Working to Lower Medication Errors - Credit Where it is Due

Ken Margolin

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Michael Leonard, MD, is an anesthesiologist who has written on the subject of medication error reduction. Readers who have followed my blogs may know that the anesthesiology profession was a leader amongst physicians and hospital professionals in analyzing the causes of medication errors and other medical mistakes. The doctors who studied the problem, such as Lucien Leape, MD, and others, realized that a team approach was essential to the effective practice of modern medicine. They also realized that an attitude of awareness of the causes of medical errors and how those causes might be present in every individual case, was essential. Their insights must be instilled into practicing doctors and new generations of medical professionals - something that does not happen overnight.

Dr. Leonard has written of the notion of "situational awareness," meaning the importance of insuring that one's (and the medical team's) awareness of a situation comports with reality. This is especially difficult - and essential - during a crisis. In an article written for the web site for the Agency for Healthcare Research & Quality, Leonard gives the example of operating team members being so focused on a particular crisis, such as difficulty placing a central line, for example, that they fail to appreciate another, life-threatening crisis, such as progressive respiratory failure. Situational awareness is a philosophy and skill that is taught in the military, in aviation, and to others in various high stress, high stakes occupations. It is appropriate for the medical profession, especially when life itself is at risk.