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by Yaneer Bar-Yam
Step V: Improve communication
Improved capacity for flexibility of response is more important than practicing only a single action—in tennis and in healthcare.

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.

The same holds true for medical errors: understanding the many possible ways errors can occur rather than just the last one, and the ways thing 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.

solving problems of science and society