by Yaneer Bar-Yam
Step V: Improve Communication

Ten years ago, the Institute of Medicine’s report on the extent of serious medical errors brought the issue to the attention of medical professionals and the public. According to the Institute and the FDA, medication-related errors cause over 1 million harmful drug events each year. Even one case of medical error may result in tragedy for those directly affected and may be traumatic for the professionals involved.

How can this problem be solved?

First, it must be said that the often-suggested electronic prescription system is not the solution to medication errors—unless the system is well designed. Research shows that different electronic systems affect errors quite differently, ranging from eliminating 99% of them to increasing the error rate and all possibilities in between. Moreover, these systems can cause a variety of unanticipated side effects that compromise patient safety. This paradox can be understood once the real sources of medical errors are understood.

For many errors, the solution lies in adding redundancy. What does this mean?

To explain, we can turn to another context where the prevention of errors is important: writing checks.

Where money is involved, we are careful to make sure the information is conveyed clearly. To this end, we write the amount twice, in both words and numerals. This is done, purely and simply, to prevent errors. Electronic check-writing systems also make sure that critical information is “double-checked.” Another example is the double entry of e-mail addresses or passwords when one registers for online accounts. Why enter the same information twice? To make sure it is correctly received.

Duplication of information entry reduces the likelihood of communication error.

The same principle of redundancy can and should be applied to writing prescriptions.

Why isn’t this done already? The system we use today for writing prescriptions was developed when there were far fewer medications. As the number of possibilities increases we have to be increasingly careful to make sure that enough information is communicated so that the right prescription is delivered.

Thus, whether written or electronic, what matters is how well the system is designed.

The caveat is that every critical piece of a prescription must be written twice, to ensure that few if any errors occur. There are five critical pieces of information on a standard prescription: Patient, Drug, Dose, Route (oral, intravenous, etc.) and Time. Each of these must be written in two ways, or double-checked after electronic entry.

For example, the patient could be designated by both name and ID number. The drug could be doubly specified by writing both the medication and the indication (the condition for which it is prescribed), or both the generic and trade names. Dosage, route of drug delivery, and time of administration could be written out fully and abbreviated, rather than given only in abbreviated form.

For electronic systems, autocompletion and simple check boxes should be avoided. These items are more prone to error precisely because they are quick and easy. Instead, it is important to have the prescriber provide all key information longhand and verify it. Writing something twice admittedly takes more time but the prevention of errors, as in writing checks, must be considered of primary importance.

It is possible to write less when there is less potential for misunderstanding. For example, if the route is already determined by the medication, then the route can just be indicated as “Standard.” For now, however, we should be conservative in shortcuts; once medication errors are dramatically reduced, we can carefully study which efficiencies can be implemented without errors being introduced.

Hitting the right target is harder when there are more targets. The more medications and treatments there are the more accurate the system has to be to avoid errors that shift from one of the possible medications to another.

Electronic systems also should be carefully designed to avoid distraction and disruption. The difference between a well-designed intuitive way of entering prescriptions, with appropriate redundancy, and a poorly designed system is the difference between success and failure.

Communication is not only central to prescription errors, but is also central to other forms of medical errors. Errors generally arise not because of an individual’s action, but because of the way individuals work together. Improvement of communication and coordination is often the solution. The development and competition of workgroup teams recommended in Step II are key to reducing errors throughout healthcare, because such groups can improve local team coordination and communication.

In looking for ways to solve the problem of medical errors, improving upon the analysis of the source of medical errors is important too. Too often, the process of examination only looks at a specific error—what went wrong in this particular case—and a particular practice is blamed, and a particular solution is offered to that practice. Instead, we should abstract from the level of individual errors and find the patterns among effective and ineffective cases.

Focusing on just the individual error is as ineffective as a tennis player only practicing the one last shot he or she missed, over and over. In most cases, it makes more sense to work on improving speed, agility, and the player’s ability to respond to a large set of possible shots. The next challenging shot will not be the same as the last one.

Improved capacity for flexibility of response is more important than practicing only a single action—in tennis and in healthcare.

