Medical Error Agenda
-Understanding error in industry and healthcare
-Types and sources of human error
-Decreasing the potential for error
-How information systems can help
-Can information systems be harmful?
-Types and sources of human error
-Decreasing the potential for error
-How information systems can help
-Can information systems be harmful?
Previous Work in Error from Industry
-Industrial, nuclear, airline, NASA accidents
-Bad outcomes occur through interaction of human, system and organizational errors (unpredictable)
-Tightly-coupled vs. loosely-coupled systems
-Importance of problem-reporting and experience
-Progressive improvement through sustained effort
99% error-free is not adequate (current industrial goal is 3 errors per 1 million actions, 99.9997%)
-Financial incentives are important in reducing error
-Impressive success over 30 years
-Bad outcomes occur through interaction of human, system and organizational errors (unpredictable)
-Tightly-coupled vs. loosely-coupled systems
-Importance of problem-reporting and experience
-Progressive improvement through sustained effort
99% error-free is not adequate (current industrial goal is 3 errors per 1 million actions, 99.9997%)
-Financial incentives are important in reducing error
-Impressive success over 30 years
