Understanding models of error in clinical practice

摘要

As humans, we all make errors, both professionally and In our personal lives. We sometimes forget to do things, get distracted and do the wrong thing, and make what turn out to be wrong decisions. Within the UK pharmacy setting, dispensing errors occur in 0.04-9.8% of dispensed items in community pharmacy, and 0.008-0.02% within hospital pharmacy1'2-3-4'5. The wide range is at least partly a result of different definitions of error and different methods used to detect them. The most common types of error identified in such studies include the wrong drug, wrong strength, wrong dosage form, wrong quantity and incorrect labelling6. Pharmacists are also involved in identifying and rectifying the prescribing errors that occur in around 5% of prescribed medicines in UK general practice7 and 7% of prescribed medicines in hospitals8. Psychological theories of human error can help us understand why these errors occur and identify strategies to prevent them. This article aims to provide pharmacy staff and other healthcare professionals with the background knowledge to understand theoretical models of human error and how they apply in clinical practice.