Attitudes to error and patient safety

Prometheus: Critical Studies in Innovation

Volumn 23, Issue 3, 2005, Pages 253-263

  Webster, Craig S ^a   Grieve, Diana J ^a  

^a UNIVERSITY OF AUCKLAND   (New Zealand)

Author keywords

Anaesthesia; Attitudes; Iatrogenic error; Safety; Technological change

Indexed keywords

HEALTH CARE; SAFETY;

EID: 26244457176     PISSN: 08109028     EISSN: None     Source Type: Journal    
DOI: 10.1080/08109020500209946     Document Type: Article

References (46)

1. Institute of Medicine, To Err is Human - Building a Safer Health System, National Academy Press, Washington, DC, 2000, p. 5.
2. C. S. Webster, Implementation and Assessment of a New Integrated Drug Administration System (IDAS) as an Example of a Safety Intervention in a Complex Socio-technological Workplace, PhD thesis, University of Auckland, Auckland, 2004, available from cwγlear.net.nz;
3. P. L. Johnstone, 'Technology-related factors contributing to labour intensification of surgical production', Prometheus, 23, 2005, pp. 27-46.
4. See the major national reports from the health care systems of the United States and Britain: Institute of Medicine, op. cit.;
5. Department of Health, An Organisation with a Memory - Report of an Expert Group on Learning from Adverse Events in the NHS, Stationery Office, London, 2000.
6. 'Hospital errors kill thousands', New Zealand Herald, 1 December 1999, p. B5;
7. M. Waites, 'End the scandal of medicine mix-ups', Yorkshire Post, 1 December 2001, p. 1;
8. D. M. Berwick, 'Not again! Preventing errors lies in redesign - not exhortation', British Medical Journal, 322, 2001, pp. 247-8;
9. R. J. S. Birks, 'Safety matters' [editorial], Anaesthesia, 56, 2001, pp. 823-4.
10. Debate in the medical literature is on-going, however, for a cross-section of opinion see: D. S. Nunn and W. L. M. Baird, 'Ampoule labelling' [editorial], Anaesthesia, 51, 1996, pp. 1-2;
11. J. A. W. Wildsmith, 'Doctors must read drug labels, not whinge about them', British Medical Journal, 324, 2002, p. 170;
12. C. S. Webster, D. J. Mathew and A. F. Merry, 'Effective labelling is difficult, but safety really does matter', Anaesthesia, 57, 2002, pp. 201-2;
13. L. S. Jensen, A. F. Merry, C. S. Webster, J. Weller and L. Larsson, 'Evidence-based strategies for preventing drug administration error during anaesthesia', Anaesthesia, 59, 2004, pp. 493-504;
14. Webster, 2004, op. cit.
15. The November 2000 Annual Scientific Meeting of the Continuing Education Committee of the Anaesthetists of New Zealand (CECANZ), held in Auckland, New Zealand.
16. Statistical analysis was performed using Systat 10 for Windows (SPSS Inc., Chicago, IL, USA). To allow for multiple comparisons and post hoc testing we took a conservative approach to our analysis by using non-parametric tests and by designating P≤0.01 as significant. Group comparisons were performed with the Wilcoxon signed-rank test or the Mann-Whitney test as appropriate. The Fisher's exact test was used to compare proportions. For background information on these methods see: D. G. Altman, Practical Statistics for Medical Research, CRC Press, Boca Raton, 1999;
17. B. S. Everitt, The Cambridge Dictionary of Statistics, Cambridge University Press, Cambridge, 1998.
18. Note, anaesthetists are those personnel able to give an anaesthetic - this includes trainee anaesthetists. The other-clinician group is made up of allied health professionals who work closely with anaesthetists but who cannot give an anaesthetic - this group includes anaesthetic technicians.
