Stretching the Search for the ‘Why’ of Error: The Systems Approach

There is More to Error in Healthcare than the Care Provider

Typically when an error occurs in healthcare, the care provider is considered the cause. Because that person committed the act that lead to the adverse outcome efforts to address the error are directed to that person. Indeed, human factors practitioners have developed remedial training and their medical device design activities have emphasized user interface design. This paper presents the case for expanding that focus based on the realization that the act of committing an error is a behavior and behavior reflects the interaction of the person and factors in the environment. The counterintuitive findings that more errors occur in prescribing medications with computer order entry than with handwritten script are discussed in terms of this approach.

Inquiries into Malaysia's socio-technical disasters: recommendations and lessons learnt

Most democratic countries hold inquiries into disasters. One of their key functions is to establish the cause of an event and to learn lessons in order to prevent a recurrence. In addition, they offer an opportunity for communal catharsis, permitting the public to vent anger, distress and frustration and to exert pressure for policy changes. Malaysia has experienced six landmark socio-technical disasters since 1968, which resulted in the proposal or amendment of various safety/emergency acts and regulations. The authors used a grounded theory approach utilising a constant comparative method to analyse the recommendations made by the inquiries into these events. Data indicate that social and technical recommendations comprise 85 and 15 per cent, respectively, of the total recommendations made by the inquiry committees. This paper offers suggestions for improving the management of inquiry tribunals, as they will remain a valuable source of information for society and corporations to learn from past incidents.

Factors contributing to incidents in medicine administration. Part 1

Part one of this two-part article explores the factors contributing to errors during the administration of medicines through a detailed literature review. Medication incidents cause serious harm to patients. In a typical NHS hospital approximately 7000 medication doses are administered daily (Audit Commission, 2002a). The costs of errors to patients, practitioners and the NHS are significant. While some errors can be prevented, it is unlikely that they will ever be eliminated as they arise from human nature (Kohn et al, 2000). There is a lack of strong evidence in the literature about what nurses feel the factors contributing to medication errors are. The majority of studies were carried out in the USA and tended to be carried out by non-nurses with the exception of those by Gladstone (1995), Hand and Barber (2000) and King (2004). Gibson (2001) felt that nurses' experiences and knowledge appear to be undervalued.