Advertisement

General Principles of How Errors Occur and How They May Be Reduced

  • Maxwell L. Smith
  • Stephen S. Raab
Chapter

Abstract

This introductory chapter covers general principles of how errors occur and how they can potentially be prevented. The definition of medical error is reviewed, and various classification schemas for the identification of different error types are investigated. Two well-known error causation models are compared and contrasted. The second half of the chapter focuses on error detection methodology and potential ways to reduce errors. Various quality improvement methods are reviewed. Finally, the challenging concept cognitive errors at the interpretative level are evaluated.

Keywords

Error Lean Quality Swiss cheese Heinrich Eindhoven 

References

  1. 1.
    Kohn LT, Corrigan J, Donaldson MS. To err is human: building a safer health system. Washington, D.C.: National Academy Press; 2000:xxi, 287 p.Google Scholar
  2. 2.
    McDonald CJ, Weiner M, Hui SL. Deaths due to medical errors are exaggerated in Institute of Medicine report. JAMA. 2000;284:93–5.CrossRefGoogle Scholar
  3. 3.
    Sussman I, Prystowsky MB. Pathology service line: a model for accountable care organizations at an academic medical center. Hum Pathol. 2012;43:629–31.CrossRefGoogle Scholar
  4. 4.
    Stroobants AK, Goldschmidt HM, Plebani M. Error budget calculations in laboratory medicine: linking the concepts of biological variation and allowable medical errors. Clin Chim Acta. 2003;333:169–76.CrossRefGoogle Scholar
  5. 5.
    Smith ML, Raab SS. Assessment of latent factors contributing to error: addressing surgical pathology error wisely. Arch Pathol Lab Med. 2011;135:1436–40.CrossRefGoogle Scholar
  6. 6.
    Smith ML, Wilkerson T, Grzybicki DM, Raab SS. The effect of a Lean quality improvement implementation program on surgical pathology specimen accessioning and gross preparation error frequency. Am J Clin Pathol. 2012;138:367–73.CrossRefGoogle Scholar
  7. 7.
    Headrick LA, Barton AJ, Ogrinc G, et al. Results of an effort to integrate quality and safety into medical and nursing school curricula and foster joint learning. Health Aff. 2012;31:2669–80.CrossRefGoogle Scholar
  8. 8.
    Zarbo RJ, Meier FA, Raab SS. Error detection in anatomic pathology. Arch Pathol Lab Med. 2005;129:1237–45.PubMedPubMedCentralGoogle Scholar
  9. 9.
    novis DA, konstantakos G. Reducing errors in the practices of pathology and laboratory medicine: an industrial approach. Am J Clin Pathol. 2006;126:S30–5.Google Scholar
  10. 10.
    Lundberg GD. Acting on significant laboratory results. JAMA. 1981;245:1762–3.CrossRefGoogle Scholar
  11. 11.
    Valenstein P, College of American Pathologists. Quality management in clinical laboratories: promoting patient safety through risk reduction and continuous improvement. Northfield: College of American Pathologists; 2005:vii, 257 p.Google Scholar
  12. 12.
    Battles JB, Kaplan HS, Van der Schaaf TW, Shea CE. The attributes of medical event-reporting systems: experience with a prototype medical event-reporting system for transfusion medicine. Arch Pathol Lab Med. 1998;122:231–8.PubMedGoogle Scholar
  13. 13.
    Meier FA, Zarbo RJ, Varney RC, et al. Amended reports: development and validation of a taxonomy of defects. Am J Clin Pathol. 2008;130:238–46.CrossRefGoogle Scholar
  14. 14.
    Reason J. Human error: models and management. BMJ. 2000;320:768–70.CrossRefGoogle Scholar
  15. 15.
    Perneger TV. The Swiss cheese model of safety incidents: are there holes in the metaphor? BMC Health Serv Res. 2005;5:71.CrossRefGoogle Scholar
  16. 16.
    Heinrich HW. Industrial accident prevention: a scientific approach. New York: McGraw-Hill; 1931.Google Scholar
  17. 17.
    Manuele F. Reviewing Heinrich: dislodging two myths from practice to safety. Prof Saf. 2011;10:52–61.Google Scholar
  18. 18.
    Davies HT, Nutley SM, Mannion R. Organisational culture and quality of health care. Qual Health Care: QHC. 2000;9:111–9.CrossRefGoogle Scholar
  19. 19.
    Milligan F, Dennis S. Building a safety culture. Nurs Stand. 2005;20:48–52.CrossRefGoogle Scholar
  20. 20.
    Kaufman G, McCaughan D. The effect of organisational culture on patient safety. Nurs Stand. 2013;27:50–6.CrossRefGoogle Scholar
  21. 21.
    Zardawi IM, Bennett G, Jain S, Brown M. Internal quality assurance activities of a surgical pathology department in an Australian teaching hospital. J Clin Pathol. 1998;51:695–9.CrossRefGoogle Scholar
  22. 22.
    Hollnagel E. Safety-I and safety-II: the past and future of safety management. Boca Raton: CRC Press; 2014.Google Scholar
  23. 23.
    Weick KE, Sutcliffe KM. Managing the unexpected: sustained performance in a complex world. 3rd ed. Hoboken: John Wiley & Sons, Inc.; 2015.Google Scholar
  24. 24.
    Raab SS, Stone CH, Wojcik EM, et al. Use of a new method in reaching consensus on the cause of cytologic-histologic correlation discrepancy. Am J Clin Pathol. 2006;126:836–42.CrossRefGoogle Scholar
  25. 25.
    Kaplan HS, Battles JB, Van der Schaaf TW, Shea CE, Mercer SQ. Identification and classification of the causes of events in transfusion medicine. Transfusion. 1998;38:1071–81.CrossRefGoogle Scholar
  26. 26.
    Liker JK. The Toyota way: 14 management principles from the world’s greatest manufacturer. New York: McGraw-Hill; 2004:xxii, 330 p.Google Scholar
  27. 27.
    Spear SJ, Bowen HK. Decoding the DNA of the Toyota production system. Harv Bus Rev. 1999;77:97–106.Google Scholar
  28. 28.
    Zarbo RJ. The oncologic pathology report. Quality by design. Arch Pathol Lab Med. 2000;124:1004–10.PubMedGoogle Scholar
  29. 29.
    Kahneman D. Thinking, fast and slow. 1st ed. New York: Farrar, Straus and Giroux; 2011:499 p.Google Scholar
  30. 30.
    Zarbo RJ. Leaders wanted: a call to change the status quo in approaching health care quality, once again. Am J Clin Pathol. 2010;134:361–5.CrossRefGoogle Scholar
  31. 31.
    Luft HS. Economic incentives to promote innovation in healthcare delivery. Clin Orthop Relat Res. 2009;467:2497–505.CrossRefGoogle Scholar
  32. 32.
    Raab SS, Stone CH, Jensen CS, et al. Double slide viewing as a cytology quality improvement initiative. Am J Clin Pathol. 2006;125:526–33.CrossRefGoogle Scholar

Copyright information

© Mayo Foundation for Medical Education and Research 2019

Authors and Affiliations

  • Maxwell L. Smith
    • 1
  • Stephen S. Raab
    • 2
  1. 1.Department of Laboratory Medicine and PathologyMayo Clinic ArizonaScottsdaleUSA
  2. 2.Department of PathologyUniversity of Mississippi Medical CenterJacksonUSA

Personalised recommendations