By: Sara Unger
While identifying reasons why medical errors occur and constructing models of how to manage them has proved relatively straightforward, implementing and meaningfully evaluating solutions in 'real-world' settings has proven considerably more difficult. From an information systems (IS) perspective, although the promise of technology remains powerful. Using medical handover as a field-site, this research-in-progress paper presents an adaptation of James Reason's 'Swiss Cheese Model' to conceptualize the complex factors at play in medical errors in terms of human, system and informational elements. This research paper then examines how drawing on this model it is possible to generate and implement a methodological approach that both enhances a holistic understanding of medical error management and illuminates criteria that can be used to meaningfully identify an appropriate role for information technology in medical error mitigation.
Dr. Gray D. Kao treated Ricardo for his prostate cancer; it is a common surgical procedure: doctor implants dozens of radioactive seeds in the prostate gland to attack the disease, but Dr. Kio implant most of the seeds, 40 in all, inserted in healthy bladder, instead in prostate. According to federal rules, regulation it was a serious mistake. Dr. Kio performs another surgery on Ricardo to make his mistake clear second time but he failed in second seed implant too. No one reported this second mistake. Ricardo was still in so much pain, and suspicious about that still something wrong in his body. Doctors then prescribed narcotics. “It was just a succession of painkiller after painkiller after painkiller, and it got to the point where I said, ‘I don’t want any more morphine,’ ” Pastor Flippin said. The Nuclear Regulatory Commission; and the joint commission (a group that accredited the hospitals); they had not taken any action upon finding problems or neither any investigating on implants errors. The...
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