What is the problem?
To Err is Human. This is how a landmark paper from 2000 starts, recognizing that “the problem is not bad people in health care–it is that good people are working in bad systems that need to be made safer“*. The consequences of errors can be described by adverse events. Adverse events that are related to medication and or drug/fluid incidents constitute about 20% of all types of adverse events, which makes this the second most common type of adverse event†.