Reducing error in safety critical health care delivery

  • Authors:
  • Marilyn Sue Bogner

  • Affiliations:
  • Institute for the Study of Human Error, LLC

  • Venue:
  • HESSD'09 Proceedings of the 7th FIP WG 13.5 international conference on Human Error, Safety and Systems Development
  • Year:
  • 2009

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Abstract

A behavioral goal in the safety critical delivery of health care is minimizing the likelihood of error in the diagnosis and treatment of presenting symptoms. The prevailing belief in the United States is that information technology (IT) can effectively address such health care delivery problems. The veracity of this belief was not upheld by a study of the application of IT to health care (Stead & Lin, 2009). The study found that IT applications introduce problems such as difficult to detect forms of error and provide little support for clinicians' imposing cognitive tasks. This paper presents a model that addresses both of those issues. The model supports the clinicians' cognitive process of knowledge acquisition through differential diagnosis by creating an evidence based construct of the specific patient. The IT implementation of the model based on a systems engineering concept is described and implications considered for reducing the likelihood of error.