Human Error and Patient Safety
- PMID: 36315764
- Bookshelf ID: NBK585626
- DOI: 10.1007/978-3-030-59403-9_3
Human Error and Patient Safety
Excerpt
This chapter introduces the topic of error as an essential foundation for an understanding of patient safety. We introduce psychological classifications of error and then, using clinical examples, show how we can use these ideas to understand how errors occur and how chains of small errors can combine to cause harm to patients. We outline a practical approach to conducting investigations into healthcare incidents. Finally, we offer some reflections on how doctors experience errors and how best to support yourself or your colleagues when things do not go as well as intended.
Copyright 2021, The Author(s).
Sections
- 3.1. Introduction
- 3.2. What Is an Error?
- 3.3. Understanding Error
- 3.4. Understanding the Influence of the Wider System
- 3.5. Contributory Factors: Seven Levels of Safety
- 3.6. Putting It All Together: Illustration of Two Cases from an Acute Care Setting
- 3.7. Conducting Your Own Incident Investigation
- 3.8. Systems Analysis of Clinical Incidents
- 3.9. Supporting Patients, Families, and Staff
- 3.10. Conclusions and Recommendations
- References
References
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- Woods DD, Cook RI. Nine steps to move forward from error. Cogn Technol Work. 2002;4(2):137–44.
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- Hollnagel E. Cognitive reliability and error analysis method: CREAM. Oxford: Elsevier; 1998.
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- Senders JW, Moray N, North Atlantic Treaty Organization. Conference on the nature and source of human error, 2nd: 1983: Bellagio, I, Human error: cause, prediction, and reduction. Hillsdale, NJ: L. Erlbaum Associates; 1991.
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- Reason JT. Human error. Cambridge: Cambridge University Press; 1990.
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- Reason JT. Managing the risks of organizational accidents. Aldershot: Ashgate; 1997.
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