Understanding and Preventing Errors
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.
KeywordsCause Analysis Computerize Physician Order Entry Hindsight Bias Root Cause Analysis Computerize Physician Order Entry System
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- 2.Reason J. Managing the Risks of Organizational Accidents. Burlington, VT: Ashgate; 1997.Google Scholar
- 4.Womack JP, Jones JT, Roos D, Sammons-Carpenter D. The Machine That Changed the World. New York: Harper Collins; 1990.Google Scholar
- 5.Gano DL. Apollo Root Cause Analysis. Yakima, Washington, DC: Apollonian; 1992.Google Scholar
- 6.Veterans Affairs, National Center for Patient Safety. NCPS Triage Cards™ for Root Cause Analysis; 2001. Available at: http://www.va.gov/ncps/CogAids/Triage/index.html. Accessed December 21, 2008.
- 7.Baigan JP. NCPS Root Cause Analysis Tools. Veterans Affairs, National Center for Patient Safety; 2008. Availabe at: http://www.patientsafety.gov/CogAids/RCA/index.html. Accessed December 21, 2008.
- 9.Grissinger M, Rich D. JCAHO: meeting the standards for patient safety. Joint Commission on Accreditation of Healthcare Organizations. J Am Pharm Assoc (Wash). 2002;42:S54–S55.Google Scholar
- 10.DeRosier J, Stalhandske E, Bagian JP, Nudell T. Using health care failure mode and effect analysis: the VA national center for patient safety's prospective risk analysis system. Jt Comm J Qual Improv. 2002;28:209, 248–267.Google Scholar
- 15.[No authors listed]. FMEA (failure mode analysis): a new QI tool to help improve case management processes. Hosp Case Manag. 2003 Mar;11(3):33–36.Google Scholar