Deborah A. Boehm-Davis

MEDICAL RESEARCH

Developing Procedures to Reduce Medical Errors In 1999, “To Err is Human” was released by the Institute of Medicine. This report argued that somewhere between 44,000 and 98,000 people die in hospitals as the result of a preventable medical error. Previous research suggests that these errors arise from a number of different sources. Four areas seem to account for the majority of these errors. These include environmental issues (e.g., fatigue), equipment malfunctions, teamwork/communications issues, and distractions/ interruptions. The goal of this project is to develop crew resource management (CRM) procedures tailored to a specific Health System hospital that are designed to improve the quality of patient services and promote patient safety. CRM is an approach to improving performance that uses all of the resources available in making decisions. Originally developed in the aviation domain, the CRM concept has been extended for use in other domains where individuals or teams are required to make quick decisions while under pressure to perform. In this project, CRM procedures will be applied to reduce the factors that contribute to medical errors. For example, as applied to understanding the prescribing and delivery of medications, this would mean using medical records, the computerized prescribing system, the systems used in the pharmacy to dispense medication, and the new robotic systems for delivery in addition to the expertise of the physicians, nurses, pharmacists and other personnel involved in this process. We hope to be able to demonstrate that our new processes and procedures reduce the incidence of medical error in this particular Health System.