Abstract
In 1999, the Institute of Medicine published a widely cited report [1] that suggested between 44,000 and 98,000 people die each year because of preventable medical error. Even the more conservative estimate suggests that medical error causes more death annually than motor vehicle accidents, breast cancer, or AIDS. This report resulted in unprecedented focus of attention on the issue of error in medicine. However, there is little evidence of widely available improvements in patient safety. According to leading patient safety researcher Lucian Leape, of the primary barriers to progress ‘the first such challenge is (the) complexity’ of medical practice [2].
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References
Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.
Leape L, Berwick D. Five years after to err is human: what have we learned? J Am Med Inform Assoc. 2005;293:2385–90.
Reason J. Human error. Cambridge: Cambridge University Press; 1990.
Amalberti R. The paradoxes of almost totally safe transportation systems. Saf Sci. 2001;37(2–3):109–26.
West CP, Huschka MM, Novotny PJ, Sloan JA, Kolars JC, Habermann TM, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. J Am Med Inform Assoc. 2006;296(9):1071.
Wu AW. Medical error: the second victim. West J Med. 2000;172(6):358–9.
Mizrahi T. Managing medical mistakes: ideology, insularity and accountability among internists-in-training. Soc Sci Med. 1984;19(2):135–46.
Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? J Am Med Inform Assoc. 1991;265(16):2089–94.
Kaldjian LC, Forman-Hoffman VL, Jones EW, Wu BJ, Levi BH, Rosenthal GE. Do faculty and resident physicians discuss their medical errors? J Med Ethics. 2008;34(10):717–22.
Schenkel SM. Resident perceptions of medical errors in the emergency department. Acad Emerg Med. 2003;10(12):1318–24.
Kachalia A, Kaufman SR, Boothman R, Anderson S, Welch K, Saint S, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010;153(4):213–21.
Varjavand N, Bachegowda LS, Gracely E, Novack DH. Changes in intern attitudes toward medical error and disclosure. Med Educ. 2012;46(7):668–77.
Helmreich RL. On error management: lessons from aviation. Br Med J. 2000;320(7237):781–5.
Rogers DA, Regehr G, MacDonald J. A role for error training in surgical technical skill instruction and evaluation. Am J Surg. 2002;183(3):242–5.
Crosby PB. Quality is free: the art of making quality certain. New York: McGraw-Hill; 1979.
Rasmussen J. The role of error in organizing behaviour. Ergonomics. 1990;33:377–85.
Phillips DP, Barker GEC. A July spike in fatal medication errors: a possible effect of new medical residents. J Gen Intern Med. 2010;25(8):774–9.
Patel VL, Cohen T, Murarka T, Olsen J, Kagita S, Myneni S, et al. Recovery at the edge of error: debunking the myth of the infallible expert. J Biomed Inform. 2011;44(3):413–24.
Chi MTH, Glaser R, Farr MJ. The nature of expertise. Hillsdale: Lawrence Erlbaum Associates; 1988.
Patel VL, Arocha JF, Kaufman DR. Diagnostic reasoning and medical expertise. Psychology of Learning and Motivation. 1994;31:187–252.
Amalberti R, Wioland LL. Human error in aviation. In: Soekkha H, editor. Aviation safety: human factors, system engineering, flight operations, economics, strategies, management. Utrecht: VSP; 1997. p. 91–108.
Morel G, Amalberti R, Chauvin C. Articulating the differences between safety and resilience: the decision-making process of professional sea-fishing skippers. Hum Factors. 2008;50(1):1–16. Epub 2008/03/22.
Hollnagel E. Resilience engineering concepts and precepts. Burlington: Ashgate Publishing Limited; 2006.
Kubose TT, Patel VL, Jordan D. Dynamic adaptation to critical care medical environment: error recovery as cognitive activity. In: Proceedings of the 24th Annual Conference of the Cognitive Science Society. Virginia: Fairfax; 2002. p. 43–4.
Nyssen AS, Blavier A. Error detection: a study in anaesthesia. Ergonomics. 2006;49:517–25.
Klein G, Pliske R, Crandall B, Woods DD. Problem detection. Cogn Technol Work. 2005;7(1):14–28.
Cohen T, Blatter B, Almeida C, Shortliffe E, Patel VL. Distributed cognition in the psychiatric emergency department: a cognitive blueprint of a collaboration in context. Artif Intell Med. 2006;37:73–83.
Hutchins E. Cognition in the wild. Cambridge: MIT Press; 1995, xviii, 381 p.
Cohen T, Blatter B, Almeida C, Patel VL. Reevaluating recovery: perceived violations and preemptive interventions on emergency psychiatry rounds. J Am Med Inform Assoc. 2007;14(3):312–9.
