Medical error and harm understanding, prevention, and control
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| 1. Verfasser: | |
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| Format: | Buch |
| Sprache: | English |
| Veröffentlicht: |
Boca Raton, Fla. [u.a.]
CRC Press
2011
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| 020 | |a 1439836949 |9 1-4398-3694-9 | ||
| 035 | |a (OCoLC)730026875 | ||
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| 100 | 1 | |a Jenicek, Milos |e Verfasser |4 aut | |
| 245 | 1 | 0 | |a Medical error and harm |b understanding, prevention, and control |c Milos Jenicek |
| 264 | 1 | |a Boca Raton, Fla. [u.a.] |b CRC Press |c 2011 | |
| 300 | |a XXIII, 360 S. |b graph. Darst. | ||
| 336 | |b txt |2 rdacontent | ||
| 337 | |b n |2 rdamedia | ||
| 338 | |b nc |2 rdacarrier | ||
| 500 | |a "This book arrives at a time of heightened concerns about patient safety in medical care and the overall responsibility assumed by health professionals. It begins by exploring experiences of error and harm in general, and it covers medical errors that can be attributed to system failures and errors in an individual's reasoning, subsequent decision-making, and execution of tasks in medical care. It focuses on how to detect, correct, and avoid errors and their sometimes disastrous consequences. The book concludes with an analysis of the contributions and expectations of physicians in tort litigation and legal decision-making"--Provided by publisher. | ||
| 500 | |a Includes bibliographical references and index | ||
| 650 | 4 | |a Medical errors | |
| 650 | 4 | |a Medical Errors | |
| 650 | 4 | |a Medical Errors |x prevention & control | |
| 650 | 4 | |a Safety Management |x methods | |
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| 999 | |a oai:aleph.bib-bvb.de:BVB01-022552356 | ||
Datensatz im Suchindex
| _version_ | 1804145692151644160 |
|---|---|
| adam_text | Titel: Medical error and harm
Autor: Jenicek, Milos
Jahr: 2011
Contents
Author s
Very
Short
Introduction:
Minimizing
Errors
in
Medicine.........xv
1
Putting
Medical
Error
in
Context:
Minimizing
Errors
in
Medicine—Beyond
the
Oops!
Factor............................................1
Executive
Summary................................................................................1
Thoughts
to
Think
About.......................................................................2
Introductory
Comments:
Errors
as
Part
of
Advances
in
Medicine..........4
How
to
View
Medical
Errors
Today........................................................4
What
Is
Covered
in
This
Book................................................................6
Considering
the
Medical
Error
Problem
in
Light
of
Recent
Experience..............................................................................................6
Medical
Error
and
Patient
Safety............................................................9
How
This
Book
Might
Contribute
to
the
Present
State
of
Human
Error
Experience
and
Patient
Safety......................................................10
References.............................................................................................11
2
The
Valued
Legacy
of
Error
and
Harm
in
General:
Error
and
Harm
across
General
Human
Experience
in
Nonmedical
Domains—Welcome
to
Lathology..................................................15
Executive
Summary..............................................................................15
Thoughts
to
Think
About.....................................................................16
Introductory
Comments.......................................................................17
A
Brief
History
of
Recent
Human
Error
Experience.............................18
Definition
of
Human
Error
and
Other
Related
Terms..........................19
Note
about
Heterogeneity
of
Terms.............................................20
Note
about
Error
versus
Accident................................................20
Note
regarding
Error
versus
Adverse
Effect..................................26
Taxonomy
of
Error................................................................................26
Person
versus
System....................................................................27
vii
viii
?
