Patient Safety and Quality Improvement
 Modules  Module 3: The “Science” of Human Error
1. Introduction to Course
2. History of Patient Safety
3. The Science of Human Error
4. The Analysis of Medical Error
5. Evidence-Based Medical Practice
6. Communication and Information Transfer
7. Adverse Patient Outcomes
8. The Role of the Patient and Family
9. Environmental Safety in the Medical Setting
10. Safe Medical Practice In Ambulatory Settings

Key Definitions

  • Error
    • “All occasions in which a planned sequence of mental or physical activities fails to achieve its intended outcome, and when these failures cannot be attributed to the intervention of some chance agency”
      --Reason, 1990
  • Slips and lapses
    • “Errors which result from some failure in the execution and/or storage of an action sequence, regardless of whether or not the plan which guided them was adequate to achieve its objective.”
    • --Reason, 1990
  • Mistakes
    • “Deficiencies or failures in the judgmental and/or inferential processes involved in the selection of an objective or in the specification of the means to achieve it, irrespective of whether or not the actions directed by this decision-scheme run according to plan”
    --Reason, 1990
 
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