To Err is Human - Building a Safer Health SystemThe Institute of Medicine has recently published a report on the safety of the health system. To order a copy of the report To Err Is Human: Building a Safer Health System go to www.iom.edu/iom/iomhome.nsf/ages/Recently+Released+Reports In the March ACCE News its editor Dr Joe Dyro comments this report from the perspective of a clinical engineer. Below a few excepts from his comment: "The book's key theme is that legitimate liability concerns discourage reporting of errors. Learning from mistakes may require some creativity." "The book reports that upwards of 120,000 people die each year from medical errors in hospitals. Unfortunately, the number who die from causes in whole or in part from medical devices is unknown. Most studies of adverse events blame devices only when an outright failure has occurred. Technical complications are usually attributed to human error. Human error is inextricably linked to medical device design, however. Designing devices that can be easily, safely and effectively used in a crisis is the goal." "Do not underestimate the clinical engineer's role in all this. Consider the following from the IOM report: Because of the immense variety and complexity of medications now available, it is impossible for nurses or doctors to keep up with all of the information required for safe medication use. The pharmacist has become an essential resource in modern hospital practice. In the above sentence, replacing medications with medical devices and pharmacist with clinical engineer gives a clear picture of the reality: Because of the immense variety and complexity of medical device now available, it is impossible for nurses or doctors to keep up with all of the information required for safe medical device use. The clinical engineer has become an essential resource in modern hospital practice." | ||