In September two premature babies at an Indianapolis hospital received adult doses of a blood thinner and died. The error, blamed on drug handling procedures, is only one of many in an industry plagued with safety issues. If a program announced in September is successful, proven ergonomic measures used to prevent accidents in the high-risk aviation industry could find their way into health care.
It is not overstatement to describe the health care industry as plagued with errors. The Ergonomics
Report™, a subscription publication designed for readers with a professional interest in human factors and ergonomics, observed in its August issue the jolt the health care industry received from news that medical errors are one of the Top Ten leading causes of death in the United States. The survey released in August by The Commonwealth Fund also found that the United States ranks highest in the world in medical errors.
The Aviation Consulting Group (TACG), which specializes in aviation human factors training and program development, believes that the answer to cutting the number of drug and other health care errors lies in adopting the human factors and crew resource management (CRM) training that has been so effective in aviation.
According to the TACG press release on the new program, CRM teaches aviation personnel how to use all available resources and work effectively as a team. The training covers skills that include communications processes, decision behavior, workload management, distraction avoidance, preparation, planning, vigilance and stress reduction.
TACG president Bob Baron described medication errors as one of the primary hotspots in health care. “I have read countless cases of errors caused by similar/same sounding drugs and improper dosing,” he explained. “Almost all of these errors occurred due to deficiencies in the written and verbal communication process and all of them could have been prevented.” The company advocates looking for problem in entire systems instead of blaming the people at the sharp end.
Sources: TACG; The Ergonomics