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 1980s 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
Lets talk about it
Teach me
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