An investigation into error detection and recovery in UK National Health Service screening programmes

[摘要] The purpose of this thesis is to gain an understanding of the problems that may impede detection and recovery of NHS laboratory screening errors. This is done by developing an accident analysis technique that isolates and further analyzes error handling activities, and applying it in four case studies; four recent incidents where laboratory errors in NHS screening programmes resulted in multiple misdiagnoses over months or even years. These errors resulted in false yet plausible test results, thus being masked and almost impossible to detect in isolated cases.This technique is based on a theoretical framework that draws upon cognitive science and systems engineering, in order to explore the impact of plausibility on the entire process of error recovery. The four analyses are then integrated and compared, in order to produce a set of conclusions and recommendations.The main output of this work is the “Screening Error Recovery Model”; a model which captures and illustrates the different kinds of activities that took place during theorganizational incident response of these four incidents. The model can be used to analyze and design error recovery procedures in complex, inter-organizational settings,such as the NHS, and its Primary/Secondary care structure.

[发布机构] University:University of Glasgow;Department:School of Computing Science

[关键词] Patient safety, laboratory error, screening programmes, accident analysis