A cognitive taxonomy of medical errors

Abstract

Theoretically, the proposed cognitive taxonomy provides a method to systematically categorize medical errors at the individual level along cognitive dimensions, leads to a better understanding of the underlying cognitive mechanisms of medical errors, and provides a framework that can guide future studies on medical errors. Practically, it provides guidelines for the development of cognitive interventions to decrease medical errors and foundation for the development of medical error reporting system that not only categorizes errors but also identifies problems and helps to generate solutions. To validate this model empirically, we will next be performing systematic experimental studies.

A Survey of Neonatal Parenteral Nutrition Design Practices in North Carolina

“…As these systems are developed, basic safety concepts such as dose limits, electronic computations, and legible printed orders 30 should be preserved. However, advances in computer resources and communication technology, such as the graphical user interface and Internet connectivity, offer new opportunities for clinical Level: Level refers to the medical error system hierarchy described by Zhang et al, 25 which progresses from errors committed by single individuals to errors described at the (inter)national level. Electronic system correctable: The likelihood that the incidence of error described would be reduced or eliminated if a basic electronic parenteral nutrition order design system was used.…”

“…About half may have been eliminated using an electronic parenteral nutrition design system. Zhang et al 25 described the occurrence of medical errors in a hierarchical structure, rising from errors singularly attributed to an individual's incorrect decision or action, through errors involving multiple individuals, technology resources or hospital departments, to a top level involving (inter)national regulations. Table 1 illustrates their hierarchical structure with an associated sample neonatal parenteral nutrition-related medical error we created as an example for each level.…”

“…for supplementation to the final mixture. We used a hierarchical structure based on the framework by Zhang et al 25 (Table 1 described below), to classify parenteral nutrition related errors.…”

“…The nutritionist and pediatric pharmacist attended patient rounds based on their effort allocation to the NICU. Enteral feeding and parenteral nutrition orders were created by the primary health-care provider who presented a brief summary of the infant's medical Table 1 Error level 25 Neonatal parenteral nutrition example…”

Evaluating and Predicting Patient Safety for Medical Devices With Integral Information Technology

“…2,3 Our research has focused on developing methods for evaluating and predicting medical errors in medical device use from the perspectives of cognitive science and user interface design. [4][5][6] Medical device use errors are a common source of patient injury and death. Numerous research reports, medical error reports, and other documents show a clear link between usability problems and user error.…”