Patel VL, Cohen T. New perspectives on error in critical care. Curr Opin Crit Care. 2008;14(4):456–9.
Hazlehurst B, Gorman PN, McMullen CK. Distributed cognition: an alternative model of cognition for medical informatics. Int J Med Inform. 2008;77:226–34.
Xiao Y. Artifacts and collaborative work in healthcare: methodological, theoretical, and technological implications of the tangible. J Biomed Inform. 2005;38:26–33.
Patel VL, Kaufman DR, Arocha JF. Emerging paradigms of cognition in medical decision making. J Biomed Inform. 2002;35:52–75.
Malhotra S, Jordan D, Shortliffe E, Patel VL. Workflow modeling in critical care: piecing together your own puzzle. J Biomed Inform. 2007;40(2):81–92.
Laxmisan A, Hakimzada AF, Sayan OR, Green RA, Zhang J, Patel VL. The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care. Int J Med Inform. 2007;76:801–11.
Patel VL, Zhang J, Yoskowitz NA, Green R, Sayan OR. Methodological review: translational cognition for decision support in critical care environments: a review. J Biomed Inform. 2008;41(3):413–31.
Perkins DN. The mind’s best work. Cambridge: Harvard University Press; 1981.
Ohlsson S. Restructuring revisited. Scand J Psychol. 1984;25(2):117–29.
Sun R, Merrill E, Peterson T. From implicit skills to explicit knowledge: a bottom-up model of skill learning. Cognit Sci. 2001;25(2):203–44.
Gick ML, Holyoak KJ. Schema induction and analogical transfer. Cogn Psychol. 1983;15(1):1–38.
Rasmussen J. The role of error in organizing behaviour. Qual Saf Health Care. 2003;12(5):377–85. PubMed PMID: 14532371. Pubmed Central PMCID: 1743771. Epub 2003/10/09.
Patel VL, Groen GJ. The general and specific nature of medical expertise: a critical look. In: Ericsson A, Smith J, editors. Towards a general theory of expertise: prospects and limits. Cambridge: Cambridge University Press; 1991. p. 93–125.
Patel VL, Evans DA, Groen GJ. Biomedical knowledge and clinical reasoning. In: Evans DA, Patel VL, editors. Cognitive science in medicine: biomedical modeling. Cambridge: MIT Press; 1989. p. 53–112.
Holyoak KJ, Thagard P. Analogical mapping by constraint satisfaction. Cognit Sci. 1989;13(3):295–355.
Brown JS, Burton RR. Diagnostic models for procedural bugs in basic mathematical skills. Cognit Sci. 1978;2(2):155–92.
Brown JS, VanLehn K. Repair theory: a generative theory of bugs in procedural skills. Cognit Sci. 1980;4(4):379–426.
Keselman A, Kaufman DR, Kramer S, Patel VL. Fostering conceptual change and critical reasoning about HIV and AIDS. J Res Sci Teach. 2007;44(6):844–63.
Kanse L, van der Schaaf TW, Vrijland ND, van Mierlo H. Error recovery in a hospital pharmacy. Ergonomics. 2006;49(5–6):503–16. PubMed PMID: 16717007.
Kessels-Habraken M, Van der Schaaf T, De Jonge J, Rutte C. Defining near misses: towards a sharpened definition based on empirical data about error handling processes. Soc Sci Med. 2010;70(9):1301–8.
Norman DA. The psychology of everyday things. New York: Basic Books; 1988.
Allwood CM. Error detection process in statistical problem solving. Cognit Sci. 1984;8(4):413–37.
Hales BM, Pronovost PJ. The checklist-A tool for error management and performance improvement. J Crit Care. 2006;21(3):231–5. PubMed PMID: 16990087.
Wilkinson WE, Cauble LA, Patel VL. Error detection and recovery in dialysis nursing. J Patient Saf. 2011;7(4):213–23. PubMed PMID: 22064625. Epub 2011/11/09.
Razzouk E, Cohen T, Almoosa K, Patel VL. Approaching the limits of knowledge: the influence of priming on error detection in simulated clinical rounds. In: AMIA annual symposium proceedings. 2011. p. 1155–64.
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Cohen, T., Patel, V.L. (2014). A Framework for Understanding Error and Complexity in Critical Care. In: Patel, V., Kaufman, D., Cohen, T. (eds) Cognitive Informatics in Health and Biomedicine. Health Informatics. Springer, London. https://doi.org/10.1007/978-1-4471-5490-7_2
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DOI: https://doi.org/10.1007/978-1-4471-5490-7_2
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