Koczmara Christine, Dueck Carol, Jelincic Valentina
ISMP Canada.
Dynamics. 2006 Fall;17(3):22-5.
Front-line health care practitioners are often safety nets preventing errors from reaching patients. Nurses in critical care environments commonly deal with high-risk patients, high-alert medications and extreme conditions, placing themselves and medication systems under greater pressures. Human error cannot be eradicated. However, the systems in which practitioners work and interact can be made safer and more fault-tolerant. When errors occur, nurses are in a unique position to provide valuable insights. Practitioner reporting and sharing of incident information internally and externally can enhance patient safety by helping to prevent recurrence of similar events.