Medical algorithms and patient safety

I wrote a book on medical algorithms, "Why Do Doctors Kill and Cripple Patients, or Why Do a Doctor Need Algorithms?" In the book, I tried to show that the illustrated medical algorithms are a promising path for the development of medicine. The book contains fundamentally new ideas related to the Reform of the medical education system based on high-accuracy medical algorithms. The purpose of the article is to acquaint readers with the main ideas of the book.

Medical algorithm is a relatively new and poorly defined concept. In a broad sense, this is any calculation, formula, statistical survey, nomogram or reference table that is useful in health care (any computation, formula, statistical survey, nomogram, or look-up table, useful in healthcare) - as said in English Wikipedia.

Russian Wikipedia reports some other information. According to the Federal State Educational Standard of Higher Professional Education in the specialty "060101 General Medicine", physicians should:

• use the algorithm of diagnosis (main, concomitant, complications) ..., to perform the main diagnostic measures to identify urgent and life-threatening conditions;
• to carry out the algorithm for the choice of drug and non-drug therapy to patients with infectious and non-infectious diseases, to the management of physiological pregnancy, childbirth.

This is closer to the point.

For the purposes of this article, one should significantly narrow the concept of “medical algorithm” and define it as a sequence of actions and decisions of a doctor in the provision of medical care. For example:

• in the treatment of tuberculosis,
• when performing surgery on the rectum,
• when providing emergency assistance to victims of terrorist attacks, plane crashes or floods.

In the book [1], I tried to explain in detail the essence and purpose of medical algorithms, as well as to prove that they will have an important role to play in the development of medicine and medical education.

A medical algorithm is fundamentally different from a mathematical algorithm in that it contains steps that are not fully defined [2].

Disadvantages of medical algorithms. How to overcome them?

Algorithms of actions and decisions of a doctor, presented in the medical literature, in my opinion, do not withstand criticism and do not correspond to the needs of the practice. You can point out system defects in the description of medical algorithms, note the low quality of the used notations. Examples of non-ergonomic and inconvenient tools are flowcharts of algorithms according to GOST 19.701-90 and ISO 5807-85, UML, decision trees.

Algorithmic incompetence, the inability to ensure the accuracy of algorithms, confusion in diagnosis because of the inability to specify all the branch points of the algorithm - this is not a complete list of weak points [3].

Unfortunately, such errors are constantly found in medical textbooks, manuals, clinical guidelines and protocols. They entail negative consequences. The general reason for these shortcomings is that a single standard of medical algorithms has not yet been created in the world [3].

This disadvantage introduces tangible difficulties in the work of doctors and generates errors that adversely affect patients. Mistakes can and often do lead to death, permanent disability or other harm to patients [3].

It can be assumed that the shortcomings can be eliminated, and the situation can be improved by creating a new ergonomic language for the presentation of medical algorithms. Based on this, I developed a convenient and practical for medical practitioners medical algorithmic language of high precision "DRAGON", which has already been tested [4].

The dramatic and convenient flowcharts of DRAGON facilitate the work of doctors, streamline, structure, discipline clinical thinking and increase patient safety. Thanks to DRAGON, complex and extensive algorithms for prevention, diagnosis, treatment, emergency care, resuscitation, rehabilitation, prognosis become clear, understandable and quickly perceived [5].

As the doctor notes honey. Sciences, Corresponding Member of RAS G.V. Order, the use of the language DRAGON in medicine will give "gain, and significant. It is assumed that the clinical thinking of doctors will undergo favorable changes and turn into a high-precision clinical thinking. As a result, the number of medical errors will noticeably decrease, and patient safety will increase ”[6].

The graphic flowcharts of the DRAGON language (dragon-algorithms) are a clear support for high-powered clinical thinking; they are able to provide a high standard of quality and improve medical care for the population [7].

