Ethics, Patient Safety, Medication Errors, and Quality Improvement Reporting
Error, near miss, adverse event
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm. A near miss was caught before reaching the patient; an adverse drug event is harm from a medication, whether or not preventable. Distinguish these before choosing a response.
Safety systems
High-leverage practices: standard concentrations, independent double checks for high-alert drugs, tall-man lettering for look-alike/sound-alike names, barcode scanning, removing concentrated electrolytes from floor stock, and closed-loop ordering. A just culture separates system failures from reckless behavior while still holding individuals accountable for intentional violations.
Reporting
Maryland expects serious events reported through the proper channel: the Board for practice violations and certain serious errors, the Office of Health Care Quality for hospital events, and internal incident reporting for near misses. Reporting is not discipline; the purpose is learning. Internal review documents may carry legal protections, so know what must be disclosed.
Worked example
A tenfold insulin overdose is caught at final verification. The pharmacist files an internal near-miss report, checks whether the order set permitted a trailing zero or an ambiguous abbreviation, and proposes a system fix. Because no patient was harmed, no external report is triggered, but the pattern is tracked.
Ethics
Duties include patient confidentiality, honesty in records, avoiding conflicts of interest, refusing to participate in diversion, and respecting autonomy, including the right to refuse counseling or a substitution.
Traps
Calling every error a near miss; assuming mandatory reporting means the patient need not be told; blaming an individual when the question really asks for a system fix.