home care, community pharmacies, or any other setting in which health care is delivered.
This chapter uses a case study to illustrate a series of definitions and concepts in patient safety. After presentation of the case study, the chapter will define what comprises a system, how accidents occur, how human error contributes to accidents and how these elements fit into a broader concept of safety. The case study will be referenced to illustrate several of the concepts. The next section will examine whether certain types of systems are more prone to accidents than others. Finally, after a short discussion of the study of human factors, the chapter summarizes what health care can learn from other industries about safety.
An Illustrative Case in Patient Safety
Infusion devices are mechanical devices that administer intravenous solutions containing drugs to patients. A patient was undergoing a cardiac procedure. This patient had a tendency toward being hypertensive and this was known to the staff.
As part of the routine set-up for surgery, a nurse assembled three different infusion devices. The nurse was a new member of the team in the operating room; she had just started working at the hospital a few weeks before. The other members of the team had been working together for at least six months. The nurse was being very careful when setting up the devices because one of them was a slightly different model than she had used before.
Each infusion device administered a different medication that would be used during surgery. For each medication, the infusion device had to be programmed according to how much medication would flow into the patient (calculated as "cc's/hour"). The medications had different concentrations and each required calculation of the correct dose for that specific patient. The correct cc's/hour were programmed into the infusion devices.
The anesthesiologist, who monitors and uses the infusion devices during surgery, usually arrived for surgery while the nurse was completing her set-up of the infusion devices and was able to check them over. This particular morning, the anesthesiologist was running behind from a previous surgery. When he arrived in the operating room, the rest of the team was ready to start. The anesthesiologist quickly glanced at the set-up and accepted the report as given to him by the nurse.
One of the infusion devices was started at the beginning of surgery. About
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To Err Is Human: Building a Safer Health System . Washington, DC: The National Academies Press,
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