Medical Error and Harm: Understanding, Prevention, and Control, 1st Edition (Hardback) book cover

Medical Error and Harm

Understanding, Prevention, and Control, 1st Edition

By Milos Jenicek

Productivity Press

384 pages | 21 B/W Illus.

Purchasing Options:$ = USD
Hardback: 9781439836941
pub: 2010-07-02
$98.95
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Description

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.

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, inthe 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

Table of Contents

Putting medical error and harm in context. Reducing errors and harm in medicine; beyond the ‘oops!’ factor

Errors as part of advances in medicine

How can we look at and consider medical errors today

What is covered in this book

The view of medical error problem in the light of the recent experience

Medical error and patient safety

How this book might contribute to the present state of human error experience and patient safety

The valued legacy. Error and harm across general human experience in the non-medical domains. Welcome to lathology.

A brief history of the recent human error experience

Definition of human error and other related terms

Taxonomy of error

Cognition and cognitive process at the core of error, and of its understanding and control

Models of error, their development and contributing sites and entities in context

An epidemiological approach to the error problem human error domain through the eyes of medicine and epidemiology

Implications regarding the search for understanding, control and prevention of error today

Ensuing state of the human error domain today

 

Error and harm in the health sciences. Defining and classifying human error and its consequences in clinical and community settings

Overview of our today understanding of error today

Overview of approaches to error in medicine

Definition of medical error

Variables and their taxonomy in the medical error domain

Describing medical error and harm. Their occurrence and nature in clinical and community settings

Research, knowledge acquisition, and intervention strategies in the general error domain as viewed by a methodologically minded physician-epidemiologist

Descriptions of single cases, small sets of error cases and harm cases

Back to epidemiology: what happens now? Occurrence studies, descriptive

epidemiology, magnitude and distribution (‘in‘whom, where and when’) of the error and harm problem

How to describe and report the occurrence of medical error and harm; very brief

guidelines

Analyzing medical error and harm. Search for their causes and consequences

Searching for "new" (yet unknown) causes and consequences of medical error and harm; etiological research, analytical observational epidemiology

Challenge of deriving cause-effect relationships from one or very few past observations; a priori causal attribution

Off beat searches for causes; siding with mainstream epidemiological experience

"Experimental" demonstration of medical error and harem causes and its compromises and alternatives

Is the mainstream epidemiological methodology of causal research feasible in the domain of medical error and harm?

Flaws in operator’s reasoning and decision making before action

Note about medical error and medical harm

System error vs. individual human error

Reminder regarding some fundamental considerations

Flawed argumentation and reasoning as sites and generators of error and harm argumentation and human error and harm analysis from a logical perspective

Where and when errors occur. Cognitive pathways as sites of error

Prevention, intervention and control of medical error and harm. Clinical epidemiological considerations of actions and their evaluation

Basic definitions, concepts and strategies of intervention in lathology

Basic angles of evaluation in lathology: Structure, process, outcomes, and other subjects to evaluate

What should be evaluated at the individual level: knowledge, attitudes, and skills

Experimental, quasi-experimental and non-experimental evaluation of interventions to understand and better control medical error and harm problems

Taking medical error and harm to court. Contributions of physicians and expectations of physicians in tort litigation and legal decision-making

Medical, surgical and public health malpractice claims and litigation

Language of medicine and law

General philosophy and strategies of medicine and law

The law process and its stages

Cause-effect relationships in medicine and law

Litigating the argumentative way

Disclosure of medical errors: Working in law and epidemiology with what is available

A difficult mix: medicine, ethics and law

Conclusions

Challenges in focus

Confounding error and harm

Persisting diversity of semantics and taxonomy

Lack of epidemiology

Dichotomy in lathology

Lack of training in lathology

Better knowledge, attitudes and skills in the management of error and harm

A need for better knowledge of cases of error and harm

Challenge of communication

Interaction between stakeholders in the error and harm domain in medicine

Psychological, social and legal challenges to perpetrators of error and creators of harm

Material gains and losses related to error and harm

Possible ethical challenges

Individual human error vs. system error

Lack of pragmatic choices regarding what to do in lathology

Unexpected roles, uses and potentials of logic, critical thinking and evidence in generating error management activities

Legal considerations

A Brief and (hopefully) Harmonized Glossary

Appendices

Subject Categories

BISAC Subject Codes/Headings:
BUS041000
BUSINESS & ECONOMICS / Management
LAW093000
LAW / Medical Law & Legislation
TEC017000
TECHNOLOGY & ENGINEERING / Industrial Health & Safety