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Understanding and Preventing Errors

  • Michael Apkon
Part of the Health Informatics book series (HI)

Abstract

Medical care requires the coordinated action of many actors to provide fail-safe care across time, space, and specialty. Patients are subjected to dangerous procedures and potentially toxic medications where the margins of safety are thin. The processes we use to decide which procedures and medications are appropriate as well as those used to perform or deliver them effectively rely on people to perform flawlessly regardless of the environmental and system factors that hinder performance. The results are inevitable: error and failure are inescapable properties of the healthcare system. Lucien Leape1 reminds us that we must “accept the notion that error is an inevitable accompaniment of the human condition, even among conscientious professionals with high standards.” However, each error or failure also provides an opportunity to learn how complex systems function and to develop strategies that will reduce the likelihood and risk of failure. Whereas failure is inevitable, learning is optional.

Keywords

Cause Analysis Computerize Physician Order Entry Hindsight Bias Root Cause Analysis Computerize Physician Order Entry System 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Michael Apkon
    • 1
  1. 1.Yale-New Haven Children's HospitalNew Haven

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