Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery

This paper shows how discontinuities in the process of drug delivery enable but also underdetermine the isolation of a culprit in adverse medication events. A case example illustrates how we are forced to abandon conceptualizations of blame that assume a dichotomy (either culpable or not), and shift instead to a more nuanced version that estimates the degree to which an actor desired, generated, or could have foreseen the harmful outcome, and the extent to which constraints external to the actor altered the event. The paper concludes that meaningful safety interventions in a system as diverse, socially embedded and complex as health care delivery cannot just build on "good science" (e.g., good methods) to generate "root" causes. Rather, they need to somehow be sensitive to how and which narratives of success and failure are created, as these constrain which countermeasures are likely to be encouraged, funded, and accepted.

Patient Safety and Quality Improvement Act of 2005

OBJECTIVE

To review Public Law (PL) 109-41-the Patient Safety and Quality Improvement Act of 2005 (PSQIA)-and summarize key medication error research that contributed to congressional recognition of the need for this legislation.

DATA SOURCES

Relevant publications related to medication error research, patient safety programs, and the legislative history of and commentary on PL 109-41, published in English, were identified by MEDLINE, PREMEDLINE, Thomas (Library of Congress), and Internet search engine-assisted searches using the terms healthcare quality, medication error, patient safety, PL 109-41, and quality improvement. Additional citations were identified from references cited in related publications.

STUDY SELECTION AND DATA EXTRACTION

All relevant publications were reviewed. Summarization of the PSQIA was carried out by legal textual analysis.

DATA SYNTHESIS

PL 109-41 provides privilege and confidentiality for patient safety work product (PSWP) developed for reporting to patient safety organizations (PSOs). It does not establish federal mandatory reporting of significant errors; rather, it relies on existing state reporting systems. The Act does not preempt stronger state protections for PSWP. The Agency for Healthcare Research and Quality is directed to certify PSOs and promote the establishment of a national network of patient safety databases. Whistleblower protection and penalties for unauthorized disclosure of PSWP are among its enforcement mechanisms.

CONCLUSIONS

The Act protects clinicians who report minor errors to PSOs and protects the information from disclosure, but providers must increasingly embrace a culture of interdisciplinary concern for patient safety if this protection is to have real impact on patient care.

The ethics and practical importance of defining, distinguishing and disclosing nursing errors: A discussion paper

Nurses globally are required and expected to report nursing errors. As is clearly demonstrated in the international literature, fulfilling this requirement is not, however, without risks. In this discussion paper, the notion of 'nursing error', the practical and moral importance of defining, distinguishing and disclosing nursing errors and how a distinct definition of 'nursing error' fits with the new 'system approach' to human-error management in health care are critiqued. Drawing on international literature and two key case exemplars from the USA and Australia, arguments are advanced to support the view that although it is 'right' for nurses to report nursing errors, it will be very difficult for them to do so unless a non-punitive approach to nursing-error management is adopted.

Prescription and medication records

All nurses are required to keep contemporaneous records which are unambiguous and legible. The NMC has reprinted the UKCC guidelines for records and record keeping (UKCC, 1998). The Department of Health has provided advice in its guidance on the implementation of independent nurse prescribing on the standards for prescription writing (DH, 2002).

[Adverse drug reactions and professional indemnity insurance]

In 2004, the 116000 French doctors who belong to the MACSF group "Sou Medical" submitted 41 declarations of adverse drug reactions (2% of all accident declarations). The most numerous related to complications of anticoagulant treatments (11 declarations). Aside from accidents due to inappropriate supervision (oral anticoagulants), which tend to be more frequently hemorrhagic than thrombotic, these declarations highlight the emergence of accidents resulting from poor management of anticoagulant treatment (oral anticoagulants, antiplatelet drugs) during invasive procedures, and that are more frequently thrombotic (stroke, myocardial infarction) than hemorrhagic. The legal decisions handed down in the same year as a result of complaints by victims of adverse drug reactions generally penalised the doctor for making a wrong prescription, but sometimes also the pharmacist who supplied the drug and the nurse who administered it, in cases where the medical prescription clearly did not comply with the product's approved uses.

Staff nurse removed from nursing register for mis-management of drug rounds

David was a staff nurse employed by a large hospital trust in the north of England. He usually worked on night duty and was known for his efficiency in completing nursing tasks. David entered nursing in his forties after being made redundant by the local car manufacturer. During his time in the motor industry he had always worked nights and therefore when he qualified as a nurse he always intended to do night duty.

Medical errors: five years after the IOM report

Five years after publication of the Institute for Medicine's landmark 1999 report,To Err Is Human, notable advances have been made. They include the development of performance standards, an increase in error reporting, integration of information technology, and improved safety systems. But the IOM notes that efforts are still needed to improve safety and reduce errors, including development of data standards for patient safety information, establishment of a national health information infrastructure, and comprehensive patient safety programs in health care organizations.

An unusual case of diarrhoea

Case histories are based on actual medical negligence claims, however certain facts have been omitted or changed by the author to ensure the anonymity of the parties involved. Medication errors in general practice are relatively common. This article describes a medication error that led to a patient complaint and claim.

Matron who continued to make numerous drug administration errors

Brenda is a pharmacist who works in the community and helps with the inspection of private nursing homes. Each home she inspects has one announced inspection per year and one that is unannounced. If there are any issues which make it necessary for her to visit the home again, she does this unannounced.