In July, builders broke ground on a new hospital in Rwanda’s Burera district, near the Uganda border. The design relies on simple features to reduce the spread of airborne disease: outdoor walkways instead of enclosed halls, waiting rooms alfresco and large windows staggered at different levels on opposing walls to keep air circulating.
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.
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.