Serious problems in medical education

Medical errors occur where doctors work - in hospitals, clinics and medical centers. However, the root cause of many errors lies in the shortcomings of the medical education system. The fact is that the system of training medical personnel from year to year reproduces the misunderstanding of the concept of “medical algorithm”. As a result, algorithmic ignorance and illiteracy are characteristic of the mass medical consciousness.

Most medical algorithms are presented in the domestic and world medical literature in the form of text in a natural language. This is unacceptable, because the usual language "is not suitable for describing exact algorithms" [8].

The widespread use of medical language to write medical algorithms is incorrect, dangerous, and subject to correction. This is one of the causes of medical errors [3] [9].

To get rid of errors, mathematics is not enough. The language of DRAGON uses the principle of “invisible mathematics” [10], which satisfies the requirements of both mathematics and cognitive ergonomics. The latter is necessary in order to take into account the human factor, to increase the algorithms' comprehensibility, to make them understandable, readable, suitable for perception, memorizing and facilitating the thinking of doctors [11].

G.V. Ordering notes: “Due to the readability of [DRAGON], meaningful errors in the algorithm are easily apparent and, as a rule, are quickly identified by the author of the medical algorithm, his colleagues or reviewers, and are eliminated” [12].

The perception of complex scientific texts and, in particular, medical algorithms can be facilitated and accelerated by replacing text with graphics. This is explained by the fact that “the human brain is mainly focused on visual perception and people receive information when viewing graphic images faster than reading a text” (an example is infographics) [13].

Medical students and doctors receive medical information more quickly if presented in the form of graphic images. The system of medical education is proposed to be rebuilt, based on the following principle:

“To make life easier for students and doctors when studying medicine and speed up the learning process, it is necessary to abandon the textual representation of medical algorithms and replace it with an ergonomic (people-friendly) graphical representation” [14].

The practical implementation of this principle provides a visual medical algorithmic language of high precision DRAGON.

This applies to many of the documents used in the system of medical education. All types of medical literature in which medical algorithms are treated, explained or described are outdated. This means that to some extent outdated and in need of improvement:

• medical textbooks
• medical manuals,
• medical standards
• clinical guidelines
• clinical protocols [15].

The bottom line is that the old understanding and old ways of writing medical algorithms are outdated. They should give way to ergonomic (people-friendly) high-precision medical algorithms [15].

G.V. Order “formulated and substantiated a fundamental and at the same time practically significant problem - the problem of algorithmization of medicine on the basis of the medical algorithmic language of high accuracy” [16].

Agreeing with G.V. Poryadin R.Y. Nadishauskene writes: “Knowledge of an algorithmic language of high accuracy (the language DRAGON) becomes a necessary condition for teaching medicine. It becomes as mandatory for a medical student as the mastery of the Latin language ”[17].
All this confirms the need for reform of the medical education system.

The complexity of the thinking of doctors

Medicine is very complicated and with each passing year it continues to become more complex. According to G.V. “The development and accumulation of medical knowledge and technologies imposes new requirements on the qualifications of medical specialists, which, in turn, inevitably affects the system of undergraduate and postgraduate medical education. There is a continuous process of increasing the burden on the doctors' doctors, forcing them to solve more and more complex mental tasks ”[18]. Difficulty engenders errors that adversely affect patient safety.

The excessive complexity of the doctors thinking is reasonably worrisome, as it is often the cause of medical errors with serious consequences [19]. The proposed Reform is based on the cognitive-ergonomic method of algorithmization, “which allows to eliminate the excessive complexity of thinking in order to help doctors and facilitate their life” [19].

The method makes it possible to simplify an overly complex therapeutic and diagnostic task and turn it into an easily visible one, which does not cause difficulties for the doctor [19]. The use of ergonomic dragon algorithms can reduce the intellectual burden on the doctor’s brain, make it feasible and comfortable. And due to this, reduce the number of medical errors [19].

The excessive complexity of the thinking of doctors is partly caused by a defect in the educational system. The latter does not have simple and effective means of facilitating and accelerating the process of acquiring profound knowledge by students. As a result, medical students and doctors experience unjustified difficulties in studying medical textbooks, manuals, and other medical literature. This generates excessive expenditure of time from medical students and doctors, and it requires unreasonably great efforts from average minds. As a result, the quality of professional training of graduates of medical schools suffers.

