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Nutrition Informatics Blog



"To Err is Human"

It has now been over a decade—ten years since the publication To Err is Human hit the news.  Thanks to the Institute of Medicine and National Academies Press, you can still read the full report online, download the PDF, locate a summary, or purchase a hard copy.  The conclusion is the same—regardless of what version you read:  “Preventable adverse events are a leading cause of deaths in the United States.”The report estimated between 44,000 and 98,000 preventable deaths occur each year.  Most often this report comes up somewhere in the discussion of electronic health records (EHR), because the potential to have a systematic approach to workflow, access to all pertinent data and decision support reminders lead us to believe that EHRs will help us prevent these medical errors. 

Why am I bringing this up now?  It’s obvious the country is moving to adopt EHRs. I bring it up in defense of human beings--not EHRs.  I took a walk yesterday with a friend—my favorite place of peace—the beautiful Chesapeake and Ohio Canal.   I immediately knew something was troubling my walking friend.  Long story—a man of our age –her daughter’s previous coach had died—medical error.  An intern had unknowingly given the medication via an incorrect route.  Human error.  A system of checks and counter checks was in place, yet the intern—in the interest of time—skipped them.

There are no words adequate for such a discussion.  All of the “what ifs?” had already been asked by everyone.  If anything of value came of the discussion, it is perhaps the reiteration of the title—to err is human.  As we adopt EHRs, we have to realize that they do not run themselves—electronic health records are used by humans (who are still fallible) –and we still need processes, procedures, safeguards and checklists to assure that we do not use them incorrectly.  My heart goes out to such families and the humans on the other side who intended only to help. And thanks for peaceful places like the Canal—where you can walk and talk and cry in private.

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Comments (1):
11/2/2010 12:03:43 AM by Linda Bourgault

Nice post. My heart goes out to both sides too.

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