In busy hospitals human mistakes can result in serious consequences. One common mistake is a medication error where either a nurse or pharmacist incorrectly prescribes or fills a prescription. This can happen easily with medication that have similar sounding names such as Celebrex and Cerebyx, or in a noisy fast paced environment a medication may be entered in the wrong patients chart.
Dr. Donald Berwick, steward of the Medicare and Medicaid programs, has been fighting to improve efficiency and reduce errors at hospitals across the country and in Illinois. Berwick has looked outside of the medical field to find innovative ways to reduce errors. One simple change that has been effective is a quiet zone where nurses are able to place medication orders without interruption.
Berwick has been pushing for systemic change and has taken pointers from the aviation industry. According to the L.A. Times, an average traveler today has a 1 in a 20 million chance of dying in an accident, yet 1 in 7 Medicare patients is injured while in the hospital.
One way that Federal Aviation Administration cut accidents was through a rule that prohibited nonessential conversation in the cockpit when pilots were taking off and landing.
Systems engineering, a blend of science and psychology, has been credited with making air travel safer. The medical field has been slow to recognize the interconnectedness of medical care. Hospitals must identify why errors occur and work to prevent them. Systems engineering is ideally suited to this process.
Berwick described one instance of a breakdown in the system when two drugs were packaged in similar brown bottles with striped labels. Nurses would mistake the two drugs with lethal consequence.
While Berwick continues to look for ways to improve the quality of care at hospitals across the nation, he is concerned that federal cost cutting will ignore the slower process of improving quality to reduce costs. Federal funds must be invested in programs that improve quality as well as efficiency.