Contents
Planning
versus
Execution...........................................................27
Expertise,
Its
Quality,
and
Uses...................................................28
Cognition
and
Cognitive
Process
as
a
Core
Source
of
Error
and
of
Its
Understanding
and
Control.............................................................28
Models
of
Error,
Their
Development,
and
Contributing
Sites
and
Entities
in
Context................................................................................30
Person-Oriented
Models..............................................................30
Rasmussen s
Model
of
Human
Activity
in
Relation
to
Error...................................................................................31
Person-Related
Errors
in
the
Domain
of
Skills,
Rules,
and
Knowledge...................................................................33
Models
of
Reasoning
and
Decision
Making
Related
to
Informal
Logic
and
Critical
Thinking:
Aristotle,
Toulmin,
Heuristics...........................................................33
Argument
and
Argumentation
Models
in
Optimal
Conditions..........................................................................34
System
Functioning-Oriented
Models,
or
One
Thing
Goes
with
and
Leads
to
Another .........................................................40
A
Practical
Example
of
an
Erroneous
Event
and
of
Its
Steps
as
Seen
through
Their
Identification
in
Various
Taxonomies
of
Error........................................................................................41
An
Epidemiological
Approach
to
the
Error
Problem.............................42
A
Word
about
Root
Cause
Analysis
and
Research.......................44
Beyond
Epidemiology:
Other
Models
of
Search
for
Causes.........45
Epidemiological
Implications
of
the
Error
Analysis
Problem.......46
Thought
Experiment:
A
Complement
to
Epidemiology?..............47
Implications
in
the
Search
for
Understanding,
Control,
and
Prevention
of
Error
Today.....................................................................47
In
the
Research
Domain..............................................................48
In
the
Control
and
Prevention
Domains......................................49
Conclusions:
Ensuing
State
of
the
Human
Error
Domain
Today.........49
References.............................................................................................51
3
Error
and
Harm
in
Health
Sciences:
Defining
and
Classifying
Human
Error
and
Its
Consequences
in
Clinical
and
Community
Settings.......................................................................57
Executive
Summary..............................................................................57
Thoughts
to
Think
About.....................................................................58
Introductory
Comments.......................................................................59
Overview
of
Our
Understanding
of
Error
Today..................................60
Contents
?
ix
Overview
of
Approaches
to
Error
in
Medicine......................................61
Definitions
of
Medical
Error,
Associated
Entities,
Terms......................62
Current
Definitions
of
Medical
Error
and
Medical
Harm...........63
Associated
Entities,
Terms,
and
Their
Definitions.......................64
Critical
Incident,
Error,
Harm:
Comments
on
Current
Terms
Used
in
Medical
Lathology..........................................................71
Variables
and
Their
Taxonomy
in
the
Medical
Error
Domain..............73
Migration
of
Error
Taxonomy
from
Industry
to
Health
Sciences:
An
Example..................................................................74
Medical
Error
and
Related
Factors
and
Variables:
Other
Approaches..................................................................................74
Taxonomy
by
Types,
Circumstances
and
Conditions,
Consequences,
and
Corrections
of
Medical
Error...............77
Slips
and
Mistake-Related
Taxonomy.................................77
Clinical
Factors
and
Specialty-Oriented
Taxonomies.........80
Exhaustive
and
Multi-Axial
Taxonomies............................81
Notes
about
Related
Variables
and
Contributing
and
Mitigating
Factors.......................................................................83
Note
about
Related
Variables..............................................84
Note
about
Contributing
and
Mitigating
Factors...............84
Conclusions:
Implications
of
Definitions
and
Taxonomy
for
Research
and
Management
of
the
Medical
Error
Domain....................85
References.............................................................................................88
4
Describing
Medical
Error
and
Harm:
Their
Occurrence
and
Nature
in
Clinical
and
Community
Settings..................................93
Executive
Summary..............................................................................93
Thoughts
to
Think
About.....................................................................94
Introductory
Comments.......................................................................95
Research,
Knowledge
Acquisition,
and
Intervention
Strategies
in
the
General
Error
Domain
as
Viewed
by
a
Methodologically
Minded
Physician
Epidemiologist.........................................................96
Descriptions
of
Single
Cases,
Small
Sets
of
Error
Cases,
and
Harm
Cases........................................................................................100
Choosing
a
Research
or
Intervention
Subject.............................100
Reporting
Unique,
Infrequent,
or
Rare
Cases
beyond
the
Customary
Methods
of
Clinical
Practice:
Case-Based
Qualitative
Research
and
Narrative
Methods
in
the
Area
of
Quality
Improvement................................................................103
Qualitative
Research.........................................................103
?
Contents
Case
Studies
of
Medical
Error
and
Harm.........................105
Two
Examples
of
Qualitative
Research
in
Medicine
and
in
the
Domain
of
Medical
Error................................107
Reporting
Single
Cases
of
Error
and
Harm
the
Medical
Way...........................................................................................108
Reporting
Case
Series
of
Error
and
Harm.................................110
Back
to
Epidemiology:
What
Happens
Now?
