Health Care System Vulnerabilities

Understanding the Root Causes of Patient Harm

Nathaniel Thompson-Moore; Michael G. Liebl

Am J Health Syst Pharm. 2012;69(5):431-436.

Abstract and Introduction

Introduction

Adverse drug events (ADEs) are any injuries resulting from the use of a drug and can be broken down into two categories: adverse drug reactions (ADRs) and medication errors. ADRs are any undesirable experiences associated with the use of a medicine in a patient, whereas medication errors are defined as any preventable events that may cause or lead to inappropriate medication use or patient harm.^[1,2] Medication errors are the most common type of error affecting patient safety in hospitals^[3] and occur most often at points in transfer of care—at admission, transfer between hospital units, or at discharge.^[4] There is an abundance of literature evaluating ADEs at various points of a patient's transition across the health care continuum; however, literature surveying the prevalence of ADEs across the full spectrum of care is lacking. This article explores potential vulnerabilities of the health care system as we track a patient's movement from his arrival at the emergency department (ED) through admission and transfer to the intensive and acute care units and to the patient's hospital discharge.

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