If such a sobering statistic hasn’t changed medical errors, then what can? Jones and our team of physician consultants analyzed the human element of medical errors, and why physicians are bound to make mistakes despite their best intentions.
MEDITECH’s Physician Consultant team recently came together to discuss the culture of medical errors, and what EHR vendors can do to alleviate some of the factors contributing to human error in medicine. Lead Physician Informaticist Steven Jones, MD, opened the meeting with the following discussion points:
“We all know of the groundbreaking ‘To Err is Human’ report from the Institute of Medicine in 1999 that estimated as many as 98,000 people die in hospitals from preventable medical errors,” Jones began. “Despite this alarming statistic, other studies released since then have shown that error rates are not decreasing, in spite of our best efforts.”
“The seminal 1994 JAMA article, “Error in Medicine,” by Lucian Leape, explored the perfectionist culture in healthcare that is drilled into clinicians during residency,” Jones shared with the group. “Leape’s report says ‘physicians are expected to function without error, an expectation that physicians translate into the need to be infallible.’ We come to view error as a failure of character.’”
“This need to be infallible leads to lying or covering up mistakes when they happen,” he continues. “It’s hard to get physicians to own up to their mistakes and admit how or why they happened.”
This culture of perfection usually leads to the healthcare system punishing the person, not the process, behind the error.
“All humans err, and we do it frequently,” says Jones. “We only get 85% of our regular tasks right, and that is as long as we’re well-slept, well-fed, and not stressed about our personal lives or whatever else.”
“As such,” he continues, “we should only punish the truly reckless, purposely ‘bad’ individuals who are acting maliciously and not those good physicians who have simply made an honest mistake.”
Jones explains further why humans are prone to error, outlining Leape’s theories of how the human mind thinks through the models of a “System 1” and “System 2.” System 1 thinking is automatic, fast, effortless, subconscious, and it involves pattern recognition. “Humans do this beautifully, it’s like second nature to us,” says Jones.
“System 2 involves methodical, logical, algorithmic or computational thinking. ‘If this, then that.’ System 2 is slow. It’s intentional and difficult to sustain over long periods. Although System 2 keeps an eye on System 1, research shows that System 2 is lazy and prone to error.”
Since mistakes are more likely to happen in System 2, Jones challenged the room to determine how we can make more of our tasks System 1 processes. “Human thinking develops with increasing expertise over time,” says Jones. “So what can we do as an EHR vendor to help that goal?”
MEDITECH Physician Consultant Jennifer McKay, MD, MS, thinks we need to develop software with human behavior in mind. “We need to think about the impact of the number of clicks it takes to perform a task, because that has a big impact on our efficiency and physicians always want to be fast and efficient.”
“MEDITECH’s Click Reduction Initiative is already doing a good job reaching out to our end users to improve workflow and usability,” says McKay, “but we will continue this effort with our Development team to improve the intuitiveness of our system and ultimately support the physician in your quest to deliver safe, error-proof care.”