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The Error of Counting "Errors"
... Controversy exists in the idea of counting errors, with some authors suggesting alternative approaches that focus on avoidance of potentially punitive contexts and instead frame errors as starting points of investigation into systematic problems [47][48][49][50]. In our efforts to examine the potential contribution of overcrowding to error, we endeavor to follow the maxim recently put forth "to discover opportunities to better aid clinicians in coping with hazard and complexity" [51]. ...
... The presence of a medical error does not necessarily imply the occurrence of a medical harm. Injury and medical error may have only an indirect relationship [48]. However, this does not diminish the value of measuring medical errors. ...
Despite the growing problems of emergency department (ED) crowding, the potential impact on the frequency of medication errors occurring in the ED is uncertain. Using a metric to measure ED crowding in real time (the Emergency Department Work Index, or EDWIN, score), we sought to prospectively measure the correlation between the degree of crowding and the frequency of medication errors occurring in our ED as detected by our ED pharmacists.
We performed a prospective, observational study in a large, community hospital ED of all patients whose medication orders were evaluated by our ED pharmacists for a 3-month period. Our ED pharmacists review the orders of all patients in the ED critical care section and the Chest Pain unit, and all admitted patients boarding in the ED. We measured the Spearman correlation between average daily EDWIN score and number of medication errors detected and determined the score's predictive performance with receiver operating characteristic (ROC) curves.
A total of 283 medication errors were identified by the ED pharmacists over the study period. Errors included giving medications at incorrect doses, frequencies, durations, or routes and giving contraindicated medications. Error frequency showed a positive correlation with daily average EDWIN score (Spearman's rho = 0.33; P = .001). The area under the ROC curve was 0.67 (95% confidence interval, 0.56-0.78) with failure defined as greater than 1 medication error per day.
We identified an increased frequency of medication errors in our ED with increased crowding as measured with a real-time modified EDWIN score.
... What we find is that the sources of successful operation See Rasmussen (1990b) is the standard statement of the difficulty and see Hollnagel and Amalberti,4 (2001), Amalberti (2001). For examples of the difficulty in health care see Cook et al., A Tale of Two Stories (1999) and follow ups such as Wears and Nemeth (2007), Wears (2008), Patterson and Wears (2009), and Cook and Nemeth (2010). ...
Beginning with the question "what is human error?" misleads stakeholders into a thicket of difficulties where answers seem always just around the corner but never actually come into view. The efforts to answer this seemingly simple question -- efforts that inevitably become entangled with hindsight bias, social factors and lose sight of the research base -- actually block progress on safety.
How to respond to those who seek definitions and taxonomies in their efforts to improve safety? Faced with an equally difficult problem in 1897, Frank Church replied to a letter from an 8 year old girl named Virginia who asked if there really was a Santa Claus. As a way of summarizing what the New Look research has revealed behind the label human error, we provide our own version of both Virginia's letter and Church’s response.
... For instance, other investigators have stated that ED systems must be changed in order to lower the incidence of errors [11], and Camargo et al. recently concluded that systems factors such as staffing, teamwork, and safety culture are important mediators of error in the ED [12]. In aggregate, ED PSI studies, including the present investigation, provide a significant, growing body of evidence supporting those who have argued that heightened focus should be placed on the work environment and other factors that contribute to error rather than on the error itself [14,16,17]. ...
Background
Emergency Department (ED) care has been reported to be prone to patient safety incidents (PSIs). Improving our understanding of PSIs is essential to prevent them. A standardized, peer review process was implemented to identify and analyze ED PSIs. The primary objective of this investigation was to characterize ED PSIs identified by the peer review process. A secondary objective was to characterize PSIs that led to patient harm. In addition, we sought to provide a detailed description of the peer review process for others to consider as they conduct their own quality improvement initiatives.
Methods
An observational study was conducted in a large, urban, tertiary-care ED. Over a two-year period, all ED incident reports were investigated via a standardized, peer review process. PSIs were identified and analyzed for contributing factors including systems failures and practitioner-based errors. The classification system for factors contributing to PSIs was developed based on systems previously reported in the emergency medicine literature as well as the investigators’ experience in quality improvement and peer review. All cases in which a PSI was discovered were further adjudicated to determine if patient harm resulted.
