Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Sociotechnical Aspects: Clinicians and Technology
Lecture:Medical errors
Patient safety
Slide content:Focus of This Lecture Medical errors and patient safety Medical errors: Mistakes that occur during medical care Patient safety: Reduction in patient harm Reducing medical errors and improving patient safety are core aims of modern medicine 4
Slide notes:Unit 10 addresses the sociotechnical aspects of clinicians and technology. The sociotechnical systems approach recognizes the interaction between people and technology in workplaces as well as interaction between societys complex infrastructures and human behavior. This lecture discusses medical errors and patient safety. Medical errors are mistakes that occur during medical care. Many of the errors that occur could have been prevented. A formal definition, according to Grober and Bohnen [ bo -nen ] (2005), describes a medical error as [quote]One, the failure of a planned action to be completed as intended (an error of execution) or the use of a wrong plan to achieve an aim (an error of planning); two, an unintended act (either of omission or commission) or one that does not achieve its intended outcome; or three, deviations from the process of care, which may or may not cause harm to the patient. [end quote] Patient safety refers to the fact that patients can be harmed as a consequence of errors, and they need to be protected against harm during health care delivery. Medical ethics emphasizes the concept of primum non nocere [ pree -mum non no- kay - rey ], which is Latin for first, do no harm. This is one of the fundamental ethical considerations that medical students are taught, and when they take the Hippocratic Oath as new physicians, they promise to do no harm. According to the World Health Organization, [quote] The simplest definition of patient safety is the prevention of errors and adverse effects to patients associated with health care. While health care has become more effective, it has also become more complex, with greater use of new technologies, medicines, and treatments. Health services treat older and sicker patients who often present with significant co-morbidities requiring more difficult decisions as to health care priorities. Increasing economic pressure on health systems often leads to overloaded health care environments. [end quote] Todays trends and challenges require clinicians to keep patient safety at the forefront of all that they do, and reducing medical errors and improving patient safety are core aims of modern medicine. 4