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by Yaneer Bar-Yam
Step V: Improve Communication
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.

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.

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.

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