Occurrence
Studies,
Descriptive
Epidemiology,
Magnitude,
and
Distribution
( in
Whom,
Where,
and
When )
of
the
Error
and
Harm
Problem............112
A
Short
Epidemiological
Reminder............................................112
Incident
and
Incidence.....................................................113
Risk
and
Hazard...............................................................114
Error
and
Harm
Reporting
in
Hospital
Care.............................114
Error
and
Harm
Reporting
in
Primary
Care..............................115
Guidelines
for
Describing
and
Reporting
Medical
Error
and
Harm
Occurrence.........................................................................................116
Conclusion...........................................................................................119
References...........................................................................................121
Analyzing
Medical
Error
and
Harm:
Searching
for
Their
Causes
and
Consequences.............................................................127
Executive
Summary............................................................................127
Thoughts
to
Think
About...................................................................128
Introductory
Comments.....................................................................130
Searching
for
New
(Not
Yet
Known)
Causes
and
Consequences
of
Medical
Error
and
Harm:
Etiological
Research,
Analytical
Observational
Epidemiology...............................................................131
Challenge
of
Deriving
Cause—Effect
Relationships
from
One
or
Very
Few
Observations:
An
A
Priori
Causal
Attribution.....................139
Challenges
of
Limited
Causal
Proof
or
Causes
Yet
to
Be
Established.................................................................................139
Is
It
Possible
to
Estimate
and
Analyze
Probabilities
of
Rare
Events?.......................................................................................140
Single-Error
Event
or
Few
Error
Events
Reporting....................142
Offbeat
Searches
for
Causes:
Siding
with
Mainstream
Epidemiological
Experience................................................................142
Root
Cause
Analysis
in
the
Health
Domain..............................143
Other
Approaches
to
Cause—Effect
Studies
in
Lathology
through
Observational
Methods................................................149
Causal
Trees.....................................................................149
Probabilistic
Risk
Analysis.................................................151
Contents
?
xi
Significant-Event
Analysis................................................
152
Systems
Analysis:
Beyond
Incident
Reports
and
Root
Cause
Analysis..................................................................153
Experimental
Demonstration
of
Medical
Error
and
Harm
Causes
and
Its
Compromises
and
Alternatives.................................................155
No
Experimentation
or
Observational
Research
Is
Feasible?
Thought
Experiment
( What
If
Reasoning)
to
the
Rescue........................................................................................155
A
Word
about
Modeling
in
Epidemiology
and
Lathology.........156
Is
the
Mainstream
Epidemiological
Methodology
of
Causal
Research
Feasible
in
the
Domain
of
Medical
Error
and
Harm?..........157
Conclusions........................................................................................158
References...........................................................................................161
6
Flaws
in
Operator
Reasoning
and
Decision
Making
Underlying
Medical
Error
and
Harm...............................................................167
Executive
Summary............................................................................167
Thoughts
to
Think
About...................................................................168
Introductory
Comments.....................................................................170
Note
about
Medical
Error
and
Medical
Harm....................................171
System
Error
versus
Individual
Human
Error.....................................172
Reminder
regarding
Some
Fundamental
Considerations....................173
Flawed
Argumentation
and
Reasoning
as
Sites
and
Generators
of
Error
and
Harm:
Argumentation
and
Human
Error
and
Harm
Analysis
from
a
Logical
Perspective....................................................175
Mistakes
and
Errors
in
Medical
Lathology................................178
Fallacies,
Biases,
and
Cognitive
Errors
in
Medical
Lathology..................................................................................179
Where
and
When
Errors
Occur:
Cognitive
Pathways
as
Sites
of
Error...............................................................................................181
Reviewing
Diagnoses:
Searching
for
Errors
in
the
Clinimetric
Process.......................................................................................182
Reviewing
the
Path
from
Diagnosis
to
Treatment
Decisions
and
Orders.................................................................................188
Reviewing
Decisions
as
Sources
of
Error
and
Harm..................188
Reviewing
Actions
as
Sources
of
Error
and
Harm.....................190
Obtaining
Results
and
Evaluating
Their
Impact........................192
Errors
in
Making
Prognoses......................................................193
Follow-up,
Surveillance,
Forecasting-Related
Errors..................194
Conclusions........................................................................................195
References...........................................................................................199
xii
?