The absence of convenient, easily perceived ergonomic graphic algorithms of high accuracy in textbooks, manuals, clinical guidelines and protocols is a noticeable drawback that complicates the understanding of the material and reduces the efficiency of the educational process [19].

The reform is designed to reduce these difficulties. DRAGON language reduces the time spent by students while improving the quality of education. Medical algorithms should be convenient for human visual perception, easy to remember and comfortable for human thinking. Dragon algorithms facilitate and accelerate the learning of the medical profession [20].

The former methods of teaching doctors have been partially exhausted and need to be improved on the basis of the wide use of ergonomic graphic algorithms of high accuracy. The language DRAGON provides a visual support for clinical thinking, provides medical decisions of high accuracy.

The reform will create favorable conditions for the thinking of doctors. Intellectual stress on the brain of doctors must be commensurate with their strengths and abilities. Clinical thinking should turn into high precision algorithmic clinical thinking [8] [21].

Patient safety. Reports of the US Institute of Medicine

The National Academy of Medicine of the United States (formerly: "Institute of Medicine") has prepared a series of reports aimed at improving the quality of care and patient safety [22] [23] [24] [25]. On the recommendation of the Institute of Medicine, a hearing was held in the United States Congress and the Patient Safety and Quality Improvement Act of 2005 was signed by President George W. Bush. July 29, 2005.
In these reports, measures are proposed to improve patient safety primarily of an organizational nature.

Omission in US Institute of Medicine reports

The findings and suggestions of the National Academy of Medicine of the United States (Institute of Medicine) are important but not sufficient.

Medical errors depend on many reasons, including the shortcomings of medical language, which, being a natural language, is not adapted for an accurate and convenient description of medical algorithms and does not have the special tools necessary for this [26].

Algorithms of prevention, diagnosis, treatment, emergency care, resuscitation, rehabilitation, prognosis are a scientific problem of primary importance, which is directly related to the prevention of medical errors and patient safety. However, this problem was completely overlooked in the reports of the Institute of Medicine, which reduces the value of its conclusions and recommendations [27].

Defects in the medical language can have a negative impact on the professional thinking of doctors, which is the cause of errors. The measures proposed in the reports of the US Institute of Medicine are incomplete, because they do not take into account the mental errors of doctors that affect patient safety.

Intellectual errors of doctors, i.e. mistakes in mental operations indicate the complexity of medical thinking and are closely related to language. To eliminate errors, we need a formalization of the language. Lack of formalism creates grounds for error. For this reason, professional medical language inevitably causes doctors to make mistakes, is dangerous for patients, and needs to be improved.

Increase the expressive capabilities of the medical language

Professional medical language is not accurate enough and is poorly adapted to describe complex and ramified, often hours-long and multi-day medical actions, decisions and procedures performed in the diagnosis, treatment, emergency care, reanimation, rehabilitation, prognosis. Branching sequences of medical actions contain thousands of routes, junctions and intersections. All these branches and dead ends must be clearly seen and carefully considered.

Modern medical language does not allow the doctor to see and analyze these and other dangers in order to fully protect patients from medical errors.

To eliminate the shortcomings, it is necessary to carry out an enriching transformation of the medical language, expanding its possibilities with the help of the medical algorithmic language of high accuracy.

The language DRAGON is designed to stimulate and increase the productivity of clinical thinking of doctors, to standardize the presentation of medical algorithms in the medical literature, to algorithmize domestic and world medicine.

Medical knowledge is divided into two types: knowledge of “what” (declarative) and knowledge of “how” (procedural). Today, both types of knowledge are described in a uniform manner, using the same language, which negatively affects patient safety.

The proposed language improvement will correct the defect and account for DIFFERENCES between declarative and procedural knowledge. As a result, medical workers will receive a new opportunity - the ability to work DIFFERENTLY with knowledge. For this you need to have DIFFERENT means for declarative and procedural knowledge.

