Human Error in Medicine

Human Error in Medicine

Human Error in Medicine

Human Error in Medicine

Synopsis

This edited collection of articles addresses aspects of medical care in which human error is associated with unanticipated adverse outcomes. For the purposes of this book, human error encompasses mismanagement of medical care due to:

• inadequacies or ambiguity in the design of a medical device or institutional setting for the delivery of medical care;

• inappropriate responses to antagonistic environmental conditions such as crowding and excessive clutter in institutional settings, extremes in weather, or lack of power and water in a home or field setting;

• cognitive errors of omission and commission precipitated by inadequate information and/or situational factors -- stress, fatigue, excessive cognitive workload.

The first to address the subject of human error in medicine, this book considers the topic from a problem oriented, systems perspective; that is, human error is considered not as the source of the problem, but as a flag indicating that a problem exists. The focus is on the identification of the factors within the system in which an error occurs that contribute to the problem of human error. As those factors are identified, efforts to alleviate them can be instituted and reduce the likelihood of error in medical care.

Human error occurs in all aspects of human activity and can have particularly grave consequences when it occurs in medicine. Nearly everyone at some point in life will be the recipient of medical care and has the possibility of experiencing the consequences of medical error. The consideration of human error in medicine is important because of the number of people that are affected, the problems incurred by such error, and the societal impact of such problems. The cost of those consequences to the individuals involved in medical error, both in the health care providers' concern and the patients' emotional and physical pain, the cost of care to alleviate the consequences of the error, and the cost to society in dollars and in lost personal contributions, mandates consideration of ways to reduce the likelihood of human error in medicine.

The chapters were written by leaders in a variety of fields, including psychology, medicine, engineering, cognitive science, human factors, gerontology, and nursing. Their experience was gained through actual hands-on provision of medical care and/or research into factors contributing to error in such care. Because of the experience of the chapter authors, their systematic consideration of the issues in this book affords the reader an insightful, applied approach to human error in medicine -- an approach fortified by academic discipline.

Excerpt

James T. Reason University of Manchester

This last decade or so has seen a growing openness on the part of the medical profession regarding the part played by human error in mishaps to patients. The pursuit of safety is a multidisciplinary enterprise, and this is as true for patient safety, hitherto an exclusively medical domain, as for any other kind. This new spirit of glasnost has led to an increasing number of fruitful research partnerships between doctors (particularly anesthetists) and human factors specialists. One of the most important results of these collaborations has been the awareness that medical accidents share many important causal similarities with the breakdown of other complex sociotechnical systems, such as the Chernobyl Unit 4 reactor. Some idea of what factors are involved in these accidents is provided by the sad story of Valeri Legasov, the chief Soviet investigator of the Chernobyl accident.

FRONTLINE ERRORS ARE NOT THE WHOLE TRUTH

In August 1986, 4 months after the world's worst nuclear accident at Chernobyl, a Soviet team of investigators, headed by academician Valeri Legasov, presented their findings to a meeting of nuclear experts, convened in Vienna by the International Atomic Energy Agency. In a verbal report lasting 5 hours, Legasov described both the sequence of events leading up to the accident and the heroic attempts to contain its aftermath. In his address, Legasov put the blame for the disaster squarely on the errors and especially the procedural violations committed by the plant operators. The report was . . .

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