HCA 375 WEEK 3 ASSIGNMENT

Apr 1st, 2015
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Medical ErrorHCA 375 Continuous Quality Monitoring & AccreditationI will determine if the error was result of an action versus inaction. The nature of the determination differs between these two groups. If no action took place, there is no physical evidence and small opportunity to resolve whether or not a step in a procedure was ignored. The intention of primarily cognitive is internal to the cognition of the decision maker and is tough to apart out from knowledge states and one's rules. So, we have less intention issue to experiment of such cases where there was an action, from many situations of health care have many actors who might have had differing international states that may require to be solved. On the other side inaction cases are more important in identifying system errors. The much reported of 1994 death of patient at the Dana Farber cancer institute, who took daily four times of chemotherapy dose and died in short period of time, could have been ignored as a single human slip of dosage entry. But still there were many questions raised about subsequent system like why it gone unnoticed on the subsequent three months, why the error was not caught by physicians, pharmacists and nurses. And why there was no post mortem and many more questions. These in actions were all reporting of system problems after determined by accrediting and licensing bodies (Crane2001,Winslow and Bohmer1999).Skill based performances commanded by stored pattern

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