Reducing Error

Interesting news on reducing medical errors, via Modern Healthcare:

Data show that a jumbo jet's worth of patients die each day from medical errors, so it is fitting that an aviation comparison was used in a new study of one source of errors--the handoff of patients from one physician to another.

The study in the December issue of the journal Academic Medicine found that unlike among air traffic controllers and other vital safety operations, there are few systems to deal with patient handoff when one physician leaves the hospital and another takes over. The result is that the handoff is routinely botched--the result of poor communication and training and insufficient information systems--with dire implications for patients.

The solution is to teach physicians the handoff process using a model based on principles of adult learning, effective feedback and clinical experience, the study authors say. "Computerized medical records can facilitate face-to-face handoffs," he says. "Body language and other crucial factors are lost when the handoff is done over the phone and a written handoff may be difficult to read--doctors have notoriously poor penmanship--errors especially in numbers or decimal places are easy to make, and written notes are open to misinterpretation or misplacement."

I love the jumbo jet a day analogy because the gravity of medical errors is often prone to understatement. And in the post 9/11 world, extending the analogy further and comparing doctors to air traffic controllers is particularly potent.

But here's what I don't understand. Obviously EMRs can reduce errors, but if what the study authors believe is true -- that there's no substitute for a face-to-face handoff-- they can only do so much.

Along with HIT fixes, we should also be asking how can we facilitate more face to face handoffs. If my recent hospital stay is any indicator, that's no small task. Considering my doctors seemed to be on completely different schedules, and considering the pressure to be as efficient and speedy as possible, it's no wonder this task isn't always accomplished. How can we reduce those pressures, along with additional methods of reducing errors (EMRs), to prevent those 100,000 deaths? Any one of us could be included in that statistic this year. If face-to-face handoffs can't be attained, is it possible to integrate video conferencing technology?

Comments

[Adrock]

All great points. My personal experience of an ER visit proved some very same flaws in a hand-off. The doctors changed shifts and so the one that got me while I first went in was not the same when I was discharged. The discharge doctor was looking over my records and test results and using a lot of "Uh..."s Nothing serious in my case of course, but at the very least it was discomforting to me.

[bangvap]

Reducing Errors in Health Care:
AHRQ research has shown that medical errors may result most frequently from systems errors—organization of health care delivery and how resources are provided in the delivery system.