• G R Baker and P Norton.
• Department of Health Administration, University of Toronto.
• Healthc Pap. 2001 Jan 1;2(1):10-31.

AbstractMedia reports of adverse events experienced by patients raise questions about whether these are isolated exceptions or part of a larger problem. There is no reliable Canadian data on medical error; but there is little reason to expect that the situation differs markedly from Australia or the United States which have rigorously studied the problem. Research in Australia has concluded that as many as 16% of hospital patients are injured as a result of their treatment. The Australian study and more recent research in the United States have created widespread concern that an epidemic of error exists in healthcare. Fortunately, experts in healthcare and other industries, have pointed toward a number of solutions that will reduce these errors. Three key strategies need to be pursued First, better information about the numbers and types of errors that occur is needed to help pinpoint change efforts. Non-punitive reporting policies must be put in place, to assist in altering the traditional culture of blame that has discouraged error reporting. Second, a set of strategies have to focus on developing more effective systems, including physician-order entry and medication administration systems which have been shown to have a dramatic impact in reducing errors. These systems are expensive, but their importance in reducing injury - and greatly reducing the costs of additional care that come from such injuries - make them an essential part of the answer. Finally, healthcare organizations need to work to create more effective cultures oriented toward preventing errors and intercepting errors that inevitably occur. These cultures will require a new emphasis on teamwork, a continual focus on redesigning care systems, particularly in high risk areas such as operating rooms, intensive care units and emergency rooms. These are not easy tasks and will require investments in new equipment and new skills. These steps are essential if we are to maintain public confidence in healthcare.

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