Georgia Hospitals Use Systems Engineering to Reduce Errors

For three decades, safety measures have been so thoroughly integrated into commercial aviation that now the odds of dying in a plane crash are one in 20 million. But Medicare patients still face a one in seven chance of injury during a hospital stay, according to a Los Angeles Times article. However, changes across the nation and in Atlanta hospitals seek to reduce the occurrence of medical negligence and medical malpractice.

Why are the risks of injury so high for patients during hospital stays? That's the question a former pediatrician and quality officer at a large health plan has been asking for more than two decades. Dr. Donald Berwick has devoted his professional career to pinpointing and correcting hospital errors through a process called systems engineering.

How are Systemic Errors Addressed

Systems engineering is a blend of science and psychology, which factors in potential human error in a complicated systems environment. Thirty years ago, the Federal Aviation Administration (FAA) started using systems engineering to review its practices after crashes were linked to distracted flight crews.

Similarly, Berwick recognized that the medical system itself often induced competent medical professionals to make dangerous and costly mistakes. Through improved tracking, communication and other integrated actions Berwick became convinced that the quality of healthcare could improve.

A study released recently by the Institute of Medicine, titled To Err is Human has also brought urgency to the issue of medical errors. The report noted that up to 98,000 Americans die in U.S. hospitals every year due to preventable medical errors. By some estimates, errors, unnecessary care and other waste may eat up a third of the nearly $1 trillion spent on Medicaid and Medicare each year.

Signs of Success in Atlanta

Berwick sees improvements. Recently in Atlanta, he noted a hospital quiet zone where nurses are allowed to place medication orders without interruption. The simple change has cut costs and saved lives by eliminating prescription errors.

While hospitals continue to make needed changes, such as implementing a quiet zone to reduce prescription errors, injuries are still occurring due to medical negligence. If during a hospital stay a new injury develops, contact an experienced medical malpractice attorney to discuss remedies and how best to proceed.