Human Error In Medicine 1994
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Bogner No cover image Human Error in Medicine By Marilyn Sue Bogner Read preview Synopsis This edited collection of articles addresses aspects of medical care in which error in medicine lucian leape human error is associated with unanticipated adverse outcomes. For the purposes of this book,
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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 var
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Me Forgot Password? Login or Sign up for a Free Account My Topics of Interest My CME My Profile Sign Out Home Topics Issues WebM&M Cases Perspectives Primers Submit Case CME / CEU Training Catalog https://psnet.ahrq.gov/resources/resource/1524/error-in-medicine Info Glossary About PSNet Help & FAQ Contact PSNet Email Updates Editorial Team Technical Expert/Advisory Panel Terms & Conditions / Copyright PSNet Privacy Policy External Link Disclaimer Commentary Published December 1994 Error in medicine. Classic Leape LL. JAMA. 1994;272:1851-1857. Topics Resource Type Journal Article › Commentary Target Audience Health Care Providers Error Types Noncognitive Errors ("Slips & Lapses") Cognitive Errors ("Mistakes") Origin/Sponsor United States of error in America More Cite Copy Citation: Leape LL.Error in medicine. JAMA. 1994; 272: 1851-1857 Download Citation File: RIS (Zotero) EndNote BibTex Medlars ProCite RefWorks Reference Manager Share Facebook Twitter Linkedin Email Print Leape discusses how traditional methods of error reduction in medicine have focused on individual performance rather than on the systems in which individuals operate. With reference to Reason, he briefly reviews the cognitive psychology of error in medicine human error, distinguishing between performance and error at the schematic or "skill" level, where an error is a "slip" (or "lapse"), and at the rule-based or "knowledge" level, where an error is a "mistake." Using the aviation industry as an example, Leape advances a systems-based approach to improving patient safety. Rather than relying on the absence of human error, as has been traditional in medicine, he advocates systems that assume human errors will occur and that are designed to minimize their occurrence and absorb them when they happen. He reviews several specific systems modifications to accomplish this transformation, as well as advocates national policy changes to institutionalize safety improvement. PubMed citation Available at Disclaimer Related commentary Disclaimer Related Resources Meeting/Conference › California Meeting/Conference Diagnostic Error in Medicine 9th International Conference. Society to Improve Diagnosis in Medicine. November 6–8, 2016; Loews Hollywood Hotel, Los Angeles, CA. Newspaper/Magazine Article When doctors get the wrong patient. Whitman E. Mod Healthc. September 25, 2016. Journal Article › Commentary Performing the wrong procedure. Minnier T, Phrampus P, Waddell L. JAMA. 2016;316:1207-1208. Journal Article › Commentary Preventing diagnostic errors in primary care. Ely JW, Graber ML. Am Fam Physician. 2016;94:426-4
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