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Ambiguity and Workarounds as Contributors to Medical Error

Steven J. Spear, DBA, MS, MS; and Mark Schmidhofer, MD, MS
[+] Article, Author, and Disclosure Information

From Harvard Business School, Boston, Massachusetts, and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Acknowledgments: The authors thank Dr. Frank Davidoff and Mr. John Elder for their substantial contributions to earlier drafts of this manuscript.

Grant Support: By the Harvard Business School Division of Research.

Potential Financial Conflicts of Interest: Consultancies: S.J. Spear (for industrial and health care organizations with respect to implementing a management process similar to the Toyota Production System); M. Schmidhofer (principal with True North Institute, Inc., which provides consulting services to organizations seeking to implement processes similar to the Toyota Production System).

Requests for Single Reprints: Steven J. Spear, DBA, MS, MS, Harvard Business School, Morgan Hall T13, Boston, MA 02163; e-mail, sspear@hbs.edu.

Current Author Addresses: Dr. Spear: Harvard Business School, Morgan Hall T13, Boston MA 02163.

Dr. Schmidhofer: Cardiovascular Institute, University of Pittsburgh Medical Center, 200 Lothrop Street, F 350.2, Pittsburgh, PA 15213.

Ann Intern Med. 2005;142(8):627-630. doi:10.7326/0003-4819-142-8-200504190-00011
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The Quality Grand Rounds series in Annals illustrates how work-system conditions can produce errors and adverse events (1). The human cost of medical error provided incentive for such studies (25).

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