The Presentation

The Presentation

The link above will give you a peek at my presentation on our study.

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Swiss Cheese Model

It may not always be necessary to prevent errors at all the phases simultaneously, to prevent a fatal medical error.
This is best explained by a time tested management model that has long been used by the aviation industry and other emergency services. It is known as the Swiss Cheese Model. Its applications in the health-care industry has brought to light important concepts in medication error prevention.

According to the Swiss - Cheese Model, every industry has a defense system. These defenses are represented by the slices of cheese. The weaknesses in these defenses are represented by the holes in these slices of cheese. When these weaknesses (holes) momentarily allign themselves, they permit a fatal error to occur. Thus a fatal error can be prevented to a certain extent by preventing the errors at various phases.

Medication Errors - Understanding the Issue

The amount of damage medication errors incur to the health industry, both in form of life and financially, has taken the medical fraternity by surprise. The situation demands immediate attention to devise methods to help prevent such errors.
Inorder to come up with a suitable plan of action, understanding the issue is of paramount importance.

As shown in the picture on the left, a medication error can include one of four errors:

1. Prescription Errors

2. Transcription Errors

3. Dispensing Errors

4. Administration Errors





The picture on the right shows the different phases

1. Prescription

2. Transcription

3. Dispensing

4. Administration

5. Monitoring

Methods can be devised to help prevent errors at these various levels.

The Problem

Medication Errors rank as the 8^th leading cause of death in the United States.
As stated by the 1999 Institute of Medicine Report " To Err is Human: Building a safer health system", 44,000 - 98,000 Americans die each year as a result of medical errors. Apart from the loss the errors cause to life, there are some grave financial losses incurred as well. It has been estimated that financial losses caused by medication errors amount to 17 to 29 billion USD. On an average, a patient will be subjected to a medication error each day he or she occupies a hospital bed.

The Agency for Healthcare Research and Quality’s March 2001 Report, “Reducing and Preventing Adverse Drug Events to Decrease Hospital Costs” also reported a cost of 5.6 million USD due to prolonged hospitalizations inflicted by adverse drug events.

A new report from the Institute of Medicine of the National Academies, documents 1.5 million people being exposed to medication errors and an extra and an additional medical cost of 3.5 billion USD annually for treating them.