Gaps and Resilience Emily S . Patterson VA Getting at Patient
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چکیده
For Human Error in Medicine (second edition) M. S. Bogner (ed.) 2 Introduction There is great interest in reducing the frequency and consequences of " human error " in healthcare, similar to past efforts in aviation, nuclear power generation, and space operations. Overall, the study of " human error " has been approached two ways. One approach is that erratic people degrade an otherwise safe system. With this view, it is critical to prevent fundamentally error-prone individuals from making mistakes. Attempts to reduce human error include reporting errors, developing taxonomies of error types to tabulate counts within the types, estimating likelihoods of error, and implementing procedures and technology to reduce error counts. In contrast to this is an approach where people are viewed as the primary source of resilience in creating safety under resource and performance pressure (Cook and Woods, 1994). Progress in this " new look " paradigm comes from aiding people under pressure from conflicting goals to improve patient safety are focused on increasing system resilience by investing in a context-sensitive understanding of the gaps that arise in system operation and the expert strategies that are used to bridge these gaps in practice. This chapter provides an overview of this second approach to the study of human error, and illustrates the application of five strategies to increase resilience in medication administration using bar code medication administration software.
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تاریخ انتشار 2004