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Systems Dysfunction Common Cause of Errors
Probably in any field of human endeavor, systems dysfunction is the biggest source of errors, not individual errors. This is illustrated by this abstract. The data was collected from studying Family Practitioners (FP). Problems in the health care system is the biggest source of injury and death in the health care industry.
Qual Saf Health Care 2002 Sep;11(3):233-238
A preliminary taxonomy of medical errors in family practice.
Dovey SM, Meyers DS, Phillips RL Jr, Green LA, Fryer GE, Galliher JM, Kappus J, Grob
P.
SETTING: The National Network for Family Practice and Primary Care Research. PARTICIPANTS: Family physicians. MAIN OUTCOME MEASURES: Medical error category, context, and consequence. RESULTS: Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failures (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died.
CONCLUSIONS: This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.
Example of Diagnostic Error False Positive Biopsy Prescription Error Systems Errors Flying Infusion Pump Printed Prescription Medical Errors a National Problem Compunding Medication Error Pediatric Surgery Errors
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