Reducing and Mitigating Human Error in Medicine

Abstract

Although precise definitions and models of human error in medicine remain elusive, there is little doubt that adverse events, sometimes involving human error, threaten patient safety and can be addressed by human factors approaches to error. In this chapter, we combine an information-processing framework that identifies perceptual, cognitive, and behavioral requirements of operators involved in health care activities with a system-based perspective that helps define when these needs are met by the health care context. We focus on errors and adverse events related to four broad areas of medical activities: medical device use, medication use, team collaboration, and diagnostic/decision support. For each area, we review evidence for specific error types, operator and system factors that contribute to these errors, and possible mitigating strategies related to design and training interventions that enable health care systems to better meet operators' perceptual, cognitive, and behavioral needs. This review reveals progress in identifying sources of human error and developing mitigating strategies in the areas of medical device and medication use, in part because of tools from human factors engineering that identify user needs and how to design environments to support them. Much less is known about how error emerges from work practices in complex settings, such as collaboration among team members. There is a need for theoretical frameworks to analyze error in the context of routine work practices. Such frameworks will bridge cognitive analyses of individual operators and tasks and more comprehensive theories of organizations, to guide interventions that target medical error at multiple levels.