Technological System Solutions to Clinical Communication Error

Human beings are fallible and even the most expert practitioner is prone to error. Unfortunately, in healthcare, these errors can result in the loss of human life. The Institute of Medicine’s (IOM’s) report1 estimating that between 44,000 and 98,000 Americans die each year as the result of medical error illustrates the need for systematic approaches to error reduction. Healthcare administrators must constantly be alert to the potential for error and design system countermeasures to prevent errors, detect errors when they happen, and mitigate the effects of errors.2 In a review of 16,000 hospital deaths due to error, the leading cause of death was found to be communication errors, which resulted in twice as many deaths as did clinical inadequacy.3 A study of the verbal exchanges between nurses and physicians in an intensive care unit showed an error rate of 37%.4 Faulty communication was found to be responsible for 12% of error in emergency care.5 In other contexts, results vary from 23%6 to 30% in general practice,7 25% in pediatric surgery,8 and 91% in a study of medical residents.9

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