Validation Engineering Approaches for Reducing Medical Errors Viewing Medical Errors from a Context-of-Care Perspective

Abstract

The study of adverse incidents typically focuses on the person associated with the activity that precipitates the incident. This is despite the research and theory that indicates behavior is the product of the person interacting with the environment. This is changing somewhat — the term “systems” has become a buzzword for factors other than the person that contribute to error, particularly in addressing error in health care. This presentation describes the Artichoke Model, an evidence-based systems approach to understanding behavior. That model decomposes the context of an activity into 8 interacting hierarchal nested systems of factors. By analyzing an incident with respect to those systems, factors contributing to behavior that resulted in the incident can be identified and remedial activities instituted. Such activities can effectively reduce the likelihood of error because they are targeted to an identified rather than presumed contributor to error. Examples from the literature are discussed.