Misadventures in Health Care: Inside Stories presents an alternative approach to attributing the cause of medical error solely to the health care provider. That alternative, the systems approach, pursues why an incident occurs in terms of factors in the context of care that affect the care provider to induce an error. The basis for this approach is the fact that an error is an act, an act is behavior, and behavior is a function of the person interacting with the environment. Eleven vignettes illustrate the importance of the systems approach by describing health care incidents from the perspective of the care providers--the perspective that can identify the factors that actually affect the provider. These stories provide general readers with opportunities to apply their knowledge in analyzing incidents to identify error-inducing factors.
This book is important reading for policymakers, researchers and practitioners in law and in all medical specialties, and professionals in the social sciences, human factors, and engineering. In addition to sensitizing the reader to the importance of contextual factors in error, Misadventures in Health Care is a case study reference to supplement texts in professional schools such as law and medicine, as well as the full range of academic disciplines. It also is important reading for the general public because it presents an approach for addressing a very pressing social problem-- that of misadventures in health care.
Contents: M.S. Bogner, Series Foreword. A. Chapanis, Foreword. M.S. Bogner, Preface: The Other Perspective. M.S. Bogner, Understanding Human Error. J.V. Linden, The Trouble With Blood Is It All Looks the Same: Transfusion Errors. C.F. Mackenzie, Y. Xiao, Stopping Bad Things From Happening to Good People in Shock Trauma Centers. R. Berguer, Misadventures in General Surgery. C.L. MacKenzie, A.J. Lomax, J.A. Ibbotson, Safety and Error Issues in Minimally Invasive Surgery. U. Matern, The Laparoscopic Surgeon's Posture. M.B. Weinger, Anesthesia Incidents and Accidents. F.J. Seagull, P.M. Sanderson, The Trojan Horse of the Operating Room: Alarms and the Noise of Anesthesia. Y. Donchin, The Intensive Care Unit May Be Harmful to Your Health. D.M. Korniewicz, M. El-Masri, Challenges and Adverse Events in the Home. D.C. Park, I. Skurnik, Aging, Cognition, and Patient Errors in Following Medical Instructions. K. Dandurand, Prescription for Error: Can Health Care Providers Really "Do No Harm"? M.S. Bogner, All the Men and Women Merely Players.