• Medical errors
    • Unintended act (omission or commission) that does not achieve its intended outcome
    • How do they arise?
      • Human error
        • Skill based
          • Slip
            • Hiccup in normal subconscious action
          • Lapse
            • Fails to carry out task due to distraction
        • Rule based
          • Apply wrong rule to to given situation (eg misdiagnosis)
        • Knowledge
          • Loss of situational awareness, not knowing significance of clinical information
      • System errors
        • Active failures
          • Errors by a person
        • Latent errors
          • Accidents waiting to happen
    • Predisposing factors
      • Stress
      • Fatigue
      • Alcohol/substance abuse
    • Barriers
      • Fear of litigation
      • Ingrained attitude to errors
      • Productivity pressures
      • Lack of protocols and regulations
    • CEACCP
      Link:ceaccp.oxfordjournals.org/content/3/6/179.full.pdf