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Taxonomy of Errors: Adverse Event/Near Miss Analysis

  • Dennis L. FowlerEmail author
Chapter

Abstract

Errors in healthcare delivery cause many deaths each year. These errors may be caused by individual lapses or mistakes that are inevitable or they may be caused by latent conditions within an organization. Any given error may result in either an adverse event or a near miss. The large difference in outcome between an error that causes harm and the same error that results in a near miss may be as simple as chance or may be related to the presence or absence of one or more latent conditions. Correcting or preventing latent conditions and maximizing the system’s defenses can either prevent errors or mitigate the consequences of errors and reduce subsequent harm.

Selected Readings

  1. 1.
    Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results from the Harvard medical practice study 1. 1991. Qual Saf Health Care. 2004;13:145–51.PubMedCrossRefGoogle Scholar
  2. 2.
    Leape LL, Brennan TA, Laird NM, et al. The nature of adverse events in hospitalized patients: results from the Harvard medical practice study II. NEJM. 1991;324:377–84.PubMedCrossRefGoogle Scholar
  3. 3.
    Reason J. Human error. New York: Cambridge University; 1990.Google Scholar
  4. 4.
    Reason J. Managing the risks of organizational accidents. Hampshire, England: Ashgate Publishing; 1997.Google Scholar
  5. 5.
    Institute of Medicine. To err is human. Kohn LT, Corrigan JM,Donaldson MS, editors. Washington, DC: National Academy Press; 1999.Google Scholar
  6. 6.
    Spencer FC. Human error in hospitals and industrial accidents: Current concepts. JACS. 2000;191:410–8.Google Scholar
  7. 7.
    Zhang J, Patel VL, Johnson TR, et al. Toward an action based taxonomy of human errors in medicine. In: Proc of 24th Conference of Cognitive Science Society; AMIA Annual Symposium Proceedings. 2002:934–938.Google Scholar
  8. 8.
    Reason J. Human error: models and management. BMJ. 2000;320:768–70.PubMedCrossRefGoogle Scholar
  9. 9.
    Reason J. Beyond the organisational accident: the need for “error wisdom” on the frontline. Qual Saf Health Care. 2004;13(Suppl II):ii28–33.PubMedCrossRefGoogle Scholar
  10. 10.
    Reason J. Safety in the operating theatre – Part 2: Human error and organisational failure. Qual Saf Health Care. 2005;14:56–61.PubMedGoogle Scholar
  11. 11.
    Brannick MT, Fabri PJ, Zayas-Castro J, et al. Evaluation of an error-reduction training program for surgical residents. Acad Med. 2009;84:1809–14.PubMedCrossRefGoogle Scholar
  12. 12.
    Cushieri A. Nature of human error implications for surgical practice. Ann Surg. 2006;244:642–8.CrossRefGoogle Scholar
  13. 13.
    Leape LL. Reporting of adverse events. N Engl J Med. 2002;347:1633–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Blendon RJ, DesRoches CM, Brodie M, et al. Views of practising physicians and the public on medical errors. N Engl J Med. 2002;347:1933–40.PubMedCrossRefGoogle Scholar
  15. 15.
    Bilimoria KY, Kmiecik TE, DaRosa DA, et al. Development of an Online Morbidity, Mortality, and Near-Miss Reporting System to Identify Patterns of Adverse Events in Surgical Patients. Arch Surg. 2009;144(4):305–11.PubMedCrossRefGoogle Scholar
  16. 16.
    McCafferty MH, Polk HC. Addition of “Near-Miss” Cases Enhances a Quality Improvement Conference. Arch Surg. 2004;139:216–7.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Department of SurgeryColumbia University College of Physicians and SurgeonsNew YorkUSA

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