180,000 people die each year due to malpractice

65% were caused by preventable errors

HOWEVER--2-14% of all patients experience non threatening errors

1% error rate for physicians

Why is the Error Rate in the Practice of Medicine so High

not so public

powerful emphesis on being perfect--cultural--and not admiting weakness or imperfection--dealt with privately--threat of malpractice

The Medical Approach to Error Prevention

perfection--peer pressure to enforce

Lessons from Psychological and Human Factors Research

A Theory of Cognition

skill based--preprogramed paters--schemata

rule-based--if X then Y

knowledge-based--concious analytical synthesis

Mechanisms of Congintve Erros

mistakes in skill based, often confusing two simmilar ones

tired, sick

Rule based mistakes--wrong rule or wrong application--biased memory

Latent Errors

errors in design are just waiting to happen

Prevention of Accidents

make it difficult to err, but also accept that errors will happen and continously work around it

buffers and redundancy

simplify, constrain, standardize,

The Aviation Model

lots of buffers, redundancy, external evalution, specific proceedures--still lots of errors, BUT they are corrected

The Medical Model

root causes not investigated, systemic errors not fixed

not enough standardization and routinization

extream education and cirtification

Hospital Changes to Reduce Hosptial Injuries

should be able to aply other techniques to hospitals

define the problem, collect data

Reduce Reliance on Memory--short term

Improved INofmation Access

Ereror Proofing

Standardization

Training

redundancy and buffers

Institutionalization of Saftey

Implementing System Changes

Total Quality Management

physicians and hospitals need to accept the idea that errors will happen and need to deal with them productively