Download or read book Human Reliability And Error In Medical System written by B S Dhillon and published by World Scientific. This book was released on 2003-09-05 with total page 233 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.
Download or read book To Err Is Human written by Institute of Medicine and published by National Academies Press. This book was released on 2000-03-01 with total page 312 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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
Download or read book Improving Diagnosis in Health Care written by National Academies of Sciences, Engineering, and Medicine and published by National Academies Press. This book was released on 2015-12-29 with total page 473 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.
Download or read book Patient Safety written by Sidney Dekker and published by CRC Press. This book was released on 2016-04-19 with total page 254 pages. Available in PDF, EPUB and Kindle. Book excerpt: Increased concern for patient safety has put the issue at the top of the agenda of practitioners, hospitals, and even governments. The risks to patients are many and diverse, and the complexity of the healthcare system that delivers them is huge. Yet the discourse is often oversimplified and underdeveloped. Written from a scientific, human factors
Download or read book Reliability Technology Human Error and Quality in Health Care written by B.S. Dhillon and published by CRC Press. This book was released on 2008-02-21 with total page 212 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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
Download or read book Human Reliability and Error in Transportation Systems written by Balbir S. Dhillon and published by Springer Science & Business Media. This book was released on 2007-07-11 with total page 191 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.
Download or read book Distracted Doctoring written by Peter J. Papadakos and published by Springer. This book was released on 2017-07-31 with total page 264 pages. Available in PDF, EPUB and Kindle. Book excerpt: Examining-room computers require doctors to record detailed data about their patients, yet reduce the time clinicians can spend listening attentively to the very people they are trying to help. This book presents original essays by distinguished experts in their fields, addressing this critical problem and making an urgent case for reform, because while electronic technology has revolutionized the practice of medicine, it also poses a unique challenge to health care. Smartphones in the hands of doctors and nurses have become dangerously seductive devices that can endanger their patients. Distracted Doctoring is written for anesthesiologists and surgeons, as well as general practitioners, nurses, and health care administrators and students. Chapters include Electronic Challenges to Patient Safety and Care; Distraction, Disengagement, and the Purpose of Medicine; and Managing Distractions through Advocacy, Education, and Change.
Download or read book Handbook of Human Factors and Ergonomics in Health Care and Patient Safety written by Pascale Carayon and published by CRC Press. This book was released on 2016-04-19 with total page 855 pages. Available in PDF, EPUB and Kindle. Book excerpt: The first edition of Handbook of Human Factors and Ergonomics in Health Care and Patient Safety took the medical and ergonomics communities by storm with in-depth coverage of human factors and ergonomics research, concepts, theories, models, methods, and interventions and how they can be applied in health care. Other books focus on particular human
Download or read book Patient Safety and Quality written by Ronda Hughes and published by Department of Health and Human Services. This book was released on 2008 with total page 592 pages. Available in PDF, EPUB and Kindle. Book excerpt: "Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/
Download or read book Systemic and Human Factors that Contribute to Medical Error written by LaTasha R. Burns and published by . This book was released on 2017 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.
Download or read book Human Error in Medicine written by Marilyn Sue Bogner and published by CRC Press. This book was released on 2018-02-06 with total page 428 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.
Download or read book A Human Error Approach to Aviation Accident Analysis written by Douglas A. Wiegmann and published by Routledge. This book was released on 2017-12-22 with total page 174 pages. Available in PDF, EPUB and Kindle. Book excerpt: Human error is implicated in nearly all aviation accidents, yet most investigation and prevention programs are not designed around any theoretical framework of human error. Appropriate for all levels of expertise, the book provides the knowledge and tools required to conduct a human error analysis of accidents, regardless of operational setting (i.e. military, commercial, or general aviation). The book contains a complete description of the Human Factors Analysis and Classification System (HFACS), which incorporates James Reason's model of latent and active failures as a foundation. Widely disseminated among military and civilian organizations, HFACS encompasses all aspects of human error, including the conditions of operators and elements of supervisory and organizational failure. It attracts a very broad readership. Specifically, the book serves as the main textbook for a course in aviation accident investigation taught by one of the authors at the University of Illinois. This book will also be used in courses designed for military safety officers and flight surgeons in the U.S. Navy, Army and the Canadian Defense Force, who currently utilize the HFACS system during aviation accident investigations. Additionally, the book has been incorporated into the popular workshop on accident analysis and prevention provided by the authors at several professional conferences world-wide. The book is also targeted for students attending Embry-Riddle Aeronautical University which has satellite campuses throughout the world and offers a course in human factors accident investigation for many of its majors. In addition, the book will be incorporated into courses offered by Transportation Safety International and the Southern California Safety Institute. Finally, this book serves as an excellent reference guide for many safety professionals and investigators already in the field.
