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Grantee: The New York Academy of Medicine, New York, NY, USA Project Summary: In 1999 the Institute of Medicine published, To Err is Human, a report detailing the tens of thousands of deaths each year in the United States attributable to preventable medical errors. Medical errors cause more deaths annually than motor vehicle accidents, breast cancer, or HIV. This report resulted in an unprecedented focus of attention on the problem of errors in medical practice. Even so, follow up studies by The Commonwealth Fund and others find modest improvements in patient safety since the report. Why does medical error seem resistant to correction? In part, it is because of the complexity of medical systems. Resilience to perturbation is a defining hallmark characteristic of complex systems. Therefore, it should not be completely surprising that conventional approaches to error reduction are poorly suited to the complexity of systems like medical care. For example, while the culture of medicine traditionally looks for and assigns blame for error to a single individual, medical error is only rarely the result of the actions of a single person, and the importance of systemic causes of medical error has been raised by several leading error researchers. Human error will always be a factor, but recurring systemic weaknesses are amenable to intervention and correction. Contemporary error research suggests that the process of error commission, detection and correction are an integral part of cognitive work in any complex modern-day workplace. Combining these two ideas -- understanding how error occurs in a complex system and understanding the cognitive demands of medical decision making -- to improve the practice of critical care teams is the focus of this collaborative activity. Experts in medical decision making at Arizona State University and University of Texas Houston will work directly with emergency room and critical care teams at hospitals in Phoenix and St. Louis.
Project Lead: Vimla L. Patel, Ph.D.Co-PIs: Trevor Cohen and Jiajie Zhang (UTHealth-Houston), David Kaufman (Columbia University), Timothy Buchman (Emory University in Atlanta), Kanav Kahol (Arizona State University)
Grant Title: Cognitive Complexity and Error in Critical Care, ER, and Trauma
Program Area: Studying Complex Systems
Grant Type: Collaborative Activity Award
Year Awarded: 2007
Duration: 5 years