1. INTRODUCTION
|
3
Healthcare in the United States is facing a crisis. In 1999 a landmark
report titled “To Err Is Human”
1
concluded that 44,000 to 98,000 peo-
ple a year die from medical errors, at a cost of $17–29 billion per year.
A more recent study puts the estimate at 100,000–400,000 deaths per
year.
2
Here’s a quote from the latter:
In a sense, it does not matter whether the deaths of 100,000, 200,000
or 400,000 Americans each year are associated with PAE (Prevent-
able Adverse Eects) in hospitals. Any of these estimates demand
assertive action.
Jenny’s story is, unfortunately, not uncommon. These situations hap-
pen every day, and not only in the US. However, it’s important not to
blame the nurses, or we miss the entire context that led up to these
grave mistakes. There’s a concept used in the healthcare field called the
Swiss Cheese model of accident causation. This model (see Figure 1-2)
compares human systems to multiple slices of holed cheese.
There may be multiple layers to pass through before a mistake affects
the patient. For example, when there is a medication error, the source
of the error can occur in any of these “layers”: the doctor’s prescription,
the pharmacist filling it, the medication being stocked correctly, the
nurse preparing and giving it, and the mechanism used to administer
it to the patient. Each layer has its own holes (flaws in the preventative
measures), but together they reduce the chances of an error happen-
ing. In our example, nurses were the last layer of defense, so it’s easy to
blame them for the mistake that happened. But in fact, interface design
should act as the last layer in that model. It usually accomplishes that
by reducing the cognitive load required to complete a task, thus allow-
ing more resources to be dedicated to error prevention. Unfortunately,
in the healthcare industry, it instead leads to making more holes.
1 Kohn, Linda T., Janet M. Corrigan, and Molla S. Donaldson, eds. “To Err Is Human:
Building a Safer Health System.” Washington, DC: The National Academies Press, 2000.
2 James, J. T. “A New, Evidence-Based Estimate of Patient Harms Associated with Hospital
Care.” Journal of Patient Safety 9:3 (2013): 122–128. doi:10.1097/pts.0b013e3182948a69
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