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Healthcare Error Proliferation Model
The healthcare error proliferation model is an adaptation of James Reason’s Swiss Cheese Model designed to illustrate the complexity inherent in the contemporary healthcare delivery system and the attribution of human error within these systems. The healthcare error proliferation model explains the etiology of error and the sequence of events typically leading to adverse outcomes. This model emphasizes the role organizational and external cultures contribute to error identification, prevention, mitigation, and defense construction. Introduction Healthcare systems are ''complex'' in that they are diverse in both structure (e.g. nursing units, pharmacies, emergency departments, operating rooms) and professional mix (e.g. nurses, physicians, pharmacists, administrators, therapists) and made up of multiple interconnected elements with ''adaptive'' tendencies in that they have the capacity to change and learn from experience. The term ''complex adaptive systems'' (CAS) was coine ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Swiss Cheese Model
The Swiss cheese model of accident causation is a model used in risk analysis and risk management, including aviation safety, engineering, healthcare, emergency service organizations, and as the principle behind layered security, as used in computer security and defense in depth. It likens human systems to multiple slices of Swiss cheese, stacked side by side, in which the risk of a threat becoming a reality is mitigated by the differing layers and types of defenses which are "layered" behind each other. Therefore, in theory, lapses and weaknesses in one defense do not allow a risk to materialize, since other defenses also exist, to prevent a single point of failure. The model was originally formally propounded by James T. Reason of the University of Manchester, and has since gained widespread acceptance. It is sometimes called the "cumulative act effect". Although the Swiss cheese model is respected and considered to be a useful method of relating concepts, it has been subjec ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Iatrogenic Disorder
Iatrogenesis is the causation of a disease, a harmful complication, or other ill effect by any medical activity, including diagnosis, intervention, error, or negligence. "Iatrogenic", ''Merriam-Webster.com'', Merriam-Webster, Inc., accessed 27 Jun 2020. First used in this sense in 1924, the term was introduced to sociology in 1976 by Ivan Illich, alleging that industrialized societies impair quality of life by overmedicalizing life."iatrogenesis" ''A Dictionary of Sociology'', . updated 31 May 2020. Iatrogenesis may thus include mental suffering via medical beliefs or a practitioner's statements. Some iatrogen ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Medical Terminology
Medical terminology is a language used to precisely describe the human body including all its components, processes, conditions affecting it, and procedures performed upon it. Medical terminology is used in the field of medicine Medical terminology has quite regular morphology, the same prefixes and suffixes are used to add meanings to different roots. The root of a term often refers to an organ, tissue, or condition. For example, in the disorder known as hypertension, the prefix "hyper-" means "high" or "over", and the root word "tension" refers to pressure, so the word "hypertension" refers to abnormally high blood pressure. The roots, prefixes and suffixes are often derived from Greek or Latin, and often quite dissimilar from their English-language variants. This regular morphology means that once a reasonable number of morphemes are learnt it becomes easy to understand very precise terms assembled from these morphemes. Much medical language is anatomical terminology, concern ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Error
An error (from the Latin ''error'', meaning "wandering") is an action which is inaccurate or incorrect. In some usages, an error is synonymous with a mistake. The etymology derives from the Latin term 'errare', meaning 'to stray'. In statistics, "error" refers to the difference between the value which has been computed and the correct value. An error could result in failure or in a deviation from the intended performance or behavior. Human behavior One reference differentiates between "error" and "mistake" as follows: In human behavior the norms or expectations for behavior or its consequences can be derived from the intention of the actor or from the expectations of other individuals or from a social grouping or from social norms. (See deviance.) Gaffes and faux pas can be labels for certain instances of this kind of error. More serious departures from social norms carry labels such as misbehavior and labels from the legal system, such as misdemeanor and crime. Departures ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Swiss Cheese Model
The Swiss cheese model of accident causation is a model used in risk analysis and risk management, including aviation safety, engineering, healthcare, emergency service organizations, and as the principle behind layered security, as used in computer security and defense in depth. It likens human systems to multiple slices of Swiss cheese, stacked side by side, in which the risk of a threat becoming a reality is mitigated by the differing layers and types of defenses which are "layered" behind each other. Therefore, in theory, lapses and weaknesses in one defense do not allow a risk to materialize, since other defenses also exist, to prevent a single point of failure. The model was originally formally propounded by James T. Reason of the University of Manchester, and has since gained widespread acceptance. It is sometimes called the "cumulative act effect". Although the Swiss cheese model is respected and considered to be a useful method of relating concepts, it has been subjec ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Serious Adverse Event
A serious adverse event (SAE) in human drug trials is defined as any untoward medical occurrence that at any dose #Results in death #Is life-threatening #Requires inpatient hospitalization or causes prolongation of existing hospitalization #Results in persistent or significant disability/incapacity #May have caused a congenital anomaly/birth defect #Requires intervention to prevent permanent impairment or damage The term "life-threatening" in the definition of "serious" refers to an event in which the patient was at risk of death at the time of the event; it does not refer to an event which hypothetically might have caused death if it were more severe. Adverse events are further defined as “Any untoward medical occurrence in a patient or clinical investigation subject administered a pharmaceutical product and which does not necessarily have to have a causal relationship with this treatment.” Research Investigators in human clinical trials are obligated to report these events in ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Root Cause Analysis
