title: Human factors and medication errors: a case study.
abstract: Human beings are error prone. A significant component of human error is flaws inherent in human cognitive processes, which are exacerbated by situations in which the individual making the error is distracted, stressed or overloaded, or does not have sufficient knowledge to undertake an action correctly. The scientific discipline of human factors deals with environmental, organisational and job factors, as well as human and individual characteristics, which influence behaviour at work in a way that potentially gives rise to human error. This article discusses how cognitive processing is related to medication errors. The case of a coronial inquest into the death of a nursing home resident is used to highlight the way people think and process information, and how such thinking and processing may lead to medication errors.
authors.affiliation: School of Health Professions, Murdoch University, Perth, Australia.
authors.forename: Heather
authors.initials: H
authors.lastname: Gluyas
authors.forename: Paul
authors.initials: P
authors.lastname: Morrison
mesh_terms: D001315:Australia; D002423:Cause of Death; D003071:Cognition; D054796:Drug Dosage Calculations; D006801:Humans; D008508:Medication Errors; D009020:Morphine / Q000008:administration & dosage* / Q000009:adverse effects*; D009735:Nursing Homes; D009740:Nursing Staff; D012307:Risk Factors
chemical_list: D009020:Morphine
keywords: Case study; drug calculations; education; errors; human factors; medication; medication errors; patient safety