Medical Error and Technologies Research Workshop, London, 3 November 2004

First Meta-Network workshop captures flavour of things to come

The first META network research workshop was held at the London School of Economics on November 3 2004. Welcoming participants, Tony Cornford said that the goal of the network was to make connections and help to build a stronger focus in research  on  medical error and technology issues. The aim of the workshop was to capture the flavour of some of the new work that was underway in the field within  various research centres, and to get the feel for the range of people,  disciplines and theoretical perspectives that have entered the field. 

Setting the scene for the day, Nick Barber  explained that the whole medication error issue had exploded onto the UK policy scene with the publication of the American report “To err is human”. The huge estimates for medical error fatalities cited in that report had taken the media by storm, and policy had to follow such a provocative intervention. Work on errors was now being taken seriously in the UK, but it still lacked a strong theoretical basis. 

 “There is a lay belief- also held by some policy-makers - that IT will “solve things”, said Prof Barber. “But does it? New drugs have side effects, but we don’t look for the side effects of new technology.”

Most of those chosen to present  <click here for summary of  presentations> were in the early stages of  their PhD projects, and their presentations raised many useful and interesting  questions.

The tension between researchers’ duty to patients and to other research subjects in patient safety studies was one key issue debated. For example, in what circumstances and in what way should researchers report clinical negligence? Should the anonymity of subjects be always preserved?

 Different definitions of error, and difficulties in defining the boundary between error and normal variation were also the focus for discussion.  For example, Sisse Olsen  pointed out that different surgeons had different operating  “styles”- some messier than others. “It’s variability in practice, but where is the line? Too rigid a definition forces regression to the mean.”

Systems design was another topic area raised in discussion and a number of participants noted problems with technology , for example in user interfaces, in data extraction and data reporting. In general, computerised systems were structured to support processes rather than for accessing and reporting, so it could often be difficult to retrieve historical data. Ideally, it was noted, all error checking and reporting activity (understood loosely to embrace a number of distinct styles of computer use and human interventions), should be structured so that organisations could learn from them. However, for example, pharmacists’ interventions were often only reported to the doctor who had made an error. This may mean  that consultants were not aware of the types of errors made by junior doctors. 

This lead to a further discussion on the origins and sources of technologies used to address error within health care.  Penny Ross   was concerned that national “generic” computer systems could possibly make things worse for some users, because people learned in different ways. She suggested that systems which worked  were “bespoke not off the peg”.  

For a more systematic set of emerging discussing points click here.