Download or read book To Err Is Human written by Institute of Medicine and published by National Academies Press. This book was released on 2000-04-01 with total page 312 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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
Download or read book Textbook of Patient Safety and Clinical Risk Management written by Liam Donaldson and published by Springer Nature. This book was released on 2020-12-14 with total page 496 pages. Available in PDF, EPUB and Kindle. Book excerpt: Implementing safety practices in healthcare saves lives and improves the quality of care: it is therefore vital to apply good clinical practices, such as the WHO surgical checklist, to adopt the most appropriate measures for the prevention of assistance-related risks, and to identify the potential ones using tools such as reporting & learning systems. The culture of safety in the care environment and of human factors influencing it should be developed from the beginning of medical studies and in the first years of professional practice, in order to have the maximum impact on clinicians' and nurses' behavior. Medical errors tend to vary with the level of proficiency and experience, and this must be taken into account in adverse events prevention. Human factors assume a decisive importance in resilient organizations, and an understanding of risk control and containment is fundamental for all medical and surgical specialties. This open access book offers recommendations and examples of how to improve patient safety by changing practices, introducing organizational and technological innovations, and creating effective, patient-centered, timely, efficient, and equitable care systems, in order to spread the quality and patient safety culture among the new generation of healthcare professionals, and is intended for residents and young professionals in different clinical specialties.
Download or read book Human Reliability Analysis in Healthcare written by Joey L. Deeter and published by . This book was released on 2012 with total page 80 pages. Available in PDF, EPUB and Kindle. Book excerpt: "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.
Download or read book Human Reliability written by Balbir S. Dhillon and published by Elsevier. This book was released on 2013-10-22 with total page 260 pages. Available in PDF, EPUB and Kindle. Book excerpt: Human Reliability: With Human Factors focuses on human reliability during system design. The book is organized into 13 chapters, wherein Chapter 1 presents histories of human factors and human reliability along with selective terms and definitions. Chapter 2 shows basic reliability mathematics and concepts. Subsequent chapters then elaborate on human reliability, human errors, six human reliability analysis methods, and reliability evaluation of systems with human errors. Other chapters elucidate human factors in maintenance and maintainability; human safety; human reliability data; and human factors in quality control, design, mathematical models, and formulas. Applications of human factors engineering are also addressed. The text will be valuable to human factor engineers and specialists, reliability and maintainability specialists, system and design engineers, industrial engineers, quality control engineers, and students.
Download or read book Resident Duty Hours written by Institute of Medicine and published by National Academies Press. This book was released on 2009-04-27 with total page 427 pages. Available in PDF, EPUB and Kindle. Book excerpt: Medical residents in hospitals are often required to be on duty for long hours. In 2003 the organization overseeing graduate medical education adopted common program requirements to restrict resident workweeks, including limits to an average of 80 hours over 4 weeks and the longest consecutive period of work to 30 hours in order to protect patients and residents from unsafe conditions resulting from excessive fatigue. Resident Duty Hours provides a timely examination of how those requirements were implemented and their impact on safety, education, and the training institutions. An in-depth review of the evidence on sleep and human performance indicated a need to increase opportunities for sleep during residency training to prevent acute and chronic sleep deprivation and minimize the risk of fatigue-related errors. In addition to recommending opportunities for on-duty sleep during long duty periods and breaks for sleep of appropriate lengths between work periods, the committee also recommends enhancements of supervision, appropriate workload, and changes in the work environment to improve conditions for safety and learning. All residents, medical educators, those involved with academic training institutions, specialty societies, professional groups, and consumer/patient safety organizations will find this book useful to advocate for an improved culture of safety.
