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

Analysis of 180 “Significant Events” in Nuclear Power Industry, 1983-1984

  • Human performance (52%)
    • Deficient procedures or documentation
    • Lack of knowledge or training
    • Failure to follow procedures
    • Deficient planning or scheduling
    • Miscommunication
    • Deficient supervision
    • Policy problems
    • Other
  • Design deficiencies (33%)
  • Manufacturing, etc.
  • External cause
  • Unknown
    • (INPO, 1985 – quoted by Reason, 1990)
 
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