Medical error and patient safety: human factors in medicine
Gespeichert in:
| Hauptverfasser: | , |
|---|---|
| Format: | Buch |
| Sprache: | English |
| Veröffentlicht: |
Boca Raton, Fla. [u.a.]
CRC Press
2008
|
| Schlagworte: | |
| Online-Zugang: | Inhaltsverzeichnis |
| Beschreibung: | XVI, 233 S. |
| ISBN: | 9781420064780 1420064789 |
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Datensatz im Suchindex
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|---|---|
| adam_text | Contents
Preface xv
The Authors xvii
Chapter 1 Introduction 1
Common Understanding • 1
Sophisticated Knowledge 1
Current Urgency 2
Medication Errors 2
Pediatric Dosing Errors 2
Prescription Drug Listing 2
Toxic Exposures 3
Laboratory Errors 3
Patient Identification Errors 4
Adverse Event Reports 4
Adverse Event Rates Worldwide 5
Wrong-Site Surgery 5
Infection Control 5
Time to Rebuild 6
Our Approach 6
A New Meaning for Error 7
Multidisciplinary Orientation 8
Chapter 2 General Concepts 9
Causation 9
General Causation 9
The Rule-Out Process 10
Relative Risk 10
The But-For Technique 10
Correlative Relationships 10
Substantial Factor Test 11
Concurring Cause 11
Intervening Causation 11
vi Contents
Remote Causation 11
Proximate Cause 11
Meta-Analysis 12
Risk Factors 12
Warning Causation 12
Mixed Causation 13
Bias 13
Intrinsic Bias 14
Extrinsic Bias 14
Intentional Bias 15
Knee 15
Head 16
Performance Criteria 16
Physicians 16
Nurses 17
Hospitals 17
Nonmedical Professionals 17
The Pursuit of Excellence 18
Financial Viability 18
Medical Devices and Equipment 18
Transparency 18
Harmonization 19
Teamwork 20
Rationalization 20
Assurance Techniques 21
Management of Error 21
Caveats 21
Causation 21
Bias 22
Performance 22
Transparency 22
Human Factors 22
Chapter 3 Medical Services 23
Theoretical Assumptions 23
Equal Status 23
Civility 24
Innocent Errors 24
Patient Involvement 25
Honesty 26
Ombudsman 27
Conflicts of Interest 27
System Dynamics 28
Medication Errors 29
Extent of the Problem 29
Contents vii
Prevention Strategies 29
Individual Remedies 30
Computerized Systems 30
Radio-Frequency Identification Device Technology 31
Clinical Conversations 32
Comparative Risks 32
Infection Control 34
Sources of Contamination 34
Use of Antibiotics 35
Medical Waste 36
Staff Immunization 37
Nosocomial Pneumonia 38
Call Lights 39
Drug Resistance 39
Touch Surfaces 40
Lessons Learned 43
Emergency Services 47
Handovers and Interactions 48
Health Care Facilities 50
Cost Benefits 50
Clean Air 50
Clustering and Flexibility 51
Patient Variability 51
General Criteria 52
Limitations of Service 53
Caveats 54
Proof 54
Specificity 54
Culture 54
Architecture 54
Handoffs 54
Emergency Services 55
Call Lights 55
Basic Hygiene 55
Mutations 55
Decision Making 56
Surgical Infection Control 56
Choice Behavior 56
Rules of the Road 56
The User Process 57
Chapter 4 Medical Devices 59
Risks 59
Inherent 59
viii Contents
Illustrative Problems 59
Human Error 61
Neurostimulation 62
Corrective Remedies 63
Product Life 63
Biofilms 64
Reprocessing 65
Subcontracting 65
Portability 65
Toxic Materials 66
Testing 66
Error Reduction 68
Learning Process 68
Time Delays 68
Formal Requirements 69
Analytical Techniques 69
Automation 70
External Requirements 70
Standards 70
Outsourcing 71
Disciplinary Emphasis 71
Communications 72
Effectiveness 72
Complications 72
Ambiguity 72
Content 72
Product Design 73
Essentials 73
World Trade Problems 74
