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Healthcare systems are complex in that they are diverse in both structure (e.g. nursing units, pharmacies, emergency departments, operating rooms) and professional mix (e.g. nurses, physicians, pharmacists, administrators, therapists) and made up of multiple interconnected elements with adaptive tendencies in that they have the capacity to change and learn from experience.
By gathering data about errors made, then collating, grouping and analyzing them, it can be determined whether a disproportionate amount of similar errors are being made. If this is the case, a contributing factor may be disharmony between the respective systems/routines and human nature or propensities. The routines or systems can then be ...
Applications include aviation safety, engineering, healthcare, emergency service organizations, and as the principle behind layered security, as used in computer security and defense in depth. Although the Swiss cheese model is respected and considered a useful method of relating concepts, it has been subject to criticism that it is used too ...
The National Patient Safety Agency encourages voluntary reporting of health care errors but has several specific instances, known as "Confidential Enquiries", for which investigation is routinely initiated: maternal or infant deaths, childhood deaths to age 16, deaths in persons with mental illness, and perioperative and unexpected medical ...
State regulators faulted two hospitals in Southern California for medication errors that put patients at risk, including one who suffered a brain bleed after receiving repeated doses of blood thinner.
Other latent variables correspond to abstract concepts, like categories, behavioral or mental states, or data structures. The terms hypothetical variables or hypothetical constructs may be used in these situations. The use of latent variables can serve to reduce the dimensionality of data. Many observable variables can be aggregated in a model ...
As a person living with latent autoimmune diabetes in adults (aka LADA), I know how much of an impact diet can have on my blood sugar management. So, when I decided to try a plant-based diet for ...
A never event is the "kind of mistake (medical error) that should never happen" in the field of medical treatment. [1] According to the Leapfrog Group never events are defined as "adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability." [2]