Creating an organizational culture for medication safety

Nursing Clinics of North America

Volumn 40, Issue 1, 2005, Pages 1-23

  Dennison, Robin Donohoe ^a,b  

^a UNIVERSITY OF KENTUCKY COLLEGE OF NURSING   (United States)

^b Critical Care Nursing Department   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

DRUG SAFETY; EDUCATION; HUMAN; MEDICAL STAFF; MEDICATION ERROR; ORGANIZATION; POLICY; REVIEW; TEAMWORK; TECHNOLOGY;

EID: 14744284873     PISSN: 00296465     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.cnur.2004.10.001     Document Type: Review

References (107)

1. L.T. Kohn J.M. Corrigan M.S. Donaldson To err is human: building a safer health system 1999 National Academy Press Washington, DC
2. Bridge Medical. Timeline for medication error prevention. Available at: www.mederrors.com/resource_main_set.html. Accessed November 15, 2002.
3. L.L. Leape, T.A. Brennan, and N. Laird The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II N Engl J Med 324 1991 377 384
4. American Society of Health-System Pharmacists Suggested definitions and relationships among medication misadventures, medication errors, adverse drug events, and adverse drug reactions Am J Health Syst Pharm 55 1998 165 166
5. D.W. Bates, D.L. Boyle, and M.B. Vander Vliet Relationship between medication errors and adverse drug events J Gen Intern Med 10 1995 199 205
6. D.W. Bates, D.J. Cullen, and N. Laird Incidence of adverse drug effects and potential adverse drug effects. Implications for prevention JAMA 274 1 1995 29 34
7. D.W. Bates, L.L. Leape, and S. Petrycki Incidence and preventability of adverse drug events in hospitalized adults J Gen Intern Med 8 1993 289 294
8. D.W. Bates Medication errors. How common are they and what can be done to prevent them? Drug Saf 15 1996 303 310
9. C.A. Bond, C. Raehl, and T. Franke Medication errors in United States hospitals Pharmacotherapy 21 9 2001 1023 1036
10. Z.R. Wolf Medication errors and nursing responsibility Holist Nurs Pract 4 1 1989 8 17
11. J.F. Serembus, Z.R. Wolf, and N. Youngblood Consequences of fatal medication errors for health care providers: A secondary analysis study Medsurg Nurs 10 4 2001 193 201
12. D.W. Bates, N. Spell, and D.J. Cullen The costs of adverse drug events in hospitalized patients JAMA 277 4 1997 307 311
13. D.C. Classen, S.L. Pestotnik, and R.S. Evans Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality JAMA 277 4 1997 301 306
14. J.A. Johnson, and J.L. Bootman Drug-related morbidity and mortality. A cost-of-illness model Arch Intern Med 155 1995 1949 1956
15. Lewin-VHI Nursing report card for acute care settings 1995 American Nurses Publishing Washington, DC
16. D.A. Scholz Establishing and monitoring an endemic medication error rate J Nurs Qual Assur 4 2 1990 71 85
17. L.L. Leape System analysis of adverse drug events JAMA 274 1 1995 25 43
18. M.M. Brown Managing medication errors by design Crit Care Nurs Q 24 3 2001 77 97
19. K. Olsen Medication errors: problems identified, but what is the solution? Crit Care Med 30 4 2002 944 945
20. S. Weingart, R. Wilson, and R. Gibberd Epidemiology of medical error BMJ 320 2000 774 777
21. R.M. Wilson, W.B. Runciman, and R.W. Gibberd The Quality in Australian Health Care Study Med J Aust 163 1995 458 471
22. M.R. Chassin Is health care ready for Six Sigma quality? Milbank Q 76 4 1998 565 591
23. B. Lanham, and P. Maxson-Cooper Is Six Sigma the answer for nursing to reduce medical errors and enhance patient safety? Nurs Econ 21 1 2003 39 41
24. M. Cooper Can a zero defects philosophy be applied to drug errors? J Adv Nurs 21 3 1995 487 491
