to implement bar code based systems to reduce ADEs associated with medication errors.”8

  • Smart infusion pumps—Smart infusion pumps allow hospitals to enter various drug infusion protocols into a drug library with predefined limits. If a dose is programmed outside of established limits or clinical parameters, the pump halts or emits an alarm. Some pumps have the capability of integrating patient monitoring and other patient parameters, such as age or clinical condition. Clinical trials will soon be under way to assess the performance of these devices in reducing medication error rates (Institute for Safe Medication Practices, 2002).

In addition to the above remedies, low-tech strategies, such as decreasing interruptions and distractions, providing standardized protocols, and using checklists for drug administration, have been developed and used in efforts to reduce drug errors (Pape, 2003). Ensuring safe staffing levels (see Chapter 5) and preventing nurse fatigue as described earlier in this chapter can also reasonably be expected to help protect against medication administration errors. Effective redesign of medication administration also depends on the creation of a culture of safety and the establishment of a fair and just error-reporting system that is conducive to the discovery of medication errors (as discussed in Chapter 7).


Absence of handwashing is an example of a health care error of omission—an error that results from the failure to take an action, as opposed to an error of commission accompanying the performance of an action. Errors of omission are usually more difficult to detect than those of commission. However, the prevalence of the absence of handwashing is indicated by the tremendous morbidity, mortality, and health care costs resulting from hospital-acquired infections—found in 7–10 percent of hospitalized patients and causing approximately 80,000 deaths per year (Lautenbach, 2001). Infections are also are the major cause of transfer of nursing home residents to hospitals (CMS, 2002). It is also well established that (1) most hospital-acquired pathogens are transmitted from patient to patient via the hands of health care workers, and (2) handwashing is the simplest and most effective, proven method for reducing the incidence of nosocomial infections. Nevertheless, Lautenbach (2001) presents an array of evidence that handwashing by all health care workers is performed at very low rates. In the 11 studies reviewed, rates of handwashing ranged from 16 to 81 percent; only two studies noted compliance levels above 50 percent.


Federal Register, Volume 68, No. 50, Friday March 14, 2003, Proposed Rule. Page 12520.

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