An individual-based framework for the study of medical error

International Journal for Quality in Health Care

Volumn 18, Issue 4, 2006, Pages 314-319

  Veazie, Peter J ^a  

^a UNIVERSITY OF ROCHESTER   (United States)

Author keywords

Clinical guidelines; Decision making; Medical error

Indexed keywords

HEMOGLOBIN A1C; METFORMIN;

ARTICLE; CONCEPTUAL FRAMEWORK; DIABETES MELLITUS; GOAL ATTAINMENT; HUMAN; HUMAN FACTORS RESEARCH; LEGAL ASPECT; MEDICAL DECISION MAKING; MEDICAL ERROR; MEDICATION ERROR; PATIENT INFORMATION; PRESCRIPTION; PRIORITY JOURNAL; PROBLEM SOLVING;

DECISION MAKING; HUMANS; MEDICAL ERRORS; PATIENT CARE; QUALITY ASSURANCE, HEALTH CARE;

EID: 33748100920     PISSN: 13534505     EISSN: 14643677     Source Type: Journal    
DOI: 10.1093/intqhc/mzl011     Document Type: Article

References (33)

1. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999.
2. Quality Interagency Coordination Task Force. Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. Report of the Quality Interagency Coordination Task Force (QuIC) to the President, February 2000, http://www.quic.gov/report/toc.htm.
3. Eisenberg JM, Meyer G, Foster N. Medical errors and patient safety: A growing research priority. Health Serv Res 2000; 35 (3): Xi-xv.
4. Meyer G, Foster N, Christrup S, Eigsenberg J. Setting a research agenda for medical errors and patient safety. Health Serv Res 2001; 36 (1): x-xx.
5. Merry A, Smith AM. Errors, Medicine and the Law. New York: Cambridge University Press, 2001.
6. Weingart SN, Wilson RM, Gibbert RW, Harrison B. Epidemiology of medical error. Br Med J 2000; 320: 774-777.
7. Rosenthal MM, Sutcliffe KM, eds. Medical Error. What Do We Know? What Do We Do? San Francisco: Jossey-Bass, 2002.
8. Reason J. Human Error. New York: Cambridge University Press, 1990.
9. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. Br Med J 1998; 316: 1154-1157.
10. Reason J. Human errors: Models and management. Br Med J 2000; 320: 768-770.
11. Reason J, Parker D, Lawton R. Organizational controls and safety: The varieties of rule-related behavior. J Occup Organ Psychol 1998; 71: 289-304.
12. Taylor-Adams S, Vincent C, Stanhope N. Applying human factors methods to the investigation and analysis of clinical adverse events. Saf Sci 1999; 31: 143-159.
13. van Vuuren W. Organisational failure: Lessons from industry applied in the medical domain. Saf Sci 1999; 33: 13-29.
14. Chang A, Schyve PM, Croteau RJ, O'leary DS, Loeb JM. The JCAHO patient safety event taxonomy: A standardized terminology and classification schema for near misses and adverse events. Int J Qual Health Care 2005; 17: 95-105.
15. Pradhan M, Edmonds M, Runciman WB. Quality in healthcare: Process. Best Pract Res Clin Anaesthesiol 2001; 15 (4): 555-571.
16. Boreham NC, Shea CE, Mackway Jones K. Clinical risk and collective competence in the hospital emergency department in the UK. Soc Sci Med 2000; 51: 83-91.
17. Lisby M, Nielsen LP, Mainz J. Errors in the medication process frequency, type, and potential. Int J Qual Health Care 2005; 17 (1): 15-22.
18. Ternov S, Akselsson R. System weaknesses as contributing causes of accidents in health care. Int J Qual Health Care 2005; 17 (1): 5-13.
19. Dean B, Schachter M, Vincent C, Barber N. Causes of prescribing errors in hospital inpatients: A prospective study. Lancet 2002; 359: 1373-1378.
20. Koppel R, Metlay JP, Cohen A et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005; 293 (10): 1197-1203.
21. Landrigan CP, Rothschild JM, Cronin JW et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004; 351(18): 1838-1848.
22. Olivena A, Michalakea I, Zalmana D, Dormana E, Yeshurunb D, Odeha M. Prevention of prescription errors by computerized, online surveillance of drug order entry. Int J Med Inf 2005; 74 (5): 377-386.
23. Owen JE, Walker RJ, Edgell L et al. Implementation of a predialysis clinical pathway for patients with chronic kidney disease. Int J Qual Health Care 2006; 18 (2): 145-151.
24. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med 2003; 348 (25): 2526-2539.
25. Dhillon BS. Human Reliability and Error in Medical System. New Jersey: World Scientific, 2003.
26. Dhillon BS. Human Reliability with Human Factors. New York: Pergamon Press, 1986.
27. Huchingson DR. New Horizons for Human Factors in Design. New York: McGraw-Hill, 1981.
28. Wickens CDD, Lee J, Gordon-Becker S, Liu YD. Introduction to Human Factors Engineering, second edition. Upper Saddle River: Prentice Hall, 2004.
29. Neisser U. Cognition and Reality Principles and Implications of Cognitive Prychology. San Francisco: Freeman, 1976.
30. Newell A. Heuristic programming: Ill-structured problems. In: Aronofsky J, ed. Progress in Operations Research. New York: Wiley, 1969: 360-414.
31. Simon HA. Rational choice and the structure of the environment. Psychol Rev 1956; 63: 129-138.
32. Dhillon BS. Human error in medication. In: Human Reliability and Error in Medical System. New Jersey: World Scientific, 2003: 89-104.
33. Ericsson KA, Simon HA. Protocol Anaysis: Verbal Reports as Data, revised edition. Cambridge: MIT Press, 1993.