Tag Archives: medical error

Response to “Paper Kills”

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.)

References:

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.

 

More medical errors–Operating on the wrong side of the patient’s brain!

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.

[link]

“From the Doctor’s Brain to the Patient’s Vein”

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.