Medical Error and Harm : Understanding, Prevention and Control

by Jenicek, Milos

• ISBN13: 9781439836941
• ISBN10: 1439836949
• Edition: 1st
• Format: Hardcover
• Copyright: 2010-06-01
• Publisher: CRC

Summary

This book arrives at a time of heightened concerns about patient safety in medical care and the overall responsibility assumed by health professionals. It begins by exploring experiences of error and harm in general, and it covers medical errors that can be attributed to system failures and errors in an individual's reasoning, subsequent decision-making, and execution of tasks in medical care. It focuses on how to detect, correct, and avoid errors and their sometimes disastrous consequences. The book concludes with an analysis of the contributions and expectations of physicians in tort litigation and legal decision-making. 

Table of Contents

Author's Very Short Introduction: Minimizing Errors in Medicine	p. xv
Putting Medical Error in Context: Minimizing Errors in Medicine-Beyond the ôOops!ö Factor	p. 1
Executive Summary	p. 1
Thoughts to Think About	p. 2
Introductory Comments: Errors as Part of Advances in Medicine	p. 4
How to View Medical Errors Today	p. 4
What Is Covered in This Book	p. 6
Considering the Medical Error Problem in Light of Recent Experience	p. 6
Medical Error and Patient Safety	p. 9
How This Book Might Contribute to the Present State of Human Error Experience and Patient Safety	p. 10
References	p. 11
The Valued Legacy of Error and Harm in General: Error and Harm across General Human Experience in Nonmedical Domains-Welcome to Lathology	p. 15
Executive Summary	p. 15
Thoughts to Think About	p. 16
Introductory Comments	p. 17
A Brief History of Recent Human Error Experience	p. 18
Definition of Human Error and Other Related Terms	p. 19
Note about Heterogeneity of Terms	p. 20
Note about Error versus Accident	p. 20
Note regarding Error versus Adverse Effect	p. 26
Taxonomy of Error	p. 26
Person versus System	p. 27
Planning versus Execution	p. 27
Expertise, Its Quality, and Uses	p. 28
Cognition and Cognitive Process as a Core Source of Error and of Its Understanding and Control	p. 28
Models of Error, Their Development, and Contributing Sites and Entities in Context	p. 30
Person-Oriented Models	p. 30
Rasmussen's Model of Human Activity in Relation to Error	p. 31
Person-Related Errors in the Domain of Skills, Rules, and Knowledge	p. 33
Models of Reasoning and Decision Making Related to Informal Logic and Critical Thinking: Aristotle, Toulmin, Heuristics	p. 33
Argument and Argumentation Models in Optimal Conditions	p. 34
System Functioning-Oriented Models, or ôOne Thing Goes with and Leads to Anotherö	p. 40
A Practical Example of an Erroneous Event and of Its Steps as Seen through Their Identification in Various Taxonomies of Error	p. 41
An Epidemiological Approach to the Error Problem	p. 42
A Word about. Root Cause Analysis and Research	p. 44
Beyond Epidemiology: Other Models of Search for Causes	p. 45
Epidemiological Implications of the Error Analysis Problem	p. 46
Thought Experiment: A Complement to Epidemiology?	p. 47
Implications in the Search for Understanding, Control and Prevention of Error Today	p. 47
In the Research Domain	p. 48
In the Control and Prevention Domains	p. 49
Conclusions: Ensuing State of the Human Error Domain Today	p. 49
References	p. 51
Error and Harm in Health Sciences: Defining and Classifying Human Error and Its Consequences in Clinical and Community Settings	p. 57
Executive Summary	p. 57
Thoughts to Think About	p. 58
Introductory Comments	p. 59
Overview of Our Understanding of Error Today	p. 60
Overview of Approaches to Error in Medicine	p. 61
Definitions of Medical Error, Associated Entities, Terms	p. 62
Current Definitions of Medical Error and Medical Harm	p. 63
Associated Entities, Terms, and Their Definitions	p. 64
