
  • To highlight the limitations of individualistic error approaches.
  • To promote a systemic perspective for enhancing drug safety.

Summary:

  • Current healthcare systems often adopt an individualistic approach to errors, leading to blame and lost learning opportunities.
  • A systemic view, successful in fields like aviation, considers human limitations and process failures.
  • Medication errors are a significant public health problem, necessitating a focus on the entire drug use process for safety.

Impact:

  • Implementing a systemic approach can reduce the occurrence of preventable medication errors.
  • Improved patient safety and reduced healthcare costs.
  • Fostering a culture of learning from errors within healthcare organizations.

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