Results
In 24 months, 469 cases were investigated, identifying 152 PSIs. In total, 188 systems failures and 96 practitioner-based errors were found to have contributed to the PSIs. In twelve cases, patient harm was determined to have resulted from PSIs. Systems failures were identified in eleven of the twelve cases in which a PSI resulted in patient harm.
Conclusion
Systems failures were almost twice as likely as practitioner-based errors to contribute to PSIs, and systems failures were present in the majority of cases resulting in patient harm. To effectively reduce PSIs, ED quality improvement initiatives should focus on systems failure reduction.
... Identifying the failures of individuals, or what individuals could or should have done to avoid failure, does not determine why and what they did when their actions were deemed to be reasonable. Not being able to explain why individuals committed an error will provide an environment for it to occur again within the workplace (Wears, 2008). Thus, it is necessary to understand the casual mechanism of errors and learn through experience to prevent their occurrence. ...
Design errors can have a negative impact on the cost, schedule and safety performance of construction projects. They can also have an adverse effect on an organisation's profitability, as additional work requires resources and time to rectify the error that has occurred. The reduction (i.e. measures designed to limit the occurrence of failures) and containment (i.e. measures designed to increase the detection and accelerate the recovery of errors) of design errors can therefore ameliorate organisational and project performance as well as improve safety. A systemic framework that classifies design error reduction and containment strategies according to people, organisation and project is propagated. It is suggested that when people, organisational and project strategies are implemented, incongruence then the propensity for design error reduction will significantly increase. The proposed framework can be used as a point for reference for implementing error management strategies to anticipate for ‘what might go wrong’ in construction projects.
... Identifying the failures of individuals, or what individuals could or should have done to avoid failure, does not determine why and what they did when their actions were deemed to be reasonable. Not being able to explain why individuals committed an error will provide an environment for it to occur again within the workplace (Wears, 2008). Thus, it is necessary to understand the casual mechanism of errors and learn through experience to prevent their occurrence. ...
Design errors can have a negative impact on the cost, schedule and safety performance of construction projects. They can also have an adverse effect on an organization's profitability, as additional work requires resources and time to rectify the error that has occurred. The reduction (i.e. measures designed to limit the occurrence of failures) and containment (i.e. measures designed to increase the detection and accelerate the recovery of errors) of design errors can therefore ameliorate organizational and project performance as well as improve safety. A systemic framework that classifies design error reduction and containment strategies according to people, organization and project is propagated. It is suggested that when people, organizational and project strategies are implemented, incongruence then the propensity for design error reduction will significantly increase. The proposed framework can be used as a point for reference for implementing error management strategies to anticipate for ‘what might go wrong’ in construction projects.
... The reviewer had >10 years of experience in quality improvement; however, the single-reviewer format allowed for subjectivity and anecdotally led to inconclusive investigations if the reviewer and involved practitioner(s) disagreed over the findings. The reviews considered both practitioner-based and systems errors, but the process was not standardized leading to concerns that systems errors especially may have been under-identified [23]. Feedback was provided to involved practitioners; however reporter, departmental and hospital-wide feedback were not standardized. ...
/st>Incident reporting is an important component of health care quality improvement. The objective of this investigation was to evaluate the effectiveness of an emergency department (ED) peer review process in promoting incident reporting.
/st>An observational, interrupted time-series analysis of health care provider (HCP) incident reporting to the ED during a 30-month study period prior to and following the peer review process implementation and a survey-based assessment of physician perceptions of the peer review process' educational value and its effectiveness in identifying errors.
/st>Large, urban, academic ED.
and INTERVENTIONS: /st>HCPs were invited to participate in a standardized, non-punitive, non-anonymous peer review process that involved analysis and structured discussion of incident reports submitted to ED physician leadership.
/st>Monthly frequency of incident reporting by HCPs and physician perceptions of the peer review process.
/st>HCPs submitted 314 incident reports to the ED over the study period. Following the intervention, frequency of reporting by HCPs within the hospital increased over time. The frequencies of self-reporting, reporting by other ED practitioners and reporting by non-ED practitioners within the hospital increased compared with a control group of outside HCPs (P = 0.0019, P = 0.0025 and P < 0.0001). Physicians perceived the peer review process to be educational and highly effective in identifying errors.
