In healthcare institutions and with treatment at home, patients face the risk of medical errors. A landmark study by the Institute of Medicine (IOM), entitled "To Err is Human: Building a Safer Healthcare System," estimated that as many as 98,000 Americans die each year due to a variety of medical errors. In 2003, the health committee of the council of Europe set up a committee of experts to investigate and make recommendations regarding adverse events during healthcare.

In the UK, the National Patient Safety Agency (NPSA), a special health authority, was created in July 2001 with the task of improving the safety and quality of care through reporting, analyzing and learning from adverse events involving National Health Service (NHS) patients. For example, whilst the incidence level is difficult to quantify, data reports to the Medicines and Healthcare Regulatory Agency (MHRA) showed that of the nearly fifteen million infusions performed in the NHS every year, at least 700 unsafe incidents are reported, 19 per cent of which are attributed to user error.

Furthermore, according to the World Health Organization’s (WHO) World Health Report 2002:

• Healthcare comprises a complex combination of processes, technologies and human interactions.
• Harm arises from human shortcomings, substandard or faulty products, side effects of drugs and drug combinations, and hazards by medical devices, procedures and systems.
• Failures are possible at every point of the process of care giving.
• The risks are associated with different healthcare settings, including hospitals, physicians’ offices, nursing home, pharmacies and patients’ homes.

Where hospital medication errors occur
The hospital medication use process is comprised of four stages:

• Prescribing (whereby the physician indicates what drug a patient should receive when and at what dosage)
• Transcribing (when the order is entered into the pharmacy system)
• Dispensing (when a given drug is distributed to the patient floor by the pharmacy)
• Administration (the last stage, when the nurse gives the drug to the patient)

Errors in medication use can occur at any one of these four stages. Fortunately, many errors in prescribing, transcribing, and dispensing are intercepted prior to administering the drug to the patient. Unfortunately, as data has shown almost no errors that occur during administration are caught, thereby causing 51 percent of all preventable and potential ADEs. Therefore, medication administration is where Hospira has focused its efforts.

Types of errors
To help reduce the risk of ADEs, experts have identified the types of errors that occur during the hospital medication-use process.

Wrong dose and wrong drug are two leading types of errors, accounting for 39 percent.

Error-reduction strategies
The five rights of medication administration are:

• Right Drug
• Right Dose
• Right Patient
• Right Time
• Right Route

By confirming the accuracy of the drug, dose, patient, time, and route, medication errors at the bedside can be prevented before an ADE occurs. Medication Management systems, with bar code capabilities, are devised to help caregivers confirm these five rights and reduce medication errors.

Hospira is committed to helping hospitals reduce medication errors and improve patient safety by applying bar codes to all injectable drugs and I.V. solutions. Bar code-reading technology has been incorporated into several Hospira infusion devices.