each country said treatment risks had not been completely explained during their hospital stay. In addition, 55 to 64 percent of patients said physicians had not always reviewed all their medications during the past year, and 47 to 69 percent stated that physicians did not always explain the side effects of medications (CMWF, 2005).

Usually, people are not told about an error unless injury or death occurs. In a nationally representative survey of hospital risk managers, the vast majority reported that their hospital’s practice was to disclose harm at least some of the time, although only one-third of hospitals actually had board-approved policies for doing so in place (Lamb et al., 2003). More than half of respondents stated that they would always disclose a death or serious injury; when presented with actual clinical scenarios, however, respondents revealed they were much less likely to disclose preventable harm than to disclose nonpreventable harm of comparable severity. In a 2004 survey by the Premier Safety Institute, no respondents indicated that disclosures of errors causing serious or short-term harm were never given; 57 percent said such errors were frequently disclosed to patients or families, while 37 percent said such disclosures were always made (PSI, 2004).

The following is an example of a medication error that resulted in a fatality:

Eighteen-month-old Josie King was admitted to the hospital for first- and second-degree burns received when she climbed into a hot tub. She spent 10 days in the pediatric intensive care unit, with her mother being vigilant as to the details of her care. Josie was recovering and was transferred to an intermediate care floor for a few more days. After her central line was removed, however, her condition worsened. Although her mother expressed concern about Josie’s new symptoms, which at one point included sucking avidly on a wet washcloth, those concerns were not addressed by the shift nurses. Moreover, despite a doctor’s order that no narcotics be administered to the child, and over the objections of her mother, Josie received a narcotic pain medication 2 days before she was to go home. She then experienced cardiac arrest. In retrospect, the child’s symptoms reflected progressive dehydration. Josie’s mother is among the many individuals, parents, and surrogates whose voices are often ignored by providers (JKF, 2002).

The following are examples of medication errors with the potential to result in death or serious harm:

A child with leukemia was discharged from the hospital with a nasogastric tube in place for intermittent enteral feeding. While readmitted for chemotherapy, he developed an infection and had a peripherally inserted central catheter (PICC) emplaced for the administration of antibiotics. He recovered from the infection and was discharged. Shortly thereafter, the



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement