Error detection: a study in anaesthesia.
Although error has been shown as the main cause of accidents in complex systems, little attention has been paid to error detection. However, reducing the consequences of error depends largely on error detection. The goal of this paper is to synthesize the existing scientific knowledge on error detection, mostly based on studies conducted in laboratory or self reporting and to further knowledge through the analysis of a corpus of cases collected in a complex system, anaesthesia. By doing this, this paper is better able to describe how this knowledge can be used to improve understanding of error detection modes. An anaesthesia accident reporting system developed and organized at two Belgian University Hospitals was used in order to collect information about the error detection patterns. Results show that detection of errors principally occurred through the standard check (routine monitoring of the environment). Significant relationships were found between the type of error and the error detection mode, and between the type of error and the training level of the anaesthetist who committed the error.
Nyssen
A-S
AS
University of Liège, Cognitive Ergonomics, FAPSE, B32, 5 bld du Rectorat, 4000, Liège, Belgium. asnyssen@ulg.ac.be
Blavier
A
A
D016907:Adverse Drug Reaction Reporting Systems; D000758:Anesthesia / Q000009:adverse effects*; D000761:Anesthesia Department, Hospital / Q000592:standards*; D001530:Belgium; D006804:Ergonomics; D006785:Hospitals, University; D006801:Humans; D008508:Medication Errors / Q000145:classification*; D018570:Risk Assessment; D012308:Risk Management / Q000379:methods*; D013597:Systems Analysis