The same holds true for medical errors: understanding the many possible ways errors can occur rather than just the last one, and the way things work correctly, will allow us to recognize the weaknesses and improve the strengths of the system.

The Institute of Medicine originally reported up to 100,000 deaths per year due to medical errors, and up to $29 billion in additional costs incurred. More recent reports have found these numbers to be even higher. The price in human and financial terms is too great. We can and must fix the problem.

Next: Step VI: Create disinfection gateways.

For Further Reading:

1. Y. Bar-Yam, Making things work. (NECSI Knowledge Press, Cambridge, MA, 2004). See chapter 11.

2. Y. Bar-Yam, System care: multiscale analysis of medical errors—eliminating errors and improving organizational capabilities, NECSI Technical Report (9/1/2004).

3. Y. Bar-Yam, M. Smith, A. Wachman, S. Topolski, Prescription form with redundancy, New England Complex Systems Institute.

4. A. Goldstein, Overdose kills girl at Children's Hospital, Washington Post (4/20/2001).

5. R. Shapiro, Preventable Medical Malpractice: Revisiting the Dennis Quaid Medication/Hospital Error Case, The Injury Board Blog Network (8/9/2010).

6. Experts to probe factors behind overdose error, Edmonton Journal (5/8/2007).

7. To err is human: building a safer health system, Institute of Medicine (The National Academies Press, Washington, DC, 2000).

8. Preventing medication errors: quality chasm series, Institute of Medicine (The National Academies Press, Washington, DC, 2007). [Press release: Medication errors injure 1.5 million people and cost billions of dollars annually; report offers comprehensive strategies for reducing drug-related mistakes. National Academies press release (7/20/2006).]

9. M. Graban, Statistics on healthcare quality and patient safety, Leanblog compilation (8/9/2009).

10. Drugs: Drug safety and availability: Medication errors, US Dept. of Health & Human Services, Food and Drug Administration.

11. FDA and ISMP launch campaign to reduce medication mistakes caused by unclear medical abbreviations, Food and Drug Administration press release (6/14/2006).

12. Doing what counts for patient safety: federal actions to reduce medical errors and their impact, Report of the Quality Interagency Coordination Task Force (QuiC) to the president on medical errors (2/2000).

13. National summit on medical errors and patient safety research, Quality Interagency Coordination Task Force (11/30/2006).

14. S. J. Weiner, A. Schwartz, F. Weaver, J. Goldberg, R. Yudkowsky, G. Sharma, A. Binns-Calvey, B. Preyss, M. M. Schapira, S. D. Persell, E. Jacobs, R. I. Abrams, Contextual errors and failures in individualizing patient care: a multicenter study, Annals of Internal Medicine, 153, 69-75 (2010).

15. In-hospital deaths from medical errors at 195,000 per year, healthgrades study finds, HealthGrades press release (7/27/2004).

16. A. G. Kennedy, B. Littenberg, A modified outpatient prescription form to reduce prescription errors, Joint Commission Journal on Quality and Patient Safety 30, 480-487 (2004).

17. B. Chaudhry, J. Wang, S. Wu, M. Maglione, W. Mojica, E. Roth, S. C. Morton, P. G. Shekelle, Systematic review: Impact of health information yechnology on quality, efficiency, and costs of medical care, Annals of Internal Medicine, 144, 742-752 (2006).

18. R. Koppel, J. P. Metlay, A. Cohen, B. Abaluck, A. R. Localio, S. E. Kimmel, B. L. Strom, Role of computerized physician order entry systems in facilitating medication errors, Journal of the American Medical Association, 293, 1197-1203 (2005).

19. R. L. Wears, M. Berg, Computer technology and clinical work: still waiting for Godot, Journal of the American Medical Association, 293, 1261-1263 (2005).

20. D. Liebovitz, Health care information technology: A cloud around the silver lining? Archives of Internal Medicine, 169, 924-926 (2009).

21. J. S. Ash, D. F. Sittig, E. G. Poon, K. Guappone, E. Campbell, R. H. Dykstra, The extent and importance of unintended consequences related to computerized provider order entry, Journal of the American Medical Informatics Association, 14, 415 (2007).

