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Brain Games

By Dennis Tribble posted 01-02-2012 17:58

I took some time off over the holidays, which meant, among other things, irregular hours and lots of night time television. A show that has captured my attention is one on National Geographic Channel called Brain Games.
By now most of you know that I have become fascinated by the notion of the limits of human diligence. On one of these programs, I watched as a group of people who witnessed a theft describe what they saw. What was interesting was (a) how little of the detail around them they actually noticed and (b) how easy it was for someone to plant the notion of things that weren't there or hadn't occurred.
Statistics in the show were interesting. An intelligent adult can only keep track of 5 or so things at a time, if they really concentrate. Even then, we don't really 'multi-task"; we actually switch our attention from one thing to another. Now think about all the balls we have to keep in the air when we work in a pharmacy. Is it any wonder that we occasionally make a mistake?
As I listened to this show I was reminded of a technician who once told me that they could keep 15 or 20 things going on simultaneously within a hood and never lose track of any of them. The information in this show strongly suggested that to be impossible. Indeed, it sounds like trying to manage that many projects at one time seriously increases the risk of error.
Yet, when we look at sterile compounding facilities, we tend to prize, even promote individuals who work this way.
Is it any wonder we haven't moved the needle on medication safety in ten years?
I am reminded that those high-reliability industries where the cost of human error may not be a single human life, but thousands, or the desolation of our ecosystem, all have in common that they have studied, and embraced the notion of severe limits of human diligence, and have built systems, and technologies to accept that the errors will occur, and to catch them and prevent them from becoming harm.
Maybe we need to do the same things for pharmacy.
What do you think?

#Informaticists #Quality #Informatics #MedicationSafety #MedicationSafetyOfficers #PatientSafety



01-31-2012 17:44

Good question... the reason I think we haven't moved the needle is because we have little or no evidence of changes in outcome. The Institute of Medicine published numbers in 1999 and then again in 2009 showing virtually no change in the landscape. Today there are no numbers to indicate that our outcome data is showing any improvement.
Smart pumps and BCMA have had a rather poor showing in the outcomes department. Both of these perpetuate the problem that the detection is occurring at the end of the process, when the problems needed to have been detected and corrected long before they got that far.
Bar coding during dispensing has just about the best story to tell (Bill Churchill first told it back in 2006). It is really the first application of technology that attempts to build quality into the dispensing process. Robotics that are well designed do the same, although we tend to implement them as if the human were somehow less fallible.
The kicker to me, however, is that we still operate pharmacies as an assembly line where a pharmacist at the end of the line must check every product as it comes off to be certain it is ok. Brain Games makes it abundantly clear that no human being (even a Pharmacist!) can pay that close attention to that much detail for that long.
Until we are willing to change that fundamental paradigm, I believe that the rest of what we are doing is simply nibbling at the edges of the problem.

01-31-2012 17:11

Yeah that multi-tasking thing is a myth. Even when you are good at it which I can be you end up doing a mediocre job on all tasks instead of an excellent job one task at a time... It always infuriates me when the quantity people are valued over the quality people.
I kind of think that we are building systems and technologies to catch errors as we understand the root causes of errors. Barcode scanning throughout the dispensing process for example. Robotic dispensing. BCMA. Smart pumps are some that come immediately to my mind. I am curious in why you think pharmacy hasn't done this...