Human Errors in Medical Practice: Systematic Classification and Reduction with Automated Information Systems

Journal of Medical Systems

Volumn 27, Issue 4, 2003, Pages 297-313

  Kopec, D ^a   Kabir, M H ^a   Reinharth, D ^b   Rothschild, O ^a   Castiglione, J A ^a  

^a CITY UNIVERSITY OF NEW YORK   (United States)

^b LONG ISLAND JEWISH MEDICAL CENTER   (United States)

Author keywords

Error(s) classification; Human errors; Information systems; Medical errors; Systems

Indexed keywords

AUTOMATION; COMPUTER PROGRAM; DIAGNOSTIC ERROR; GENERAL PRACTITIONER; HEALTH CARE SYSTEM; HEALTH ECONOMICS; HUMAN; MEDICAL DECISION MAKING; MEDICAL ERROR; MEDICAL INFORMATION SYSTEM; MEDICAL PRACTICE; MEDICATION ERROR; REVIEW; ADULT; ARTICLE; CHILD; CLASSIFICATION; FEMALE; MALE; MEDICAL INFORMATICS; ORGANIZATION; UNITED STATES;

ADULT; CHILD; FEMALE; HUMANS; INSTITUTE OF MEDICINE (U.S.); MALE; MEDICAL ERRORS; MEDICAL INFORMATICS APPLICATIONS; SOFTWARE; UNITED STATES;

EID: 0141834049     PISSN: 01485598     EISSN: None     Source Type: Journal    
DOI: 10.1023/A:1023796918654     Document Type: Review

References (49)

