title: To err is human, to share is divine.
abstract: Front-line health care practitioners are often safety nets preventing errors from reaching patients. Nurses in critical care environments commonly deal with high-risk patients, high-alert medications and extreme conditions, placing themselves and medication systems under greater pressures. Human error cannot be eradicated. However, the systems in which practitioners work and interact can be made safer and more fault-tolerant. When errors occur, nurses are in a unique position to provide valuable insights. Practitioner reporting and sharing of incident information internally and externally can enhance patient safety by helping to prevent recurrence of similar events.
authors.affiliation: ISMP Canada.
authors.forename: Christine
authors.initials: C
authors.lastname: Koczmara
authors.forename: Carol
authors.initials: C
authors.lastname: Dueck
authors.forename: Valentina
authors.initials: V
authors.lastname: Jelincic
mesh_terms: D016907:Adverse Drug Reaction Reporting Systems; D002170:Canada; D015984:Causality; D003299:Cooperative Behavior; D003422:Critical Care / Q000458:organization & administration*; D016208:Databases, Factual; D004282:Documentation; D004348:Drug Labeling; D004349:Drug Packaging; D006801:Humans; D033181:Information Dissemination; D008508:Medication Errors / Q000379:methods / Q000451:nursing* / Q000517:prevention & control* / Q000706:statistics & numerical data; D024802:Nurse's Role / Q000523:psychology; D009741:Nursing Staff, Hospital / Q000458:organization & administration* / Q000523:psychology; D012308:Risk Management / Q000458:organization & administration*; D013597:Systems Analysis