Reducing Error and Enhancing Access to Home Use of Medical Devices: Designing from the Perspective of the Home Care Provider

Error reporting for accountability programs that ask the provider to report any error he or she committed, such as “Dr. Kildare lacerated Mrs. Patient’s liver,” provides information about who did what. Shortly after the publication of the Institute of Medicine report, Congress created the Agency for Health care Research and Quality and appropriated $50 million per year for 5 years to fund research to reduce the incidence of error by 50% at the end of that time. Research on error conducted by the nuclear power, manufacturing, aviation, and other industries identified categories of environmental factors associated with error. The categories that are analogous across industries are applicable to health care with the slight modification that the entity upon which actions are taken, i.e., the product of the endeavor, is a patient rather than a widget or nuclear power plant.