A cognitive taxonomy of medical errors

AbstractObjective. Propose a cognitive taxonomy of medical errors at the level of individuals and their interactions with technology.Design. Use cognitive theories of human error and human action to develop the theoretical foundations of the taxonomy, develop the structure of the taxonomy, populate the taxonomy with examples of medical error cases, identify cognitive mechanisms for each category of medical error under the taxonomy, and apply the taxonomy to practical problems.Measurements. Four criteria were used to evaluate the cognitive taxonomy. The taxonomy should be able (1) to categorize major types of errors at the individual level along cognitive dimensions, (2) to associate each type of error with a specific underlying cognitive mechanism, (3) to describe how and explain why a specific error occurs, and (4) to generate intervention strategies for each type of error.Results. The proposed cognitive taxonomy largely satisfies the four criteria at a theoretical and conceptual level.Conclusion. Theoretically, the proposed cognitive taxonomy provides a method to systematically categorize medical errors at the individual level along cognitive dimensions, leads to a better understanding of the underlying cognitive mechanisms of medical errors, and provides a framework that can guide future studies on medical errors. Practically, it provides guidelines for the development of cognitive interventions to decrease medical errors and foundation for the development of medical error reporting system that not only categorizes errors but also identifies problems and helps to generate solutions. To validate this model empirically, we will next be performing systematic experimental studies

Student Nurse Perceptions of Effective Medication Administration Education

Nursing faculty strive to educate students in a manner that prevents errors, promoting quality, patient-centered care. This endeavor is dependent upon meaningful and effective education that incorporates educational experiences reflective of the service sector. Anecdotal reports from clinical faculty and student nurses suggest that academic medication administration education may not optimally prepare students for safe entry into clinical practice. The aim of this phenomenologic qualitative research is to understand student nurse perceptions regarding teaching strategies and learning activities that prepared them for safe medication administration in acute care clinical settings. Focus group interviews resulted in two broad themes that are identified as Effective Education and Gaps in Education. Within these broad themes, findings revealed that students value faculty demonstrations, peer-learning opportunities, and repetitive practice with timely feedback. Study findings also pointed to educational gaps. Students reported needing to learn communication and conflict resolution strategies that would help them manage real-world interruptions, distractions, and computer generated alerts. Study findings recommend implementing relevant decision-support technology within academic lab learning activities

Occupational injuries among construction workers at the Chep Lap Kok Airport construction site, Hong Kong : analysis of accident rates, and the association between injuries, error types and their contributing factors : a thesis presented in partial fulfilment of the requirements for the degree of Master of Aviation at Massey University, Palmerston North, New Zealand

Accidents on construction sites are a major cause of morbidity and mortality in Hong Kong. This study investigated the likely causes of occupational injuries that were present among the construction workers during the construction of the new Chep Lap Kok (CLK) Airport in Hong Kong. In order to accumulate the requisite information, 1648 accident investigation reports in a four-year period (1993-1996) were reviewed. The first part of the study described the pattern and magnitude of occupational injuries among the CLK construction workers and compared the accident rates of the CLK workers with those of the construction industry as a whole in Hong Kong. The study examined the effects of the workplace infrastructure at CLK in order to explain why this site presented fewer work place injuries and accidents than other workplaces. The second part of the research used these injury and accident occurrences as the basis to construct the causes of accidents and injuries within an error causation classification system. The results showed that at CLK, the commonest workplace injury was contusion & crushing which appeared to be due to mistakes made through lapses in memory often caused by pressure of work being imposed on the employee. This section also indicated what types of errors were most closely associated with what kinds of injuries and what conditions were most likely to trigger these types of events. Among the major associations were links between contusion and crushing and violation error, perceptual error; between memory lapse and work pressure, equipment deficiencies, poor working environment, fatigue, and between violation error and work pressure. The research suggested that work pressure was an important contributing factor to construction injury and it increased the prevalence of a human error type namely, memory lapse many fold. The outcomes from this study provide important new information on the causes and types of errors which have led to occupational injuries among construction workers in Hong Kong. A better understanding of the human factors-based causes of accidents and injuries in the construction industry and an inculcation of a safety culture on construction sites are critically important in the reduction of the rate of construction accidents and improvement of workers' human performance. The results should assist the construction industry in the designing accident prevention training and education strategies, estimating human error probabilities, and the monitoring organizational safety performance

Developing higher order thinking in medical education through reflective learning and research

