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 of cognitive errors at the interpretative level is evaluated.
This is a preview of subscription content, log in via an institution to check access.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Kohn LT, Corrigan J, Donaldson MS. To err is human: building a safer health system. Washington, D.C.: National Academy Press; 2000.
McDonald CJ, Weiner M, Hui SL. Deaths due to medical errors are exaggerated in Institute of Medicine report. JAMA. 2000;284(1):93–5.
Sussman I, Prystowsky MB. Pathology service line: a model for accountable care organizations at an academic medical center. Human Pathol. 2012;43(5):629–31.
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(2):169–76 (Review).
Smith ML, Raab SS. Assessment of latent factors contributing to error: addressing surgical pathology error wisely. Arch Pathol Lab Med. 2011;135(11):1436–40.
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(3):367–73.
Headrick LA, Barton AJ, Ogrinc G, Strang C, Aboumatar HJ, Aud MA, et al. Results of an effort to integrate quality and safety into medical and nursing school curricula and foster joint learning. Health Aff (Millwood). 2012;31(12):2669–80 (Research Support, Non-U.S. Gov’t).
Zarbo RJ, Meier FA, Raab SS. Error detection in anatomic pathology. Arch Pathol Lab Med. 2005;129(10):1237–45 (Research Support, U.S. Gov’t, P.H.S.).
Novis DA, Konstantakos G. Reducing errors in the practices of pathology and laboratory medicine: an industrial approach. Am J Clin Pathol. 2006;126(Suppl 1):S30–5.
Lundberg GD. Acting on significant laboratory results. JAMA. 1981;245(17):1762–3 (Comparative Study Editorial).
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.
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(3):231–8 (Research Support, U.S. Gov’t, P.H.S.).
Meier FA, Zarbo RJ, Varney RC, Bonsal M, Schultz DS, Vrbin CM, et al. Amended reports: development and validation of a taxonomy of defects. Am J Clin Pathol. 2008;130(2):238–46 (Research Support, U.S. Gov’t, P.H.S. Validation Studies).
Reason J. Human error: models and management. BMJ. 2000;320(7237):768–70.
Perneger TV. The Swiss Cheese model of safety incidents: are there holes in the metaphor? BMC Health Serv Res. 2005;5:71.
Heinrich HW. Industrial accident prevention: a scientific approach. New York: McGraw-Hill; 1931.
Manuele F. Reviewing Heinrich: dislodging two myths from practice to safety. Prof Saf. 2011(Oct 2011):52–61.
Davies HT, Nutley SM, Mannion R. Organisational culture and quality of health care. Qual Health Care. 2000;9(2):111–9 (Research Support, Non-U.S. Gov’t Review).
Milligan F, Dennis S. Building a safety culture. Nurs Stand. 2005;20(11):48–52.
Kaufman G, McCaughan D. The effect of organisational culture on patient safety. Nurs Stand. 2013;27(43):50–6.
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(9):695–9.
Raab SS, Stone CH, Wojcik EM, Geisinger KR, Dahmoush L, Garcia FU, et al. Use of a new method in reaching consensus on the cause of cytologic-histologic correlation discrepancy. Am J Clin Pathol. 2006;126(6):836–42 (Research Support, U.S. Gov’t, P.H.S.).
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(11–12):1071–81 (Comparative Study Research Support, U.S. Gov’t, P.H.S.).
Liker JK. The Toyota way: 14 management principles from the world’s greatest manufacturer. New York: McGraw-Hill; 2004.
Spear SJ, Bowen HK. Decoding the DNA of the Toyota production system. Harv Bus Rev. 1999;77(5):97–106.
Zarbo RJ. The oncologic pathology report. Quality by design. Arch Pathol Lab Med. 2000;124(7):1004–10.
Kahneman D. Thinking, fast and slow. 1st ed. New York: Farrar, Straus and Giroux; 2011.
Zarbo RJ. Leaders wanted: a call to change the status quo in approaching health care quality, once again. Am J Clin Pathol. 2010;134(3):361–5 (Editorial).
Luft HS. Economic incentives to promote innovation in healthcare delivery. Clin Orthop Relat Res. 2009;467(10):2497–505.
Raab SS, Stone CH, Jensen CS, Zarbo RJ, Meier FA, Grzybicki DM, et al. Double slide viewing as a cytology quality improvement initiative. Am J Clin Pathol. 2006;125(4):526–33.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2015 Springer Science+Business Media New York
About this chapter
Cite this chapter
Smith, M., Raab, S. (2015). General Principles of How Errors Occur and How They May Be Reduced. In: Nakhleh, R. (eds) Error Reduction and Prevention in Surgical Pathology. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-2339-7_3
Download citation
DOI: https://doi.org/10.1007/978-1-4939-2339-7_3
Published:
Publisher Name: Springer, New York, NY
Print ISBN: 978-1-4939-2338-0
Online ISBN: 978-1-4939-2339-7
eBook Packages: MedicineMedicine (R0)