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Medical Errors 2005

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Error in Patient Care and Clinical Practice ,[object Object],[object Object],[object Object],[object Object],[object Object]
Medical Error Agenda ,[object Object],[object Object],[object Object],[object Object],[object Object]
Previous Work in Error from Industry ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Focus of Attention on Medical Error ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
General Definition of Medical Error ,[object Object],[object Object],[object Object]
Classification of Medical Errors ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Leape et al. Preventing Medical Injury. Qual Rev Bull 19(5):144-149, 1993.
Primary Studies ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Leape et al. N Engl J Med 324(6):377-384, 1991. Gawande et al. Surgery 126:66-75, 1999.
Representative Supporting Studies ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Analysis and Recommendations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],1 Thomas et al. JAMA 267:2487-2492, 1992.
Error and Medical Culture ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Medical Processes are Sensitive to Error ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Human Error
Types of Human Error ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Reasons for Human Error ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Risky Work Processes and Human Error ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Propagation of Error Latent Error Human Error Human Error Latent Error Human Error Monitoring System Accident X
Decreasing Error
Decreasing Error ,[object Object],[object Object],[object Object]
Reporting Systems for Errors ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
The Importance of “Near-Misses” ,[object Object],[object Object],[object Object],[object Object],[object Object]
Analyzing and Responding to Error ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Strategies for Limiting Error ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Information Systems and Medical Error ,[object Object],[object Object],[object Object],[object Object],[object Object]
Drug Therapy and Medical Error ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Detection of Adverse Drug Events ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Jha, et al. JAMIA 5(3):305-314, 1998.
Prevention of Drug Therapy Errors ,[object Object],[object Object],[object Object],[object Object],[object Object],Classen, et al. JAMA 266(20):2847-2851, 1991. Bates, et al. JAMIA 6(4):313-312, 1999. Theurmann et al. Drug Saf 25:713-24, 2002
Potential Benefits of Information Systems ,[object Object],[object Object],[object Object],[object Object],[object Object]
Problems with Information Systems
Effect of Hospital “Computerization” on Physician Performance ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],1 Garg et al. JAMA 293(10)1223-1238, 2005 2 Nebeker et al. Arch Intern Med 165:1111-1116, 2005
Information Systems Create New Opportunities for Error ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
An Example Case Horsky et al. JAMIA 12:377-382, 2005
Case Description ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case Description (2) ,[object Object],[object Object],[object Object],[object Object],[object Object]
Case Description (3) ,[object Object],[object Object],[object Object],[object Object]
Key Issues ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Summary ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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