Critical Incident, Error, Harm: Comments on Current Terms Used in Medical Lathology	p. 71
Variables and Their Taxonomy in the Medical Error Domain	p. 73
Migration of Error Taxonomy from Industry to Health Sciences: An Example	p. 74
Medical Error and Related Factors and Variables: Other Approaches	p. 74
Taxonomy by Types, Circumstances and Conditions, Consequences, and Corrections of Medical Error	p. 77
Slips and Mistake-Related Taxonomy	p. 77
Clinical Factors and Specialty-Oriented Taxonomies	p. 80
Exhaustive and Multi-Axial Taxonomies	p. 81
Notes about Related Variables and Contributing and Mitigating Factors	p. 83
Note about Related Variables	p. 84
Note about Contributing and Mitigating Factors	p. 84
Conclusions: Implications of Definitions and Taxonomy for Research and Management of the Medical Error Domain	p. 85
References	p. 88
Describing Medical Error and Harm: Their Occurrence and Nature in Clinical and Community Settings	p. 93
Executive Summary	p. 93
Thoughts to Think About	p. 94
Introductory Comments	p. 95
Research, Knowledge Acquisition, and Intervention Strategies in the General Error Domain as Viewed by a Methodologically Minded Physician Epidemiologist	p. 96
Descriptions of Single Cases, Small Sets of Error Cases, and Harm Cases	p. 100
Choosing a Research or Intervention Subject	p. 100
Reporting Unique, Infrequent, or Rare Cases beyond the Customary Methods of Clinical Practice: Case-Based Qualitative Research and Narrative Methods in the Area of Quality Improvement	p. 103
Qualitative Research	p. 103
Case Studies of Medical Error and Harm	p. 105
Two Examples of Qualitative Research in Medicine and in the Domain of Medical Error	p. 107
Reporting Single Cases of Error and Harm the ôMedicalö Way	p. 108
Reporting Case Series of Error and Harm	p. 110
Back to Epidemiology: What Happens Now? Occurrence Studies, Descriptive Epidemiology, Magnitude, and Distribution (ôin Whom, Where, and Whenö) of the Error and Harm Problem	p. 112
A Short Epidemiological Reminder	p. 112
Incident and Incidence	p. 113
Risk and Hazard	p. 114
Error and Harm Reporting in Hospital Care	p. 114
Error and Harm Reporting in Primary Care	p. 115
Guidelines for Describing and Reporting Medical Error and Harm Occurrence	p. 116
Conclusion	p. 119
References	p. 121
Analyzing Medical Error and Harm: Searching for Their Causes and Consequences	p. 127
Executive Summary	p. 127
Thoughts to Think About	p. 128
Introductory Comments	p. 130
Searching for ôNewö (Not Yet Known) Causes and Consequences of Medical Error and Harm: Etiological Research, Analytical Observational Epidemiology	p. 131
Challenge of Deriving Cause-Effect Relationships from One or Very Few Observations: An A Priori Causal Attribution	p. 139
Challenges of Limited Causal Proof or Causes Yet to Be Established	p. 139
Is It Possible to Estimate and Analyze Probabilities of Rare Events?	p. 140
Single-Error Event or Few Error Events Reporting	p. 142
Offbeat Searches for Causes: Siding with Mainstream Epidemiological Experience	p. 142
Root Cause Analysis in the Health Domain	p. 143
Other Approaches to Cause-Effect Studies in Lathology through Observational Methods	p. 149
Causal Trees	p. 149
Probabilistic Risk Analysis	p. 151
Significant-Event Analysis	p. 152
Systems Analysis: Beyond Incident Reports and Root Cause Analysis	p. 153
Experimental Demonstration of Medical Error and Harm Causes and Its Compromises and Alternatives	p. 155
No Experimentation or Observational Research Is Feasible? Thought Experiment (ôWhat Ifö Reasoning) to the Rescue	p. 155
A Word about Modeling in Epidemiology and Lathology	p. 156
Is the Mainstream Epidemiological Methodology of Causal Research Feasible in the Domain of Medical Error and Harm?	p. 157
Conclusions	p. 158
References	p. 161
Flaws in Operator Reasoning and Decision Malting Underlying Medical Error and Harm	p. 167
