Learning from investigation: Experience with understanding healthcare adverse events

Christopher P. Nemeth, Richard I. Cook, Yoel Donchin, Meghan Dierks, Emily Patterson, Yuval Bitan, Jay Crowley, Stephanie McNee, Tina Powell

Research output: Chapter in Book/Report/Conference proceedingConference contributionpeer-review

4 Scopus citations

Abstract

Thorough, objective investigation of medical adverse events rarely happens due to the complexity of the environment, litigation, risk, and socio-political implications. Special concerns can, and do, undermine investigation depth, breadth, and quality. Healthcare's distinct difference from other high hazard sectors requires a unique approach to adverse event investigation. We report on the initial results of a 15-month pilot program now underway to model a national healthcare investigation team. An example of adverse event investigation and organizational response illustrates these issues.

Original languageEnglish
Title of host publicationProceedings of the Human Factors and Ergonomics Society 50th Annual Meeting, HFES 2006
Pages914-917
Number of pages4
StatePublished - 1 Dec 2006
Externally publishedYes
Event50th Annual Meeting of the Human Factors and Ergonomics Society, HFES 2006 - San Francisco, CA, United States
Duration: 16 Oct 200620 Oct 2006

Publication series

NameProceedings of the Human Factors and Ergonomics Society
ISSN (Print)1071-1813

Conference

Conference50th Annual Meeting of the Human Factors and Ergonomics Society, HFES 2006
Country/TerritoryUnited States
CitySan Francisco, CA
Period16/10/0620/10/06

ASJC Scopus subject areas

  • Human Factors and Ergonomics

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