Customer Satisfaction 74
Critical Comments 74
Conclusions 75
Caveats 76
Risks 76
Analysis 76
Culture 76
Corrective Action 76
Medical Communication 76
Recalls 77
Biofilms 77
Ease of Use 77
Life Testing 77
Degree of Safety 78
Open Communications 78
Remote Patient Management 78
Contents %%
Chapter 5 Analysis 79
Corrective Action 79
Preventive Action 79
System Analysis 80
Human Error Control 80
Risk Assessment 81
Mistaken Belief s 82
Observational Demeanor 82
Correct Terminology 82
Complete Process 83
Post-Control Measures 83
Operational Discipline 83
Error Troubleshooting 84
Traceability 84
Industrial Engineering 84
Quality Assurance 85
Introduction 85
Drug Delivery 85
Change Management 85
Bed Assignment 86
Medication Administration 86
Pharmacy Errors 86
Quality Techniques 87
Quality Standards 87
Limitations 88
Quality Programs 89
Caution 89
Other Disciplines 89
Government and Industry Reviews 90
In-House Teams 90
Personality Factors 90
Individual Responsibility 91
Minimalists 91
Discretionary Agents 92
Caveats 92
Choice 92
Reaction 92
Persistence 92
Self-Help 93
Economic Evaluations 93
Risk Assessments 93
Fuzziness 93
Application 94
Time Frames 94
x Contents
Chapter 6 Human Factors 95
Hospital Beds 95
Fatigue 96
Characteristics 96
Causes 96
Prevention 97
On-Call Problems 97
Work Shifts 98
Defiant Actions 99
Stress 100
Situation Awareness 102
Reduction and Integration 104
Patient Handling 106
Drug-Altered Behavior 107
Macroergonomics 107
Team Training 108
Human Factors Experts 110
Cultural Change Ill
Sentinel Events Ill
Tubing and Catheter Connections Ill
Electrical Mismatches 112
Plugs and Disposable Interconnects 112
Surgical Fires 113
Ventilator Problems 114
Scope of Activities 115
Caveats 117
Stress 117
Fatigue 118
Situation Awareness 118
Defiant Actions 118
Self-Limitations 118
Human Engineering 119
Cognitive Illusions 119
Brand Bias 119
Packaging 119
Electronics 120
Chapter 7 Management Errors 121
Introduction 121
Illustrative Error Sources 121
Managerial 121
Organizational 122
Transformational Issues 122
Transitional Clinics 123
Contents xi
Nursing Home Changes 123
Assisted-Living Facilities 125
Home Use Devices 125
Reliability of Implantable Devices 126
Disclosures 128
Pandemics 129
Management Principles 132
Introduction 132
Shared Goals 132
Placebo Effects 133
Layering 133
Management Concerns 134
Conformance 134
Competition 135
Electronic Records and Telemedicine 136
Health Middlemen .137
Caveats 138
Risk Control 138
Management Action 139
Remote Control 139
Error Detectives 139
Liability Reasoning 139
Management Oversight 140
Personal Attitudes 140
Feedback 140
Conflict 141
Unpaid Claims 141
Chapter 8 Communications 143
Interactivity 143
Acknowledged Problems 143
Physician-Patient Communications 143
Multiple Communication Errors 144
System Errors 144
Laboratory Mistakes 145
Consumer Beliefs 145
The Culture of Silence 146
Supplemental Techniques 146
Cascade Analysis 146
Cluster Analysis 146
Network Analysis 147
Critical Path Analysis 147
Important Variables 147
Technical Information 148
xii Contents
Psychological Costs 148
Intellectual Factors 150
Emotional Factors 151
Nurse-Patient Communications 151
Cognitive Dissonance 152
Records Control 152
Signal Detection and Perceptual Set 153
Communicating Consent 154
Informed Consent 154
Unconsciousness 156
Comatose Patients 156
Misreading Symptoms 157
Caveats 157
Garbling 157
Effectiveness 158
