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Int J Qual Health Care. 2006 Aug;18(4):314-9. Epub 2006 May 3.

An individual-based framework for the study of medical error.

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  • 1Department of Community and Preventive Medecine, University of Rochester.



In the late 1990s, medical error came into focus as a problem to be explicitly acknowledged and addressed. Research on this topic is amassing in the epidemiology of medical error and the system and human factors that contribute to error. In addition, however, an understanding of medical errors in terms of the underlying decision process is needed.


To present an individual-based framework for the study of medical errors in the context of the decision maker.


A framework is developed in terms of four state spaces: the decision environment, problem, goal, and action spaces. The role of information uncertainty is discussed. The framework is purposefully simple to provide flexibility and options for research-specific extensions, but sufficient structure is imposed to guide understanding and investigation.


Understanding medical error in terms of the proposed framework can guide research and subsequent interventions by illuminating where in the decision process such errors are generated.

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