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The serious problem of medical errors isn't new, but in the past, the problem hasn't received the attention it warranted. The President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry released a report in 1998 that identified medical errors as one of the four major challenges facing the nation in improving healthcare quality. Since then, awareness of the issue has been growing.

According to a 2000 Institute of Medicine (IOM) report, preventable medical errors of all kinds are killing between 44,000 and 98,000 people per year. In trying to figure out how to fix the problem, it's easy to try and figure out who was to blame - and who should take responsibility.

Ultimately, pointing the finger at a particular individual, procedure or device is not the key to reducing, preventing or eliminating medical errors. Recognizing that medical errors are a healthcare system problem is the first step.

Improve the System

Healthcare professionals are human and, like everyone else, make mistakes. "One of the main difficulties is this issue of trying to assign responsibility," explains Yaneer Bar-Yam, president of the New England Complex Systems Institute (NECSI) in Cambridge, MA, and author of Making Things Work: Solving Complex Problems in a Complex World.

NECSI is an independent educational and research institute dedicated to advancing the study of complex systems. Very often people want to find a nurse, physician, pharmacist or administrator and make them responsible, but that's the wrong answer. "It still makes one person be in charge, and they cannot work in a way that will make the system effective," Bar-Yam says.

There are properties of the system that can provide effective and error-free medical care, he says, including effective communication and coordinated behaviors of multiple individuals. "The errors happen at the interfaces between people," Bar-Yam states, "and working together is something that has to be understood how to do."

But it's never been a part of the training. The education of nurses and doctors doesn't focus on the problem of communication and team function, he says.

One of the main insights of the study of complex systems, notes Bar-Yam, is that it teaches you how to create collective responsibility and how it should impact on how people act. "The whole system just doesn't recognize that the nature of medical care today is based upon groups of people working together rather than individuals doing individual tasks," he says.

Other Sources of the Problem

Suzanne Gordon, an expert on nursing issues, agrees with Bar-Yam in that medical errors are a healthcare system problem. She believes one of the system problems that can lead to errors is inequality in power relationships and the inability of people on healthcare teams to function as team members.

"I think that one of the really important things to look at is how do people on these teams make decisions and take each other into consideration? How is the workplace organized in terms of case load, exhaustion and hours at work?" she asks.

"There is a significant component that's being ignored, which is, what are the conditions of work, in particular, healthcare work places? If doctors and nurses are overloaded, [for example], there's much more room for error. There's only so much information a brain can process."

"The other part of it has to do with understanding the role of the drive for efficiency in healthcare," Bar-Yam says.

"The problem is that people are trying to make healthcare into a mass production system. There are clear distinctions that should be made between what kinds of tasks can be done in a mass production way and what cannot be done," he says. "It is possible to make healthcare more efficient, but it's a question of recognizing where efficiency can be effective and where efficiency leads to ineffectiveness."

Preventing Medical Errors: What's the Solution?

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