Human Error in Medicine

By Marilyn Sue Bogner | Go to book overview

18
Afterword

Jens Rasmussen HURECON

There has been much discussion in this book about the systems nature of human error in medicine, that is, factors in the entire system in which clinicians function that impinge on them and induce them to commit errors. There also has been discussion about the need for viable information systems that provide data pertaining to the system, the environment in which clinicians function and the activities of clinicians themselves. The following discussion presents a taxonomy for describing malfunctions associated with human behavior that was developed for use in an industry other than medicine, but has potential for the medical arena.

Because the conditions that precipitate human error tend to be analogous across industries, efforts in domains other than medicine are applicable to medicine as several authors in this book have noted. The taxonomy described subsequently is not presented as a definitive way of organizing and analyzing data for the study of human error in medicine. Rather, the taxonomy is presented as an initial, well thought-out framework on which to build databases related to human error in medicine. The results of analyses of those data could be used to guide efforts to effectively reduce the incidence of human error in medicine.

The need for information systems based on a systems perspective has been identified for operation of high-hazard systems such as nuclear power and chemical process plants. Great efforts have been spent on the establishment of human error databases for design and operation of such systems. In spite of decades of effort, no reliable human error database exists today for predictive analysis in the operation of plants for such process industries. This does not, however, imply that the analysis of human error incidents is

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