Reducing Medical Errors Through Better Documentation

Abstract

Preventable medical errors occur with alarming frequency in US hospitals. Questions to address include what is a medical error, what errors occur most often, and what solutions can health information technologies offer with better documentation. Preventable injuries caused by mismanagement of treatment happen in all areas of care. Some result from human fallibility and some from system failures. Most errors stem from a combination of the two. Examples of combination errors include wrong-site surgeries, scrambled laboratory results, medication mishaps, misidentification of patients, and equipment failures. Unavailable patient information and illegible handwriting lead to diagnosing and ordering errors. Recent technology offers viable solutions to many of these medical errors. Computer-based medical records, integration with the pharmacy, decision support software, Computerized Physician Order Entry Systems, and bar coding all offer ways to avoid tragic treatment outcomes. Persuading and training hospital staff to use the technology poses a problem, as does budgeting for the new equipment. However, the technology would prove its worth in time. The Institute of Medicine and coalition groups such as Leapfrog Group have recognized the problem that permeates the health care industry, manifests in many ways, and requires the many solutions that information technology offer.

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