The Essentials of Patient Safety - Clinical Human Factors Group

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The Essentials of Patient Safety did it happen (the contributory factors). The investigator needs to differentiate between those contributory factors that are only relevant on that particular occasion and those which are longstanding or permanent features of the unit. For instance there may be a failure of communication between two midwives which might be an isolated occurrence or might reflect a more general pattern of poor communication on the unit. Ideally the patient, or a member of their family, should also be interviewed though as yet this does not often happen. From accident analysis to system design We are now at a transitional point in the book between the understanding and analysis of incidents and the coming chapters which discuss methods of prevention and quality improvement. The seven levels framework has outlined the patient, task and technology, staff, team, working environment, organisational and institutional environmental factors that are revealed in analyses of incidents. These same factors also point to the means of intervention and different levels on which safety and quality must be addressed, which we will illustrate in the next two chapters. KEY POINTS An error is something realised only after the event Slips and lapses are errors of action and memory Mistakes are errors of knowledge and planning Errors can only be properly understood in context Patient, task, individual, team, environment, organisational and institutional context factors may all influence incidents and accidents References 1. Cook RI, Woods DD, Miller CA. A tale of two stories: contrasting views of patient safety, US National Patient Safety Foundation 1998. 2. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. British Medical Journal. 1998;316(7138):1154-7. 3. Woods DD, Cook RI. Nine steps to move forward from error. Cognition Technology and Work, 2002;4(2):137-44. 4. Senders JW, Moray N. Human error: course, prediction and reduction. Hillsdale, NJ: Lawrence Earlbaum Associates; 1991. 5. Hollnagel E. Cognitive reliability and error analysis method. Oxford: Elsevier; 1998. 26
The Essentials of Patient Safety 6. Reason JT. Human error. New York: Cambridge University Press; 1990. 7. Reason JT. Human error: models and management. British Medical Journal, 2000;320(7237):768-70. 8. Reason JT. Managing the risks of organisational accidents. Aldershot: Ashgate; 1997. 9. Toft B. External inquiry into the adverse incident that occured at Queen's Medical Centre, Nottingham. London: Department of Health, 2001. 10. Reason JT. Understanding adverse events: the human factor. In: Vincent C, editor. Clinical risk management: Enhancing patient safety. London: BMJ Books; 2001. p. 9-30. 11. Vincent CA. Analysis of clinical incidents: a window on the system not a search for root causes. Quality and Safety in Health Care, 2004;13(4):242-3. 27
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