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At the 7th Annual NPSF Lucian Leape Institute Forum, Dr. Robert Wachter spoke about the digitization of medicine and novel patient safety risks that are emerging as unwanted by-products. Much of the healthcare community, he explained, believes that the use of EMRs, barcode scanning systems, and automated alerts to providers will mistake-proof the care we deliver; however, the reality is that health IT, when implemented in an imperfect setting, can result in serious iatrogenic harm. To illustrate this point, Dr. Wachter shared the story of a medical error that occurred at his own institution. His anecdote detailed how, through a series of computer and human error, a well-intentioned team of providers delivered a 39-fold overdose of a common antibiotic to a 16-year-old patient. Thankfully, the patient survived, but Dr. Wachter’s point is clear: even with the best health IT systems in the world, we are still far from delivering care that is completely error-free.

It is in the moments following medical error that the personal and compassionate relationship between patients and providers is far more important than any piece of technology. We need systems like CARe that encourage providers to have these relationships and that foster respect and dignity for both the patient and the provider. The current norm in many healthcare settings is to separate patients from providers following a medical error. Such separation, however, makes it difficult to overcome and learn from the mistake. The CARe program bridges this gap by promoting a medical culture that values honesty and transparency while making use of the most low-tech tool available to us: communication. CARe reminds us that communication is at the heart of the healing process and that, without it, the patient cannot be made whole again.

We have come to learn that errors are not always the result of poor clinical judgment. More often, adverse events occur because teams of well-intentioned clinicians miscommunicate with each other or with the patient. This observation is borne out not only by countless anecdotes similar to Dr. Wachter’s, but also by current CARe data. The failure to communicate effectively is due, in large part, to the complicated way in which we deliver care. Busy schedules, administrative demands, and the physical design of the spaces in which we work all limit communication among care team members. Health IT might help catch us when we’re about to make a poor clinical decision, but in the absence of a flawless system, we still need teams that communicate well with each other and, above all, we need teams that communicate well with patients.

Despite all of today’s technological innovation, the day that we are able to deliver truly error-free care may be farther away than we’d like to accept. Until then, we must continue to test, disseminate, and improve upon models like CARe and work towards putting patients back where they belong: in the center.


Stephanie Roche - Quality Research Analyst, Department of Health Care Quality at Beth Israel Deaconess Medical Center

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