[From Rick Marken (2001.08.16.0820)]
I have a question regarding one of the projects I'm working on here at
RAND. The project involves the development of standards for electronic
prescribing systems. One potential advantage of electronic prescribing
systems is reduction of Rx errors. Studies have found that from 4% to 6%
of the Rx's written have some kind of error (wrong medication name,
wrong dosage, etc). Very few Rx errors lead to what are euphemistically
called "adverse drug events". But it would be nice to get the Rx error
rate as close to zero as possible.
I am involved in the study as the expert in "human error". One of the
people I work with (for whom I have enormous respect) is very interested
in doing a "root cause analysis" of prescribing errors. This is kind of
a funny notion to me; it suggests that errors are the last step in a
causal chain that begins with the "root cause". But I think the causal
implications of "root cause" are really a lot weaker than this. The
examples of "root causes" I've seen look less like causes
than...something else. But what? I can't seem to get my little PCT brain
around it (perhaps because when I'm doing my "real" work I try to avoid
stepping on people's agendas while maintaining my scientific integrity
as best as I can). For example, the "root cause" of the Mars orbiter
failure, according to the investigation board, was "...failure to use
metric units in the coding of a ground software file...used in
trajectory models". It's hard to see this as a "cause" in the usual
sense. It's more like "setting the occasion", but I feel like I'm
blathering when I say such stuff.
I think the interest in root causes in Rx errors comes from the belief
that if your know these root causes you can see how electronic
prescribing systems could eliminate them. This actually sounds
reasonable to me. Is this because my PCT brain goes completely numb out
here in the real world? Or is there some way that this could make sense
from a PCT perspective.
I would appreciate any thoughts about this (root causes, human error,
the causes -- or reasons-- for error, etc) from those of you whose PCT
brains are still intact during the working day.
Best regards
Rick
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Richard S. Marken, Ph.D.
MindReadings.com
10459 Holman Ave
Los Angeles, CA 90024
Tel: 310-474-0313
E-mail: marken@mindreadings.com