Actions to take that prevent mistakes

Here are some steps to an error-free hospital

Looking for suggestions on where to start when trying to create a health care delivery system free of mistakes? The following suggestions are from Donald Berwick, MD, president and chief executive officer of the Institute for Healthcare Improvement in Boston. Ethics committees can help develop programs that foster a mistake-free health care delivery system by incorporating these actions into everyday practice. While many seem obvious, they aren’t necessarily practiced, he says.

1. Simplify. Reduce the number of steps in a work process and the number of times an instruction is given or something changes hands. Reduce nonessential equipment, software, and procedures. The fewer steps to a process, the fewer chances for error.

2. Standardize. Limit unneeded variety in drugs, equipment, supplies, and rules. If a procedure is done the same way all the time, it’s less likely to be done wrong.

3. Stratify. On the other hand, avoid the "one-size-fits-all" mentality. Instead, substitute with something more accurate, such as "five sizes fit 80%." Over-standardization can cause errors.

4. Improve communication patterns. "When an air-traffic controller says, ‘Land on runway 16,’ the pilot is expected to repeat those words to acknowledge that he’s received the message," says Berwick. "It should become common in operating rooms, intensive care units, and emergency departments for team members to repeat oral orders to make sure they got them correctly."

5. Use defaults properly. Make the correct action the easiest one. "A default is the rule that operates if nothing else intervenes," Berwick explains. "It’s a standard order. Anything that’s potentially unsafe should be harder to do and require more energy."

6. Automate cautiously. "At Chernobyl and Three Mile Island [sites of nuclear accidents], there was a heavy emphasis on automation," Berwick says. "Over-automation prevented the operators from judging the true state of the system. It created an illusion of safety, so human vigilance decreased."

7. Use sensible checklists. One response to safety concerns is to establish more protocols and screens. "That works up to a point," says the National Patient Safety Foundation’s Martin J. Hatlie, JD, who serves as executive director of the Chicago-based foundation. "But professionals sometimes need to override the system and use judgment based on experience and firsthand observation."

Or view checklists in another way. "Checklists and procedures minimize variables and give you a greater possibility of consistent results. But when they become something other than tools, they take away human judgment," says airline pilot, author, and safety analyst John Nance, who serves on the foundation’s board of directors.

"Sometimes, you need to drop the checklist and fly the plane. The same applies in medicine. The patient has a unique disease process. We don’t pay physicians or pilots just to follow lists."

8. Use affordances. Sometimes called forcing functions, these are features of equipment design that force correct use by providing clues to proper operation. For example, buttons are for pushing.

"A telephone handset feels uncomfortable if you hold it in any position but the right one," Berwick says. "Design the equipment to let it tell you how it’s supposed to be used."

Most cars with automatic transmissions, for instance, won’t start unless the gear shift is in park. That’s to prevent starting a car in drive and having it lurch forward suddenly. "That’s a design characteristic that makes it impossible for you to make a mistake," says health policy professor Lucian Leape, MD, a pediatric surgeon at the Harvard School of Public Health in Cambridge, MA. "In medicine, you can’t design away all errors. But you can make them less likely."

9. Respect human limitations. When designing tasks and work systems, don’t require undue effort. Consider stress, workload, time pressure, and the human body’s circadian rhythm — or internal clock — and limits to memory. "People just get tired," Berwick says. "It’s not carelessness, but a human trait. You can’t override human limits by exhorting people to be more careful. It ought to be obvious that people suffering from sleep deprivation won’t perform well."

Short-term memory is notoriously fallible, especially when there are frequent interruptions, Leape says. People easily can forget to finish vital tasks. "Instead of having physicians try to remember a dosage, we can have a system where the information is presented to them on a computer or checklist."

10. Redesign the patient record. "The patient record in its current form is among the chief offenders in creating and maintaining hazardous conditions," Berwick says. "It’s a collection of obsolete rules and habits. It’s too voluminous. Vital information is buried. It needs to be an instrument to benefit the people who depend on it. Right now, it’s a document based on legalities and tradition. We need a coordinated national effort to redesign it."

(Editor’s note: This article first appeared in Medical Economics, April 28, 1997. Reprinted with permission.)