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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 ...
A complex adaptive healthcare system (CAHS) is a care delivery enterprise with diverse clinical and administrative agents acting spontaneously, interacting in nonlinear networks where agents and patients are information processors, and actively co-evolve with their environment with the purposed to produce safe and reliable patient-centered outcomes.
Variations in healthcare provider training & experience [45] [52] and failure to acknowledge the prevalence and seriousness of medical errors also increase the risk. [53] [54] The so-called July effect occurs when new residents arrive at teaching hospitals, causing an increase in medication errors according to a study of data from 1979 to 2006.
A list of events was compiled by the National Quality Forum and updated in 2012. [3] The NQF’s report recommends a national state-based event reporting system to improve the quality of patient care. Artificial insemination with the wrong donor sperm or donor egg; Unintended retention of a foreign body in a patient after surgery or other procedure
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 ...
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 ...
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 ...
Sentinel events can be caused by major mistakes and negligence on the part of a healthcare provider, and are closely investigated by healthcare regulatory authorities. Sentinel events are identified under The Joint Commission (TJC) accreditation policies to help aid in root cause analysis and to assist in development of preventive measures.