As automation and information technology systems have been developed with the goal of providing safer health care with better outcomes, other problems have arisen relative to our ability to use and apply technology safely in the patient care arena. The medication use process (prescribing/ordering, transcription, preparation/dispensing, and administration to end user) has been subject to a science and technology explosion over the past 30-40 years not only with drug products themselves, but also relative to automation-based devices than can impact each phase of the process. Bates et al. estimated that the majority of adverse drug events (ADEs) occurred during the ordering (56%) and administration (34%) phases, and millions of dollars have been spent devising automated systems for each step of the process that will outwit human propensity for error. However, we understand little more of how to circumvent healthcare-related errors than we did over a decade ago. Effects Analysis (FMEA) have been applied to healthcare settings in order to better understand the systems in which and reasons why errors occur. Of greater concern is that these tools are applied after the fact when an error is recognized as having occurred and serious consequences have potentially resulted (tip of the iceberg events).
Last date updated on June, 2014