Medical Accidents in Hospital Care: Applications of Failure Analysis to Hospital Quality Appraisal

摘要: Article-at-a-Glance Background Medical accidents can be understood as patient injuries that result from interaction of physician or nurse error during the provision care with faults latent in hospital system. are not random events but discoverable associations between human and system through application methods failure analysis evaluation injuries. Case The goal a is to make apparent otherwise obscured. Analyses seek answer several questions. What characteristics failed prevent slip, mistake, rule violation evolving into an accident? changes might have offset, prevented, active contributing sequence culminating injury? Brief descriptions eight cases medical provided this article. For three these cases, approach used identify injury; within represent errors; points which occurrence subsequent events. Conclusions Within framework current quality appraisal, attribution injury historically has focused on clinician error. Yet unless detected corrected, persist create circumstances "accidents waiting happen." Understanding causal factors evolution usefully applied toward improvement appraisal iatrogenic and, application, reduction rates adverse outcomes.