In 1999, the U.S. Institute of Medicine (IOM) reported that between 44,000 and 98,000 Americans die each year as a result of medical error, indicating more deaths due to medical errors than car accidents, breast cancer, or AIDS. That unsettling statistic was shared by Dr. Kengo Miyo from Tokyo University Hospital last weekend at AAMI 2014 in Philadelphia. He was participating in a session entitled, Hospital Information Systems from the Point of Patient Safety, which was presented by the Japanese Society of Medical Instrumentation.

Human error took center stage as the speakers discussed ways they have seen it reduced, and promising avenues to eliminate it entirely. Increasing the breadth of electronic health records (EHRs), bar coding medicine, the challenges associated with error alert systems, and political action taken by the respective countries of the speakers, were all factors taken into consideration.

An excess or deficient dose, errors in timing of administration, misreading labels, or simply failing to administer medication; these are all potentially deadly forms of error. Miyo described one case in which a woman was prescribed a muscle relaxer called Sakushizon, but went home with an anti-inflammatory called Sakushin. Wherever these mistakes originate — be it the ward where the prescription was written, in the pharmacy where it was filled, or at the bedside where the nurse administered it — there is no room for them in today's health care system.
According to research published by the Journal of the Japanese Society for Quality Control, triple and quadruple checking for errors should theoretically increase accuracy but in actuality, the potential for human error begins to rise again beyond double checking, (a possible explanation for this could be a diminished feeling of responsibility among checkers). That study would recommend the use of electronic alert systems to catch errors, but it isn't that simple. Those systems sometimes have a tendency toward false alarms, which, like the boy who cried wolf, can lead to an indifference to alarms called alert fatigue.

"For effective error prevention, a systematic approach according to the actual workflow in the hospital is required." said Miyo, "We need not only development of software functions but also innovation of hardware." By customizing alerts to the patterns within the hospital's data base, these systems can be improved upon, medication can be handled more systematically, and clinicians can better safeguard themselves against human error.

More Industry Headlines