Medical Errors Report #26

A Four-Year Solution Implementation Study

Bad and Confusing Procedures Lead to Medical Errors

Bad procedure is one of the major causes of deadly medical errors in many hospitals. Procedures are the operational guidelines for performing tasks in most hospitals. Many years of observations of hospital procedures from various departments have taught me that, most procedures are never tested by those who are supposed to use them. All procedures to be used for performing critical patient tasks must be tested by those who are going to use them, regardless of who has written the procedure or whether it comes as a manufacturer’s set of instructions. There have been many cases in which a supervisor wrote a procedure that workers were unable to use because of misleading instructions. On telling the supervisor about the possible problem with the procedure, instead of the supervisor trying to fix the problem she got angry. The problem was never solved and the error continued. In some situations, employees got so frustrated that they decided to rewrite the procedure themselves.

 Complicated Computer Systems Lead to Systemic Failures

While computerization of a health-care system helps to move information faster and more accurately, complicated computer processes have been identified as another source of error within some health-care facilities. In these cases, the computers either were not built to spot errors or the procedure was too complicated. Many hospital computer systems are not built with checks and balances. The challenge of the future for designing hospital computer systems is not only to achieve simplicity, but also to design a computer system to help spot possible errors by building checks into the system to spot errors before impacting patients. 

 Bill Goodwin’s article, “Enquiring Set Up into Hospital IT Failure” (Computer Weekly, June 15, 2000) discusses how a hospital computer error led 150 pregnant women to be wrongly advised that their babies were at low risk for developing Down’s Syndrome. According to the report, the computer error took place at Northern General Hospital where blood samples were analyzed during early pregnancy. After four months, it was discovered that a programming error led to the miscalculations. As a result, women at high risk of having a Down Syndrome baby were wrongly diagnosed as being at low risk and never offered further tests.

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