Human Reliability And Error In Medical System
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Human Reliability And Error In Medical System
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Author : B S Dhillon
language : en
Publisher: World Scientific
Release Date : 2003-09-05
Human Reliability And Error In Medical System written by B S Dhillon and has been published by World Scientific this book supported file pdf, txt, epub, kindle and other format this book has been release on 2003-09-05 with Medical categories.
Human reliability and error have become a very important issue in health care, owing to the vast number of associated deaths each year. For example, according to the findings of the Institute of Medicine in 1999, around 100000 Americans die each year because of human error. This makes human error in health care the eighth leading cause of deaths in the US. Moreover, the total annual national cost of the medical errors is estimated at between $17 billion and $37.6 billion.There are very few books on this subject, and none of them covers it at a significant depth. The need for a book presenting the basics of human reliability, human factors and comprehensive information on error in medical systems is essential. This book meets that need.
Reliability Technology Human Error And Quality In Health Care
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Author : B.S. Dhillon
language : en
Publisher: CRC Press
Release Date : 2008-02-21
Reliability Technology Human Error And Quality In Health Care written by B.S. Dhillon and has been published by CRC Press this book supported file pdf, txt, epub, kindle and other format this book has been release on 2008-02-21 with Medical categories.
The effective and interrelated functioning of system reliability technology, human factors, and quality play an important role in the appropriate, efficient, and cost-effective delivery of health care. Simply put, it can save you time, money, and more importantly, lives. Over the years a large number of journal and conference proceedings articles o
To Err Is Human
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Author : Institute of Medicine
language : en
Publisher: National Academies Press
Release Date : 2000-03-01
To Err Is Human written by Institute of Medicine and has been published by National Academies Press this book supported file pdf, txt, epub, kindle and other format this book has been release on 2000-03-01 with Medical categories.
Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine
Human Error In Medicine
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Author : Marilyn Sue Bogner
language : en
Publisher: CRC Press
Release Date : 2018-02-06
Human Error In Medicine written by Marilyn Sue Bogner and has been published by CRC Press this book supported file pdf, txt, epub, kindle and other format this book has been release on 2018-02-06 with Technology & Engineering categories.
This edited collection of articles addresses aspects of medical care in which human error is associated with unanticipated adverse outcomes. For the purposes of this book, human error encompasses mismanagement of medical care due to: * inadequacies or ambiguity in the design of a medical device or institutional setting for the delivery of medical care; * inappropriate responses to antagonistic environmental conditions such as crowding and excessive clutter in institutional settings, extremes in weather, or lack of power and water in a home or field setting; * cognitive errors of omission and commission precipitated by inadequate information and/or situational factors -- stress, fatigue, excessive cognitive workload. The first to address the subject of human error in medicine, this book considers the topic from a problem oriented, systems perspective; that is, human error is considered not as the source of the problem, but as a flag indicating that a problem exists. The focus is on the identification of the factors within the system in which an error occurs that contribute to the problem of human error. As those factors are identified, efforts to alleviate them can be instituted and reduce the likelihood of error in medical care. Human error occurs in all aspects of human activity and can have particularly grave consequences when it occurs in medicine. Nearly everyone at some point in life will be the recipient of medical care and has the possibility of experiencing the consequences of medical error. The consideration of human error in medicine is important because of the number of people that are affected, the problems incurred by such error, and the societal impact of such problems. The cost of those consequences to the individuals involved in medical error, both in the health care providers' concern and the patients' emotional and physical pain, the cost of care to alleviate the consequences of the error, and the cost to society in dollars and in lost personal contributions, mandates consideration of ways to reduce the likelihood of human error in medicine. The chapters were written by leaders in a variety of fields, including psychology, medicine, engineering, cognitive science, human factors, gerontology, and nursing. Their experience was gained through actual hands-on provision of medical care and/or research into factors contributing to error in such care. Because of the experience of the chapter authors, their systematic consideration of the issues in this book affords the reader an insightful, applied approach to human error in medicine -- an approach fortified by academic discipline.
Systemic And Human Factors That Contribute To Medical Error
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Author : LaTasha R. Burns
language : en
Publisher:
Release Date : 2017
Systemic And Human Factors That Contribute To Medical Error written by LaTasha R. Burns and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 2017 with Education categories.
