How can we improve medication errors?

Whenever possible, simplify.

Both the number of steps, and the medications count.

The fewer, the better.

Let's look at a very simple example,

one that anyone who travels by airline knows all too well.

When I have a very important meeting, I often book a direct flight.

This requires me to drive to a larger airport Orlando or

Jacksonville rather than used the local Gainesville Airport.

Why do I accept the inconvenience of two hour drive to Orlando or Jacksonville?

Let's calculate the likelihood of me being on time to my meeting.

Many flights have an on time percentage of 80%.

Therefore if I take a direct flight from Orlando or

Jacksonville, I have a 20% chance of being late.

Not great, but what happens if I book a connecting flight,

each with an 80% on time record?

Reliability is now 0.8 times 0.8 or 0.64.

Therefore the chance of being late nearly doubles increasing to 36%.

The other danger of course is if the plane is late I could miss my connection.

Now we understand why the fewer steps the better.