/st>The implementation of a non-punitive peer review process that provides timely feedback and is perceived as being valuable for error identification and education can lead to increased incident reporting by HCPs.
... Because these events are often incorrectly attributed to physician error (rather than systems errors) and subject physicians to personal, professional, and legal liabilities, it is not surprising that physicians often practice medicine in a manner that minimizes their personal risk. 14 Additionally, physicians and patients may have different risk thresholds. Physicians may be more risk averse than patients because patients have not seen the rare but devastating outcomes that physicians have seen. ...
... To sum up, the HF paradigm proposes that the performance of cognitive work mediates between work system design on the one hand, and patient, employee, and organizational outcomes, on the other. The implication is to shift away from a paradigm centered on errors (and by implication, away from counterproductive practices such as counting errors [Dekker 2007;Wears 2008]), and toward a paradigm that seeks to understand work performance and aims to design systems that support performance. The benefits of the HF paradigm over the traditional error-based paradigm can be demonstrated by considering the case of electronic medical records (EMR), a putative lever for patient safety. ...
According to the human factors paradigm for patient safety, health care work systems and innovations such as electronic medical records do not have direct effects on patient safety. Instead, their effects are contingent on how the clinical work system, whether computerized or not, shapes health care providers' performance of cognitive work processes. An application of the human factors paradigm to interview data from two hospitals in the Midwest United States yielded numerous examples of the performance-altering effects of electronic medical records, electronic clinical documentation, and computerized provider order entry. Findings describe both improvements and decrements in the ease and quality of cognitive performance, both for interviewed clinicians and for their colleagues and patients. Changes in cognitive performance appear to have desirable and undesirable implications for patient safety as well as for quality of care and other important outcomes. Cognitive performance can also be traced to interactions between work system elements, including new technology, allowing for the discovery of problems with "fit" to be addressed through design interventions.
... Staff in ED do not operate in isolation, but instead are seen as parts of complex, joint cognitive systems: that is, communities of practice composed of tools, procedures, artifacts, and coworkers, distributed over time and space and conditioned by organizational, professional, and institutional contexts. 45 Radiologists often do not integrate optimally in this system, maintaining some degree of isolation and parallel diagnostic processing. In the ED, critical data is often generated by medical imaging, but its conversion into patient value, and timely and appropriate clinical action, is not assured. ...
... Cell counts were made unilaterally in anatomically matched, single sections for each region. Raw cell counts were corrected using the Abercrombie correction as described in Guillery (2002). Briefly, raw cell counts for each animal at each age were multiplied by the correction factor determined by using the formula T/Tϩh, where T ϭ section thickness and h ϭ mean nuclear diameter. ...
Steroid hormones play an influential role in neural development. In addition to androgens and estrogens of fetal and neonatal origin, the developing brain may also be exposed to progesterone. In this regard, identifying forebrain nuclei that are sensitive to progesterone during neural development may elucidate the impact of progesterone on the developing brain. Using immunocytochemistry, the present study documented the distribution of progesterone receptor (PR) expression in the rat forebrain from embryonic day (E) 17 through postnatal day (P) 28. The results indicate that PR expression in the developing brain is extensive, present in numerous forebrain nuclei, but transient, in that PR expression was absent in most nuclei by P28. Regions displaying the highest levels of PR-immunoreactivity (PRir) were found in preoptic and hypothalamic nuclei including the medial preoptic, anteroventral periventricular, arcuate, and ventromedial nuclei. PRir was moderately abundant in the limbic region, particularly in subdivisions of the amygdala, the bed nucleus of the stria terminalis, and hippocampus. The choroid plexus and neocortex were additional structures that demonstrated relatively abundant levels of PRir. The presence PR expression in the developing forebrain implicates the involvement of progesterone and PR in fundamental mechanisms of neural development.
