NCPS: Taking Aim at Medication Errors, Question 2

The chance of an error occurring will never be eliminated from human conduct. The real goal of a patient safety program should be to prevent harm to patients, by significantly improving the probability that a desired patient outcome can be achieved. This can only be accomplished by taking a systems approach to problem solving, focused on prevention, not punishment. Historically, those in medicine have relied on people being perfect and equipment never failing. It never worked and, for too long, most were afraid to admit it. NCPS was founded on the belief that this failed approach must be abandoned, as it unrealistically requires personal perfection to make a care system succeed.

The time had come to look past the overly simplified answer: that an adverse event is always someone's fault. The real cause is most often a chain of events that has gone unnoticed, leading to a recurring safety problem. It is seldom related to the actions of just one individual. NCPS takes a preventive approach to improving patient care by looking for ways to break that link in the chain of events that can cause a recurring problem. The focus is on building care systems that are "fault-tolerant." Such systems reduce or eliminate the possibility that harm can come to a patient, because these systems are designed to succeed even if individual components fail. The fault-tolerance principle has been used for years by the aviation industry and other high-reliability industries with safety records that far surpass those of health care.
 

Question 1

Question 2

Question 3

Question 4

PDF Patient Safety Alert: Insulin U-500 Safety Enhancements (March 2009)

PDF NCPS: Diabetes and Insulin Management Topic Summary

For more general information on preventing, catching and reporting errors, see our Safety and Error Prevention page.