Patients as actors: The patient's role in detecting, preventing, and recovering from medical errors

PURPOSE Patients have the most to gain from reducing medical errors; yet, little research has been done to investigate the role they could or already do play in detecting and preventing errors in their own health care. The purpose of this study is to examine patient's role in detecting, preventing, and recovering from medical errors in outpatient oncology. METHODS In this paper, we use cognitive work analysis and Rasmussen's taxonomy of human performance to describe five cases of medical errors that occurred in an outpatient, cancer-care setting. We detail the role of the patient in each case, and analyze each role using constructs from previous studies of human behavior and errors. RESULTS Observational data indicates that patients engage in a range of tasks that identify, prevent, and recover from medical errors in outpatient cancer care. The results of this study point to the importance of considering patients and their work in both the design of patient-care information systems and the structure of clinical-care environments that enable safe and effective health care.

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