Cognition 158
Informed Consent 158
Misreading 158
Beliefs 158
Silence 158
Caution 159
Nurse Communications 159
Fraud, Waste, and Abuse 159
Time Lags 159
Chapter 9 Drug Delivery 161
Containers 161
Labels 163
Warnings : 164
Basic Objectives 164
Residual Risk 164
Compliance 164
Graphics and Symbols 165
SignOffs 165
Adequacy 166
Reinforcement 166
Mental Processes 167
Potentiation 167
Subthreshold Reactions 168
Language Control 168
Intrinsic Brain Activity 169
Derivative Criteria 170
Pill Matching 171
Instructions 171
Contents xiii
Regulation 172
Special Conditions of Use 172
Antibiotic Approvals 173
Expert Panels 173
Over-the-Counter Drugs 174
FDA Limitations 175
Public Policy Concerns 176
Prescription Directions 176
Security and Counterfeiting 178
Recalls 179
Possible Problems 182
Complexity 182
Scale-Up 182
Waste 182
Verification 183
Collaboration 183
Networking and Privacy Protection 183
Online Searches 183
Privacy Rules 184
Waiver of Privacy 184
Responses 185
Patient Concerns 186
Caveats 188
Messages 188
Symbols and Graphics 188
Warnings 188
Over-the-Counter Drugs 188
Labels 188
Packaging 188
Outserts 189
Internet Prescriptions 189
Patients 189
Disclosure of Errors 189
Standards 190
Robustness 190
Health Care Costs 190
Adverse Events 191
Noncompliance 191
References and Recommended Reading 193
Appendix 205
Standards Organizations 205
Marks of Approval 207
Selected Standards and Regulations 207
Subject Index 213
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| spelling | Peters, George A. Verfasser aut Medical error and patient safety human factors in medicine George A. Peters ; Barbara J. Peters Boca Raton, Fla. [u.a.] CRC Press 2008 XVI, 233 S. txt rdacontent n rdamedia nc rdacarrier Medizin (DE-588)4038243-6 gnd rswk-swf Fehlleistung (DE-588)4016619-3 gnd rswk-swf Fehlerverhütung (DE-588)4276213-3 gnd rswk-swf Fehlleistung (DE-588)4016619-3 s Medizin (DE-588)4038243-6 s DE-604 Fehlerverhütung (DE-588)4276213-3 s Peters, Barbara J. Verfasser aut HBZ Datenaustausch application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=020147504&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis |
| spellingShingle | Peters, George A. Peters, Barbara J. Medical error and patient safety human factors in medicine Medizin (DE-588)4038243-6 gnd Fehlleistung (DE-588)4016619-3 gnd Fehlerverhütung (DE-588)4276213-3 gnd |
| subject_GND | (DE-588)4038243-6 (DE-588)4016619-3 (DE-588)4276213-3 |
| title | Medical error and patient safety human factors in medicine |
| title_auth | Medical error and patient safety human factors in medicine |
| title_exact_search | Medical error and patient safety human factors in medicine |
| title_full | Medical error and patient safety human factors in medicine George A. Peters ; Barbara J. Peters |
| title_fullStr | Medical error and patient safety human factors in medicine George A. Peters ; Barbara J. Peters |
| title_full_unstemmed | Medical error and patient safety human factors in medicine George A. Peters ; Barbara J. Peters |
| title_short | Medical error and patient safety |
| title_sort | medical error and patient safety human factors in medicine |
| title_sub | human factors in medicine |
| topic | Medizin (DE-588)4038243-6 gnd Fehlleistung (DE-588)4016619-3 gnd Fehlerverhütung (DE-588)4276213-3 gnd |
| topic_facet | Medizin Fehlleistung Fehlerverhütung |
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