25. D. Anderson, and C.S. Webster A systems approach to the approach of medication error on the hospital ward J Adv Nurs 35 1 2001 34 41
26. J.H. Larrabee, M. Ruckstuhl, and J. Salmons Interdisciplinary monitoring of medication errors in a nursing quality assurance program Nursing Quality Assurance 5 4 1991 69 78
27. J. Greene From whodunit to what happened Hosp Health Netw 73 4 1999 50 54
28. J. Osborne, K. Blais, and J. Hayes Nurses' perceptions: when is it a medication error? J Nurs Adm 29 4 1999 33 38
29. J. Gladstone Drug administration errors: a study into the factors underlying the occurrence and reporting of drug errors in a district general hospital J Adv Nurs 22 4 1995 628 637
30. M.D. Murphy Individual characteristics of nurses who committed medication administration errors. Cases which resulted in licensure discipline by the Colorado Board of Nursing Issues 13 1992 11 13
31. H. Cohen, E.S. Robinson, and M. Mandrack Getting to the root of medication errors: survey results Nursing 33 9 2003 36 46
32. V.S. Crane New perspectives on preventing medication errors and adverse drug events Am J Health Syst Pharm 57 7 2000 690 697
33. J. Rasmussen, and A. Jensen Mental procedures in real-life tasks: a case study of electronic trouble shooting Ergonomics 17 1974 293 307
34. L.L. Leape Error in medicine JAMA 272 23 1994 1851 1857
35. W.N. Kelly Potential risks and prevention, part 4: reports of significant drug errors Am J Health Syst Pharm 58 15 2001 1406 1412
36. J. Reason Human error 1990 Cambridge University Press Cambridge (England)
37. J. Reason Understanding adverse events: human factors C. Vincent Clinical risk management 1995 BMJ Publishing Group London 31 54
38. C.E. Meurier Understanding the nature of errors in nursing: using a model to analyse critical incident reports of errors which had resulted in an adverse or potentially adverse event J Adv Nurs 32 1 2000 202 207
39. J. Reason Human error: models and management BMJ 320 2000 768 770
40. P. Pronovost, A.W. Wu, and T. Dorman Building safety into ICU care J Crit Care 17 2 2002 78 85
41. S.M. Crow, and S.J. Hartman Organizational culture: its impact on employee relations and discipline in health care organizations Health Care Manag (Frederick) 21 2 2002 22 28
42. S. Carson Organisational Change S. Hamer G. Collinson Achieving evidence-based practice: a handbook for practitioners 1999 Bailliere Tindall Leeds (UK)
43. S.J. Closs, and F.M. Cheater Utilization of nursing research: culture, interest, and support J Adv Nurs 19 1994 762 773
44. M. Cooper Towards a model of safety culture Safety Science 36 2000 111 136
45. A. Page Keeping patients safe: transforming the work environment for nurses 2003 National Academy Press Washington, DC
46. A.R. Killen, and S.C. Beyea Learning from near misses in an effort to promote patient safety AORN J 77 2 2003 423 425
47. C. Tokarski Effective practices: Improve Patient Safety Summit 2001 Medscape Managed Care 1 1 2001 1009
48. B.J. Wakefield, D.S. Wakefield, and T. Uden-Holman Nurses' perceptions of why medication administration errors occur Medsurg Nurs 7 1 1998 39 43
49. J. Sutton, P. Standen, and A. Wallace Incidence and documentation of patient accidents in hospital Nurs Times 90 33 1994 29 35
50. R. Hackel, L. Butt, and G. Banister How nurses perceive medication errors Nurs Manage 27 1 1996 33 34
51. C. Elnitsky, B. Nichols, and K. Palmer Are hospital incidents being reported? J Nurs Adm 27 11 1997 40 46
52. Agency for Healthcare Research and Quality. Medical errors: the scope of the problem. An epidemic of errors. Available at: www.ahrq.gov/qual/errback.htm. Accessed December 4, 2001.
