Seminar C4 – Error causation and taxonomy

 

 

Errors occur! Human error is unavoidable and pervasive. The hospital setting is one of the riskiest settings worldwide. Hospitals realised this in the last decades and started to find approaches to avoid errors. Errors are a symptom of failure not a cause. Therefore, the first step is to identify the causes of errors. A human error may trigger a serious incident, but in complex organisation such as hospitals there are usually systemic factors underlying this. In this context, there is recently more and more attention to measure and monitor safety culture/attitude within an organisation. Some taxonomies exist to classify causes of errors. Results can be compared across different wards in a hospital or even national/world-wide. The analysis of causes is the basis to develop preventive measures. Interventions need to minimise the possibility for human error as well as to minimise the impact when errors occur.

 

 

 

After the presentation the participant should be able:

 

• to classify errors in the medication process;

• to explain the different types of errors and the human factors behind them;

• to develop and evaluate interventions to improve medication safety.