Declarative knowledge will, as before, be described in the existing medical language, and procedural knowledge in the DRAGON language in the form of convenient and visual graphic instructions (dragon algorithms).

Additional measures to improve patient safety

The reports of the National Academy of Medicine of the USA do not take into account the fact that one of the causes of medical errors is the poor quality of medical algorithms. In my opinion, an additional system of measures is needed to ensure patient safety:

• the widespread use in medicine of the ergonomic (people-friendly) medical algorithmic language of high precision;
• medical education reform based on the high-precision medical algorithmic language DRAGON;
• algorithmization of medical literature;
• standardization of the presentation of medical algorithms in the medical literature;
• formation and development of the institute of certification of medical algorithms;
• coordination of international efforts in the standardization of medical algorithms;
• coordination of international efforts to certify medical algorithms (and, in the foreseeable future, the creation of an International Certification Center for Medical Algorithms under the auspices of the World Health Organization).

Testing the language "DRAGON" and reviews of doctors

The approbation of the language DRAGON was carried out in Lithuania at the initiative of the Lithuanian side and gave positive results [4]. Below are the reviews of the doctors who led the groups of Lithuanian specialists who develop medical algorithms in the DRACON language in various fields of health care [28]:

Doctor of Medical Sciences A. Kudryavichene, neonatologist: “The language DRAGON is an excellent tool for teaching practical skills and their standardization. It allows to reveal everything, even the smallest, but very important actions ”[29].

MD, Professor M. Kluchinskas, obstetrician-gynecologist: “The language DRAGON allows you to systematize processes with minimal use of the text - both in work organization and in performing medical procedures. It helps everyone to equally understand and perform specific actions ... Allows you to speed up the memorization of actions "[30].

Doctor of Medical Sciences, Professor J. Dambrauskas, abdominal surgeon : “The great advantage of the DRAKON language is that it allows you to specifically identify all stages of the procedure or process ... Mentally, you can repeat the process step by step, and then divide each step into steps ... Procedure or process You can perform mentally, and then in reality. DRAGON is a tool for mental training. ”[30]

Doctor B. Kumpaitene, anesthesiologist-resuscitator: “The use of the DRAGON language for the author developing the algorithm is that every skill, every procedure, is crystallized and standardized. The benefit to the learner is a clear way of doing things. DRAGON answers the questions “what to do if” ”[29].

A. Vileykite: “Using the language DRAGON allows standardizing and ergonomically present the most complex procedure ... If everything is correctly described on DRAGON, then everything will be perfectly executed” [29].

MD, Professor Dinas Vaytkaitis, head. Department of Extreme Medicine: “The language DRAGON gives clarity and clarity to the processes used in medicine. It allows you to “automate” practical skills training for students. It can be the basis for clinical decision-making technology ”[31].

Doctor of Medical Sciences, P. Dobozhinskas, Executive Director of the Medical Center: “The use of the DRAGON language effectively helps in creating and describing complex, dynamic solutions to medical problems. This greatly facilitates the implementation of standardized simulation training, introducing a culture of patient safety and the principles of quality medical service delivery across a medical institution, region or state ”[31].

Doctor of Medical Sciences, Professor R.J. Nadishauskene, head. obstetrics and gynecology clinics, chief specialist in obstetrics and gynecology of the Republic of Lithuania:
“Algorithmization of medicine implies a significant restructuring of the medical education system and its translation into an algorithmic path ... The practical experience accumulated in Lithuania using the DRAGON language to represent complex and diverse medical algorithms can serve as a serious basis for major structural decision making by health care managers and the medical education system in the field of algorithmization Medicine " [17].

In Lithuania, four textbooks have been published based on the DRAKON language: “Initial emergency obstetric care” [32], “Specialized resuscitation of newborns” [33], “Emergency medical care” [34], “Trauma” [35], see also [36 ]. In addition, Lithuanian doctors use the language DRAGON in international medical projects.

