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:Types of Errors Errors caused by individuals: Unintended acts of omission or commission Acts that do not achieve their intended outcomes Errors caused by organizational systems: Complexity of health care and health care technology Complexity of disease and dependence on intricate clinical collaborations and interventions 8
Slide notes:There are two fundamentally different types of errors. The first are errors caused by individuals; these may be unintended acts of omission or acts of commission. An example of an unintended act of omission is when a patient is transferred from one unit of the hospital to another and an important medication is left off the medication list. An example of an unintended act of commission is when a medication that is intended for one patient is delivered to another patient. Individual errors can also be acts that dont achieve their intended outcomes. An example would be a misdiagnosis based on an error. The second main type of error is error caused within the environment of the provider organization. These system errors are a function of the complexities inherent in provider organizations, in health care technology, and in treating multiple disease situations, as well as of the dependence of the process of health care on a multiplicity of clinicians and interventions. The organizational environment includes the workflow, operational processes, and procedures found within a provider organization. 8