Government agencies, purchasers of group health care, and health care providers are working together to make the U.S. health care system safer for patients and the public.

Medical errors happen when something that was planned as a part of medical care doesn't work out, or when the wrong plan was used in the first place. Medical errors can occur anywhere in the health care system, including:

1. Hospitals.
2. Clinics.
3. Outpatient surgery centers.
4. Doctors' offices.
5. Nursing homes.
6. Pharmacies.
7. Patients' homes.

Errors can involve any of the following areas:

8. Medicines.
9. Surgery.
10. Diagnosis.
11. Equipment.
12. Lab reports.

They can happen during even the most routine tasks, such as when a hospital patient on a salt-free diet is given a high-salt meal.

OSF HealthPlans is communicating to your patients 20 tips to help prevent medical errors. The 20 tips will be communicated as a four part series in OSF HealthPlans’ member newsletter, OSF Health Notes. These tips are available at www.ahrq.gov/consumer/20tips.htm

1. The single most important way you can help to prevent errors is to be an active leader of the health care team.
Most errors result from problems created by today's complex health care system. But errors also happen when doctors and their patients have problems communicating. For example, a recent study supported by the Agency for Healthcare Research and Quality (AHRQ) found that doctors often do not do enough to help their patients make informed decisions. Uninvolved and uninformed patients are less likely to accept the doctor's choice of treatment and less likely to do what they need to do to make the treatment work.

2. Make sure to ask your patients about everything they are taking. This includes prescription, over-the-counter medicines, and dietary supplements such as vitamins and herbs.
Encourage your patients to bring all of their medicines and supplements with them to their visit. "Brown bagging" the medicines can help you and your patient talk about them and find out if there are any problems. It can also help you keep your records up to date, which can help you deliver better quality care.

3. Make sure to ask about any allergies and adverse reactions your patient has had to medicines.
This can help you avoid prescribing a medication that could potentially harm your patient.

4. When you write a prescription, make sure it is legible.
If your handwriting is not legible, the pharmacist may not be able to read it.

13. What is the medicine for?
14. How it is to be taken, and for how long?
15. What side effects are likely? What to do if they occur?
16. Is this medicine safe to take with other medicines or dietary supplements?
17. What food, drink, or activities should be avoided while taking this medicine?

6. Encourage your patients to ask the pharmacist: Is this the medicine that my doctor prescribed?
A study by the Massachusetts College of Pharmacy and Allied Health Sciences found that 88 percent of medicine errors involved the wrong drug or the wrong dose.

7. Encourage your patients to ask the pharmacist for clarification of the directions on the prescription labels.
Prescription labels can be hard to understand. For example, the patient may ask if "four doses daily" means taking a dose every 6 hours around the clock or just during regular waking hours.

8. Encourage your patients to ask the pharmacist for the best device to measure liquid medicine and how to use it.
Research shows that many people do not understand the right way to measure liquid medicines. For example, many use household teaspoons, which often do not hold a true teaspoon of liquid. Special devices, like marked syringes, help people to measure the right dose. Being told how to use the devices helps even more.

9. Encourage your patients to ask for written information about the side effects a medication can cause.
If your patient knows what might happen, he or she will be better prepared if it does-or, if something unexpected happens instead. That way, the patient can report the problem right away and get help before it gets worse. A study found that written information about medications can help patients recognize problem side effects and then give that information to you or the pharmacist.

10. Encourage your patients to ask questions regarding the number of procedures or surgeries a hospital/facility has performed.
Research shows that patients tend to have better results when they are treated in hospitals that have a great deal of experience with their condition. Remember that OSF HealthPlans’ members have a choice of hospitals within the network.

11. Encourage your patients to consider asking all health care workers, who have direct contact with him or her, whether they have washed their hands.
Handwashing is an important way to prevent the spread of infections. Yet, it is not done regularly or thoroughly enough. A recent study found that when patients checked whether health care workers washed their hands, the workers washed their hands more often and used more soap.

12. When you discharge patients from the hospital, thoroughly explain the treatment plan you would like them to use at home.
This includes learning about his or her medications and finding out when he or she can get back to regular activities. Research shows that at discharge time, doctors think their patients understand more than they really do about what they should or should not do when they return home.

13. If your patient is having surgery, make sure that you as their PCP, the surgeon, and your patient all agree and are clear on exactly what will be done.
Doing surgery at the wrong site (for example, operating on the left knee instead of the right) is rare. But even once is too often. The good news is that wrong-site surgery is 100 percent preventable. The American Academy of Orthopaedic Surgeons urges its members to sign their initials directly on the site to be operated on before the surgery.

14. Encourage your patients to speak up if they have questions or concerns.
Patients have a right to question anyone who is involved with his or her care.

15. Make sure that you, as the PCP, are in charge of your patient’s care. If you are the specialist, make sure that you communicate all aspects of care with the patient’s PCP.
This is especially important if the patient has many health problems, many specialists or are in a hospital.

16. Encourage your patients to communicate all health information to each of his or her physicians and/or specialists.
Do not assume that everyone knows everything they need to care for your patient.

17. Encourage your patient to bring a family member or friend to be his or her advocate.
Even if he or she doesn’t think they need the help now, they might need it at a later date.

18. Know that "more" is not always better.
It is imperative to explain why a test or treatment is needed and how it can help. Education is key to empowering your patient’s health care decision making.

19. If you order a test, tell your patient not to assume that no news is good news.
Encourage your patient to call about the results.

20. Educate your patient about his or her condition and expected treatments.
This may include verbal explanation, handouts, websites, or any other available resources that may be helpful. For example, treatment recommendations based on the latest scientific evidence are available from the National Guidelines Clearinghouse at www.guideline.gov.

A Federal report on medical errors can be accessed online at www.quic.gov/report, and a print copy (Publication No. OM 00-0004) is available from the AHRQ Publications Clearinghouse. Call 1-800-358-9295 or e-mail: ahrqpubs@ahrq.gov.

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