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

Taxonomy of Human Errors (Reason, 1990)

  • Skills-Based Performance
    • Inattention
    • Double-capture slips (distraction by higher-priority item)
      • Omissions following interruptions
      • Reduced intentionality (often related to time delay – doing the wrong thing, or forgetting what was supposed to be done)
      • Perceptual confusions
      • Interference errors (simultaneous actions get entangled – incongruous blends of speech and action)
    • Overattention: Mistimed or inappropriate checks
      • Omissions
      • Repetitions
      • Reversals
  • Rule-Based Performance
    • Misapplication of good rules
      • First exceptions
      • Countersigns and nonsigns
      • Informational overload
      • Rule strength
      • General rules
      • Redundancy
      • Rigidity
  • Application of bad rules
    • Encoding deficiencies
    • Action deficiencies
      • Wrong rules
      • Inelegant (clumsy) rules
      • Inadvisable rules
  • Knowledge-Based Performance
    • Selectivity
    • Workspace limitations
    • Out of sight, out of mind
    • Confirmation bias
    • Overconfidence
    • Biased reviewing
    • Illusory correlation
  • Halo effects
  • Problems with causality
  • Problems with complexity
    • Problems with delayed feed-back
    • Primary mistakes (everyone)
      • Insufficient consideration of processes in time
      • Difficulties with exponential developments
      • Think in causal series, not causal nets
  • Mistakes of poor performers
    • Thematic vagabonding (flitting between issues,
      treating each superficially)
    • Encysting (dwelling on some things, ignoring others)
    • Intellectual “emergency reaction” (things going badly
      wrong)
      • Reduction in intellectual level
      • Thinking reduces to reflexive behavior
 
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