Suggestions for the improvement of medicine and medical education

Illustrated algorithms for diagnosis and treatment - a promising path for the development of medicine. Given the above, I propose:

• Adopt the DRAGON medical algorithmic language as a standard for recording medical algorithms in the medical literature: in medical textbooks, manuals, standards, clinical guidelines, clinical protocols, journal publications.
• Introduce the study of the specified language in the program of undergraduate and postgraduate medical education for doctors of all specialties.

What can the ministry of health do

At the first stage, without attracting additional funding, the Ministry of Health may:

1. Bring information about the language of the DRAGON and leadership [1] to the subordinate educational institutions, organizations and institutions.
2. Recommend the language DRAGON for use in medicine.
3. Recommend when conducting medical Olympics include tasks on the compilation of medical algorithms in the language of DRAGON.

At the second stage, under the leadership of the Ministry of Health, it is necessary to develop a Program for the implementation of the Reform, indicating the required resources: stages, terms, participants, financing, materials, personnel, etc.

Conclusion

Medicine is considered a poorly formalized area of ​​knowledge, and this is true. However, the prerequisites are already ripe to change the situation. The proposed Reform will make a significant step towards ergonomic formalization of medicine, which is consistent with the principles of mathematization, humanization, standardization and evidence-based medicine.

The reform will provide an opportunity not only to improve the quality of medical care to the population in the interests of patient safety, but also to occupy a leading position in international cooperation, ahead of the most developed countries in the issues of algorithmization of medical education and medical literature, as well as certification of medical algorithms that will help strengthen the position of Russia and Russian medical science in the international arena.

Application and download link

A detailed description of the project, including an account of the language of the DRAGON, a detailed justification of the proposed Reform and a comparison with the reports of the US National Academy of Medicine on patient safety is presented in the attached book containing 21 chapters, 340 pages, 130 illustrations, and 245 references.

The preface "Prospects for the development of medicine and medical education" to the book was written by a doctor of medical sciences, professor, corresponding member of the Russian Academy of Sciences, head. Department of RNIMU Orderin G.V. (In the past, the dean of the medical faculty and the vice rector for educational work of the Pirogov Russian National Research Medical University).

The epilogue to the book was written by the doctor of medical sciences, professor, head. Obstetrics and Gynecology Clinic of the Lithuanian University of Health Sciences, Chief Obstetrician and Gynecologist of Lithuania Nadisauskienė R.J.

The history of the creation of the medical language DRAGON

The story is. Lithuanian doctors read my books and began to use the language of DRAGON, after having simplified it, throwing away some of the functions and adapting it for medical purposes. After reviewing their developments, I came to the conclusion that as a programming language, DRAGON is not needed by doctors. They need another - a language for the exact description of complex and extensive actions and decisions of the doctor, allowing to present the algorithm in a visual graphical form. That is, in the form of simple and convenient instructions, suitable for widespread use.

It can be said that the medical version of the language DRAGON was born in Lithuania on the initiative of Lithuanian doctors and scientists, who invested a lot of work in its development and improvement.
Scientists and teachers of the Lithuanian University of Health Sciences (Lietuvos sveikatos mokslų universitetas) analyzed the “space” DRAGON, removed the excess, made useful additions and applied for medical needs.

In this regard, I made a decision: based on the Lithuanian experience, to create a new algorithmic language designed specifically for medicine. At the same time, I decided to keep the “cosmic” name DRAGON, which has already gained fame as a symbol of ergonomics and convenience. For example, on Wikipedia, the DRAKON article is available in eight languages.

This is how the “medical language DRAGON” appeared, described in my book [1]. The book is a synthesis of the experience of Lithuanian doctors and the further development of the ideas of cognitive ergonomics. The cosmic origin of the medical language has played an important role, as it has ensured a thorough refinement and reliability of the results, corresponding to the high quality standards of the rocket and space industry.


Vladimir Danilovich Parondzhanov