S E Feldman1, D W Roblin. 1. Department of Surgery, University of California at San Francisco-Mt Zion Medical Center 94120, USA. sefmd@itsa.ucsf.edu
Abstract
BACKGROUND: Medical accidents can be understood as patient injuries that result from interaction of physician or nurse error during the provision of care with faults latent in the hospital system. Medical accidents are not random events but are events with discoverable associations between human error and system faults through application of methods of failure analysis in the evaluation of patient injuries. CASE ANALYSIS: The goal of a failure analysis is to make apparent system faults that are otherwise obscured. Analyses seek to answer several questions. What characteristics of the system failed to prevent a slip, mistake, or rule violation from evolving into an accident? What system changes might have offset, or prevented, the active error from contributing to the sequence of events culminating in injury? Brief descriptions of eight cases of apparent medical accidents are provided in this article. For three of these cases, the failure analysis approach is used to identify the sequence of events contributing to the patient injury; identify events within this sequence that represent active errors; and identify points within this sequence that represent system faults which failed to prevent the occurrence of subsequent events. CONCLUSIONS: Within the framework of current methods of hospital quality appraisal, attribution of patient injury historically has focused on clinician error. Yet unless detected and corrected, system faults persist and create circumstances of "accidents waiting to happen." Understanding of casual factors in the evolution of medical accidents can be usefully applied toward improvement in the quality of hospital appraisal of iatrogenic injuries and, through that application, toward reduction in the rates of adverse outcomes.
BACKGROUND: Medical accidents can be understood as patient injuries that result from interaction of physician or nurse error during the provision of care with faults latent in the hospital system. Medical accidents are not random events but are events with discoverable associations between human error and system faults through application of methods of failure analysis in the evaluation of patient injuries. CASE ANALYSIS: The goal of a failure analysis is to make apparent system faults that are otherwise obscured. Analyses seek to answer several questions. What characteristics of the system failed to prevent a slip, mistake, or rule violation from evolving into an accident? What system changes might have offset, or prevented, the active error from contributing to the sequence of events culminating in injury? Brief descriptions of eight cases of apparent medical accidents are provided in this article. For three of these cases, the failure analysis approach is used to identify the sequence of events contributing to the patient injury; identify events within this sequence that represent active errors; and identify points within this sequence that represent system faults which failed to prevent the occurrence of subsequent events. CONCLUSIONS: Within the framework of current methods of hospital quality appraisal, attribution of patient injury historically has focused on clinician error. Yet unless detected and corrected, system faults persist and create circumstances of "accidents waiting to happen." Understanding of casual factors in the evolution of medical accidents can be usefully applied toward improvement in the quality of hospital appraisal of iatrogenic injuries and, through that application, toward reduction in the rates of adverse outcomes.
Authors: James B Battles; Nancy M Dixon; Robert J Borotkanics; Barbara Rabin-Fastmen; Harold S Kaplan Journal: Health Serv Res Date: 2006-08 Impact factor: 3.402