Organisational errors

It is widely known that 70 % of accidents have a human cause related to operator errors. Equally, if one adds to this the contribution of designers and managers to what are called technical errors (breakdowns) or organisational errors (management decisions, social climate), 100 % of accidents actually have direct or indirect causes associated with human factors. 

A hypercycle is a more complex organisation form. Its precondition is the presence of several RNA quasi-species which are able to amalgamate chemically with certain proteins (enzymes or their precursors). If such a protein is linked to a quasi-species, the resulting duo favours the replication of a second quasispecies. According to Dyson, the linked populations get stuck in a stable equilibrium. Problems occur at this level Any theory on the origin of replication has the central problem that the replication process must occur perfectly in order to ensure survival . If there are replication errors, these will increase from generation to generation, until the system collapses the error catastrophe has then occurred ... 

It is important that all relevant information, communication and documentation are available for all practitioners involved in the care of the patient. The organisational aspect is to make this possible and easily usable for care. The professional aspect is to correctly use the system for input and output. This includes documentation and follow-up on aims, planning and all other relevant activities. The patient opinion and need must also be addressed and documented. Many of the problems have the potential to cause errors. This is described in Chapter 7 and also in other chapters. Here we focus on the basic organisational and professional features of the medication system in the elderly. 

Many international organisations have focused on prevention of errors and harm and have identified problems and developed tools and campaigns for awareness and improvement... 

Experience from hundreds of organisations has shown that poor communication of medical information at transition points is responsible for as many as 50% of all medication errors in the hospital and up to 20% of adverse drug events (IHI MedReconcilliation 2008). In our different settings at a university and county hospitals, we had errors in 40-85% of the elderly patients before starting a new practice. 

Each time a patient moves from one setting to another, clinicians should compare previous medication orders with new orders and plans for care and reconcile any differences. If this process does not occur in a standardised manner designed to ensure complete reconciliation, medication errors may lead to adverse events and harm (IHI MedReconcilliation 2008). Several national organisations round the world have now produced help to reduce errors with medication reconciliation. Some examples are given below. 

Detecting the incidence and type of adverse drug events (ADEs) and medication errors is important for improving the quality of health care delivery. Problems include missing dose, wrong dose, frequency, and route errors. The consequence (ADE) of the errors depends on medication and patient factors as described previously. Some of these problems are organisational and related to chart order system and prescribing. 

In the present organisation of the programs, the above tasks require the cumbersome rewriting of parameter lists and small but important changes in the different routines. Such processes are error prone and are better avoided. 

But even a small-scale trial-and-error strategy has to be organised within society. As discussed in the previous section, iimovations are rather improbable and disadvantaged by stractural frameworks. Iimovations depend upon freedom for them to be developed. At the same time safety barriers have to be formulated within which the search process can move freely. For example, possible environmental effects must be anticipated, necessitating controlled release in small increments and retrievability must be ensured. (Quantitative and qualitative restrictions must be imposed so that retrieval and repair options can still be effective if a trial is aborted. This approach is more successful if the persistence and spatial range of a chemical is low than for persistent chemicals like CFCs and PCBs. This requires that limited Teaming spaces or experimentation spaces have to be created intentionally under technical and economic risk considerations. Small increments and a steady increase are to be preferred, accompanied by intensive monitoring of detectable consequences. 

The guiding principles for the selection or development of speciation procedures are similar to those recommended for other forms of chemical analysis. For example, the initial step should be careful definition of the problem, including listing of the analytical specifications (e.g. type of analysis, concentration range, potential sources of error). This step can be followed by selection of a suitable measurement procedure, nomination of a selective separation procedure (if required) and organisation of the total protocol. 

Accuracy can also be demonstrated through participation in properly conducted interlaboratory studies, which are also useful to detect systematic errors (Gtinzler 1996) related to, e.g. sample pretreatment (e.g. extraction, clean-up), final measurement (e.g. calibration error, spectral interference) and laboratory competence. As described below, interlaboratory studies are organised in such a way that several laboratories analyse a common material which is distributed by a central laboratory responsible for the data collection and evaluation. 

With an effort to make the method work in an organised system of users in diverse laboratories, potential systematic error sources will tend to be diffused in a... 

Step 6. Having identified such structural factors (the real root causes), the model must allow interpretation of these, i.e. it must suggest ways of influencing these factors, to eliminate or diminish error factors and to promote or introduce recovery opportunities in the human-machine systems and indeed in the organisation as a whole. 

Human (operator) Error cannot be separated entirely from the Technical and Organisational context of task performance (see figure 2.1). At the very least one should know the importance of Human Behaviour relative to that of the Technical and Organisational factors in understanding the causes of accidents and near misses. On the basis of our own pilot CCR studies (Van der Schaaf, 1989) the following extensions arc suggested ... 

In this chapter we will rephrase, summarise and extend the set of practical aspects related to designing and implementing near miss reporting systems. First five general factors will be listed, followed by a more detailed discussion of two of these data collection, and acceptability. Also the overall important factor of training will be briefly outlined, Finally the relationship between an organisation s prevailing view of human error and its safety culture will be discussed. 

Systemic safety management especially prominent after a major organisational disaster, which forces the organisation to take a fundamental look at its entire safety philosophy the appropriate view of human error is the system-induced error concept, which says that many human errors can be... 

Figure 6.1 summarises the relationship between Lucas (1992) types of organisational safety culture and their predominant model of human error on one hand, and Westrum s (1988) tripartite division of organisations on the other. 

Review results in an organised manner Correct errors, if any, by means of continuous measurements. 

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