The Agency for Healthcare Research and Quality (AHRQ) report "Diagnostic Errors in the Emergency Department" generated significant mass media interest with negative implications for the safety of contemporary emergency care. The assumptions and methodology underlying this report are problematic, while multiple ongoing efforts to improve the quality and quantity of diagnostic research are missed, neglected, or ignored. The AHRQ report identifies reasonable target diseases for targeting diagnostic quality improvement efforts, as well as viable methods by which to measure any initiatives impact on diagnostic error. We note additional opportunities to improve the status quo by funding emergency department-based diagnostic research and healthcare system-level patient safety research and highlighting innovative approaches to diagnostic science within emergency medicine.
While it is clear that target tissue and the periphery in general play an important role for the survival and maintenance of motoneurons, the underlying mechanisms remain unclear. The experiments described in this thesis use a model of axotomy-induced motoneuron death to study the effect of insulin-like growth factor-1 (IGF-1) isoforms, diet and muscle damage on the survival of adult facial motoneurons. Particular attention is paid to the effects on motoneurons of the autocrine/paracrine-acting splice variant of IGF-1 (MGF), which has been isolated recently from active skeletal muscle. Using stereological methods, it was found that facial nerve avulsion of ad libitum-fed adult rats resulted in approximately 80% loss of motoneurons. However, diet restriction, which is known to alter IGF-1 levels, of rats from the age of 6 months reduced the number of facial motoneurons by about 50% at 24 months-of-age but prevented any further loss of motoneurons following facial nerve avulsion. These results challenge the common view that diet restriction is universally beneficial. MGF gene transfer prior to nerve avulsion conferred marked neuroprotection of facial motoneurons at 1-month post injury. Such neuroprotection was approximately two-fold greater than that obtained with the liver-type IGF-1 (endocrine) splice variant. MGF E-domain peptide delivered to avulsed motoneurons also protected motoneurons at 1 month. In addition to MGF gene transfer, muscle denervation was also associated with perturbations of MGF mRNAs. Direct damage to target-muscle prior to nerve avulsion rendered motoneurons more resistant to death. Specific markers for motoneuron survival, death, regeneration and neuroglial activation were used throughout the study to characterise the response of motoneurons to nerve avulsion. The results are discussed in the context of current theories of motoneuron target-dependence and the possible neurotrophic effects of MGF.
Nothing has been more prolific over the past century than human/machine interaction. Automobiles, telephones, computers, manufacturing machines, robots, office equipment, machines large and small; all affect the very essence of our daily lives. However, this interaction has not always been efficient or easy and has at times turned fairly hazardous. Cognitive Systems Engineering (CSE) seeks to improve this situation by the careful study of human/machine interaction as the meaningful behavior of a unified system. Written by pioneers in the development of CSE, Joint Cognitive Systems: Foundations of Cognitive Systems Engineering offers a principled approach to studying human work with complex technology. The authors use a top-down, functional approach and emphasize a proactive (coping) perspective on work that overcomes the limitations of the structural human information processing view. They describe a conceptual framework for analysis with concrete theories and methods for joint system modeling that can be applied across the spectrum of single human/machine systems, social/technical systems, and whole organizations. The book explores both current and potential applications of CSE illustrated by examples. Understanding the complexities and functions of the human/machine interaction is critical to designing safe, highly functional, and efficient technological systems. This is a critical reference for students, designers, and engineers in a wide variety of disciplines.
Our fascination with new technologies is based on the assumption that more powerful automation will overcome human limitations and make our systems 'faster, better, cheaper,' resulting in simple, easy tasks for people. But how does new technology and more powerful automation change our work? Research in Cognitive Systems Engineering (CSE) looks at the intersection of people, technology, and work. What it has found is not stories of simplification through more automation, but stories of complexity and adaptation. When work changed through new technology, practitioners had to cope with new complexities and tighter constraints. They adapted their strategies and the artifacts to work around difficulties and accomplish their goals as responsible agents. The surprise was that new powers had transformed work, creating new roles, new decisions, and new vulnerabilities. Ironically, more autonomous machines have created the requirement for more sophisticated forms of coordination across people, and across people and machines, to adapt to new demands and pressures. This book synthesizes these emergent Patterns though stories about coordination and mis-coordination, resilience and brittleness, affordance and clumsiness in a variety of settings, from a hospital intensive care unit, to a nuclear power control room, to a space shuttle control center. The stories reveal how new demands make work difficult, how people at work adapt but get trapped by complexity, and how people at a distance from work oversimplify their perceptions of the complexities, squeezing practitioners. The authors explore how CSE observes at the intersection of people, technology, and work, how CSE abstracts patterns behind the surface details and wide variations, and how CSE discovers promising new directions to help people cope with complexities. The stories of CSE show that one key to well-adapted work is the ability to be prepared to be surprised. Are you ready?.
