Focusing accident analysis on error handling activities: Three case studies in the NHS.

In safety critical systems, error detection and recovery can be equally important to error prevention. The design of adequate sensors and alarms, along with the provision of appropriate system feedback are imperative for detecting failures and their causes and controlling them before they compromise safety. In many cases, design must facilitate communication and cooperation between different groups or departments during error handling or fault resolution efforts. Formal inquiries into several National Health Service (NHS) adverse events concluded that poor error handling was a contributory cause to wider system failures. In particular, problems such as software bugs and computer interface deficiencies in immunology, pathology, radiology and other diagnostic services have gone undetected for periods of months and even years, contributing to hundreds and even thousands of misdiagnoses, and subsequently several adverse patient outcomes. This paper will present the findings of three analyses of similar UK incidents where laboratory or radiology errors went undetected for long periods of time, and once detected, communication breakdowns and organizational complications resulted in prolonging the incident time frames in systems that are highly time critical. The analysis has been conducted with an approach that focuses on the error handling activities that took place. The approach is an adaptation of STEP, which has been integrated with the ‘error recovery framework’ to describe the sequence of events from error detection to error correction (ER-STEP). The findings of the analysis conducted along with recommendations for improving laboratory error handling will also be discussed. [ABSTRACT FROM AUTHOR]