1. Medical Malpractice

2.




3. 4. 5. MANAGEMENT OF SEVERE SEPSIS
6. Missed and Delayed Diagnoses in the EDAnn Emerg Med 49 (2007), pp. 196205
Key characteristics of 79 diagnostic errors in the ED.
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14. Beauchamp & Childress

1
1
Respect for Autonomy -
2
Non-maleficence -
3
Beneficence -
4
Justice -
2
4
3
15. 16. 17. 18. 19. 20. 21. Vol.6 No.3 (2004/09)349-357
22. 23. 24. 3 1 2008.01.20
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36. 37. Relationships between Shit Work, Fatigue & Performance
Ambient factor
Shift length
Workload
Stress
Light
Noise
Temperature
Personal factor
Physical health
Affective state
Alcohol, drugs
Age
Commitments
Outside ED
Shift work
Circadian
Dys-synchronizaton
Fatigue
Sleep deprivation
Sleep debt
Impaired clinical performance
Rosens Emergency Medicine
2006, p3122
Medical Error
38. 39. Process Mapping Showing Sources of Failures
Violation producing factors
Cognitive properties of the mind
Sense making
Prolonged wait time for bed
Affective state
Procedural faults
Radiology error
Triage cueing
Medication error
Fatigue & shift work
Admit
EMS
Disposition
Assessment
Diagnosis
Treatment
Management
Ttriage
Patient presentation
Discharge
Orphaned patients
Transitions of care
Report delays
EDdesign
Information gaps
Authority gradients
Resource constraints
Teamwork problems
Laboratory error
Overcrowding
Inadequate discharge plan
Follow-up failure
Rosens Emergency Medicine
2006, p3120
40.
2000
85%
17.6%
35.3%440