Pediatric Informatics: Computer Applications in Child Health (Health ...

Chapter 29
Understanding and Preventing Errors
Michael Apkon
Objectives
To provide a framework for understanding and studying errors and risk
To discuss root cause analysis and Failure Modes and Effects Analysis in terms
of the framework
To outline and illustrate the place of informatics in error-proofing processes
29.1 Introduction
Medical care requires the coordinated action of many actors to provide fail-safe
care across time, space, and specialty. Patients are subjected to dangerous procedures
and potentially toxic medications where the margins of safety are thin. The
processes we use to decide which procedures and medications are appropriate as
well as those used to perform or deliver them effectively rely on people to perform
flawlessly regardless of the environmental and system factors that hinder performance.
The results are inevitable: error and failure are inescapable properties of the
healthcare system. Lucien Leape 1 reminds us that we must “accept the notion that
error is an inevitable accompaniment of the human condition, even among conscientious
professionals with high standards.” However, each error or failure also
provides an opportunity to learn how complex systems function and to develop
strategies that will reduce the likelihood and risk of failure. Whereas failure is
inevitable, learning is optional.
29.2 Failures, Errors, Accidents, and Risk Reduction
A number of terms can be used to describe breakdowns of the processes of care,
only some of which put patients or staff at risk. Failure refers to a condition where
a desired outcome is not achieved. Whereas failure represents a property of the
overall system, errors refer to a deviation from the most appropriate action or sets
C.U. Lehmann et al. (eds.), Pediatric Informatics: Computer Applications 369
in Child Health, Health Informatics,
© Springer Science + Business Media, LLC 2009