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At least 577 records · Page 32Linked to original sources
PubMed2002

Toward a cognitive taxonomy of medical errors.

One critical step in addressing and resolving the problems associated with human errors is the development of a cognitive taxonomy of such errors. In the case of errors, such a taxonomy may be developed (1) to categorize all types of errors along cognitive dimensions, (2) to associate each type of error with a specific underlying cognitive mechanism, (3) to explain why, and even predict when and where, a specific error will occur, and (4) to generate intervention strategies for each type of error. Based on Reason's (1992) definition of human errors and Norman's (1986) cognitive theory of human action, we have developed a preliminary action-based cognitive taxonomy of errors that largely satisfies these four criteria in the domain of medicine. We discuss initial steps for applying this taxonomy to develop an online medical error reporting system that not only categorizes errors but also identifies problems and generates solutions.

Cognition↗
PubMedDate not supplied

Medical errors: excess hospital costs and lengths of stay.

To focus on effective patient safety strategies in an environment of intense competition for resources, a method of quantifying the effect of potential sources of medical errors was developed. This study assessed excess length of stay (LOS) and hospitalization costs associated with patients who experienced errors. The distribution of the errors occurring within the mean LOS experienced by others with the same diagnosis and severity was also examined. Patients with errors had longer stays and greater costs when compared to controls.

Cost Control↗
PubMedDate not supplied

An organizational approach to understanding patient safety and medical errors.

Progress in patient safety, or lack thereof, is a cause for great concern. In this article, we argue that the patient safety movement has failed to reach its goals of eradicating or, at least, significantly reducing errors because of an inappropriate focus on provider and patient-level factors with no real attention to the organizational factors that affect patient safety. We describe an organizational approach to patient safety using different organizational theory perspectives and make several propositions to push patient safety research and practice in a direction that is more likely to improve care processes and outcomes. From a Contingency Theory perspective, we suggest that health care organizations, in general, operate under a misfit between contingencies and structures. This misfit is mainly due to lack of flexibility, cost containment, and lack of regulations, thus explaining the high level of errors committed in these organizations. From an organizational culture perspective, we argue that health care organizations must change their assumptions, beliefs, values, and artifacts to change their culture from a culture of blame to a culture of safety and thus reduce medical errors. From an organizational learning perspective, we discuss how reporting, analyzing, and acting on error information can result in reduced errors in health care organizations.

Humans↗
PubMed2006

Fatality involving vinblastine overdose as a result of a complex medical error.

The purpose of the study is a presentation of a fatal case involving an 83-year-old woman, who died due to an overdose of vinblastine-a cytostatic agent of a vinca alkaloid employed in cancer chemotherapy. The postmortem investigation included an autopsy and histological examination, as well as a toxicological analysis of post-mortem specimens collected in the course of autopsy. The authors performed a toxicological assessment of vinblastine employing liquid chromatography-atmospheric pressure chemical ionization-tandem mass spectrometry (LC-MS-MS-APCI). The determined vinblastine concentration levels amounting to 29 ng/g in blood and 52.5 ng/g in liver were in a considerable excess of values encountered in patients on chemotherapy using the drug. The fatality was investigated in the context of medical error. In the described case, the erroneous and medically unjustified administration of vinblastine was identified by a series of unfortunate events involving as many as three acting consecutively individuals: a physician, a pharmacist and a nurse. The report may thus document the clinical course of vinblastine poisoning along with postmortem changes resulting from the drug action.

Accidents, Traffic↗
PubMed2005

The IOM medical errors report: 5 years later, the journey continues.

In 1999, the Institute of Medicine released a report, To Err Is Human: Building a Safer Health System, which shed a new light for providers and patients across the nation looking at patient safety and medical errors. Since then, new ways of addressing patient safety have emerged. But how far does the healthcare system still have to go?

Humans↗
PubMed1995

CQI case study: reducing medication errors.

BACKGROUND: This article describes how the Pharmacy and Therapeutics Committee at Lutheran General Hospital (Park Ridge, IL) formed a continuous quality improvement (CQI) team and used statistical process control (SPC) tools to assess efforts to reduce medication errors. METHODS: The team worked with the nursing quality council to develop an intravenous (IV) training module for nurses that effectively decreased the average number of errors per month. The article illustrates the effective use of a run chart, a Pareto chart, and two types of control charts (p-charts and np-charts) to identify an opportunity for improvement, develop an improvement strategy, and measure the effectiveness of the intervention. CONCLUSION: Lessons learned from this case include the following: 1) Although run charts can be used as a preliminary step to determine whether a process has common-cause or special-cause variation, p-charts or np-charts are more precise tools for identifying special causes and for measuring the impact of interventions; 2) Pareto charts are useful for focusing on the areas of a process that will have the greatest impact in achieving the desired results; 3) When p-charts show little variation in control limits from month to month, the np-chart is an appropriate and more user-friendly alternative; and 4) In addition to validating the overall effectiveness of the intervention, the np-chart also helped to identify where the intervention failed.

Health Services Research↗