The Institute of Medicine's report, “To
Err is Human” determined that many errors in modern healthcare can be attributed
to either poorly designed or faulty systems. This website will attempt
to integrate some of the concepts of systems engineering into the practice
of pharmacy. This will include an introduction to root cause analysis
and other tools, such as Failure Mode and Effects Analysis (FMEA) and
Fault Tree Analysis which are currently used in safety engineering and have
a use in medication safety initiatives.
Engineering techniques can be used to do more than detect
and reduce error. While many practitioners do not want to admit it,
the practice of pharmacy can be divided into a cognitive
and a distributive component. The latter component lends itself well
to practices designed to optimize performance and minimize error. In
this case, we are referring simply to dispensing
errors.
Last site update: Sunday, July 17, 2005
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