Executive Summary	p. 167
Thoughts to Think About	p. 168
Introductory Comments	p. 170
Note about Medical Error and Medical Harm	p. 171
System Error versus Individual Human Error	p. 172
Reminder regarding Some Fundamental Considerations	p. 173
Flawed Argumentation and Reasoning as Sites and Generators of Error and Harm: Argumentation and Human Error and Harm Analysis from a Logical Perspective	p. 175
Mistakes and Errors in Medical Lathology	p. 178
Fallacies, Biases, and Cognitive Errors in Medical Lathology	p. 179
Where and When Errors Occur: Cognitive Pathways as Sites of Error	p. 181
Reviewing Diagnoses: Searching for Errors in the Clinimetric Process	p. 182
Reviewing the: Path from Diagnosis to Treatment Decisions and Orders	p. 188
Reviewing Decisions as Sources of Error and Harm	p. 188
Reviewing Actions as Sources of Error and Harm	p. 190
Obtaining Results and Evaluating Their Impact	p. 192
Errors in Making Prognoses	p. 193
Follow-up, Surveillance, Forecasting-Related Errors	p. 194
Conclusions	p. 195
References	p. 199
Prevention, Intervention, and Control of Medical Error and Harm: Clinical Epidemiological Considerations of Actions and Their Evaluation	p. 203
Executive Summary	p. 203
Thoughts to Think About	p. 204
Introductory Comments, Interventions in the Medical Error Domain	p. 206
Basic Definitions, Concepts, and Strategies of Intervention in Lathology	p. 207
Two Complementary Strategies: Human Error and System Failures	p. 209
Evaluation of Activities in Lathology	p. 210
Control of Medical Error and Harm	p. 211
Prevention of Medical Error and Harm	p. 211
Protection of Freedom from Medical Error and Harm	p. 212
Promotion of Freedom from Medical Error and Harm	p. 212
Basic Angles of Evaluation in Lathology: Structure, Process, Outcomes, and Other Subjects to Evaluate	p. 212
What Should Be Evaluated at the Individual Level: Knowledge, Attitudes, and Skills	p. 213
Experimental, Quasi-Experimental, and Nonexperimental Evaluation of Interventions to Understand and Better Control Medical Error and Harm Problems	p. 215
Randomized or Otherwise Controlled Clinical Trials	p. 216
Natural Experiment	p. 217
Before-After Studies	p. 219
Case Studies	p. 220
Healthcare Failure Mode and Effect Analysis (HFMEA)	p. 221
Systematic Reviews of Evidence	p. 225
Conclusions and Recommendations	p. 225
References	p. 227
Taking Medical Error and Harm to Court: Contributions and Expectations of Physicians in Tort Litigation and Legal Decision Making	p. 231
Executive Summary	p. 231
Thoughts to Think About	p. 232
Introductory Comments	p. 234
Medical, Surgical, and Public Health Malpractice Claims and Litigation	p. 237
Medical and Surgical Malpractice	p. 237
Public Health Malpractice	p. 238
Language of Medicine and Law	p. 239
General Philosophy and Strategies of Medicine and Law	p. 241
Law Process and Its Stages	p. 241
Happenings and Events before the Trial	p. 241
At the Trial	p. 257
After the Trial	p. 258
Cause-Effect Relationships in Medicine and Law	p. 258
Physicians' Roles in the Judicial Search for Causes	p. 260
Is the Causal Link under Review Strong and Specific Enough?	p. 262
What Is Sufficient and Best Proof for Physicians and Lawyers?	p. 262
What Do Physicians Think?	p. 262
What Do Lawyers Think?	p. 263
Disease versus Individual-Case Causes: Error as an Entity (in General) and in Specific Cases	p. 265
Litigating the Argumentative Way	p. 266
Disclosure of Medical Errors: Working in Law and Epidemiology with What Is Available	p. 268
A Difficult Mix: Medicine, Ethics, and Law	p. 270
Conclusions	p. 271
References	p. 273
Conclusions	p. 279
A Brief and (Hopefully) Harmonized Glossary	p. 289
List of Cognitive Biases	p. 309
List of Fallacies	p. 319
Medical Error and Harm-Related Case Report	p. 329
About the Author	p. 333
Index	p. 335
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