Prevention of adverse drug events: a decade of progress in patient safety

Abstract

Anesthesiology has led the medical profession’s involvement in the study of human error in clinical practice. Seminal studies by Cooper et al., Gaba et al., and the many initiatives of the Anesthesia Patient Safety Foundation resulted in technological advances and application of patient safety principles to anesthesia and, thus, contributed to the delivery of safe anesthesia care. Studies of anesthesia mortality, anesthesia morbidity, anesthesia closed claims, the development of standards of care,14–15 monitoring of pulse oximetry and end-tidal CO2, 20 have increased awareness about the importance of safe anesthetic care as a primary focus of research and clinical attention. However, until the initial Harvard Medical Practice Study provided data that indicated a serious problem existed in other areas of medicine and surgery across a broad spectrum of hospitals and patient care settings, little was being done to address the more generalized problems of human error in medicine. Recent studies examining the root causes of human error in medicine have extended the Harvard Medical Practice Study into its next phase, the Adverse Drug Event Prevention Study. The latter helped to galvanize a nationwide patient safety movement, culminating in the establishment of the National Patient Safety Foundation. More recently, a report from the Institute of Medicine emphasized the serious problem of human error in medicine and demanded improvements in patient safety throughout the scope of medical practice. In 1994, Leape characterized the medical model of error analysis as one that focuses on incidents and individuals using a problem-solving approach to identify the immediate cause of the error and then correct it. He noted that root causes of error, that is, the underlying systems failures, are rarely identified and