HA 425 Operational Analysis And Quality Improvement Assignment

HA 425: Operational Analysis and Quality Improvement

Assignment Unit 6

Student Name:  


Use the table below to describe the GEMS framework, error types and to give an example of each error type.

GEM Overall description/purpose of the model:
Error type Definition Example
Skill-based slip Stored preprogrammed commands that are administered but are not correctly read A physician orders Inderal intravenously for a patient but writes the order for the typical oral dosage.
Skill-based lapse Stored preprogrammed commands that are administered but are not correctly executed A physician forgets to prescribe beta-blockers following myocardial infarction, although he is aware of the strong research evidence that this helps prevent re-infarction and normally prescribes it in such cases.
Rule-based mistake Solutions governed by stored rules of the “if then” type but is perceived as a historical approach rather than new approaches A patient presents with a high white blood cell count and lower right quadrant pain. The physician’s schema defaults to the most frequently observed outcome (acute appendicitis), but confirmatory tests are not ordered, and the diagnosis proves incorrect.
Knowledge-based mistake Novel problems that are applied in “real time” using attentional control in conjunction with working memory but is not thoroughly researched before adding the cause Confirmation bias: A physician presumes a diagnosis of cancer based on an initial blood chemistry value and dismisses subsequent counterevidence from a biopsy.


Sollecito, W. A., Johnson, J. K. (2013). Continuous Quality Improvement in Health Care, 4th Edition. [VitalSource Bookshelf Online]. Retrieved from https://kaplan.vitalsource.com/#/books/9781449679606/