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Case 16-1:


Midway through the wound debridement, the scrub nurse noted that the sterilization indicators had not changed colors—the surgeon was operating with instruments that had not been properly sterilized. The subsequent root cause analysis revealed that the sterile processing technician, at the end of his shift, forgot to push the button to start the autoclave. The arriving technician on the next shift assumed the autoclave had finished the cycle, and not noticing that the sterilization indicator on the cart had not changed color, removed the cart with the unsterilized trays and placed them on the shelf for use.

In 1999, the Institute of Medicine (IOM) highlighted two studies from the 1980s that suggested between 44,000 and 98,000 patients die every year due to preventable medical errors.

The subsequent IOM report, Crossing the Quality Chasm, noted, “The current systems cannot do the job. Changing systems of care will.” The report went on further to describe the six aims of safety, effectiveness, efficiency, patient-centeredness, timeliness, and equity. With these aims, the IOM has defined the ultimate vision for the U.S. health care system.

The limitations of the current health care system were further highlighted by Elizabeth McGlynn's study in 2003. In that study, her group found that patients only receive 55% of the care warranted by medical evidence. Furthermore, they found that the likelihood that an individual patient would receive all appropriate care was 2.5%.

The Individual

A main contributor to the performance shortfall is the limitation of human performance. Table 16-1 shows expected human error rates in conditions under no undue time pressure or stress. Note that “under very high stress when dangerous activities are occurring rapidly,” the error rate can be as high as one in four. Therefore, system designs that depend on perfect human performance are destined to fail. Furthermore, systems designed to function in conditions of high stress with frequent dangerous activities have a higher burden in order to ensure a favorable outcome.

Table 16-1 Nominal Human Error Rates for Selected Activities

As defined by the Federal Aviation Administration, “Within the FAA, human factors entail a multidisciplinary effort to generate and compile information about human capabilities and limitations and apply ...

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