Reflection in education is not a new concept for as Meiklejohn (1882) enthused, ‘learning is a social act.’ Dewey (1933), a key twentieth century instigator of the concept of reflection, expanded upon the ideas of earlier educators including Plato, Aristotle, Confucius, Lao Tzu, Solomon, and Buddha (Houston, 1988). The preferred reflective model of Perioperative Critical Care pathway students at the University of Bedfordshire has been Reflection-for-Learning. This student-centred model of reflection was developed for their use to meet student identified needs

Mathematical models of games of chance: Epistemological taxonomy and potential in problem-gambling research

Games of chance are developed in their physical consumer-ready form on the basis of mathematical models, which stand as the premises of their existence and represent their physical processes. There is a prevalence of statistical and probabilistic models in the interest of all parties involved in the study of gambling – researchers, game producers and operators, and players – while functional models are of interest more to math-inclined players than problem-gambling researchers. In this paper I present a structural analysis of the knowledge attached to mathematical models of games of chance and the act of modeling, arguing that such knowledge holds potential in the prevention and cognitive treatment of excessive gambling, and I propose further research in this direction

Statistical competencies for medical research learners: What is fundamental?

IntroductionIt is increasingly essential for medical researchers to be literate in statistics, but the requisite degree of literacy is not the same for every statistical competency in translational research. Statistical competency can range from 'fundamental' (necessary for all) to 'specialized' (necessary for only some). In this study, we determine the degree to which each competency is fundamental or specialized.MethodsWe surveyed members of 4 professional organizations, targeting doctorally trained biostatisticians and epidemiologists who taught statistics to medical research learners in the past 5 years. Respondents rated 24 educational competencies on a 5-point Likert scale anchored by 'fundamental' and 'specialized.'ResultsThere were 112 responses. Nineteen of 24 competencies were fundamental. The competencies considered most fundamental were assessing sources of bias and variation (95%), recognizing one's own limits with regard to statistics (93%), identifying the strengths, and limitations of study designs (93%). The least endorsed items were meta-analysis (34%) and stopping rules (18%).ConclusionWe have identified the statistical competencies needed by all medical researchers. These competencies should be considered when designing statistical curricula for medical researchers and should inform which topics are taught in graduate programs and evidence-based medicine courses where learners need to read and understand the medical research literature

Improving the translation environment for professional translators

When using computer-aided translation systems in a typical, professional translation workflow, there are several stages at which there is room for improvement. The SCATE (Smart Computer-Aided Translation Environment) project investigated several of these aspects, both from a human-computer interaction point of view, as well as from a purely technological side. This paper describes the SCATE research with respect to improved fuzzy matching, parallel treebanks, the integration of translation memories with machine translation, quality estimation, terminology extraction from comparable texts, the use of speech recognition in the translation process, and human computer interaction and interface design for the professional translation environment. For each of these topics, we describe the experiments we performed and the conclusions drawn, providing an overview of the highlights of the entire SCATE project

Human Error Management Paying Emphasis on Decision Making and Social Intelligence -Beyond the Framework of Man-Machine Interface Design-

How latent error or violation induces a serious accident has been reviewed and a proper addressing measure of this has been proposed in the framework of decision making, emotional intelligence (EI) and social intelligence (SI) of organization and its members. It has been clarified that EI and SI play an important role in decision making. Violations frequently occur all over the world, although we definitely understand that we should not commit violations, and a secret to prevent this might exist in the enhancement of both social intelligence and reliability. The construction of social structure or system that supports organizational efforts to enhance both social intelligence and reliability would be essential. Traditional safety education emphasizes that it is possible to change attitudes or mind toward safety by means of education. In spite of this，accidents or scandals frequently occur and never decrease. These problems must be approached on the basis of the full understanding of social intelligence and limited reasonability in decision making. Social dilemma (We do not necessarily cooperate in spite of understanding its importance, and we sometimes make decision not to select cooperative behavior. Non-cooperation gives rise to a desirable result for an individual. However, if all take non-cooperative actions, undesirable results are finally induced to all.) must be solved in some ways and the transition from relief (closed) society to global (reliability) society must be realized as a whole. New social system, where cooperative relation can be easily and reliably obtained, must be constructed to support such an approach and prevent violation-based accidents

A taxonomy of multi-industry labour force skills

This paper proposes an empirical study of the skill repertoires of 290 sectors in the United States over the period 2002–2011. We use information on employment structures and job content of occupations to flesh out structural characteristics of industry-specific know-how. The exercise of mapping the skills structures embedded in the workforce yields a taxonomy that discloses novel nuances on the organization of industry. In so doing we also take an initial step towards the integration of labour and employment in the area of innovation studies