The Individual Error...

Ross Koppel rkoppel at SAS.UPENN.EDU
Wed Dec 18 19:58:48 UTC 2013


IMO, it's great to study near-misses....as long as you always remember 
they may not be representative of errors/misses.  Heck, they will almost 
certainly be not very representative of actual errors.
Like many, I've studied near misses a lot....because often those are the 
only ones we know about -- they were caught...and that's why we know 
about them!     Yes, a dose that kills is often investigated.  Yes, an 
arterial cut is known and perhaps studied. But those obvious sort of 
errors are where we keep getting better and better at avoiding: i.e., 
wrong site surgery.  We're like the drunk looking for his keys under the 
lamp post.  We improve our key looking/finding processes and technology 
when lighting is plentiful.

Alas, Dx errors are often in the less illuminated parts of medical care.

In lightness and shadows,

Ross

Ross Koppel, Ph.D. FACMI
Sociology Dept and Sch. of Medicine
Senior Fellow, LDI, Wharton
University of Pennsylvania, Phila, PA 19104-6299
215 576 8221 C: 215 518 0134

On 12/18/2013 2:17 PM, Bob Latino wrote:
>
> Is it appropriate to include in your definition of Individual Error, 
>  'near misses' where the error chain did not complete and thus did not 
> cause damage or death?
>
> Robert (Bob) J. Latino
>
> CEO
>
> Reliability Center, Inc., P.O. Box 1421, Hopewell, VA  23860
>
> (O) 804.458.0645  (F) 804.452.2119
>
> blatino at reliability.com <mailto:blatino at reliability.com> l 
> http://www.reliability.com <http://www.reliability.com/>__
>
>








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