Title :
Improving Health Care Systems Following An Incident Investigation
Author :
Shepherd, Marvin
Author_Institution :
Devteq Consulting, Walnut Creek, CA
Abstract :
All health care is delivered to patients through an assemblage of minisystems. (A minisystem is the smallest system that can deliver a single clinical benefit.) It is the failure of these minisystems that reportedly results in between 44,000 and 98,000 iatrogenic deaths in the United States [1], annually. Device-related, accident investigations are intended to identify the latent defects within these minisystems and to recommend corrective actions that will prevent a recurrence. A generic, system´s risk model has been developed for analyzing the performance of these minisystems. It provides the investigator with a mental model of the interacting components of the minisystem and provides a logical pathway toward the root causes of an adverse event. Of practical importance in using this model, is that operator error contributes to approximately 69% of the failures of health care minisystems [2] and a fundamental understanding of human factors and human error is required.
Keywords :
device; health care; human error; incident investigation; systems; Accidents; Assembly systems; Cognitive science; Error analysis; Human factors; Medical services; Performance analysis; Risk analysis; Safety devices;
Conference_Titel :
Engineering in Medicine and Biology Society, 2004. IEMBS '04. 26th Annual International Conference of the IEEE
Print_ISBN :
0-7803-8439-3
DOI :
10.1109/IEMBS.2004.1403982