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Quality care and public policy, above all do no harmPublic belief and trust in the healthcare system was shaken in 1999 when the Institute ofMedicine (IOM) reported that between 44,000 and 98,000 Americans die each year as a result ofmedical errors (Kohn, Corrigan, & Donaldson, 2000). To Err Is human: Building a Safer HealthSystem, published in a book by IOM-true scope of the quality problem in healthcare. The IOMnow known as National Academies of Medicine released its report. US lost more patient lives tosafety incidents every 6 months that it did in the entire Vietnam War (Kohn et al). Statisticsindicate that more deaths occur in the US each year from motor vehicle accidents, breast cancer,or acquired immunodeficiency syndrome. If documented by the centers for disease control andprevention it would rank as the third leading cause of death. As many as 400,000 Americanssuccumb to medical errors annually. Another 10,000 suffer complications daily. The total cost ofthese errors estimated to be between 17 billion-29 billion per year. Medical errors are costlyleading to loss of trust within the health care system, decreased patient satisfaction, and degradedmorale among care professionals. The FDA estimated that medication errors cause at least ondeath every day and injure approximately 1.3 million people annually.in the US.Errors occur in all phases of HC. Diagnostic -improper testing, misread, or misinterpreted labresults, or failure to act on the results. During treatment technical errors may result in theaccurate preparation or delivery of treatments. Delayed, missed, or performed incorrectly.Medical error might be the HC provider chose an inappropriate method of care or carried it outincorrectly. Medical errors are not purposeful or reckless actions that are intended to harm apatient. Throughout the literature, the term error is used to denote a mistake, close call, or nearmiss, or active or latent error. Active errors occur at the level of the frontline provider- forexample administering the wrong medication. Active errors are limited in time and space, so they
are easier to measure. Latent errors involve system defects, such as faulty maintenance onequipment, poor design, or inadequate staffing. Latent errors are more difficult to measurebecause they occur over greater periods of time and space and because they occurs over greaterperiods of time and space and because they may exist for a long time before they lead to an erroror adverse event. The nature of interactions between caregivers and patients can be a source oferrors, particularly when multiple caregivers are involved. Medication errors are common inambulatory care. one study found 4.5 million ambulatory care visits occur annually due toadverse drug events.