Adverse events human factors

Reason, J, 1995, Understanding adverse events human factors. Quality and safety in healthcare, 4 80-89. 

Panitumumab is a human monoclonal antibody directed against epidermal growth factor receptor. Common adverse events include dermatologic toxicities, fatigue, abdominal pain, nausea, and diarrhea. 

In 1990 our understanding of the underlying causes of risk were challenged with the publication of Janies Reason s Human Error [8], For the first time the role of human factors in the incident causality chain were truly characterised. He eloquently made the case for adverse events being a function not of personal inadequacies but of the environment in which individuals operate. This paved the way for transforming a largely reactive approach to risk management in healthcare to one of hazard identification and proactive risk control. 

Reason, J.T. (1997) Managing the Risks of Organisational Accidents, Ashgate, Aldershot. Reason, J.T. (2001) Understanding adverse events the human factor. Clinical Risk Management Enhancing Patient Safety, 2nd edn (ed. C. Vincent), BMJ Books, London. RedmiU, R. and Rajan, J. (1997) Human Factors in Safety Critical Systems, Butterworth Heinemann, Oxford. 

Carthey, J, E)e Leval, M, Reason, J, Leggatt,A, Wright, D, 2000, Adverse events in cardiac surgery the role played by human and organizational factors. In Safety in medicine, 117-138, Pergamon. 

Taylor-Adams, S, Vincent, C, Stanhope, N, 1999, Applying human factors methods to the investigation and analysis of clinical adverse events, Safety science, 31 143-159. 

Lin, L., Vicente, K. J., Doyle, D. Patient Safety, Potential Adverse Drug Events, and Medical Device Design A Human Factors Engineering Approach, Journal of Biomedical Informatics, Vol. 34, No. 4,2001, pp. 274-284. 

Among the significant contributions from human factors research to the field of patient safety is the notion that fallibility is part of the human condition. Therefore creating safety requires changing the conditions in which human beings work. Although individual failures and system vulnerabilities are inevitable, adverse events and harm resulting from them need not be. 

Assigning human error as the cause of medical accident allows the health care culture to reinforce an illusion of restored safety when the individual in error is removed. This approach denies the existence of system failures, identifies a scapegoat, and prevents learning. It truncates the ability to predict and prevent future adverse events. Later, after the human cause of an accident is removed, another human being will step into place. The same conditions and factors can be reassembled, and the stage is set for the medical accident to recur. 

Adverse event analysis is conducted by those knowledgeable in human factor design principles (e.g., hindsight bias). 

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