Individual, practice, and system causes of errors in nursing: A taxonomy

Journal of Nursing Administration

Volumn 32, Issue 10, 2002, Pages 509-523

  Benner, Patricia ^a   Sheets, Vickie ^a   Uris, Patricia ^a   Malloch, Kathy ^a   Schwed, Kathy ^a   Jamison, Dwayne ^a  

^a UNIVERSITY OF CALIFORNIA   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ABCIXIMAB; ADRENALIN; AMIODARONE; AMRINONE; ANTIINFECTIVE AGENT; CALCIUM; CALCIUM CHANNEL BLOCKING AGENT; CHLORAL HYDRATE; COLCHICINE; DIAZEPAM; DIGOXIN; DOBUTAMINE; DOPAMINE; EPTIFIBATIDE; ESMOLOL; FOSPHENYTOIN SODIUM; GLYCERYL TRINITRATE; HEPARIN; IBUTILIDE; INSULIN; ISOPRENALINE; LIDOCAINE; LORAZEPAM; MAGNESIUM; MIDAZOLAM; NARCOTIC ANALGESIC AGENT; NEUROMUSCULAR BLOCKING AGENT; NITROPRUSSIDE SODIUM; NORADRENALIN; UNINDEXED DRUG;

DECISION MAKING; DRUG INDUCED DISEASE; HEALTH CARE DELIVERY; HEALTH CARE QUALITY; HEALTH CARE SYSTEM; HUMAN; IATROGENIC DISEASE; MEDICAL ETHICS; NURSE PATIENT RELATIONSHIP; NURSING; PATIENT CARE; PRESCRIPTION; PROFESSIONAL PRACTICE; REVIEW;

EID: 0036792823     PISSN: 00020443     EISSN: None     Source Type: Journal    
DOI: 10.1097/00005110-200210000-00006     Document Type: Review

References (19)

1. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Committee on Quality of Healthcare in America. Washington, DC: National Academy Press; 2000.
2. Benner P, Hooper-Kyriakidis P, Stannard D. Clinical Wisdom and Interventions in Critical Care: A Thinking in Action Approach. Philadelphia: WB Saunders; 1999.
3. Liang BA. The adverse event of unaddressed medical error: identifying and filling the holes in the health-care and legal systems. Journal of Law, Medicine and Ethics. 2001;29(3-4):346-368.
4. MacIntyre A. After Virtue. 2nd ed. Notre Dame, IN: University of Notre Dame Press; 1984.
5. Benner P. Creating compassionate institutions that foster agency and respect. Am J Crit Care. 2002;11(2):164-166.
6. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377-384.
7. Leape L. Error in medicine. JAMA. 1994;272(23):1851-1857.
8. McClanahan S, Goodwin ST, Houser F. A formula for errors: good people 〈pl〉 bad systems. In: Spath PL, ed. Error Reduction in Health Care: A Systems Approach to Improving Patient Safety. Chicago and San Francisco: Health Forum, an American Hospital Association Company; jointly published by Jossey-Bass; 1999:1-15.
9. Cohen MR, ed. Medication Errors. Washington, DC: American Pharmaceutical Association; 1999.
10. Risser DT, Simon R, Rice MM, Salisbury ML. A structured teamwork system to reduce clinical errors. In: Spath PL, ed. Error Reduction in Health Care: A Systems Approach to Improving Patient Safety. Chicago and San Francisco: Health Forum, an American Hospital Association Company; jointly published by Jossey-Bass; 1999:235-278.
11. Yocum CJ, Sheets V. A Study of the Effectiveness of Nurse Disciplinary Actions by Boards of Nursing. Chicago: National Council of State Boards of Nursing; 1999.
12. Sharpe VA. Why "Do no harm?" In: Thomasma D, ed. The Influence of Edmund D. Pellegrino's Philosophy of Medicine. Dordrecht, Netherlands: Kluwer; 1998:197-215.
13. Huy QN. In praise of middle managers. Harvard Business Review. 2001;September:73-79.
14. Kock K. One train may hide another. In: Lehman D, series ed. The Best American Poetry, 1994. New York: Simon and Schuster; 1994.
15. Rubin J. Impediments to the development of clinical knowledge and ethical judgment in critical care nursing. In: Benner P, Tanner C, Chesla C, et al, eds. Expertise in Nursing Practice, Caring, Clinical Judgment, and Ethics. New York: Springer; 1996:170-192.
16. Klein G. Sources of power. How People Make Decisions. Cambridge, Mass: MIT University Press; 1998.
17. Joint Commission American Hospital Association. Sentinel Event Alert 19, May 2001. Available at: http://www.jcaho. org/sentinel/sentevnt_frm.html. Accessed May 2001.
18. U.S. Pharmacopeia. The Standard of Quality. No. 76. March 2001. USP Quality Review. Drugs with similar names. http://www.USP.org/reporting/review/rev 076.htm. Accessed August 2002.
19. National Coordinating Council for Reporting and Preventing Medication Error Taxonomy (NCCRPME). Taxonomy of medication errors; 1999. Available at: http://www.fda.gov/cder/drug/mederrors/default.htm#articles. Accessed January, 7, 2002.