Contents
7
Prevention,
Intervention,
and
Control
of
Medical
Error
and
Harm:
Clinical
Epidemiological
Considerations
of
Actions
and
Their
Evaluation............................................................................203
Executive
Summary............................................................................203
Thoughts
to
Think
About...................................................................204
Introductory
Comments,
Interventions
in
the
Medical
Error
Domain..............................................................................................206
Basic
Definitions,
Concepts,
and
Strategies
of
Intervention
in
Lathology............................................................................................207
Two
Complementary
Strategies:
Human
Error
and
System
Failures......................................................................................209
Evaluation
of
Activities
in
Lathology.........................................210
Control
of
Medical
Error
and
Harm..........................................211
Prevention
of
Medical
Error
and
Harm.....................................211
Protection
of
Freedom
from
Medical
Error
and
Harm..............212
Promotion
of
Freedom
from
Medical
Error
and
Harm..............212
Basic
Angles
of
Evaluation
in
Lathology:
Structure,
Process,
Outcomes,
and
Other
Subjects
to
Evaluate.........................................212
What
Should
Be
Evaluated
at
the
Individual
Level:
Knowledge,
Attitudes,
and
Skills............................................................................213
Experimental,
Quasi-Experimental,
and
Nonexperimental
Evaluation
of
Interventions
to
Understand
and
Better
Control
Medical
Error
and
Harm
Problems.....................................................215
Randomized
or
Otherwise
Controlled
Clinical
Trials...............216
Natural
Experiment...................................................................217
Before-After
Studies..................................................................219
Case
Studies..............................................................................220
Healthcare
Failure
Mode
and
Effect
Analysis
(HFMEA)..........221
Systematic
Reviews
of
Evidence.................................................225
Conclusions
and
Recommendations...................................................225
References...........................................................................................227
8
Taking
Medical
Error
and
Harm
to
Court:
Contributions
and
Expectations
of
Physicians
in
Tort
Litigation
and
Legal
Decision
Making...........................................................................231
Executive
Summary............................................................................231
Thoughts
to
Think
About...................................................................232
Introductory
Comments.....................................................................234
Medical,
Surgical,
and
Public
Health
Malpractice
Claims
and
Litigation............................................................................................237
Medical
and
Surgical
Malpractice.............................................237
Contents
?
xiii
Public
Health
Malpractice.........................................................238
Language
of
Medicine
and
Law..........................................................239
General
Philosophy
and
Strategies
of
Medicine
and
Law....................241
Law
Process
and
Its
Stages..................................................................241
Happenings
and
Events
before
the
Trial....................................241
At
the
Trial................................................................................257
After
the
Trial............................................................................258
Cause-Effect
Relationships
in
Medicine
and
Law..............................258
Physicians
Roles
in
the
Judicial
Search
for
Causes....................260
Is
the
Causal
Link
under
Review
Strong
and
Specific
Enough?.....................................................................................262
What
Is
Sufficient
and
Best
Proof
for
Physicians
and
Lawyers?....................................................................................262
What
Do
Physicians
Think?.............................................262
What
Do
Lawyers
Think?................................................263
Disease
versus
Individual-Case
Causes:
Error
as
an
Entity
(in
General)
and
in
Specific
Cases.............................................265
Litigating
the
Argumentative
Way......................................................266
Disclosure
of
Medical
Errors:
Working
in
Law
and
Epidemiology
with
What
Is
Available........................................................................268
A
Difficult
Mix:
Medicine,
Ethics,
and
Law.......................................270
Conclusions........................................................................................271
References...........................................................................................273
