Patient Error: A Preliminary Taxonomy

Stephen Buetow; Liz Kiata; Tess Liew; Tim Kenealy; Susan Dovey; Glyn Elwyn

doi:10.1370/afm.941

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A compelling study and argument
Anton J. Kuzel

Published on: 08 June 2009
Another (and essential) piece of the jigsaw of the nature and frequency of threats to patient safety
John E Sandars

Published on: 14 May 2009

Published on: (8 June 2009)
Page navigation anchor for A compelling study and argument
A compelling study and argument
Anton J. Kuzel, Richmond, VA, USA
As one who has solicited patient and physician stories of errors and harms in primary care, I was particularly pleased to see this study that solicited and systematically classified errors made by patients in the context of their own health care. I strongly agree with the authors when they say that attempts to fix the problems in healthcare that do not incorporate the element of patient contributions are likely to have...
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As one who has solicited patient and physician stories of errors and harms in primary care, I was particularly pleased to see this study that solicited and systematically classified errors made by patients in the context of their own health care. I strongly agree with the authors when they say that attempts to fix the problems in healthcare that do not incorporate the element of patient contributions are likely to have a smaller impact and may even be grossly misguided. What is most fascinating about this study is the inherent tension in whether a given action or lack thereof by a patient is an error or a reasonable, concious act. It seems to me that ethical systems that emphasize individual autonomy might come to one conclusion in a given case, whereas those that claim that "the needs of the many outweigh the needs of the few" might conclude just the opposite. This is the other essential ingredient of considerations of redesign - an explicit statement of values and ethics that will guide our work to make things better. I applaud the authors for their fine work. (By the way, I think the table has an error in it - shouldn't the heading be "mental error" instead of "memory error"?)
Competing interests: None declared
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Competing Interests: None declared.
Published on: (14 May 2009)
Page navigation anchor for Another (and essential) piece of the jigsaw of the nature and frequency of threats to patient safety
Another (and essential) piece of the jigsaw of the nature and frequency of threats to patient safety
John E Sandars, Leeds, Uk
This is a most welcome paper that offers a further piece of the jigsaw to complete our understanding of the nature and frequency of threats to patient safety.
We previously noted that any consideration of the causes of threats to patient safety required an appreciation of the lens from which the issue is observed.[1] Each perspective will yield a different piece of the jigsaw and the more pieces that we have th...
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This is a most welcome paper that offers a further piece of the jigsaw to complete our understanding of the nature and frequency of threats to patient safety.
We previously noted that any consideration of the causes of threats to patient safety required an appreciation of the lens from which the issue is observed.[1] Each perspective will yield a different piece of the jigsaw and the more pieces that we have then the greater the understanding of the issue.
The patient perspective has been previously under researched and this study will provide a useful addition to the literature.
A suggestion for a further study is the perspective of the doctor as to why an error occurred. There has been little previous research and the reasons cited included feeling pressured by patients or relatives to investigate or treat when the clinican felt this was inappropriate. There is always two sides to a story!
[1] Sandars J, Esmail A. The frequency and nature of medical error in primary care: understanding the diversity across studies. Fam Pract. 2003;20(3):231-236.
Competing interests: None declared
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Competing Interests: None declared.