These events, such as Jesica’s death, happen in U.S. hospitals too frequently. It is clear in this multi-step process with reliance on memory, lack of protocols, many hand-offs and lack of technology support, that there are numerous opportunities for mistakes to occur. Tragically, as patient stories play out, the system failures that resulted in Jesica’s death are not unusual.

Across the United States, hospitals are fundamentally designed the same.  Health systems are complex with many forms of communication. The work flow occurs in such a way, that many steps are “handed off” between doctors, nurses and other members of the health care team. These hand-offs increase the chance that an error may occur.  The advancement of technology and pharmaceutical agents – much of which have helped countless people - also contribute to complex interactions that can lead to errors.  Medications may be packaged similarly or may sound a like or display different dosages, yet look a like (such as pictured here). Technology advances may not be designed for all the human elements that can interact and cause an error.

The Institute of Medicine defines an error as, “a failure of a planned action to be completed as intended or the use of the wrong plan to achieve an aim.” The first term describes Jesica’s error. The IOM goes on to describe various types of errors. Errors can be two-fold: errors of omission and errors of commission - leaving out an intended treatment or administering something that was not intended.

        Increased knowledge by the consumer, asking questions and speaking up to assure follow-up is completed and questions are answered are steps in the right direction to improve partnerships for safety.

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