There is More to Error in Healthcare than the Care Provider

Abstract

Typically when an error occurs in healthcare, the care provider is considered the cause. Because that person committed the act that lead to the adverse outcome efforts to address the error are directed to that person. Indeed, human factors practitioners have developed remedial training and their medical device design activities have emphasized user interface design. This paper presents the case for expanding that focus based on the realization that the act of committing an error is a behavior and behavior reflects the interaction of the person and factors in the environment. The counterintuitive findings that more errors occur in prescribing medications with computer order entry than with handwritten script are discussed in terms of this approach.