11.21.2008

Hospitals Should Pursue Simple Solutions to Prevent Medical Errors

I have no problem with technology, but too often organizations look for a high-tech solution to a problem that can be addressed with something much simpler.


Therefore, it was refreshing to read about a recent study that suggests an easy way to reduce medical errors: color-coding medication bottles and syringes.


The study, described by The Washington Post, was conducted by anesthesiologists at Penn State Hershey, and was to be presented at a meeting this month of the American Society of Anesthesiologists.


Volunteer anesthesiologists, residents and nurses drew medications with different colored labels at an ever-increasing speed to mimic an emergency situation. When the color of the label on the syringe matched the color of the label on the medication bottle, fewer near-mistakes occurred compared to when the colors didn't match, though the number of actual mistakes was too low to make a comparison. When peel-off labels were taken off the bottle and placed on the syringe to be used, errors were reduced and fewer commands were skipped.


What I particularly like about this is not only that mistakes are reduced, but that those involved see the value in going for the simplest solution.


"Many 'high-tech' solutions have been suggested, including use of bar codes, radiofrequency identification for medications, and computerized medication administration processes," researcher Dr. Elizabeth H. Sinz, of the department of anesthesiology at Penn State Hershey, said in a news release issued by the society. "But besides their high costs, all of these methods have flaws that may produce as many errors as they eliminate. Furthermore, these solutions are often impractical for fast-paced situations in operating rooms or during emergencies."


Visual controls are a basic and extremely effective lean tool. I hope that more people will see their value and not be blinded by the glitter of technology.

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