Using Information From External Errors to Signal a “Clear and Present Danger”

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Conclusion 

The only way to make significant safety improvements is to challenge the status quo, inspire and encourage all staff to track down “bad news” about errors and risk—both internal and external—and to learn from the “bad news” so that targeted improvements can be made. We need to shatter the assumption that systems are safe until proven dangerous by a tragic event. No news is not good news when it comes to patient safety. Each organization needs to accurately assess how susceptible its systems are to the same errors that have happened in other organizations and acknowledge that the absence of similar errors is not evidence of safety. Personal experience is a powerful teacher, but the price is too high if we only learn from firsthand experiences. Learning from the mistakes of others is imperative.

This column was prepared by the Institute for Safe Medication Practices (ISMP), an independent, charitable nonprofit organization dedicated entirely to medication error prevention and safe medication use. Any reports described in this column were received through the ISMP Medication Errors Reporting Program. Errors, close calls, or hazardous conditions may be reported online at www.ismp.org or by calling 800-FAIL-SAFE (800-324-5723). ISMP is a federally certified patient safety organization (PSO), providing legal protection and confidentiality for patient safety data and error reports it receives. Visit www.ismp.org for more information on ISMP’s medication safety newsletters and other risk reduction tools. This article appeared originally in the February 9, 2017, issue of the ISMP Medication Safety Alert!

 

References

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