Medical error and harm: understanding, prevention, and control

Abstract

Putting medical error and harm in context. Reducing errors and harm in medicine beyond the 'oops!' factor Errors as part of advances in medicine How can we look at and consider medical errors today What is covered in this book The view of medical error problem in the light of the recent experience Medical error and patient safety How this book might contribute to the present state of human error experience and patient safety The valued legacy. Error and harm across general human experience in the non-medical domains. Welcome to lathology. A brief history of the recent human error experience Definition of human error and other related terms Taxonomy of error Cognition and cognitive process at the core of error, and of its understanding and control Models of error, their development and contributing sites and entities in context An epidemiological approach to the error problem human error domain through the eyes of medicine and epidemiology Implications regarding the search for understanding, control and prevention of error today Ensuing state of the human error domain today Error and harm in the health sciences. Defining and classifying human error and its consequences in clinical and community settings Overview of our today understanding of error today Overview of approaches to error in medicine Definition of medical error Variables and their taxonomy in the medical error domain Describing medical error and harm. Their occurrence and nature in clinical and community settings Research, knowledge acquisition, and intervention strategies in the general error domain as viewed by a methodologically minded physician-epidemiologist Descriptions of single cases, small sets of error cases and harm cases Back to epidemiology: what happens now? Occurrence studies, descriptive epidemiology, magnitude and distribution ('in'whom, where and when') of the error and harm problem How to describe and report the occurrence of medical error and harm very brief guidelines Analyzing medical error and harm. Search for their causes and consequences Searching for new (yet unknown) causes and consequences of medical error and harm etiological research, analytical observational epidemiology Challenge of deriving cause-effect relationships from one or very few past observations a priori causal attribution Off beat searches for causes siding with mainstream epidemiological experience Experimental demonstration of medical error and harem causes and its compromises and alternatives Is the mainstream epidemiological methodology of causal research feasible in the domain of medical error and harm? Flaws in operator's reasoning and decision making before action Note about medical error and medical harm System error vs. individual human error Reminder regarding some fundamental considerations Flawed argumentation and reasoning as sites and generators of error and harm argumentation and human error and harm analysis from a logical perspective Where and when errors occur. Cognitive pathways as sites of error Prevention, intervention and control of medical error and harm. Clinical epidemiological considerations of actions and their evaluation Basic definitions, concepts and strategies of intervention in lathology Basic angles of evaluation in lathology: Structure, process, outcomes, and other subjects to evaluate What should be evaluated at the individual level: knowledge, attitudes, and skills Experimental, quasi-experimental and non-experimental evaluation of interventions to understand and better control medical error and harm problems Taking medical error and harm to court. Contributions of physicians and expectations of physicians in tort litigation and legal decision-making Medical, surgical and public health malpractice claims and litigation Language of medicine and law General philosophy and strategies of medicine and law The law process and its stages Cause-effect relationships in medicine and law Litigating the argumentative way Disclosure of medical errors: Working in law and epidemiology with what is available A difficult mix: medicine, ethics and law Conclusions Challenges in focus Confounding error and harm Persisting diversity of semantics and taxonomy Lack of epidemiology Dichotomy in lathology Lack of training in lathology Better knowledge, attitudes and skills in the management of error and harm A need for better knowledge of cases of error and harm Challenge of communication Interaction between stakeholders in the error and harm domain in medicine Psychological, social and legal challenges to perpetrators of error and creators of harm Material gains and losses related to error and harm Possible ethical challenges Individual human error vs. system error Lack of pragmatic choices regarding what to do in lathology Unexpected roles, uses and potentials of logic, critical thinking and evidence in generating error management activities Legal considerations A Brief and (hopefully) Harmonized Glossary Appendices