Safety in healthcare has largely been framed in terms of identifying and reducing human 'errors'. Although this approach is intuitively appealing, research on safety in complex sociotechnical systems has shown it to be both misleading and counterproductive. Progress in healthcare safety requires a reframing of the problem, abandoning the concept of 'error' and replacing it by a focus on identifying and rectify- ing the vulnerabilities that sometimes lead expert workers to fail when performing tasks at which they are highly skilled. The majority of those active in the patient safety move - ment have been busily chasing 'errors' since the release of the Institute of Medicine report in November 1999.1 The efforts have been interestingly 'medicalized' 2, with elaborate classification schemes for types of 'errors', and major report - ing efforts to track and trend these 'errors' in large state and national databases. The latest manifestation of this approach is recent efforts to tie CEO compensation to reductions in the 'error count'.3 However, safety scientists in other hazardous domains have largely dispensed with the concept of 'error' as being unhelpful in understanding human performance in complex sociotechnical systems4-16, much less in crafting safer systems. It is, therefore, now time for us to move beyond the concept of 'human error.' While it may have served a limited purpose in drawing attention to a hitherto neglected problem, it is now an impediment to progress.
Normal Accidents analyzes the social side of technological risk. Charles Perrow argues that the conventional engineering approach to ensuring safety--building in more warnings and safeguards--fails because systems complexity makes failures inevitable. He asserts that typical precautions, by adding to complexity, may help create new categories of accidents. (At Chernobyl, tests of a new safety system helped produce the meltdown and subsequent fire.) By recognizing two dimensions of risk--complex versus linear interactions, and tight versus loose coupling--this book provides a powerful framework for analyzing risks and the organizations that insist we run them. The first edition fulfilled one reviewer's prediction that it "may mark the beginning of accident research." In the new afterword to this edition Perrow reviews the extensive work on the major accidents of the last fifteen years, including Bhopal, Chernobyl, and the Challenger disaster. The new postscript probes what the author considers to be the "quintessential 'Normal Accident'" of our time: the Y2K computer problem.
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From the Department of Emergency Medicine, University of Florida, Jacksonville, FL, and ClinicalSafety Research Unit, Imperial College, London, England (Wears); and the Cognitive TechnologiesLaboratory, University of Chicago, Chicago, IL (Nemeth).0196-0644/$-see front matterCopyright © 2007 by the American College of Emergency Physicians.doi:10.1016/j.annemergmed.2006.08.027
We assess the effect of emergency physicians' clinical experience on the propensity to commit a patient care error.
Seven years of data from a single emergency department's peer review activities were reviewed for all patient care errors made by emergency physicians. Emergency physician clinical experience was defined as years since completion of residency training during the year each error was made. A repeated-measures log-linear model was constructed that predicted error count and the rate of errors over time, with a correction for number of patients treated by each physician.
Of 829 cases reviewed during 7 years, there were 374 emergency physician errors identified. Mean emergency physician experience was 8.1+/-8.6 years. Emergency physicians with experience of 1.5 years or more were less likely to make an error (relative risk [RR]=0.66; 95% confidence interval [CI] 0.48 to 0.91) than those who were less experienced. Errors were not associated with emergency physician age (RR=1.01; 95% CI 0.99 to 1.03) or sex (RR=1.29; 95% CI 0.93 to 1.79).
Emergency physicians with less than 1.5 years of clinical experience may be more likely to commit errors than more experienced emergency physicians.
The reinvention of human error Available at
- Swa Dekker
Dekker SWA. The reinvention of human error. Available at: http:// www.lusa.lu.se/upload/Trafikflyghogskolan/TR2002-01_ReInvention ofHumanError.pdf. Accessed February 5, 2008.