53. P. Aspden J.M. Corrigan J. Wolcott Patient safety: achieving a new standard for care 2004 National Academy Press Washington, DC
54. P. Carroll Medication errors. The bigger picture RN 66 1 2003 52 58
55. G. Long, and C. Johnson A pilot study for reducing medication errors QRB Qual Rev Bull 7 4 1981 6 9
56. R. Lindquist, and L. Gersema Understanding and preventing adverse drug effects AACN Clin Issues 9 1 1998 119 128
57. Healthcare Information Management System Society. Patient Safety Survey HIMSS. Available at: www.infosolutions.mckesson.com/himsspatient/survey.asp. Accessed December 9, 2003.
58. D.W. Bates Using information technology to reduce rates of medication errors in hospitals BMJ 320 2000 788 791
59. R. Kaushal, K.G. Shojania, and D.W. Bates Effects of computerized physician order entry and clinical decision support systems on medication safety Arch Intern Med 163 12 2003 1409 1416
60. D.W. Bates, L.L. Leape, and D.J. Cullen Effect of computerized physician order entry and a team intervention on prevention of serious medication errors JAMA 280 15 1998 1311 1316
61. US Food Drug Administration. Questions and answers regarding the bar code proposal. Available at: www.fda.gov/oc/initiatives/barcode-sadr/qa-barcode. html. Accessed December 7, 2003.
62. C. Wiebe Patient safety concerns could spur bar code adoption Medscape Money & Medicine 3 2 2002 1 3
63. J. Douglas, and S. Larrabee Bring barcoding to the bedside Nurs Manage 34 5 2003 36 40
64. Medpathways. Pathways for medication safety: assessing bedside bar-coding readiness. Available at: www.medpathways.info. Accessed December 9, 2003.
65. Sublett P. Reducing medication errors through technology and process change. In: Healthcare Information and Management Systems Society 2003. Available at: http://www.himss.org/content/files/proceedings/2003/Sessions/ session131.pdf.
66. R. Haugh Bar code bandwagon Hosp Health Netw 77 5 2003 55 56
67. L.M. Posey Medication errors: technology coming to the rescue Pharmacy Today 8 2 2002 1 11
68. J. Yan The human factor in medication-error reduction Am J Health Syst Pharm 60 2003 1417
69. D.K. Low, and J.V. Belcher Reporting medication errors through computerized medication administration. CIN Comput Inform Nurs 20 5 2002 178 183
70. T.S. Lesar, L. Briceland, and D.S. Stein Factors related to errors in medication prescribing JAMA 277 4 1997 312 317
71. Pharmacy-nursing shared vision for safe medication use in hospitals: executive session summary Am J Health Syst Pharm 60 2003 1046 1052
72. K.J. Rempher, C.E. Lasome, and T.J. Lasome Leveraging palm technology in the advanced practice nursing environment AACN Clin Issues 14 3 2003 363 370
73. J.M. Rothschild, T.H. Lee, T. Bae, and D.W. Bates Clinician use of a palmtop drug reference guide J Am Med Inform Assoc 9 3 2002 223 229
74. K.A. Galt, E.C. Rich, and W.W. Young Impact of hand-held technologies on medication errors in primary care Top Health Inf Manage 23 2 2002 71 81
75. G.A. Pepper Errors in drug administration by nurses Am J Health Syst Pharm 52 1995 390 395
76. Institute for Safe Medication Practices. The "five rights." Available at: www.ismp.org/MSAarticles/FiveRights.htm. Accessed December 4, 2001.
77. J. Smetzer Take 10 giant steps to medication safety Nursing 31 11 2001 49 54
78. V.S. Crane New perspectives on preventing medication errors and adverse drug events Am J Health Syst Pharm 57 2000 690 697
79. American Hospital Association. AHA initiative: improving medication safety. Available at: www.aha.org/medicationsafety/AHAinitiative.asp. Accessed December 4, 2001.
80. R. Schaubhut, and C. Jones A systems approach to medication error reduction J Nurs Care Qual 14 3 2000 13 27
