Medication errors human factor

Woods, D.D. 2000a. Behind human error human factors research to improve patient safety. National Summit on Medical Errors and Patient Safety Research, Quality Interagency Coordination Task Force and Agency for Healthcare Research and Quality, September 11, 2000. www.apa.org/ppo/issues/shumfactors2.html. 

Computer systems validation personnel must also deal with design errors. A program that perfectly meets a lousy specification is a lousy program. Specifically for medical devices, books on software reliability tend to set aside the user interface issue, and treat it as the sole province of the human factor analyst. The reliability of a system is determined by how all its various parts, including the people who use it, work together. 

Practitioners and consumers often want to know the acceptable medication error rate. There is no benchmark. A zero error rate is desired, but unattainable because of human factors. If organizations can determine measuring points and consistently follow them, it might be possible to determine an internal benchmark to be used for quality improvement purposes. However, because the parameters of the measurement are unlikely to be duplicated elsewhere, use of the number for external comparisons is not valid. 

Cohen M.R., Ed. Medication Errors, Jones and Bartlett, Sudbury, MA, 1999. Schneider P.J. Applying human factors in improving medication-use safety. Am. J. Hlth.-Syst. Pharm. 2002 59 1155-1159. 

The ability to predict error and thus avoid it is the focus of the science of human factors engineering. The adaptation of this science to the medication... 

Cooper and Leape are not the only authors to understand the importance of human factors and psychology to medical harm and medical error at an early stage. For instance, Marilyn Bogner s 1994 book Human error in medicine contained many insightful and important chapters by David Woods, Richard Cook, NevUle Moray and others James Reason articulated his theory of accidents and discussed its apphcation in medicine in Medical Accidents (Vincent, Ennis and Audley, 1993). Cooper and Leape were, however, particularly important influences and they Ulustrate the more general point that some of the defining characteristics of patient safety are its acceptance of the importance of psychology and the lessons to be learnt from other safety critical industries. 

Scarborough A. Bailey L. Pounds J. 2005. Examining ATC Operational Errors Using the Human Factors Analysis and Classification System. Civil Aerospace Medical Institute, Federal Aviation Administration, Oklahoma City, OK 73125. 

Lim, R.H.M., Anderson, J. and Buckle, P. 2008b. Analysing Care Home Medication Errors A Comparison of the London Protocol and Work Domain Analysis. Presented at the 52nd Human Factors and Eigonomics Society Annual Meeting, New Yoik, 22-26 September. 

Hospital B s experience is not unique. The net effect of the completion rate measure has been that it produces data which show that many actions are not completed within a specified time frame. This has, in some hospitals led senior managers to call into question the value of the walk rounds or to drive behaviour to focus on problems that can be fixed easily. Thus the lack of integration of human factors into hospital and medical device design and the allocation of staffing and resources gets put into an unresolvable box and remain latent conditions that continue to create error traps, inefficiencies and poor patient experience. 

Brueley, M. E., Ergonomics and Error Who Is Responsible , Proceedings of the First Symposium on Human Factors in Medical Devices, 1989, pp. 6-10. 

General Approach to Human Factors during the Medical Device Development Process for Reducing Human Errors... 

Human errors can be reduced substantially by making human factors an integral part of the medical device/equipment development process (i.e., right from the concept phase to the production phase) as shown in Figure 9.2 [24],... 

Describe the general approach to human factors during the medical device development process for reducing human errors. 

Gearge, B., Polly, C., Everlyn, S., Implementation of a Patient Safety Collaborative Forum Facilitates Organizational Learning from Medical Error, Proceedings of the Human Factors and Ergonomics Society Conference, 2006, pp. 944-948. 

Pesanka, D. A., Greenhouse, R K., Rack, L. L., Delucia, G. A., Ferret, R. W., Scholle, C. C., Johnson, M. S., Ticket to Ride Reducing Handoff Risk during Hospital Patient Transport, Journal of Nursing Care Quality, Vol. 18, No. 3,2008, pp. 217-223. Peters, G. A., Peters, B. J., Medical Error and Patient Safety Human Factors in Medicine, CRG Press, Boca Raton, Florida, 2008. 

Source J. T. Reason, "The Basics of Human Factors," paper presented at the Salzburg Seminar on Medical Safety and Human Error, Apr. 25-May 2, 2001. 

Part 4 is a collection of human factors interventions from the different indnstry modes. It will introdnce the concept that human error is indeed ubicpiitous and therefore, its management should be approached from multiple applications training and development, leadership and supervision, situational awareness, distraction management etc. Novel elements in this part include research on driver distraction, medical team resource management, a new look at situational awareness, rail risk management and fatigue management in the medical field. 

In everyday situations, overlooking human factors leads to errors, frustration, alienation from technology, and, eventually, a failure to exploit the potential of people and technology. In safety-critical systems, however, such as nuclear power plants, hospitals, and aviation, the consequences can threaten the quality of hfe of virtually everyone on the planet. In the United States, for example, preventable medical errors are the eighth leading cause of death in hospitals alone, errors cause 44,000 to 98,000 deaths annually, and patient injuries cost between 17 billion and 29 billion annually (lOM, 1999). 

It is said generally that insnfficient knowledge or immature skills cause medical incidents and accidents such as false diagnosis or failure of manipulation. In addition to these factors, however, human errors of different types can occur like confusion of patients. 

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