Medical Error and Harm: Understanding, Prevention, and Control

by Milos Jenicek

Overview

Recent debate over healthcare and its spiraling costs has brought medical error into the spotlight as an indicator of everything that is ineffective, inhumane, and wasteful about modern medicine. But while the tendency is to blame it all on human error, it is a much more complex problem that involves overburdened systems, constantly changing technology, increasing specialization, and a cycle of continual funding shortfalls made even more acute by resource-wasting inefficiencies.

Medical Error and Harm: Understanding, Prevention and Control, presents the work of long time physician and teacher Milos Jenicek, a pioneering expert on epidemiology, evidence-based medicine, and critical thinking and decision making in the health sciences. Providing an extraordinarily comprehensive overview of the subject that is as thorough and scientifically organized as it is accessible and free of rhetoric, Dr. Jenicek —

• Presents a short history of error in general across various domains of human activity and endeavor, including concepts, methodologies of study, and management applications
• Provides semantic and taxonomic classifications of challenges in medical error and harm, two distinct domains
• Explores approaches used to investigate and ameliorate challenges in medicine and other health sciences
• Explains why, when, and how studies and decisions regarding errors should be carried out, such as whether risk assessment should be undertaken in the diagnosis, treatment, or prognosis stage
• Covers essential strategies for mitigating errors in the broader framework of medical care, specifically in community medicine and public health
• Considers the ever-growing role of physicians in tort law and litigation

The book also discusses whether dealing with errors is a learned skill and looks at how much of the problem with medical error is caused by the medical community’s failure to teach, learn, and understand everything there is to know about medical error, including the often neglected importance of critical thinking skills. Understanding and correcting this shortfall is a primary responsibility of every health professional, one they can begin to realize with the study of these pages.

Product Details

ISBN-13:	9781439836941
Publisher:	Taylor & Francis
Publication date:	07/02/2010
Edition description:	New Edition
Pages:	384
Product dimensions:	6.00(w) x 9.00(h) x (d)

Table of Contents

Author's Very Short Introduction: Minimizing Errors in Medicine xv

1 Putting Medical Error in Context: Minimizing Errors in Medicine-Beyond the "Oops!" Factor 1

Executive Summary 1

Thoughts to Think About 2

Introductory Comments: Errors as Part of Advances in Medicine 4

How to View Medical Errors Today 4

What Is Covered in This Book 6

Considering the Medical Error Problem in Light of Recent Experience 6

Medical Error and Patient Safety 9

How This Book Might Contribute to the Present State of Human Error Experience and Patient Safety 10

References 11

2 The Valued Legacy of Error and Harm in General: Error and Harm across General Human Experience in Nonmedical Domains-Welcome to Lathology 15

Executive Summary 15

Thoughts to Think About 16

Introductory Comments 17

A Brief History of Recent Human Error Experience 18

Definition of Human Error and Other Related Terms 19

Note about Heterogeneity of Terms 20

Note about Error versus Accident 20

Note regarding Error versus Adverse Effect 26

Taxonomy of Error 26

Person versus System 27

Planning versus Execution 27

Expertise, Its Quality, and Uses 28

Cognition and Cognitive Process as a Core Source of Error and of Its Understanding and Control 28

Models of Error, Their Development, and Contributing Sites and Entities in Context 30

Person-Oriented Models 30

Rasmussen's Model of Human Activity in Relation to Error 31

Person-Related Errors in the Domain of Skills, Rules, and Knowledge 33

Models of Reasoning and Decision Making Related to Informal Logic and Critical Thinking: Aristotle, Toulmin, Heuristics 33

Argument and Argumentation Models in Optimal Conditions 34

System Functioning-Oriented Models, or "One Thing Goes with and Leads to Another" 40

A Practical Example of an Erroneous Event and of Its Steps as Seen through Their Identification in Various Taxonomies of Error 41

An Epidemiological Approach to the Error Problem 42

A Word about. Root Cause Analysis and Research 44

Beyond Epidemiology: Other Models of Search for Causes 45

Epidemiological Implications of the Error Analysis Problem 46

Thought Experiment: A Complement to Epidemiology? 47

Implications in the Search for Understanding, Control and Prevention of Error Today 47

In the Research Domain 48

In the Control and Prevention Domains 49

Conclusions: Ensuing State of the Human Error Domain Today 49

References 51

3 Error and Harm in Health Sciences: Defining and Classifying Human Error and Its Consequences in Clinical and Community Settings 57

Executive Summary 57

Thoughts to Think About 58

Introductory Comments 59

Overview of Our Understanding of Error Today 60

Overview of Approaches to Error in Medicine 61

Definitions of Medical Error, Associated Entities, Terms 62

Current Definitions of Medical Error and Medical Harm 63

Associated Entities, Terms, and Their Definitions 64

Critical Incident, Error, Harm: Comments on Current Terms Used in Medical Lathology 71

