Human Error in Medicine Flashcards
Human error has been responsible for 70% of what type of accidents?
Airline
The discipline that deals
with the causes and effects of human error?
human factors engineering (HFE)
How many Americans die each year as a result of medical errors?
44,000 – 98,000
What is the 8th leading cause of death?
Medical mistakes
When we interact with machines or complex systems, we frequently do things contrary to our intentions. This can result in…
Inconvenience or Catastrophe
Failure to perform an intended action. It is not defined by an adverse or serious outcome.
Error
An unplanned, unexpected, and undesired event. An adverse outcome after an error must be construed to be what?
Accident
Percentage of perfusion accidents due to human error?
72.3%
Percentage of perfusion accidents due to equipment failure?
19.5%
Percentage of perfusion accidents due to indeterminate?
8.2%
Input data is are incorrectly perceived, an incorrect intention formed, and the wrong action performed.
Misperceptions
Input data correctly perceived, an incorrect intention is formed, and the wrong action performed.
Slip
Mistake
Input data correctly perceived, correct intention is formed, and the wrong action performed.
Slip
An error which arise from processes inside the actor. The elimination/reduction of such errors must involve psychology, physiology or neurology.
Endogenous Error
An error which arise from processes outside the actor. Elimination/reduction of these errors must involve engineering and design of objects and work environment
Exogenous Error
leaving out a step
Error of Omission
forgetting to turn on the gas during initiation
adding inappropriate step
Error of Commission
Hitting my thumb with a hammer
inappropriate adding of a step normally appropriate to a process
(Opening venous line during sucker bypass)
Error of Repetition
Opening the venous line during sucker bypass
correct steps, but in wrong order
Error of sequence
Weaning: turning down flow, then increasing the bite on the venous clamp