How Can We Win the War on Error?

What constitutes a medication error?

Soon after the Institute of Medicine published its landmark "To Err is Human" report, confusion

ensued on what constituted an error.

Under a broad definition that includes complications and medication misadventures, the health care system was blamed for 400,000 deaths per year, equating to roughly 1 of every 6 deaths.

Understandably, health care professionals perceived an error defined this way as an impossible standard, while other parties said no poor outcomes are ideal and the system must evolve to eliminate them. When an airplane crashes, it's considered a mishap regardless of whether the pilot was purposefully flying into the ground or an engine malfunctioned.

It’s reasonable to expect all health care professionals to strive to predict poor outcomes before they occur. Hospitals that are found to harbor repeat offenders for errors, even under the most broad definitions, will see the effect on their bottom lines.

According to the Kaiser Family Foundation, the number of dispensed prescriptions increased 36% from 1999 to 2009, while the population grew only 9% in that same decade. Instead of Generation X, this is Generation Rx. Consequently, our War on Error is more difficult to fight.

This is the exact problem pharmacists are trained to solve as medication therapy experts. A 2011 Surgeon General Report found that every dollar invested in clinical pharmacy services from 1988 to 2005 produced an overall average benefit of $10.07.

Why not invest more?