22. K. E. Walsh, W. G. Adams, H. Bauchner, R. J. Vinci, J. B. Chessare, M. R. Cooper, P. M. Hebert, E. G. Schainker, C. P. Landrigan, Medication errors related to computerized order entry for children, Pediatrics, 118, 1872-1879 (2006).

23. A. Robeznieks, Data entry is a top cause of medication errors: Training and design are seen as keys to reducing electronic prescribing errors, American Medical News (1/24/2005).

24. Y. Y. Han, J. A. Carcillo, S. T. Venkataraman, R. S. B. Clark, R. S. Watson, T. C. Nguyen, H. Bayir, R. A. Orr, Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system, Pediatrics 116, 1506-1512 (2005).

25. Computer entry a leading cause of medication errors in U.S. health systems: percentage of reported errors steadily increased from 1999 to 2003, United States Pharmacopeia press release (12/20/2004).

26. T. Holdsworth, R. E. Fichtl, D. W. Raisch, A. Hewryk, M. Behta, E. Mendez-Rico, C. L. Wong, J. Cohen, S. Bostwick, B. M. Greenwald, Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients, Pediatrics, 120, 1058-1066 (2007).

27. P. Bonnabry, C. Despont-Gros, D. Grauser, P. Casez, M Despond, D. Pugin, C. Rivara-Mangeat, M. Koch, M. Vial, A. Iten, C. Lovis, A risk analysis method to evaluate the impact of a computerized provider order entry system on patient safety, Journal of the American Medical Informatics Association, 15, 453-460 (2008).

28. K. Colpaert, B. Claus, A. Somers, K. Vandewoude, H. Robays, J. Decruyenaere, Impact of computerized physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial, Critical Care 10, R21 (2006).

29. J. M. Teich, P. R. Merchia, J. L. Schmiz, G. J. Kuperman, C. D. Spurr, D. W. Bates, Effects of computerized physician order entry on prescribing practices, Archive of Internal Medicine 160, 2741-2747(2000).

30. E. Ammenwerth, P. Schnell-Inderst, C. Machan, U. Siebert, The effect of electronic prescribing on medication errors and adverse drug events: a systematic review, Journal of the American Medical Informatics Association, 15, 585-600 (2008).

31. Computerized provider order entry, US Dept. of Health and Human Services, Agency for Healthcare Research and Quality.

32. C. E. Shannon, A mathematical theory of communication, Bell System Technical Journal 27, 379–423, 623–656 (1948).

33. C. L. Streeter, Redundancy in organizational systems, The Social Service Review 66, 97-111 (1992).

34. R. W. Hamming, Error detecting and error correcting codes, Bell System Technical Journal 29, 147-160 (1950).

35. F. J. MacWilliams, N. J. A. Sloane, The theory of error-correcting codes. (Elsevier B.V., Amsterdam, The Netherlands, 1977).

36. J. Reason, Human error: models and management, BMJ 320, 768–770 (2000).

37. C. Perrow, Normal accidents: living with high risk technologies (Princeton University Press, Princeton, NJ, 1999).

38. L. L. Leape, Errors in medicine, Clinica Chimica Acta 404, 2-5 (2009).

39. L. L. Leape et. al. Systems analysis of adverse drug events, Journal of the American Medical Association 274, 35-43 (1995).

40. C. K. Christian, M. L. Gustafson, E. M. Roth, T. B. Sheridan, T. K. Gandhi, K. Dwyer, M. J. Zinner, M. M. Dierks, A prospective study of patient safety in the operating room, Surgery 139, 159-173 (2006).

Writing and Editing Credits

Yaneer Bar-Yam with Shlomiya Bar-Yam, Karla Z. Bertrand, and Nancy Cohen

Image Credits

Page 1: "Writing Prescription" © iStockphoto / Stefan Klein

Page 2: "Check It Out" © iStockphoto / Sean Locke

Page 3: "Possibility Space" by Alexander S. Gard-Murray and Yaneer Bar-Yam

Page 4: "Aggie Women's Tennis - 27" by Stuart Seeger

Formatting Credits

Alexander S. Gard-Murray

 

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