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274 SectiOn ii Public HealtH ScienceS ` PUBLIC HEALTH SCIENCES—QUALITy ANd SAFETy
Types of medical May involve patient identification, diagnosis, monitoring, nosocomial infection, medications,
errors procedures, devices, documentation, handoffs. Medical errors should be disclosed to patients,
independent of immediate outcome (harmful or not).
Active error Occurs at level of frontline operator (eg, wrong Immediate impact.
IV pump dose programmed).
Latent error Occurs in processes indirect from operator but Accident waiting to happen.
impacts patient care (eg, different types of IV
pumps used within same hospital).
Never event Adverse event that is identifiable, serious, and Major error that should never occur.
usually preventable (eg, scalpel retained in a
surgical patient’s abdomen).
Burnout vs fatigue
Burnout Prolonged, excessive stress cynicism, detachment, motivation and interest, sense of failure and
helplessness, immunity. Medical errors due to lack of concern.
Fatigue Sleep deprivation energy and motivation, cognitive impairment. Medical errors due to
compromised intellectual function.
Medical error analysis
dESIgN mETHodS
Root cause analysis Retrospective approach. Applied after failure Uses records and participant interviews to identify
event to prevent recurrence. all the underlying problems (eg, process,
people, environment, equipment, materials,
management) that led to an error.
Failure mode and Forward-looking approach. Applied before Uses inductive reasoning to identify all the ways
effects analysis process implementation to prevent failure a process might fail and prioritizes them by
occurrence. their probability of occurrence and impact on
patients.
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