Memo From The Editor

Error-proofing

Marianne Dekker Mattera

Anyone who's had any experience with children knows that just before an infant becomes mobile you baby-proof the house. You put caps on electrical outlets and a lock on the cabinet under the sink, and you start moving breakable knickknacks up to higher shelves. If you're really thorough, you get down on the floor and look around from the baby's point of view to see what dangers lurk that you didn't notice from your adult vantage point.

Error-proofing the health care system must be approached in the same way. And you must turn your attention to it now. Sure, the public outrage kindled by the Institute of Medicine's report in 2000, which asserted that up to 98,000 deaths a year were caused by medical mistakes, has died down. But the transplant error at Duke University Medical Center in February has raised the issue to national prominence again. It's even prompted critics of malpractice tort reform to point to the grievous errors that might go uncompensated if it were enacted.

What can you do? You can examine your own practice patterns. Are they as error-proof as they might be? Do you know all the contraindications of each drug you prescribe? Do you know the medication history of each of your patients? What about the one who's in front of you at the moment? Do you use an electronic prescribing program that can track all those details? Is it time to get one? If you write out your prescriptions by hand, do you print them legibly to minimize the chance that they'll be misread?

Your prescribing patterns are just one area to look at. Look, too, at your history taking, your documentation after a patient visit, office procedures that funnel patient messages to you, and the ways you respond to those messages.

Get "down on the floor" to look at the way you practice from as many angles as you can the patient's, the pharmacist's, your staff's, the lab's. What about the physicians you refer to? Is everything clear from their point of view? Is there any way that what you're doing can be misinterpreted, introducing an error that might cause harm?

The article,"16 Rx safeguards that also safeguard you," gives you some tips on safe medication practices. They were developed by the California Medical Association in collaboration with three liability insurers and sent to all doctors in that state. We felt it was important to share those tips with doctors nationwide. Many you will be familiar with, but a quick review of basics usually sharpens resolve if we've let things slide.

Once your own practice is as error-proof as you can make it, turn your attention to your hospital's systems. If administrators haven't made moves to install systems proven to reduce errors computerized medical records, for instance, and computer order entry ask why not and push for change. Your patients deserve it, and so do you. Error-proofing is also suit-proofing.

 

Marianne Mattera. Memo from the Editor: Error-proofing. Medical Economics 2003;7:8.