Dr. Karen Joughin
Topic: Explaining How and Why Error Occur During Medical/Surgical Procedures
Date: November 18th, 2009
Time: 12:00pm to 1:30pm (Lunch will be served)
- Diamond Health Care Centre, room 2263
- IRC 305
- MSB 107
- NHSC 9-370
Harmful errors during medical & surgical procedures are costly to patients, those providing care and our health care systems. Popular methods of adverse event analysis largely focus on identifying contributing factors, in the hope that by removing or modifying such factors the error may not recur. However, eliminating the identified factors may not be possible, practical or sufficient to prevent similar errors in the future. The mechanisms of effect of the factors are poorly understood. In this presentation, a novel approach to studying errors will be revealed. An analysis of the “work” of doing a procedure, and the constraints affecting what can and cannot be done and achieved, will be shown to provide a useful framework for explaining how and why errors occur. The application of the new framework in studying difficult and unintentionally harmful procedures will be demonstrated. Advantages of this approach in identifying error-prevention (and mitigation) strategies, including training strategies, will be discussed.
This presentation is based on Dr. Joughin’s PhD work at the University of Queensland, Australia from 2003 – 2007.
Dr. Joughin also has a Master’s degree in medical education. She is a reconstructive plastic surgeon. She moved to Vancouver in the spring of 2009 to become the Assistant Dean, MD Undergraduate Program, VFMP at UBC.
As an organization accredited to sponsor continuing medical education for physicians by the Committee on Accreditation of Canadian Medical Schools (CACMS), the UBC Division of Continuing Professional Development designates this educational program as meeting the accreditation criteria of the College of Family Physicians of Canada for up to 1.5 Mainpro-M1 credits (per session). This program has been reviewed and approved by UBC Division of Continuing Professional Development. Each physician should claim only those credits he/she actually spent in the activity.
The CHES Research Rounds is a self-approved group learning activity (Section 1) as defined by the Maintenance of Certification program of the Royal College of Physicians and Surgeons of Canada.