Medication errors: analysis not blame.
This article summarizes current knowledge regarding neonatal medication errors and explicates the key concepts of human error and system error. A case report illustrates the sources of error. Medication error analysis must go beyond the blaming of individuals for active errors and explore the latent errors that exist in a complex health care environment. Using correct language to describe and define medication error may facilitate the development of a nonpunitive culture and enable effective evaluation of the causes of error.
Horns
Kimberly M
KM
Neonatal Nurse Practitioner Program, College of Nursing, University of Utah, Salt Lake City 84112, USA. kimberly.horns@nurs.utah.edu
Loper
Donna Lee
DL
D005260:Female; D006801:Humans; D015994:Incidence; D007231:Infant, Newborn; D007232:Infant, Newborn, Diseases / Q000188:drug therapy* / Q000451:nursing; D007363:Intensive Care Units, Neonatal; D008297:Male; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D017283:Neonatal Nursing / Q000592:standards*; D012307:Risk Factors; D012308:Risk Management / Q000379:methods; D014481:United States / Q000453:epidemiology