Background: Despite a focus on improving patient safety and quality of care since the publication of the 2000 report, To Error is Human, there has not been much progress toward preventing adverse medical errors. Many health care organizations are beginning to apply high reliability principles, such as human factors engineering, to help address safety problems. A use of these methods and principles has proven successful in high- risk, complex industries, such as aviation. Like aviation, the health care industry is complex and error prone. Therefore, the experiences cultivated from highly reliable industries might be useful in improving work processes and systems in health care. Purpose: The purpose of this study was to explore the lessons learned from highly reliable industries, such as aviation, by investigating systemic and human factors that led to medical errors in one health care facility. Using the Human Factors Analysis and Classification System (HFACS) to analyze and categorize causal factors from 108 root cause analyses, the study site was able to determine if an association existed between systemic and human factors. Determining what causal factors were most problematic allowed leaders to precisely focus efforts to specific interventions that would alleviate reoccurrence of the errors. Methods: This quantitative exploratory study used descriptive statistics to organize the data alongside higher reliability principles in order to meaningfully evaluate the medical errors. Results: The data analysis resulted in seven major findings, which yielded two overall indicators of focus: (1) attention to efforts that realize zero harm and (2) managing processes that effectively reduce systemic issues. Conclusion: Leadership’s attention to these major focus areas gives insight as to how patient care can be efficiently provided. Likewise, applying human factors engineering principles to medical errors can help improve patient safety, provide empirical knowledge to health care professionals, and increase reliability in the health care industry.
Human Reliability And Error In Transportation Systems
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Author : Balbir S. Dhillon
language : en
Publisher: Springer Science & Business Media
Release Date : 2007-07-11
Human Reliability And Error In Transportation Systems written by Balbir S. Dhillon and has been published by Springer Science & Business Media this book supported file pdf, txt, epub, kindle and other format this book has been release on 2007-07-11 with Technology & Engineering categories.
Human errors contribute significantly to most transportation crashes: approximately 70 to 90 percent of crashes are the result of human error. This book examines human reliability across all types of transportation systems. The material is accessible to readers with no previous knowledge in the field and is supported with a full explanation of the necessary mathematical concepts together with numerous examples and test problems.
Human Reliability Analysis In Healthcare
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Author : Joey L. Deeter
language : en
Publisher:
Release Date : 2012
Human Reliability Analysis In Healthcare written by Joey L. Deeter and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 2012 with Medical errors categories.
"Patient safety is a concern within the healthcare domain as it is estimated that tens of thousands of people die annually from preventable medical errors. For over ten years, traditional Human Reliability Analysis (HRA) techniques (e.g., Root Cause Analysis and Failure Mode and Effect Analysis) have been used in hospitals nationwide in an attempt to explain why these errors occur and what can be done to prevent them. Still, patient safety has not improved significantly. Traditional HRA techniques are limited as analysis tools. They do not consider the context in which workers operate. They are also not based on a valid psychological model that could explain human cognitive function. The Cognitive Reliability and Error Analysis Method (CREAM) is an HRA technique that allows analysts to examine worker actions through the context of performance-shaping factors. The CREAM also employs a cognitive model to explain cognitive failures. This research used the CREAM to re-analyze events containing identifiable error modes that were previously analyzed by hospital team members using the RCA technique. The results of the re-analyses using the CREAM were compared with the previous analyses from RCA events. Additionally, several RCA events were observed and detailed written narratives of the observations were used to perform further independent analyses by three independent analysts in an effort to calculate inter-rater agreement. The results exposed a gap within categories of causal factors between the two techniques. The CREAM identified organizational factors as contributing to error in the events whereas those factors were either minimized or ignored in the RCA. The results also failed to demonstrate any significant inter-rater agreement among independent analysts performing the CREAM analyses. Due to serious data limitations, detailed analyses using the CREAM were not possible."--Abstract.
To Err Is Human
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Author : Institute of Medicine
language : en
Publisher: National Academies Press
Release Date : 2000-04-01
To Err Is Human written by Institute of Medicine and has been published by National Academies Press this book supported file pdf, txt, epub, kindle and other format this book has been release on 2000-04-01 with Medical categories.
Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine
Improving Diagnosis In Health Care
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Author : National Academies of Sciences, Engineering, and Medicine
language : en
Publisher: National Academies Press
Release Date : 2015-12-29
Improving Diagnosis In Health Care written by National Academies of Sciences, Engineering, and Medicine and has been published by National Academies Press this book supported file pdf, txt, epub, kindle and other format this book has been release on 2015-12-29 with Medical categories.
Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.
Advances In Human Error Reliability Resilience And Performance
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Author : Ronald Laurids Boring
language : en
Publisher: Springer
Release Date : 2017-06-16
Advances In Human Error Reliability Resilience And Performance written by Ronald Laurids Boring and has been published by Springer this book supported file pdf, txt, epub, kindle and other format this book has been release on 2017-06-16 with Technology & Engineering categories.
This book brings together studies broadly dealing with human error from different disciplines and perspectives. They concern human performance; human variability and reliability analysis; medical, driver and pilot error, as well as automation error; reports on root cause analyses; and the cognitive modeling of human error. In addition, they highlight cutting-edge applications in safety management, defense, security, transportation, process controls, and medicine, as well as more traditional fields of application. Based on the AHFE 2017 International Conference on Human Error, Reliability, Resilience, and Performance, held on July 17–21, 2017 in Los Angeles, California, USA, the book includes experimental papers, original reviews, and reports on case studies, as well as meta-analyses, technical guidelines, best practice and methodological papers. It offers a timely reference guide for researchers and practitioners dealing with human error in a diverse range of fields. “p>