CENTER PROJECTS
Given that medical error is a system problem, the Center projects relate to the different levels of healthcare systems. In addition, each project utilizes a safety measurement or improvement method from aviation. We believe such a comprehensive approach by multiple projects within one center is the best way to understand and prevent medical errors. The specific projects of the Center include:

Project 1 - Cognitive Modeling of Medical Error (PI Zhang, UT School of Allied Health, Department of Informatics). Note: this project has been revised and incorporated into project 2. This project will create a cognitive taxonomy of medical error and develop a better understand of the thought processes that lead to medical errors.

Project 2 - Human Device Interactions (PI Johnson, UT School of Health Information Sciences). This project will evaluate how humans interact with medical devices and how errors due to poor device design can be prevented. In addition, the project will develop purchasing guidelines to help hospitals assess the design of devices during the purchasing process. Work for this project will also occur at Columbia University under the leadership of Vimla Patel.

Project 3 - Videotaping Care to Measure Error (PI Thomas, UT Medical School at Houston, Department of Medicine). To better understand the epidemiology of medical error, and to learn how to measure teamwork, this project will videotape healthcare teams. Possible settings for videotaping include trauma resuscitation at Memorial Hermann Hospital and thoracic surgery at UT M. D. Anderson Cancer Center.

Project 4 - Team Training to Improve Patient Safety (PI Helmreich, UT Austin, Department of Psychology). This project will develop, implement, and evaluate a training program to improve teamwork and prevent error. Possible settings include neonatal resuscitation at Memorial Hermann Children's Hospital, trauma resuscitation at Memorial Hermann Hospital, and thoracic surgery at UT M. D. Anderson Cancer Center. The project will also design and administer surveys to measure relevant aspects of professional and organizational culture.

Project 5 - Close Call Reporting and Error Reduction (PI Martin, UT MD Anderson Performance Improvement Department). This project will develop and implement close call reporting systems at UT M. D. Anderson, and other UT System hospitals. Based upon analysis of the close calls, quality improvement projects will be developed, tested, and with the close call reporting system, disseminated through educational programs to UT System health institutions.

Project 6 - Organizational Learning from Error (PI Tamuz, UT School of Public Health). This project will identify the organizational factors that facilitate and hinder learning from error. The project will study many of the activities of Project 5.