Systematic Analysis of a Medical Error
Step 1- Was there a Medical Error?
Was there an Adverse Event?
Did the Medical Error cause the Adverse Event?
Step 2- Did a systems error occur?Please list systems errors
□ Communication______
______
□ Information management______
______
□ Technology______
______
□ Supervision______
______
□ Workload______
______
□ Human resources support issues (staffing)______
______
Step 3- Was there an individual error? Please list individual errors
1) Knowledge- mistake from inadequate or incomplete information or base of knowledge ______
______
______
2) Skill based- performance error. Not doing the action which was intended. We think of this as a “slip”______
______
3) Rule based- the incorrect application of the information. We think of this as a “Judgment failure” ______
______
Step 4- If a judgment error occurred, what were the Heuristic Failures which contributed?
Selected Heuristic Failures
□ Anchoring Bias: Tendency to lock on to the early features of a presentation & not adjust initial impression in light of later information
□ Confirmation Bias: The tendency to seek confirming evidence to support a diagnosis rather than look for elements that would refute the hypothesis
□ Sunk Cost Bias: In which the clinician becomes unwilling to abandon a diagnosis into which considerable effort has been expended
□ Availability Bias: Disposition to judge a diagnosis as more likely if you have seen it more recently
□ Diagnosis Momentum: The tendency for a diagnosis to become “stickier” with repetition
□ Framing Effect: How the diagnostician sees things is influenced by the way it is presented
□ Multiple Alternatives Bias: The tendency when faced with multiple potential possibilities to try to simplify it to a less complex list by ignoring some options
□ Triage Cueing: The initial selection of location or specialist has disproportionate influence on subsequent care
□ Premature Closure: The tendency to accept a decision before it is completely verified
□ Base-rate neglect: Incorrect assessment of the prevalence of a disease
□ Representativeness Restraint: The diagnostician looks for typical presentations.. Will lead you to miss an atypical presentation
□ Unpacking principal: The more specific a description of an illness, the more likely it is judged to exist
□ Vertical line failure: Overly limited “silo thinking”
□ Visceral bias: Emotional arousal leads to poor decision making
Step 5-Was there an adverse event causing harm?
1- No harm, error identified prior to affecting patient3- Minor permanent harm5- Major permanent
2- Minor temporary harm4- Major temporary6- Death
Step 6- What would you disclose in this case, would you apologize, and how?
______
Step 7- What steps could be taken to reduce the probability of this error in the future?
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