Conclusions............................................................................................279
A
Brief
and
(Hopefully)
Harmonized
Glossary.....................................289
Appendix
A:
List
of
Cognitive
Biases.....................................................309
Appendix
B:
List
of
Fallacies...................................................................319
Appendix
C:
Medical
Error
and
Harm-Related
Case
Report................329
About
the
Author...................................................................................333
Index......................................................................................................335
|
| any_adam_object | 1 |
| author | Jenicek, Milos |
| author_facet | Jenicek, Milos |
| author_role | aut |
| author_sort | Jenicek, Milos |
| author_variant | m j mj |
| building | Verbundindex |
| bvnumber | BV037399640 |
| callnumber-first | R - Medicine |
| callnumber-label | R729 |
| callnumber-raw | R729.8 |
| callnumber-search | R729.8 |
| callnumber-sort | R 3729.8 |
| callnumber-subject | R - General Medicine |
| classification_rvk | XL 1500 |
| ctrlnum | (OCoLC)730026875 (DE-599)BVBBV037399640 |
| dewey-full | 610.28/9 |
| dewey-hundreds | 600 - Technology (Applied sciences) |
| dewey-ones | 610 - Medicine and health |
| dewey-raw | 610.28/9 |
| dewey-search | 610.28/9 |
| dewey-sort | 3610.28 19 |
| dewey-tens | 610 - Medicine and health |
| discipline | Medizin |
| format | Book |
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It begins by exploring experiences of error and harm in general, and it covers medical errors that can be attributed to system failures and errors in an individual's reasoning, subsequent decision-making, and execution of tasks in medical care. It focuses on how to detect, correct, and avoid errors and their sometimes disastrous consequences. 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| id | DE-604.BV037399640 |
| illustrated | Illustrated |
| indexdate | 2024-07-09T23:23:29Z |
| institution | BVB |
| isbn | 9781439836941 1439836949 |
| language | English |
| lccn | 2010018836 |
| oai_aleph_id | oai:aleph.bib-bvb.de:BVB01-022552356 |
| oclc_num | 730026875 |
| open_access_boolean | |
| owner | DE-355 DE-BY-UBR |
| owner_facet | DE-355 DE-BY-UBR |
| physical | XXIII, 360 S. graph. Darst. |
| publishDate | 2011 |
| publishDateSearch | 2011 |
| publishDateSort | 2011 |
| publisher | CRC Press |
| record_format | marc |
| spelling | Jenicek, Milos Verfasser aut Medical error and harm understanding, prevention, and control Milos Jenicek Boca Raton, Fla. [u.a.] CRC Press 2011 XXIII, 360 S. graph. Darst. txt rdacontent n rdamedia nc rdacarrier "This book arrives at a time of heightened concerns about patient safety in medical care and the overall responsibility assumed by health professionals. It begins by exploring experiences of error and harm in general, and it covers medical errors that can be attributed to system failures and errors in an individual's reasoning, subsequent decision-making, and execution of tasks in medical care. It focuses on how to detect, correct, and avoid errors and their sometimes disastrous consequences. The book concludes with an analysis of the contributions and expectations of physicians in tort litigation and legal decision-making"--Provided by publisher. Includes bibliographical references and index Medical errors Medical Errors Medical Errors prevention & control Safety Management methods Ärztlicher Kunstfehler (DE-588)4000617-7 gnd rswk-swf Ärztlicher Kunstfehler (DE-588)4000617-7 s DE-604 HBZ Datenaustausch application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=022552356&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis |
| spellingShingle | Jenicek, Milos Medical error and harm understanding, prevention, and control Medical errors Medical Errors Medical Errors prevention & control Safety Management methods Ärztlicher Kunstfehler (DE-588)4000617-7 gnd |
| subject_GND | (DE-588)4000617-7 |
| title | Medical error and harm understanding, prevention, and control |
| title_auth | Medical error and harm understanding, prevention, and control |
| title_exact_search | Medical error and harm understanding, prevention, and control |
| title_full | Medical error and harm understanding, prevention, and control Milos Jenicek |
| title_fullStr | Medical error and harm understanding, prevention, and control Milos Jenicek |
| title_full_unstemmed | Medical error and harm understanding, prevention, and control Milos Jenicek |
| title_short | Medical error and harm |
| title_sort | medical error and harm understanding prevention and control |
| title_sub | understanding, prevention, and control |
| topic | Medical errors Medical Errors Medical Errors prevention & control Safety Management methods Ärztlicher Kunstfehler (DE-588)4000617-7 gnd |
| topic_facet | Medical errors Medical Errors Medical Errors prevention & control Safety Management methods Ärztlicher Kunstfehler |
| url | http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=022552356&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA |
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