Working toward no room for error

“To err is human; to forgive, divine.”

These words come from English poet Alexander Pope’s “An Essay on Criticism, Part II, 1711.” At this point of the poem, Pope is explaining that while anyone can make a mistake, we should aspire to show mercy and forgive. However, harm or death due to human error may not make forgiveness easy.

Last month in a new study from the Department of Surgery, Johns Hopkins University School of Medicine, researchers estimate that in 2013, medical errors were responsible for 251,454 fatalities. Published in The BMJ, formerly the British Medical Journal, “Medical error – the third leading cause of death in the US,” shows that only heart disease (611,000 deaths) and cancer (585,000 deaths) outpaced medical errors.

Data collected from the U.S. Centers for Disease Control and Prevention show that medical error-related deaths surpass those from chronic lower respiratory disease (149,000), suicide (41,000), and motor vehicle accidents (34,000).

The study’s authors note that “Human error is inevitable. Although we cannot eliminate human error, we can better measure the problem to design safer systems mitigating its frequency, visibility, and consequences.”

While medical error is not included on death certificates, the authors call for better reporting to reduce the numbers of medical error deaths, stating these errors should be made “more visible when they occur so their effects can be intercepted; having remedies at hand to rescue patients; and making errors less frequent by following principles that take human limitations into account. This multi-tier approach necessitates guidance from reliable data.”

While prevention of human error cannot be fully designed into a medical device, this study underscores the growing importance that everything from equipment to implants to patient records need to share data to help reduce incidents that can lead to death.

“Standardized data collection and reporting processes are needed to build up an accurate national picture of the problem,” the authors state, and this is where medical device design engineers – from large, established OEMs down to the latest and coolest startups – will play a key role in shaping how the industry will come together under a common platform for interoperability, reporting, and warnings. I see it requiring more sensors, more software, and more collaboration between facilities and OEMs.

The authors write, “Sound scientific methods, beginning with an assessment of the problem, are critical to approaching any health threat to patients. The problem of medical error should not be exempt from this scientific approach.” How do you see preventing medical error deaths impacting your job designing and manufacturing medical devices that may help prevent death due to error? I’d like to know your thoughts, so feel free to send an email to emodic@gie.net.

Hopefully, as industry collaboration grows and better data-sharing on human errors occurs, the need to forgive, although divine, will shrink. ~ Elizabeth