Too Many Americans Harmed By Care Intended To Help Them

It’s very simple compared to the other technology in the cardiac intensive care unit at Atlanta’s Egleston Children’s Hospital–a "quiet zone" for hospital staff to fill prescriptions without interruption. In fact, it’s nothing compared to the humming machines that monitor every tiny heart beat and even breathe for small lungs, but the "quiet zone" has the potential to save nearly as many lives as other fancy technology by reducing unnecessary medication errors.

The quiet zone is nothing more than an area with a computer terminal in the corner and an orange sign on the floor that reads "Shhh…We’re in the MedZone". But the deceptively simple system has done its job well, as it has cut medication errors by two-thirds. Dr. Donald Berwick, the steward of the Medicare and Medicaid programs, as well as a pediatrician, was especially pleased by the innovation on a recent trip to the hospital. Charged with eliminating unnecessary care and other waste from taxpayer expenditures on Medicare and Medicaid, Dr. Berwick recently stated: "Too many Americans are being harmed by the care that is supposed to help them." He advocates for an approach that would make care more efficient and thereby less costly, rather than making more Americans go without healthcare altogether to cut costs.

The system at Egleston Children’s Hospital was devised after the Federal Aviation Administration’s "sterile cockpit rule", which was created 30 years ago when the FAA realized that humans are prone to distraction and that unnecessary conversation before takeoff and landing leads to more accidents. After initiating the rule, the FAA found that the number of accidents was greatly reduced. As Berwick so aptly explains:

[Humans] are frail. I have four children. I mix up their names all the time. I dropped my cup of coffee and spilled it on myself. …But mistakes can be prevented by redesigning systems to protect human beings from their own frailty.