Why do preventable medical errors still occur given the technology we have and the skill of our clinicians?
Consider the airline industry. Even with recent incidents, flying remains one of the safest modes of transportation. Why? One key reason is the use of detailed checklists and standardized procedures. These address the increasingly complex challenges of operating in the aviation space, ensuring crucial steps are not missed. This strategy not only increases safety but also enables swift issue response, adaptation, and communication when procedures need change.
In contrast, Healthcare, struggles to successfully or consistently implement similar practices. As a result, preventable medical errors affect hundreds of thousands of patients in the U.S. every year (NIH, Medical Error Reduction and Prevention, February 2024.)
How do we improve, where do we begin?
The first step to decreasing medical errors and increasing efficiency starts with understanding and validating the patient care workflows – including every handoff and detail. Once workflows are identified and validated, healthcare systems can support and improve them with appropriate technology, reducing variability and risk.
Take the typical emergency department (ED) walk-in visit as an example:
- A registration clerk checks you in and adds you to a triage list.
- A nurse triages you based on symptoms and acuity.
- If there is an available bed or your case is urgent, you are brought back. Or, if your condition is not urgent and no beds are available, you're sent back to the waiting room until one opens-up.
- A nurse gathers more information, and you are seen by a doctor. If not acute and there isn’t a bed, you are sent back to the waiting room until one opens-up.
This process, while straightforward, involves multiple steps and handoffs. When followed correctly it works well. However, when workflow knowledge is lacking or technology doesn’t support it – problems and medical errors can occur.
When Workflows Break Down
Let’s review a real-world example shared by Dr. David Wilcox in his book How to Avoid Being a Victim of the American Healthcare System. When he visited the ED with an abscess, fever, fatigue, and chills — early signs of sepsis — he was triaged and prescribed antibiotics. However, since the antibiotic wasn’t available at the time, he was sent back to the waiting room.
Six hours passed. No antibiotics. No bed. His condition worsened.
This scenario highlights a seemingly minor workflow failure — but one that had the potential for serious consequences. Why wasn’t his acuity adjusted once antibiotics were ordered? Why wasn’t there follow-up to ensure timely administration? With better workflow process tracking and technological support this could have been prevented.
Documented Workflows Lead to Fewer Medical Errors
When providers of healthcare take the time to map out patient care and business processes in workflow diagrams, they create a strong foundation for safety and efficiency - similar to the check list process used by the aviation industry.
Clinicians and staff can review these workflows to ensure accuracy and clarity, while supportive technology can be implemented to help prevent missed steps and ensure patients receive proper follow-up.
Here’s where technology like TransIT comes into play. TransIT Workflows enables organizations to:
- Capture and visualize workflows.
- Translate workflows into test scripts for validating processes alongside technology.
- Use workflows as training tools, ensuring consistent education and competency among staff.
- Update and revalidate processes easily, keeping care practices aligned with evolving needs.
- Documented workflows reduce preventable errors and increase efficiency by transforming abstract processes into actionable, testable, and trainable scenarios.
How MAKE Solutions Can Help
Preventable medical errors often result not from individual mistakes, but from broken systems, gaps in communication, outdated tools, or unclear processes. Documenting and continuously refining workflows offers a proactive way to address these issues before they lead to harm.
There’s a clear need for healthcare organizations to examine workflow steps, identify gaps as well as bottlenecks, to understand and plan for possible events - like the one David Wilcox experienced.
MAKE Solutions specializes in helping health systems streamline clinical operations and improve patient outcomes. We focus on using technology, data, process design, leadership, and operational change to reduce preventable medical errors.
Our TransIT system supports:
- Workflow capture and documentation
- Workflow-driven testing and validation
- Staff training and competency assessments
- Continuous improvement and process refinement
With TransIT, organizations can ensure every pathway within a workflow is confirmed, there are no gaps, and staff understand the processes - leading to safer, more efficient care.
Visit MAKE Solutions and explore what your organization can quickly achieve with TransIT.
For further operational excellence insights, review our other articles under Assets-Insights on our website and access our Resource Center for organizational discovery and assessment tools.
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