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

How “Systems” Can Help with Error Prevention? (Reason, 1990)

  • “Forcing Functions”
    • “Something that prevents the behavior from continuing until the problem has been corrected”
    • Example:
      • Audi accidents of 1980’s – cars uncontrollably lurching forward or backwards when shifting out of “park”
      • You now must depress foot brake to shift from “park” to “drive” or “reverse”
  • System responses to error
    • “Gagging” - prevents user from “expressing unrealizable intentions” (e.g., automatic shutoff of machine in response to dangerous input))
    • Warnings
    • “Do nothing” (not respond to illegal input)
    • Self-correct
    • “Let’s talk about it”
    • “Teach me”
 
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