First thing every morning, Lynn Pitet, of Cody, Wyo., checks her computer to see whether her mother, Helen Trost, has gotten out of bed, taken her medication and whether she is moving around inside her house hundreds of miles away in Minnesota.
I was reading a lengthy Q&A with Newt Gingrich in Freakonomics this morning, and came across the following:
Q: You discuss a united American front in your book. What healthcare platforms do you think Americans will unite around?
A: “… This system will have three characteristics, none of which are present in today’s system…. It will make use of information technology. Paper kills. It’s just that simple. With as many as 98,000 Americans dying as a result of medical errors in hospitals every year, ridding the system of paper-based records and quickly adopting health information technology would save lives and save money. We must also move toward e-prescribing to drastically reduce prescription errors.
Newt Gingrich is a powerful man. I am glad he is comfortable with and encouraging of technology. Me too! However, I am terrified of the assumption that information technology systems are inherently better or less error prone than paper systems. “Paper kills” is a nice, tight tag line that people are bound to remember. Is it true?
My earlier post on Paper Protocols saving lives and dollars in Michigan says otherwise. So does research in the context of medical adherence. Linda Liu and Denise Park (2004) identified a paper system as one of the most effective tested when it comes to diabetics remembering to measure their glucose.
It is not the material of the system, it is the design of the system that makes it either intuitive, fail-safe, or error prone. Blindly replacing known paper protocols and records with electronic alternatives is not a guaranteed improvement. This is the kind of thinking that brought us the touchscreen voting system.*
“Oh, it wouldn’t be blind,” one might say. I hope so, but a blanket statement such as “paper kills” doesn’t give me confidence. Paper doesn’t kill, bad design does.
I wouldn’t want to end this post without being clear: We need to stop pitting paper against computers and start solving:
1. Under what circumstances each is better
2. Why each would be better
3. How to best design for each. Paper isn’t going away, folks.
*The linked article mentions reliability and security without mentioning usability. I don’t want to go too far afield, so I will save my post on being unable to vote on the Georgia Flag (thanks to the compression artifacts present in the pictures, making it impossible to tell them apart.)
Liu, L. L., & Park, D. C. (2004). Aging and Medical Adherence: The Use of Automatic Processes to Achieve Effortful Things. Psychology and Aging, 19(2), 318-325.
If you’re Apple, you want people to see the similarities between their iPod and their iPhone. However, if you are a drug manufacturer, you do not want similarities between adult and pediatric medicine.
Above are bottles of Heparin, manufactured by Baxter Healthcare. Both blood thinners, one of these vials is 1,000 times more concentrated than the other. Confusion between these two bottles killed infants at an Indiana hospital back in 2002. This article provides a good overview of past cases.
I actually remember reading about this back then, and thought “Wow, there’s a good human factors lesson. How awful that children had to die to bring it into the spotlight.”
Unfortunately, this lesson stayed unlearned, as two more children were administered the adult drug this week. Because these were the newborn twins of Dennis and Kimberly Quaid, who have already spoken out on 60 Minutes about medication mistakes, we may see the problem addressed more thoroughly in the drug industry.
On a final note, these cases touch on the human desire to blame other humans rather than the systems they interact with. In the Indiana case, a mother who lost her child was quoted as saying:
“… who blames the nurses, not drug labeling, for her daughter’s death. “I don’t think it was from the label,” she said. “They are both blue, but one is lighter than the other. How could they mistake those?”
Change blindness, automaticity, expectation, fatigue, and time pressure are but a few of the factors that might have caused the error. Sometimes, it isn’t a case of someone not just “being careful.” This is actually a good thing: we can understand and solve human factors problems. We can’t make someone care.
Improvements in simulator performance didn’t come from just any Wii (see image), or any game. Marble Mania is good, for example. Tennis (astonishingly fun to play on the Wii, which uses a motion-sensitive wireless control) isn’t so helpful. “The key is to have subtle hand movements,” Kanav Kahol one of the authors of the study, told the Health Blog. “You can’t hit a tennis swing and expect to become a better surgeon. You need fine motor control.”
All Things Considered interviewed Dr. Peter Pronovost this weekend about the checklist he developed for doctors and nurses in busy hospitals. On a topical level, this illuminated the working memory demands of hospital work and statistics on how easy it is to err.
As an example, a task analysis revealed almost two hundred steps medical professionals do per day to keep the typical patient alive and well. On average, there was a 1% error rate, which equates to about two errors per day, per patient.
