Even outside the medical field, it seems like most humans are pretty bad about both writing down and consulting notes. Even worse for the notes written by another human. We really aren't particularly good at transferring knowledge / experience and it takes a lot of effort to do a good job of it, so most people don't even make much of an effort.
This really seems like a problem that still needs a lot more attention, especially in critical places like hospitals and really any long term crisis response situation where there is important knowledge gained over time with a (poorly handled) hand-off to successors.
I had some exposure to formalized incident management[1] at a previous job. There, I learned a few formalities and practices that seemed valuable, especially assigning a single coordinator to be responsible for continuity of information and coordination between many independent actors over a long period. The coordinator role had explicit hand off to their successor where the stated purpose was to transfer important working knowledge and prevent the kind of problems you (and the article) describe.
I liked the way you framed this as something universal. Is there any field where one can quickly reference knowledge from your peers to just as quickly solve a problem in practice? Maybe it's asking too much. Though I suppose it wouldn't be necessary to get everyone on board with such an idea if you have that single coordinator who everyone knows as the reference point. Although, if you think about it, even then that person would have to be available 24/7, which isn't feasible.
With patient documentation specifically, what I would really love to have is a simple search mechanism for patient notes. This still wouldn’t solve the problem of getting everyone to capture the right information. But assuming the information is there, and I'm having a real hard time sticking that right arm, I would love to be able to search for "arm", "blood draw," "stick" and see what pops up. I hope it's not something I missed entirely, but I have never used an EMR with such a feature.
Indeed, seemingly simple functionality like you describe should be bare-minimum requirement for just about any kind of information system, and yet it's almost always omitted or implemented so terribly as to negate any practical benefit to users.
> a single coordinator to be responsible for continuity of information and coordination
Years ago I saw a talk by a VA (US veteran's health care) thoracic surgeon, who was trying to entice tech folk to address the following problem. A surgeon is both team manager and skilled technician. When heads down in the technician role, the management role suffers for lack of attention. Especially severely at the VA, which did randomized staffing of operating teams, so you don't get the "group mind" and practiced gap filling of team which stays together. So surgeons would say "do X", and being distracted, not notice the order was dropped, and then proceed assuming X had happened, with regrettable results. The VA surgeon envisioned a voice system which noted the request, waited, and then whispered a nudge in someone's ear "did we do X?".
Even outside the medical field, it seems like most humans are pretty bad about both writing down and consulting notes. Even worse for the notes written by another human. We really aren't particularly good at transferring knowledge / experience and it takes a lot of effort to do a good job of it, so most people don't even make much of an effort.
This really seems like a problem that still needs a lot more attention, especially in critical places like hospitals and really any long term crisis response situation where there is important knowledge gained over time with a (poorly handled) hand-off to successors.
I had some exposure to formalized incident management[1] at a previous job. There, I learned a few formalities and practices that seemed valuable, especially assigning a single coordinator to be responsible for continuity of information and coordination between many independent actors over a long period. The coordinator role had explicit hand off to their successor where the stated purpose was to transfer important working knowledge and prevent the kind of problems you (and the article) describe.
1. https://en.wikipedia.org/wiki/Incident_management