Developing Safe Habits for Practice
Fatal and nonfatal medication errors continue to occur in American healthcare. These are reported in a variety of ways and formats, and can include sensationalistic case reports about a patient receiving the wrong medication or more rigorous science-based research reports. It is often difficult to truly quantify the number of medication errors that occur in the United States each year and the associated costs. Varied definitions used for the terms medication error, adverse drug event, and drug-related problems make for a toxic soup when trying to sort through the true impact and cost associated with medication mistakes. In most instances, it should be enough to know that U.S. patients are harmed by medications each day by well-intentioned caregivers.
Classen DC, Munier W, Verzier N, et al. Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future). J Patient Saf. 2021;17(3):e234–e240.
Yu KH, Nation RL, Dooley MJ. Multiplicity of Medication Safety Terms, Definitions and Functional Meanings: When is Enough Enough? BMJ Qual Saf. 2005;14:358–363
Horbar JD, et al. NIC/Q 2000: Establishing Habits for Improvement in Neonatal Intensive Care Units. Pediatrics. 2003;111(4):e397–e410.
Makic MB, Rauen C, Watson R, Poteet AW. Examining the Evidence to Guide Practice: Challenging Practice Habits. Crit Care Nurse. 2014;34(2):28–45.
Mandell JC. The Importance of Habits in Radiology. J Am Coll Radiol. 2020;17(1, Part A):92–94. https://doi.org/10.1016/j.jacr.2019.06.014.
Clear J. Atomic Habits: Tiny Changes, Remarkable Results: An Easy & Proven Way to Build Good Habits & Break Bad Ones. New York: Avery; 2018.
Milkman KL, Duckworth A. How to Change: The Science of Getting From Where You Are to Where You Want to Be. New York, NY: Portfolio/Penguin; 2021.
Duhigg C. The Power of Habit: Why We Do What We Do in Life and Business. New York: Random House Trade Paperbacks; 2014.
Agency for Healthcare Research and Quality. Fatigue, Sleep Deprivation and Patient Safety. AHRQ website. https://psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety. Published September 7, 2019. Accessed December 16, 2021.
McCarty J. Eric Cropp, Ex-Pharmacist in Case in Which Emily Jerry Died, Is Ready to Plead No Contest. Cleveland Plain Dealer. April 19, 2009.
ISMP. Infant Heparin Flush Overdose. ISMP Medication Safety Alert! September 21, 2006.
Ostrom C. Baby Dies at Seattle Children’s Hospital After Overdose. Seattle Times. September 28, 2010.
ISMP. Too Many Abandon the “Second Victims” of Medical Errors. ISMP Medication Safety Alert! July 14, 2011.
Hoffman, R. (2021). Patient Safety, (3)2.
Hoffman, R. (2021). Patient Safety, (3)1.
Forbes. Thoughts on the Business of Life. Forbes Quotes. https://www.forbes.com/quotes/659/. Accessed January 4, 2022.