Reducing and Mitigating Human Error in Medicine

Abstract

Although precise definitions and models of human error in medicine remain elusive, there is little doubt that adverse events, sometimes involving human error, threaten patient safety and can be addressed by human factors approaches to error. In this chapter, we combine an information-processing framework that identifies perceptual, cognitive, and behavioral requirements of operators involved in health care activities with a system-based perspective that helps define when these needs are met by the health care context. We focus on errors and adverse events related to four broad areas of medical activities: medical device use, medication use, team collaboration, and diagnostic/decision support. For each area, we review evidence for specific error types, operator and system factors that contribute to these errors, and possible mitigating strategies related to design and training interventions that enable health care systems to better meet operators' perceptual, cognitive, and behavioral needs. This review reveals progress in identifying sources of human error and developing mitigating strategies in the areas of medical device and medication use, in part because of tools from human factors engineering that identify user needs and how to design environments to support them. Much less is known about how error emerges from work practices in complex settings, such as collaboration among team members. There is a need for theoretical frameworks to analyze error in the context of routine work practices. Such frameworks will bridge cognitive analyses of individual operators and tasks and more comprehensive theories of organizations, to guide interventions that target medical error at multiple levels.

State of science: human factors and ergonomics in healthcare

“…Healthcare experts and professionals have recognised the value of HFE models and methods to improve healthcare quality (Leape 2004), in particular in the areas of patient safety culture/climate (Itoh, Andersen, and Madsen 2007), health IT design, implementation and use (Institute of Medicine 2012; Karsh 2004;Karsh et al 2010) and transitions of care (Carayon et al 2011a). Other HFE issues in the design of socio-technical systems for healthcare quality are reviewed elsewhere, for example Morrow, North, and Wickens (2005), Carayon et al (2011a) and Carayon (2012).…”

Image‐guided navigation: the surgeon's perspective on performance consequences and human factors issues

“…diagnostic decision aids (16,17). The first aspect of this model provides a classification scheme for describing automated systems.…”

Team interaction during surgery: a systematic review of communication coding schemes

“…Effective communication in any sociotechnical system is indispensable to a safe, efficient, and effective work environment [8]. The healthcare domain presents special challenges to communication because it deals with (a) varied levels of team familiarity (experience of team members from working together), (b) overlapping but different expertise and roles among team members, (c) time constraints, and (d) hierarchical structures [1, 8,9].…”