Understanding and Preventing Errors
Part of the
book series (HI)
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
Leape LL. Error in medicine. JAMA.
Reason J. Managing the Risks of Organizational Accidents
. Burlington, VT: Ashgate; 1997.Google Scholar
Fischhoff B. Hindsight not equal to foresight: the effect of outcome knowledge on judgment under uncertainty. J Exp Psychol Hum Percept Perform.
Womack JP, Jones JT, Roos D, Sammons-Carpenter D. The Machine That Changed the World
. New York: Harper Collins; 1990.Google Scholar
Gano DL. Apollo Root Cause Analysis.
Yakima, Washington, DC: Apollonian; 1992.Google Scholar
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.
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.
Apkon M, Leonard J, Probst L, DeLizio L, Vitale R. Design of a safer approach to intravenous drug infusions: failure mode effects analysis. Qual Saf Health Care.
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
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
Adachi W, Lodolce AE. Use of failure mode and effects analysis in improving the safety of i.v. drug administration. Am J Health Syst Pharm.
Robinson DL, Heigham M, Clark J. Using failure mode and effects analysis for safe administration of chemotherapy to hospitalized children with cancer. Jt Comm J Qual Patient Saf.
Kunac DL, Reith DM. Identification of priorities for medication safety in neonatal intensive care. Drug Saf.
Burgmeier J. Failure mode and effect analysis: an application in reducing risk in blood transfusion. Jt Comm J Qual Improv.
[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
Nichols JH, Bartholomew C, Brunton M, et al. Reducing medical errors through barcoding at the point of care. Clin Leadersh Manag Rev.
Ridgway M. Analyzing planned maintenance (PM) inspection data by failure mode and effect analysis methodology. Biomed Instrum Technol.
Wehrli-Veit M, Riley JB, Austin JW. A failure mode effect analysis on extracorporeal circuits for cardiopulmonary bypass. J Extra Corpor Technol.
2004; 36:351–357.PubMedGoogle Scholar
Willis G. Failure modes and effects analysis in clinical engineering. J Clin Eng.
Kozakiewicz JM, Benis LJ, Fisher SM, Marseglia JB. Safe chemotherapy administration: using failure mode and effects analysis in computerized prescriber order entry. Am J Health Syst Pharm.
Wetterneck TB, Skibinski KA, Roberts TL, et al. Using failure mode and effects analysis to plan implementation of smart i.v. pump technology. Am J Health Syst Pharm.
Nakajo T. A method of identifying latent human errors in work systems. Qual Reliab Eng Int.
Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med.
Potts AL, Barr FE, Gregory DF, Wright L, Patel NR. Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics
. 2004;113:59–63.PubMedCrossRefGoogle Scholar
Shulman R, Singer M, Goldstone J, Bellingan G. Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit. Crit Care.
Huertas Fernandez MJ, Baena-Canada JM, Martinez Bautista MJ, Arriola Arellano E, Garcia Palacios M V. Impact of computerised chemotherapy prescriptions on the prevention of medication errors. Clin Transl Oncol.
Garg AX, Adhikari NK, McDonald H, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA.
Berner ES, Maisiak RS, Cobbs CG, Taunton OD. Effects of a decision support system on physicians' diagnostic performance. J Am Med Inform Assoc.
Steele AW, Eisert S, Witter J, et al. The effect of automated alerts on provider ordering behavior in an outpatient setting. PLoS Med.
Killelea BK, Kaushal R, Cooper M, Kuperman GJ. To what extent do pediatricians accept computer-based dosing suggestions? Pediatrics
. 2007;119:e69–e75.PubMedCrossRefGoogle Scholar
Johnson CW. Why did that happen? Exploring the proliferation of barely usable software in healthcare systems. Qual Saf Health Care.
2006;15 Suppl 1:i76–i81.PubMedCrossRefGoogle Scholar
Apkon M, Mattera JA, Lin Z, et al. A randomized outpatient trial of a decision-support information technology tool. Arch Intern Med.
Scanlon M. Computer physician order entry and the real world: we're only humans. Jt Comm J Qual Saf.
Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA.
Walsh KE, Adams WG, Bauchner H, et al. Medication errors related to computerized order entry for children. Pediatrics
. 2006;118:1872–1879.PubMedCrossRefGoogle Scholar
© Springer Science+Business Media, LLC 2009