Variables and Their Taxonomy in the Medical Error Domain 73

Migration of Error Taxonomy from Industry to Health Sciences: An Example 74

Medical Error and Related Factors and Variables: Other Approaches 74

Taxonomy by Types, Circumstances and Conditions, Consequences, and Corrections of Medical Error 77

Slips and Mistake-Related Taxonomy 77

Clinical Factors and Specialty-Oriented Taxonomies 80

Exhaustive and Multi-Axial Taxonomies 81

Notes about Related Variables and Contributing and Mitigating Factors 83

Note about Related Variables 84

Note about Contributing and Mitigating Factors 84

Conclusions: Implications of Definitions and Taxonomy for Research and Management of the Medical Error Domain 85

References 88

4 Describing Medical Error and Harm: Their Occurrence and Nature in Clinical and Community Settings 93

Executive Summary 93

Thoughts to Think About 94

Introductory Comments 95

Research, Knowledge Acquisition, and Intervention Strategies in the General Error Domain as Viewed by a Methodologically Minded Physician Epidemiologist 96

Descriptions of Single Cases, Small Sets of Error Cases, and Harm Cases 100

Choosing a Research or Intervention Subject 100

Reporting Unique, Infrequent, or Rare Cases beyond the Customary Methods of Clinical Practice: Case-Based Qualitative Research and Narrative Methods in the Area of Quality Improvement 103

Qualitative Research 103

Case Studies of Medical Error and Harm 105

Two Examples of Qualitative Research in Medicine and in the Domain of Medical Error 107

Reporting Single Cases of Error and Harm the "Medical" Way 108

Reporting Case Series of Error and Harm 110

Back to Epidemiology: What Happens Now? Occurrence Studies, Descriptive Epidemiology, Magnitude, and Distribution ("in Whom, Where, and When") of the Error and Harm Problem 112

A Short Epidemiological Reminder 112

Incident and Incidence 113

Risk and Hazard 114

Error and Harm Reporting in Hospital Care 114

Error and Harm Reporting in Primary Care 115

Guidelines for Describing and Reporting Medical Error and Harm Occurrence 116

Conclusion 119

References 121

5 Analyzing Medical Error and Harm: Searching for Their Causes and Consequences 127

Executive Summary 127

Thoughts to Think About 128

Introductory Comments 130

Searching for "New" (Not Yet Known) Causes and Consequences of Medical Error and Harm: Etiological Research, Analytical Observational Epidemiology 131

Challenge of Deriving Cause-Effect Relationships from One or Very Few Observations: An A Priori Causal Attribution 139

Challenges of Limited Causal Proof or Causes Yet to Be Established 139

Is It Possible to Estimate and Analyze Probabilities of Rare Events? 140

Single-Error Event or Few Error Events Reporting 142

Offbeat Searches for Causes: Siding with Mainstream Epidemiological Experience 142

Root Cause Analysis in the Health Domain 143

Other Approaches to Cause-Effect Studies in Lathology through Observational Methods 149

Causal Trees 149

Probabilistic Risk Analysis 151

Significant-Event Analysis 152

Systems Analysis: Beyond Incident Reports and Root Cause Analysis 153

Experimental Demonstration of Medical Error and Harm Causes and Its Compromises and Alternatives 155

No Experimentation or Observational Research Is Feasible? Thought Experiment ("What If" Reasoning) to the Rescue 155

A Word about Modeling in Epidemiology and Lathology 156

Is the Mainstream Epidemiological Methodology of Causal Research Feasible in the Domain of Medical Error and Harm? 157

Conclusions 158

References 161

6 Flaws in Operator Reasoning and Decision Malting Underlying Medical Error and Harm 167

Executive Summary 167

Thoughts to Think About 168

Introductory Comments 170

Note about Medical Error and Medical Harm 171

System Error versus Individual Human Error 172

Reminder regarding Some Fundamental Considerations 173

Flawed Argumentation and Reasoning as Sites and Generators of Error and Harm: Argumentation and Human Error and Harm Analysis from a Logical Perspective 175

Mistakes and Errors in Medical Lathology 178

Fallacies, Biases, and Cognitive Errors in Medical Lathology 179

Where and When Errors Occur: Cognitive Pathways as Sites of Error 181

Reviewing Diagnoses: Searching for Errors in the Clinimetric Process 182

Reviewing the: Path from Diagnosis to Treatment Decisions and Orders 188

Reviewing Decisions as Sources of Error and Harm 188

Reviewing Actions as Sources of Error and Harm 190

Obtaining Results and Evaluating Their Impact 192

Errors in Making Prognoses 193

Follow-up, Surveillance, Forecasting-Related Errors 194

Conclusions 195

References 199

7 Prevention, Intervention, and Control of Medical Error and Harm: Clinical Epidemiological Considerations of Actions and Their Evaluation 203