Pronovost introduced checklists for each type of interaction, which resulted in Michigan hospitals going from 30% chance of infection (typical across the US) to almost 0% for a particular procedure.
Could something as simple as a checklist be the answer? No, because this intervention wasn’t “just” a checklist.
Whether trained in these areas or not, the doctors interviewed had to understand:
Team training: Nurses are trained not to question doctors, even if they are making a mistake. Solution: Pronovost brought both groups together and told them to expect the nurses to correct the doctors. (Author note: I’d be interested to see how long that works.)
Social interaction: In an ambigous situation, people are less likely to interfere (e.g., the doctor didn’t wash his or her hands, but the nurse saw them washed for the previous patient and thinks “It’s probably still ok.” Checklist solution: eliminate ambiguity through the list.
Effects of expertise: As people become familiar with a task, they may skip steps, especially steps that haven’t shown their usefulness. (e.g., if skipping a certain step never seems to have resulted in an infection, it seems harmless to skip it). Checklist solution: enforce steps for all levels of experience.
Decision making: People tend to use heuristics when in a time-sensitive or fatigued state. Checklist solution: remove the “cookbook” memory demands of medicine, leaving resources free for the creative and important decisions.
There sure seem to be lots of medical errors in the news lately. No mention of human factors:
The most recent case happened Friday when, according to the health department, the chief resident started brain surgery on the wrong side of an 82-year-old patient’s head. The patient was OK, the health department and hospital said.
In February, a different doctor performed neurosurgery on the wrong side of another patient’s head, said Andrea Bagnall-Degos, a health department spokeswoman. That patient was also OK, she said.
But in August, a patient died a few weeks after a third doctor performed brain surgery on the wrong side of his head. That surgery prompted the state to order the hospital to take a series of steps to ensure such a mistake would not happen again, including an independent review of its neurosurgery practices and better verification from doctors of surgery plans.
We can surmise from the short news article that the source of the problem seems to be working memory??
In addition to the fine, the state ordered the hospital to develop a neurosurgery checklist that includes information about the location of the surgery and a patient’s medical history, and to put in place a plan to train staff on the new checklist.
LOS ANGELES – The recent chatter on a popular social networking site dealt with a problem often overlooked in medicine: mistakes in patients’ medical charts.The twist was the patients were doctors irked to discover gaffes in their own records and sloppy note-taking among their fellow physicians.
Errors can creep into medical charts in various ways. Doctors are often under time pressure and may find themselves taking shortcuts or not fully listening to a patient’s problems. Others rely on their memory to update their patients’ files at the end of the day. Other mistakes can arise from illegible handwriting or coding problems.
It appears that HFB needs an entire section devoted to medical error. This is not surprising in light of the thousands of Americans who die from preventable errors each year.
The latest comes from Tanzenia where confusion about patient names earned brain surgery for a twisted knee, and knee surgery for a migraine sufferer.
Mr Didas who had been admitted for a knee operation after a motorbike accident is still recovering from the ordeal – he ended up unconscious in intensive care after his head was wrongly operated on. And chronic migraine sufferer Emmanuel Mgaya is likewise, still recovering from his unplanned knee surgery. The blunder was blamed on both patients having the same first name.
But a hospital official, Juma Mkwawa said it was the worst scandal that had happened at Muhimbili hospital and that, “sharing a first name cannot be an excuse”. The two surgeons responsible have been suspended. (BBC)
Before anyone retreats into the comfort of “that wouldn’t happen here,” I suggest a look at the growing literature on similar medication names and their consequences.
It is easy to be the bearer of sad stories and ill tidings. I would rather on a note for a hopeful future. Below are researchers and companies dedicated to identifying and eliminating causes of medical error.
Please add more in the comments section if you know someone working in this important context.
DETROIT — A patient undergoing treatment at the Karmanos Cancer Institute in Detroit received a dose of radiation on the wrong side of the brain, according to a report filed with the United States Nuclear Regulatory Commission.
According to the report, a crucial piece of information was misread prior to treatment with a gamma knife, which delivers a targeted form of radiation therapy that zeros in on specific locations in the brain.
The patient went through a routine MRI (magnetic resonance imaging) scan of the brain just before the procedure, but went into the scanner “feet first,” rather than the standard practice of head first, the document said.
“The gamma knife-authorized medical physicist failed to recognize the scanning error when importing the MRI images into the Gamma Knife treatment planning computer, and subsequently registered them as head first,” the report said. “This resulted in the wrong side of the patient being targeted and treated.”
What went wrong? Deviation from standards (if there are standards)? Too-busy doctors? I’ll be interested to see who gets the blame.