81. J. Phillips, S. Beam, and A. Brinker Retrospective analysis of mortalities associated with medication errors Am J Health Syst Pharm 58 19 2001 1824 1829
82. R. Bindler, and T. Bayne Medication calculation ability of registered nurses Image J Nurs Sch 23 4 1991 221 224
83. M. Segatore, D. Edge, and M. Miller Posology errors by sophomore nursing students Nurs Outlook 41 4 1993 160 165
84. E. O'Shea Factors contributing to medication errors: a literature review J Clin Nurs 8 5 1999 496 504
85. P. Ludwig-Beymer, K.T. Czurylo, and M.C. Gattuso The effect of testing on the reported incidence of medication errors in a medical center J Contin Educ Nurs 21 1 1990 11 17
86. J. Firth-Cozens Cultures for improving patient safety through learning: the role of teamwork Qual Health Care 10 4 2001 26 31
87. P. Benner Creating a culture of safety and improvement: a key to reducing medical error Am J Crit Care 10 4 2001 281 284
88. D. Watson Creating the culture of safety AORN J 77 2 2003 268 271
89. L.L. Leape, D.J. Cullen, and M.D. Clapp Pharmacist participation on physician rounds and adverse drug events in the intensive care unit JAMA 282 3 1999 267 270
90. R.J. Blendon, C.M. DesRoches, and M. Brodie Views of practicing physicians and the public on medical errors N Engl J Med 347 24 2002 1933 1940
91. G. Armitage, and H. Knapman Adverse events in drug administration: a literature review J Nurs Manag 11 2003 130 140
92. L.H. Aiken, S.P. Clarke, and D.M. Sloane Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction JAMA 288 16 2002 1987 1993
93. C. Kovner, and P.J. Gergen Nurse staffing levels and adverse events following surgery in U.S. Hospitals Image J Nurs Sch 30 1998 315 321
94. L. Unruh Licensed nurse staffing and adverse events in hospitals Med Care 41 1 2003 142 152
95. G.R. Whitman, Y. Kim, and L.J. Davidson The impact of staffing on patient outcomes across specialty units J Nurs Adm 32 12 2002 633 639
96. T. Sasichay-Akkadechanunt, C.G. Scalzi, and A.F. Jawad The relationship between nurse staffing and patient outcomes J Nurs Adm 33 9 2003 478 485
97. C.E. Meurier, C.A. Vincent, and D.G. Parmar Learning from errors in nursing practice J Adv Nurs 26 1 1997 111 119
98. M.A. Blegen, C.J. Goode, and L. Reed Nurse staffing and patient outcomes Nurs Res 47 1 1998 43 50
99. L.H. Aiken, S.P. Clarke, and R.B. Cheung Educational levels of hospital nurses and surgical patient mortality JAMA 290 12 2003 1617 1623
100. J. Needleman, P. Buerhaus, and S. Mattke Nurse-staffing levels and the quality of care in hospitals N Engl J Med 346 22 2002 1715 1722
101. P.J. Pronovost, D. Dang, and T. Dorman Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery Eff Clin Pract 4 2001 223 225
102. M.A. Curley Patient-nurse synergy: optimizing patients' outcomes Am J Crit Care 7 1 1998 64 72
103. P.L. Spath Does your facility have a "patient-safe" climate? Hosp Peer Rev 25 2000 80 82
104. M.R. Cohen, J. Senders, and N.M. Davis Failure mode and effects analysis: a novel approach to avoiding dangerous medication errors and accidents Hosp Pharm 29 1994 319 328
105. C. Fletcher Failure mode and effects analysis. An interdisciplinary way to analyze and reduce medication errors J Nurs Adm 27 12 1997 19 26
106. Joint Commission on Accreditation of Healthcare Organizations. 2003 National Patient Safety Goals. Available at: http://www.jcaho.org/ accredited+organizations/patient+safety/04+npsg/04_npsg.htm. Accessed December 28, 2003.
107. M.R. Summerfield, and T. Lawence Rethinking approaches to reducing medication errors: an examination of 10 core processes Formulary 37 9 2002 462