We provide trusted and independent expert analysis of patient safety matters across the healthcare ecosystem
We serve as independent auditors for government and non-government organizations in the pharmacy, electronic prescribing, and EHR space. We have represented pharmacies, pharmacy vendors, hospitals, and EHR vendors in cases relating to medication and prescription errors.
Medication Errors and Root Cause Analysis
Medication Errors can occur at any point in the medication life-cycle. While errors cannot always be prevented, healthcare organizations can mitigate risks and reduce harm by implementing the necessary risk prevention strategies.
The FDA receives more than 100,000 reports every year involving medication errors
Every year in the United States, more than 7,000 people die as a result of a medication error
Forty billion dollars is spent each year in the U.S. on patients affected by medication errors
Five percent of all malpractice claims can be attributed to medication errors
“any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.” // National Coordinating Council for Medication Error Reporting and Prevention
“an adverse outcome that can be attributed, with some degree of probability, to an action of a drug” // Drug Safety volume 28, pages 851–870 (2005)
The occurrence of an adverse drug event defined above does not necessarily indicate an error or poor quality care.
“result from a medication error that reaches the patient and causes any degree of harm; approximately half of ADEs are preventable.” // Agency for Health Research and Quality - Patient Safety Network
“an appreciably harmful or unpleasant reaction, resulting from an intervention related to the use of a medicinal product, which predicts hazard from future administration and warrants prevention or specific treatment, or alteration of the dosage regimen, or withdrawal of the product.” // Agency for Health Research and Quality - Patient Safety Network
Stated plainly, adverse drug effects and reactions are non preventable adverse drug events.
We utilize our domain knowledge of in‑patient hospital systems (EHR), out‑patient systems (e‑prescribing/labs/EMR), and pharmacy management system software.
We draw on our extensive experience in designing and analyzing patient safety and clinical workflows, human factors engineering issues (user centric design), safety culture.
We apply formal analyses to establish whether standards of practice and safety procedures were appropriately constructed and implemented. We determine the root cause of medication errors and adverse drug events.
Dr. Ajit Dhavle is a healthcare technologist, clinician, entrepreneur, and a problem solver with 20 years of experience in digital health, quality, e-medications, Health IT standards, and patient safety. He oversees a team of health informatics experts to provide strategy, management, SDLC, compliance, and audit services to government and commercial entities.
Alicia Morton Farlese is a retired Captain serving twenty-six years in the United States Navy Nurse Corps, and was a senior leader in national health IT policy at the US Dept. of Health and Human Services. Dr. Farlese assists clients in meeting Health IT regulations, including Information Blocking requirements of the Cures Act.