Error

Question 1

What is an error

Answer 1

A preventable event that may cause or lead to patient harm

Question 2

What does a medical error lead to

Answer 2

a) adverse events - an incident which results in harm to a patient
b) a near miss - an event which has the potential to cause harm but fails to develop further, thereby avoiding harm

Question 3

What is an error of omission n?

Answer 3

This is an error when required action is delayed or not taken

Question 4

What is an error of commission?

Answer 4

This is when the wrong action is taken

Question 5

What is an error of negligence?

Answer 5

the actions or omissions do not meet the standard of an ordinary, skilled person professing

Question 6

What is a skilled based error?

Answer 6

a) when performing a routine task that is well learnt (automatic)
b) little attention given, thus if distracted - slips of action / memory lapses

Question 7

What are rule/knowledge based errors?

Answer 7

a) an incorrect plan or course of action is chosen (no experience)
b) mistakes more likely when the tasks are more complex

Question 8

What is a violation?

-explain three types

Answer 8

A violation is a deliberate deviations from practices, procedures and standard or rules

a) routine (cutting corners)
b) necessary (to get the job done - sometimes unavoidable)
c) optimising (personal gain, selfish)

Question 9

Name some information processing limitations

Answer 9

• automaticity
• cognitive interference
• selective attention
• cognitivebias
• transferring our expectations from familiar situations to similar new ones

Question 10

Name two approaches to managing errors

Answer 10

1) The person approach - individual - errors are the products of wayward mental processes of individual people in the system
2) The system approach - organisation - adverse events are the product of many causal factors (swiss-cheese theory) - the whole system is to blame