Most error-reduction efforts begin in response to a serious
error. Individuals and practice sites have become accustomed to
reacting to an error after it has occurred. Unfortunately, only
then do they consider how to prevent the same error from being
repeated.Would it not be useful to be able to predict the types
of errors that could occur and proactively institute preventive
measures? All too often, error potential is not included in
decisions about which medications, devices, or technology to
purchase. Instead, decisions are guided by cost, third-party
formulary restrictions, contractual agreements with purchasing
groups or vendors, and pharmaceutical marketing efforts. Input
and evaluation from those who will be using the products may not
be sought, and error potential may not be considered ahead of
time. The ultimate result is unforeseen safety issues and errors
once the product is in the hands of clinical users or health
care consumers. Failure Mode and Effects Analysis (FMEA)
systematically identifies a