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Frequently Asked Questions

What is a system?

Much of the latest research on patient safety takes a systems-thinking approach. This research looks at the individual practitioner not as a potential culprit to be blamed and shamed in the event of an error, but rather the physician is one actor among a constellation of elements that determine the kind of care the patient receives. Researcher Neville Moray writes, "A system is any collection of components and the relations between them, whether the components are human or not, when the components have been brought together for a well-defined goal or purpose." For example, the physician is a component of a system that includes the medical record, his assistants, the pharmacist, the technology, and policies he works with and the relations and processes governing the interactions between these elements. Thus, when an error occurs, it is not the fault of any one person, but rather it is a consequence of the complex workings of an under-performing system.

Systems thinking is important to the practice of medicine because it helps move beyond a single event—blame and punish a particular person—to improving the work process itself so the event is less likely to happen again and the system is safer for everyone. Systems thinking also fosters a sense of teamwork in that it acknowledges the contribution of every care provider.

In your practice, think of how you work as part of a system and ways the system might be improved. For example, in a multi-physician practice, establish a single area for unfiled charts awaiting review or test results so that all caregivers have access to them. Flag charts of patients who need special care, such as diabetic foot exams or peak-flow readings. Or, provide a forum for your staff so that they can discuss the challenges of their jobs and how to improve office processes. Using the systems approach to safety and improvement can provide fresh perspectives and a positive attitude toward change in your practice.

Why is handwriting important?

Prescription for Safety

Physicians' handwriting is a source of endless jokes, but illegible orders are no laughing matter. Illegible handwriting on prescriptions takes extra time to interpret, and pharmacist callbacks result in lost time to the practitioner. Tragically, illegible handwriting is a common cause of medical error and has led to patient injury and death. According to a 1997 American Medical Association report, errors related to misread prescriptions were the second most common and expensive malpractice claim over a seven-year period.²

To prevent errors, prescriptions should:

Be legible;
Use the metric system;
Avoid abbreviations and decimals; and
Include the medicine's purpose.³

What is Idealized Office Design?

Idealized Office Design is the study of how to make medical practices safer and more efficient. At the core of idealized office design is the view that the office operates like a system: a set of interdependent parts with a common aim. The parts here may be people, procedures, infrastructure, or other elements. The elements are interdependent because the functioning of one depends on the functioning of others. The emergent relationship between the activities of the different elements, make a system more than the sum of its parts. The goal of idealized office design is to improve the parts and how they work together, creating a more robust, high-quality system.

In ambulatory care patient safety, the two most important system elements are workflow and team work. Efficient teams and smooth workflow make for reliable systems. Follow this algorithm for system analysis:

1. Consider a given system (refill authorization process, referral communication process, lab results handling, etc.).
2. Write down each of the individuals involved in that process, and note the number of interactions involved.
3. Write down where the process is subject to inefficiency or error, and note why these particular spots are error-prone.
4. Write down a specific goal to achieve for the process (i.e., "all referrals should be followed up").
5. List particular ideas that might help you accomplish the aim.

¹ Moray N. Error reduction as a system problem. In: Bogner MS, ed. Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates; 1994:67-91.
² American Society of Hospital Pharmacists. American Journal of Hospital Pharmacists 1993;50:305-14.

³ Cohen, M. Preventing Medication Errors Related to Prescribing. PowerPoint presentation. In: Patient Safety: the Other Side of the Quality Equation. Philadelphia: American College of Physicians 2001.

Last updated: 11/04/2003

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