In science Science is a systematic endeavor that builds and organizes knowledge in the form of testable explanations and predictions about the universe. Science may be as old as the human species, and some of the earliest archeological evidence for ... and engineering, root cause analysis (RCA) is a method of problem solving used for identifying the root causes of faults or problems. It is widely used in IT operations, manufacturing, telecommunications, Process control, industrial process control, accident analysis (e.g., in aviation, rail transport, or nuclear plants), medicine (for medical diagnosis), healthcare industry (e.g., for epidemiology), etc. Root cause analysis is a form of deductive inference since it requires an understanding of the underlying causal mechanisms of the potential root causes and the problem. RCA can be decomposed into four steps: * Identify and describe the problem clearly * Establish a timeline from the normal situation until the problem ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Peter Pronovost
Peter J. Pronovost (born February 22, 1965) is Chief Quality and Transformation Officer at University Hospitals Cleveland Medical Center, the main affiliate of the Case Western Reserve University School of Medicine. At UH, Pronovost is responsible for improving value across the health system, helping people stay well, get well and manage their most acute medical conditions. He is the clinical lead for population health and the lead for high-reliability medicine, with direct responsibility for the UH employee accountable care organization. He is also responsible for telehealth and virtual health programs serving patient and provider communities. He previously served as an intensive care physician and director of the ''Armstrong Institute for Patient Safety'' at the Johns Hopkins Hospital in Baltimore, Maryland. At Johns Hopkins University, he was Professor in the Departments of Anesthesiology & Critical Care Medicine as well as Surgery, Professor of Healthcare Management at the Care ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Patient Safety Organization
A Patient Safety Organization (PSO) is a group, institution, or association that improves medical care by reducing medical errors. Common functions of patient safety organizations are data collection and analysis, reporting, education, funding, and advocacy. A PSO differs from a Federally designed Patient Safety Organization (PSO), which provides health care providers in the U.S. privilege and confidentiality protections for efforts to improve patient safety and the quality of patient care delivery (see 42 U.S.C. 299b-21 et seq. and www.PSO.AHRQ.gov.) In the 1990s, reports in several countries revealed a staggering number of patient injuries and deaths each year due to avoidable errors and deficiencies in health care, among them adverse events and complications arising from poor infection control. In the United States, a 1999 report from the Institute of Medicine called for a broad national effort to prevent these events, including the establishment of patient safety centers, ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Nursing Care
Nursing is a profession within the health care sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life. Nurses may be differentiated from other health care providers by their approach to patient care, training, and scope of practice. Nurses practice in many specialties with differing levels of prescription authority. Nurses comprise the largest component of most healthcare environments; but there is evidence of international shortages of qualified nurses. Many nurses provide care within the ordering scope of physicians, and this traditional role has shaped the public image of nurses as care providers. Nurse practitioners are nurses with a graduate degree in advanced practice nursing. They are however permitted by most jurisdictions to practice independently in a variety of settings. Since the postwar period, nurse education has undergone a process of diversification towards advanced and ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Medical Error
A medical error is a preventable adverse effect of care (" iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment. Definitions The word ''error'' in medicine is used as a label for nearly all of the clinical incidents that harm patients. Medical errors are often described as human errors in healthcare. Whether the label is a medical error or human error, one definition used in medicine says that it occurs when a healthcare provider chooses an inappropriate method of care, improperly executes an appropriate method of care, or reads the wrong CT scan. It has been said that the definition should be the subject of more debate. For instance, studies of hand hygiene compliance of physicians in an ICU show that compliance varied from 19% to 85%. The deaths that result from infections caught as a result of treatment providers ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Latent Human Error
Latent human error is a term used in safety work and accident prevention, especially in aviation, to describe human errors which are likely to be made due to systems or routines that are formed in such a way that humans are disposed to making these errors. Latent human errors are frequently components in causes of accidents. The error is latent and may not materialize immediately, thus, latent human error does not cause immediate or obvious damage. Discovering latent errors is therefore difficult and requires a systematic approach. Latent human error is often discussed in aviation incident investigation, and contributes to over 70% of the accidents. By gathering data about errors made, then collating, grouping and analyzing them, it can be determined whether a disproportionate amount of similar errors are being made. If this is the case, a contributing factor may be disharmony between the respective systems/routines and human nature or propensities. The routines or systems can the ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
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