1. Brennan, T. A., The Institute of Medicine report on medical errors: Could it do harm? Tex Med. 96(6),13-15, 2000.
2. Kohn, L. T., Corrigan, J. M., and Donaldson, M. S. (eds.), To Err is Human: Building a Safer Health System, National Academy Press, Washington, DC, 2000.
3. Spencer, F. C., Human error in hospitals and industrial accidents: Current concepts. J. Am. Coll. Surg. 191:410-418, 2000.
4. Ballas, E. A., Information systems can prevent errors and quality. J. Am. Med. Inf. Assoc. 8:398-399, 2001.
5. Bates. D. W., Reducing the frequency of errors in medicine using information technology, J. Am. Med. Inf. Assoc, 8:299-308, 2001.
6. Richardson, W. C., The Institute of Medicine report on medical errors, N. Engl. J. Med. 343:663-665, 2000.
7. Berner, E. S., Webster, G. D., Shugerman, A. A., Performance of four computerbased diagnostic systems, N. Engl. J. Med. 330:1792-1796, 1994.
8. Nordenberg, T. Make No Mistake! Medical Errors Can Be Deadly, Serious FDA Consumers, pp. 13-18, Rockville, MD, 2000.
9. Kassirer, J. P., A report card on computer-assisted diagnosis - The Grade: C. N. Engl. J. Med., 330:1824-1825, 1994.
10. Overhage J. M., Perkins S, Tierney M. W., Controlled trial of direct physician order entry. J. Am. Med. Inf. Assoc. 8:361-371, 2001.
11. Luginbuhl, M., and Schnider, T. Anesthesiology. 96(1), 241-243, 2002.
12. Perrow, C., Normal Accidents, 2nd edn., Princeton University Press, Princeton, NJ, 1999.
13. Berwick, D., Eleven worthy aims for clinical leadership of health system reform. JAMA, 272(10), 797-802, 1994.
14. Reason, J. Human Error, Cambridge University Press, Cambridge, England, 1990.
15. Roberts, K., Risk, regulation, litigation and organizational issues in safety in high-hazard industries. Position paper for Workshop Organizat. Analysis High Hazard Product. Syst. Academy/Industry Dial. (NSF Grant No. 9510883-SBR), MIT Endicott House, April 15-18, Dedham, MA, 1997.
16. Sagan, S. D., The Limits of Safety, Princeton University Press, Princeton, NJ, 1993.
17. Kizer, K., VHA's patient safety improvement initiative. Presentation to the National Health Policy Forum by Under Secretary for Health, Department of Veterans Affairs, Washington, DC, May 14, 1999.
18. Van Cott, H., Human Errors: Their Causes and Reductions. In Bogner, M. S. (ed.), Human Error in Medicine, Erlbaum, Hillsdale, NJ, 1994.
19. Kopec, D., and Michie, D., Mismatch Between Machine Representations and Human Concepts: Dangers and Remedies, Report to the EEC under subprogram FAST (Forecasting and Assessment in Science and Technology). Brussels, Belgium, 1992.
20. Kopec, D., Human and Machine Representations of Knowledge, PhD Thesis, University of Edinburgh, Edinburgh, Scotland, 1983.
21. Wallace, D. R., and Kuhn, R. K., Software Quality Lessons From Medical Device Failure Data, Department of Commerce, U.S. Government, NIST, 1999.
22. Kemeny, J. I. Babbitt, B., Haggerty, P. E., Lewis, C., Marks, P. A., Marrett, C. B., McBride, L., McPherson, H. C., Peterson, R. W., Pigford, T.H., Taylor, T.B., Trunck, A.D., Report of the President's Commision on the Accident at Three Mile Island, Vol. 1, U.S. Government Printing Office, Washington, DC, 1979.
23. Bates, D. W., Cohen, M., Leape, L. L., Overhage, J. M., Shabot, M. M., Sheridan, T., Reducing the frequency of errors in medicine using information technology, J. Am. Med. Inf. Assoc. 8(4), 301, 2001.
24. Leveson, N., Safeware, Addison-Wesley, Reading, MA, pp. 114-115, 1995.
25. Weiner, E. L., and Renwick, E. C., Flight-deck automation: Promises and problems. Ergonomics, 23(10):995-1011, 1980.
26. Bradshaw, K. E., Gardner, R. M., Clemmer, T. P., Orme, J. F., Thomas, F., West, B. J., Physician decision-making-evaluation of data used in a computerized ICU. Int. J. Clin. Monit. Comput. 1(2):81-91, 1984.
27. Bates, D. W. Spell, N., Cullen, D. J., Burdick, E., Laird, N., Petersen, L. A., Small, S. D., Sweitzer, B. J., Leape, L. L., The cost of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA 277:307-311, 1997.
28. Classen, D. C., Pestotnik, S. L., Evans, R. S., Lloyd, J. F., Burke, J. P., Adverse drug events in hospitalized patients. Excess length of stay, extra cost and attributable mortality. JAMA 277:301-306, 1997.
29. Lesar, T. S., Briceland, L., Stein, D. S., Factors related to errors in medication prescribing. JAMA, 277:312-317, 1997.
30. Edmonson, A. C., Learning from mistake is easier said than done: Group and organizational influences on the detection and correction of human errors. J. Appl. Behav. Sci. 32:5-28, 1996.
31. Brenan, T. A., Leape, L. L., Laird, N., Liesi, H., Localio, R. A., Lawthers, A. G. Newhouse, J. P., Weiler, P. C., Hiatt, H. H., Incidence of adverse events and negligence in hospitalized patients. N. Engl. J. Med., 324:370-376, 1991.
32. Myhre, B. A., and McRure, D. Human error - A significant cause of transfusion mortality. Transfusion, 40:879-885, 2000.
33. Dunea, G., Soundings: A medical error. BMJ, 6; 320 (7244): 1283, 2000.
34. Not again! (Editorial). BMJ (U. S. A.) 1:155-156, 2001.
35. Yeltman, R. J., Preventing misuse errors in health care organizations. JCOM, 8(8):29-33, 2001.
36. Boenheimer, T., The American Health Care System: The movement for improved quality in health care, N. Engl. J. Med. 340:488-492, 1999.
37. Bates, D. L., Leape, L. L., Cullen, D. J. Laird, N., Petersen, L., Teich, J. M., Burdick, E., Hickey, M., Kleefield, S., Shea, B., Vander Vliet, M., Seger, D. L., Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA, 280(15):1311-1316, 1998.
38. Rose, J. R., Med. Econ. 73(11), 1996.
39. Jha, A. K., Kuperman, G. J., Teich, J. M., Leape, L., Shea, B., Rittenberg, E., Burdick, E., Seger, D. L., Vander Vliet, M., Bates, D. W., Identifying adverse drug events: Development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J. Am. Med. Inf. Assoc. 5(3):305-314, 1998.
40. Evans, R. S., Pestotnik, S. L., Clssen, D. C. Horn, S. D., Bass, S. B., Burke, J. P., Preventing adverse drug events in hospitalized patients. Ann. Pharmacother. 28:523-527, 1994.
41. Raschke, R. A., Gollihare, B., Wunderlich, T. A., Guidry, J. R., et al., A computer alert system to prevent injury from adverse drug events; Development and evaluation in a community teaching hospital. JAMA 280(15):1317-1320, 1998.
42. Hebert, P. C., Levin, A. V. sad Rothers, G. Bioethics for clinician: 23. Disclosure of medical error. CMAJ, 164(4):509-513, 2001.
43. Sussman, M. B., Haug, M. R., Human and Mechanical Error - An unknown quantity in research. Am. Behav. Sci. 11:55-56, 1967.
44. Koepke, J. A., Some comments on errors on survey questionnaires, Pathologist. 25:193-194, 1971.
45. Bradshaw, K. E., Gardner, R. M., Pryor, T. A., Development of a computerized alerting system computer and biomedical research. Comput. Biomed. Res. 22:575-587, 1989.
46. Collins D., MALPRACTICE (Wrong diagnosis of a breast mass) (Failure to diagnosis breast cancer claimed)(Unrecognized chorioamnionitis charged) (Death from cervical cancer) (Failure to monitor anesthesia level) (Death of an infant following placental abruption). Contemporary OB/GYN, 46(10):124, 2001.
47. Kronz, J. D., Westra, W. H., Epstein, J. I., Mandatory secondary opinion surgical pathology at a large referral hospital. Cancer, 86(11):2426-2435, 1999.
48. Baxt, W. G., Application of artificial neural networks to clinical medicine. Lancet 346:1135-1138, 1995.
49. Baase, S., A Gift of Fire, Prentice-Hall, Saddle River, NJ, pp. 21-24, 1997.