A systems approach to the reduction of medication error on the hospital ward

Abstract

Accidents or errors are only the tip of the incident iceberg. Through effective, nonpunitive incident reporting, which includes reports of near-misses and system problems in addition to actual accidents, the systems-approach allows the complete set of contributing factors underlying an accident to be understood and addressed. Feedback to participants and targeted improvement in the workplace is also important to demonstrate that incident data are being used appropriately, and to maintain high levels of on-going reporting and enthusiasm for the scheme. Drug administration error is a serious problem, which warrants a well-reasoned approach to its improvement.