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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.
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 ...
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 ...
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
Behind human error: Cognitive systems, computers, and hindsight. CSERIAC SOAR Report 94-01 . Crew Systems Ergonomics Information Analysis Center, Wright-Patterson Air Force Base, Ohio. {{ cite book }} : CS1 maint: multiple names: authors list ( link )
A 2006 PriceWaterhouseCoopers report for America's Health Insurance Plans (a health-insurer trade association) used the 2 percent figure and an extrapolation from the Kessler and McClellan report to estimate that the combined cost of insurance and defensive medicine accounts for 10 percent of total health care costs in the U.S. [51]