Human Error Theory Medication Errors
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Human Error Theory In Healthcare
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James Reason Human Error
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Health Search databasePMCAll DatabasesAssemblyBioProjectBioSampleBioSystemsBooksClinVarCloneConserved DomainsdbGaPdbVarESTGeneGenomeGEO DataSetsGEO ProfilesGSSGTRHomoloGeneMedGenMeSHNCBI Web SiteNLM CatalogNucleotideOMIMPMCPopSetProbeProteinProtein ClustersPubChem BioAssayPubChem CompoundPubChem SubstancePubMedPubMed HealthSNPSparcleSRAStructureTaxonomyToolKitToolKitAllToolKitBookToolKitBookghUniGeneSearch termSearch Advanced Journal list Help Journal ListHHS Author ManuscriptsPMC3057365 Stud Health Technol Inform. Author manuscript; available in PMC 2011 Mar 15.Published in final edited form as:Stud Health Technol Inform. 2010; 153: 23–46. PMCID: PMC3057365NIHMSID: NIHMS274759Patient Safety: The Role of Human Factors and Systems EngineeringPascale Carayon, Director of the http://www.ncbi.nlm.nih.gov/pubmed/19416422 Center for Quality and Productivity Improvement and Kenneth E. Wood, Professor of Medicine and AnesthesiologyPascale Carayon, Procter & Gamble Bascom Professor in Total Quality in the Department of Industrial and Systems Engineering, University of Wisconsin-Madison;Contributor Information.Author information ► Copyright and License information ►Copyright notice and DisclaimerThe publisher's final https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3057365/ edited version of this article is available at Stud Health Technol InformSee other articles in PMC that cite the published article.AbstractPatient safety is a global challenge that requires knowledge and skills in multiple areas, including human factors and systems engineering. In this chapter, numerous conceptual approaches and methods for analyzing, preventing and mitigating medical errors are described. Given the complexity of healthcare work systems and processes, we emphasize the need for increasing partnerships between the health sciences and human factors and systems engineering to improve patient safety. Those partnerships will be able to develop and implement the system redesigns that are necessary to improve healthcare work systems and processes for patient safety.1. PATIENT SAFETYA 1999 Institute of Medicine report brought medical errors to the forefront of healthcare and the American public (Kohn, Corrigan, & Donaldson, 1999). Based on studies conducted in Colo
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 https://psnet.ahrq.gov/primers/primer/21/systems-approach Cases Perspectives Primers Submit Case CME / CEU Training Catalog 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 Patient Safety Primer Last Updated: March 2015 Systems Approach Topics Resource Type Patient Safety Primers Approach to human error Improving Safety Error Reporting More Share Facebook Twitter Linkedin Email Print Background A 65-year-old woman presented to the outpatient surgery department of one of the most respected hospitals in the United States for a relatively routine procedure, a trigger finger release on her left hand. Instead, the surgeon performs a completely different procedure—a carpal human error theory tunnel release. How could this happen? Medicine has traditionally treated errors as failings on the part of individual providers, reflecting inadequate knowledge or skill. The systems approach, by contrast, takes the view that most errors reflect predictable human failings in the context of poorly designed systems (e.g., expected lapses in human vigilance in the face of long work hours or predictable mistakes on the part of relatively inexperienced personnel faced with cognitively complex situations). Rather than focusing corrective efforts on punishment or remediation, the systems approach seeks to identify situations or factors likely to give rise to human error, and change the underlying systems of care in order to reduce the occurrence of errors or minimize their impact on patients. The modern field of systems analysis was pioneered by the British psychologist James Reason, whose analysis of industrial accidents led to fundamental insights about the nature of preventable adverse events. Reason's analysis of errors in fields as diverse as aviation and nuclear power