Executive Summary 203

Thoughts to Think About 204

Introductory Comments, Interventions in the Medical Error Domain 206

Basic Definitions, Concepts, and Strategies of Intervention in Lathology 207

Two Complementary Strategies: Human Error and System Failures 209

Evaluation of Activities in Lathology 210

Control of Medical Error and Harm 211

Prevention of Medical Error and Harm 211

Protection of Freedom from Medical Error and Harm 212

Promotion of Freedom from Medical Error and Harm 212

Basic Angles of Evaluation in Lathology: Structure, Process, Outcomes, and Other Subjects to Evaluate 212

What Should Be Evaluated at the Individual Level: Knowledge, Attitudes, and Skills 213

Experimental, Quasi-Experimental, and Nonexperimental Evaluation of Interventions to Understand and Better Control Medical Error and Harm Problems 215

Randomized or Otherwise Controlled Clinical Trials 216

Natural Experiment 217

Before-After Studies 219

Case Studies 220

Healthcare Failure Mode and Effect Analysis (HFMEA) 221

Systematic Reviews of Evidence 225

Conclusions and Recommendations 225

References 227

8 Taking Medical Error and Harm to Court: Contributions and Expectations of Physicians in Tort Litigation and Legal Decision Making 231

Executive Summary 231

Thoughts to Think About 232

Introductory Comments 234

Medical, Surgical, and Public Health Malpractice Claims and Litigation 237

Medical and Surgical Malpractice 237

Public Health Malpractice 238

Language of Medicine and Law 239

General Philosophy and Strategies of Medicine and Law 241

Law Process and Its Stages 241

Happenings and Events before the Trial 241

At the Trial 257

After the Trial 258

Cause-Effect Relationships in Medicine and Law 258

Physicians' Roles in the Judicial Search for Causes 260

Is the Causal Link under Review Strong and Specific Enough? 262

What Is Sufficient and Best Proof for Physicians and Lawyers? 262

What Do Physicians Think? 262

What Do Lawyers Think? 263

Disease versus Individual-Case Causes: Error as an Entity (in General) and in Specific Cases 265

Litigating the Argumentative Way 266

Disclosure of Medical Errors: Working in Law and Epidemiology with What Is Available 268

A Difficult Mix: Medicine, Ethics, and Law 270

Conclusions 271

References 273

Conclusions 279

A Brief and (Hopefully) Harmonized Glossary 289

Appendix A List of Cognitive Biases 309

Appendix B List of Fallacies 319

Appendix C Medical Error and Harm-Related Case Report 329

About the Author 333

Index 335

What People are Saying About This

From the Publisher

… authored by a well-known physician and professor at the DeGroote School of Medicine in Ontario, Canada. Dr Jenicek begins with a review of human errors in general and then continues with a review of medical errors and the negative outcomes that follow … . The author reviews the history of medical errors and definitions by using an epidemiologic approach. He starts with a review of errors that cause traffic accidents and industrial injuries. … He also explores possible causes of medical errors, including human error or lapses in judgment and the rapid technologic growth currently observed in medicine, especially in the subspecialty areas. The author also presents numerous frameworks that can be used to identify the medical error type, possible causes, and various solutions. … Finally, he discusses medical-legal consequences of errors and how tort law has evolved over time.
—Shauna Ely Tarrac MSN, RN, CIC, CNOR, in the AORN Journal, April 2011

Jenicek makes a valiant effort to impose some order on the diverse nomenclature of lathology and delves into the difficult task of taxonomy of this subject.
—John P. A. Ioannidis, in The Lancet

Editorial Reviews

… authored by a well-known physician and professor at the DeGroote School of Medicine in Ontario, Canada. Dr Jenicek begins with a review of human errors in general and then continues with a review of medical errors and the negative outcomes that follow … . The author reviews the history of medical errors and definitions by using an epidemiologic approach. He starts with a review of errors that cause traffic accidents and industrial injuries. … He also explores possible causes of medical errors, including human error or lapses in judgment and the rapid technologic growth currently observed in medicine, especially in the subspecialty areas. The author also presents numerous frameworks that can be used to identify the medical error type, possible causes, and various solutions. … Finally, he discusses medical-legal consequences of errors and how tort law has evolved over time.
—Shauna Ely Tarrac MSN, RN, CIC, CNOR, in the AORN Journal, April 2011

Jenicek makes a valiant effort to impose some order on the diverse nomenclature of lathology and delves into the difficult task of taxonomy of this subject.
—John P. A. Ioannidis, in The Lancet

From the Publisher