Toward a cognitive taxonomy of medical errors.

Authors

Jiajie Zhang, University of Texas Health Science Center at Houston, School of Health Information Sciences, Houston TX, USA
Vimla L Patel
Todd R Johnson
Edward H Shortliffe

Publication Date

1-1-2002

Journal

Proc AMIA Symp. 2002; 934–938.

Abstract

One critical step in addressing and resolving the problems associated with human errors is the development of a cognitive taxonomy of such errors. In the case of errors, such a taxonomy may be developed (1) to categorize all types of errors along cognitive dimensions, (2) to associate each type of error with a specific underlying cognitive mechanism, (3) to explain why, and even predict when and where, a specific error will occur, and (4) to generate intervention strategies for each type of error. Based on Reason's (1992) definition of human errors and Norman's (1986) cognitive theory of human action, we have developed a preliminary action-based cognitive taxonomy of errors that largely satisfies these four criteria in the domain of medicine. We discuss initial steps for applying this taxonomy to develop an online medical error reporting system that not only categorizes errors but also identifies problems and generates solutions.

Keywords

Cognition, Humans, Medical Errors

Comments

PMCID: PMC2244173