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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.

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