Affiliation:
1. Reading University, UK
Abstract
A key approach to improving patient safety is to seek to modify both formal and informal behaviours in response to the extensive reporting of error causes in the literature. This response is primarily in two parts; a) actions to minimise the risk of error or b) actions to control against error. For a) very valuable work has also been undertaken in running human factors courses to demonstrate and try to change poor behaviour via best practice models. In the case of b) much work has been done on increasing control regimes such as checklists and also formal rules in formal procedures. However, these actions tend to be specific to specific health units, are often piecemeal and are not integrated to complement each other. Little work has been done to integrate these formal and informal/social behaviour into clinical pathways or health activities. This chapter reviews current thinking and develops a methodology and proposal for identification and control of human error in clinical pathways based on the research of the two authors.
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