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Human Errors in Medicine

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Devices are not standardized. Does not follow human factors principles ... 38,000 for ulcer surgery. Types of Human Errors in Medicine. Other types ... – PowerPoint PPT presentation

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Title: Human Errors in Medicine


1
Human Errors in Medicine
  • Lecture Notes for HI6301 - Week 12
  • Jiajie Zhang
  • March 29, 1999

2
The Extent of Human Errors
From Van Cott, 1994
3
The Extent of Human Errors in Medicine
  • Human errors in healthcare are rarely
    catastrophic. But
  • Human Error Avoidable mistakes kill 100,000
    patients a year. (Washington Post, February 18,
    1992)

4
Human Errors in Hospitalization (Brennan et al.,
1991)
3.7 adverse events
30,121 Records 51 Hospitals
5
Types of Human Errors in Medicine
  • Administration of Medications
  • Giving medication to the wrong patient or to the
    right patient in an incorrect dosage or at the
    wrong time.
  • Factors
  • Excessive nursing or pharmacy staff workload
  • poor labeling, poor lighting
  • illegible prescriptions
  • improper storage
  • inventory and control procedures

6
Types of Human Errors in Medicine
  • Image Interpretation
  • Diagnostic errors
  • Sonograms
  • X-ray
  • CAT scan
  • Electrocardiograms
  • etc.

7
Types of Human Errors in Medicine
  • Medical Technology Use
  • 50 alleged failures of devices are due to human
    errors (Nobel, 1991).
  • Many factors
  • Devices are not standardized
  • Does not follow human factors principles
  • Does not match users mental models
  • Incomplete and difficult to comprehend operating
    and maintaining procedures
  • Inadequate training or supervised practice

8
Types of Human Errors in Medicine
  • Laboratory Testing
  • Testing errors in 66 of the laboratories that
    offered drug-screening services in New York
    State. (Van Cott, 1994).
  • 262.6 milligrams/liter cholesterol was tested in
    in 5000 top laboratories in the nation. The
    reported values were 101-524 mg/liter.

9
Types of Human Errors in Medicine
  • Radiotherapy
  • 50 millicuries (incorrect) rather than 3
    millicuries (correct)
  • A wrong patient was administered 100 rad to the
    brain

10
Types of Human Errors in Medicine
  • Patient Billing
  • Errors in 97 of a sample of 13,000 audited
    hospital bills (Merken, 1989)
  • 38,000 for ulcer surgery

11
Types of Human Errors in Medicine
  • Other types
  • Errors in patient care caused by illegible
    handwriting.
  • Errors in anesthesia
  • Mismatching of blood types

12
Statistical Errors in Clinical Practice
  • Availability Bias
  • Caused by ease of access of information
  • Examples
  • ----n- (125 words), ---ing (880 words)
  • k____, --k___ (which one has more words?)
  • Rare and exotic diseases are overrepresented in
    medical journals, leading to overestimation of
    their probability

13
Statistical Errors in Clinical Practice
  • Conjunction fallacy
  • Given that a 55-year-old woman had a pulmonary
    embolism, which of the following is more likely?
  • The woman had hemiparesis and dyspnea
  • The woman had hemiparesis
  • 91 internists selected the first answer.

14
Statistical Errors in Clinical Practice
  • Anchoring Bias
  • Initial estimate affects later judgment
  • Example
  • 12345678

512
  • 87654321

2250
  • The correct answer is 40320

15
Statistical Errors in Clinical Practice
  • Causal Schemas
  • Apply causal relation to correlation
  • Example
  • Predict daughters eye color from mothers eye
    color
  • Predict mothers eye color from daughters eye
    color
  • Answer equally accurate

16
Statistical Errors in Clinical Practice
  • Hindsight Bias
  • Think after the fact that they would have known
    something before the fact when in actuality they
    would not have.

17
Statistical Errors in Clinical Practice
  • Overconfidence
  • More confident in judgments than is objectively
    justifiable.

18
Statistical Errors in Clinical Practice
  • Base Rate Neglect
  • 71 of those with breast cancer were obese,
    54 of those without breast cancer were obese
  • The probability of breast cancer in obese women
    is

or 71 - 54 17
71
  • If 5 of the population have breast cancer, then
  • The probability of breast cancer for obese women
    is
  • 6 (71 (5/54)

19
Statistical Errors in Clinical Practice
Bayes Theorem
20
Statistical Errors in Clinical Practice
21
Statistical Errors in Clinical Practice
22
Statistical Errors in Clinical Practice
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