19. Safety cultures, such as that in the aviation industry, interpret accidents or failures as indicators of faulty systems with which individuals work. Fixing these systems is the most effective way to improve long-term organisational safety. The opposite approach is the blame-centred organisational culture, which interprets accidents and failures as character weaknesses in personnel and therefore blames individuals for their carelessness or laziness when things go wrong. Thus, blame-centred cultures direct attention away from the faulty work systems that precipitate accidents, thereby leaving them untouched to continue to precipitate further accidents in the future. For further examples and discussion of these issues see: P. Hunt, 'Safety in aviation', Perfusion, 3, 1988, pp. 83-96;
20. W. B. Runciman, R. K. Webb, I. D. Klepper, R. Lee, J. A. Williamson and L. Barker, 'Crisis management - validation of an algorithm by analysis of 2000 incident reports', Anaesthesia and Intensive Care, 21, 1993, pp. 579-92;
21. R. L. Helmreich and A. C. Merritt, Culture at Work in Aviation and Medicine, Ashgate, Aldershot, 2001.
22. The Quality of Healthcare in America Project, initiated by the United States Institute of Medicine, includes as one of its goals, the reduction of error throughout health care by 50% in five years. See Institute of Medicine, op. cit.
23. It is important to realise that anaesthetists receive exhaustive training on the pharmacology and physiology of anaesthesia as part of their medical education. What we are claiming here is that they receive little specific training from an ergonomic and human factors perspective on how to give drugs to patients with the lowest possible rate of drug administration error.
24. Webster, 2004, op. cit.
25. C. S. Webster, A. F. Merry, L. Larsson, K. A. McGrath and J. Weller, 'The frequency and nature of drug administration error during anaesthesia', Anaesthesia and Intensive Care, 29, 2001, pp. 494-500.
26. Y. Baruch, 'Response rate in academic studies - a comparative analysis', Human Relations, 52, 1999, pp. 421-38;
27. J. A. Krosnick, 'Survey research', Annual Review of Psychology, 50, 1999, pp. 537-67.
28. Baruch, op. cit.
29. Other factors may be influencing anaesthetists' responses in this study, but these are less easily detected in our data. For background information on optimist bias see: J. F. Ross, The Polar Bear Strategy - Reflections on Risk in Modern Life, Perseus Books, Reading, 1999;
30. A. M. Adams and A. F. Smith, 'Risk perception and communication - recent developments and implications for anaesthesia', Anaesthesia, 56, 2001, pp. 745-55;
31. Webster, 2004, op. cit.
32. P. S. Myles, J. A. Symons and K. Leslie. 'Anaesthetists' attitudes towards awareness and depth-of-anaesthesia monitoring', Anaesthesia, 58, 2003, pp. 11-6.
33. Institute of Medicine, op. cit.
34. C. S. Webster, 'Doctors must implement new safety systems, not whinge about them', Anaesthesia, 57, 2002, pp. 1231-2.
35. J. Reason, Human Error, Cambridge University Press, New York, 1990;
36. Berwick, op. cit.;
37. Webster, 2002, op. cit.
38. Reason, op. cit.;
39. A. F. Merry and C. S. Webster, 'Labelling and drug administration error', Anaesthesia, 51, 1996, pp. 987-8.
40. Webster, 2004, op. cit.;
41. A. F. Merry, C. S. Webster and D. J. Mathew, 'A new, safety-oriented, integrated drug administration and automated anesthesia record system', Anesthesia and Analgesia, 93, 2001, pp. 385-90.
42. C. S. Webster, A. F. Merry, P. H. Gander and N. K Mann, 'A prospective, randomised clinical evaluation of a new safety-orientated injectable drug administration system in comparison with conventional methods', Anaesthesia, 59, 2004, 80-7.
43. Reason, op. cit.;
44. Webster, 2004, op. cit.
45. D. M. Gaba, 'Anaesthesiology as a model for patient safety in health care', British Medical Journal, 320, 2000, pp. 785-8;
46. J. B. Cooper and D. Gaba, 'No myth - anesthesia is a model for addressing patient safety', Anesthesiology, 97, 2002, pp. 1335-7.