Operational failures and interruptions in hospital nursing

Health Services Research

Volumn 41, Issue 3 I, 2006, Pages 643-662

  Tucker, Anita L ^a,b   Spear, Steven J ^c  

^a UNIVERSITY OF PENNSYLVANIA   (United States)

^b UNIVERSITY OF PENNSYLVANIA   (United States)

^c INSTITUTE FOR HEALTHCARE IMPROVEMENT   (United States)

Author keywords

Medical errors; Nursing work environment; Work systems

Indexed keywords

ARTICLE; HOSPITAL CARE; HOSPITAL EQUIPMENT; MANAGER; NURSING; PATIENT CARE; PERSONNEL MANAGEMENT; PRODUCTIVITY; TASK PERFORMANCE; UNITED STATES; WORK ENVIRONMENT; WORK SCHEDULE;

CROSS-SECTIONAL STUDIES; EQUIPMENT FAILURE; HEALTH CARE SURVEYS; HUMANS; INTERVIEWS; NURSING INFORMATICS; NURSING STAFF, HOSPITAL; UNITED STATES;

EID: 33646548956     PISSN: 00179124     EISSN: 14756773     Source Type: Journal    
DOI: 10.1111/j.1475-6773.2006.00502.x     Document Type: Article

References (68)

1. Aiken LH SP Clarke DM Sloane 2001 An International Perspective on Hospital Nurses' Work Environments The Case for Reform Policy, Politics, and Nursing Practice 2 4 255 63
2. Aiken LH SP Clarke DM Sloane J Sochalski JH Silber 2002 Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction Journal of American Medical Association 288 16 1987 93
3. Ajiboye P 2004 What the Public Say Nursing Standard 18 17 14 5
4. Bates DW 2002 Unexpected Hypoglycemia in a Critically Ill Patient Annals of Internal Medicine 137 2 110 6
5. Beaudoin LE L Edgar 2003 Hassles Their Importance to Nurses' Quality of Work Life Nursing Economics 21 3 106 13
6. Benner P P Hooper-Kyriakidis D Stannard 1999 Clinical Wisdom and Interventions in Critical Care: A Thinking-In-Action Approach Philadelphia W. B. Saunders Company
7. Benner P C Tanner 1987 Clinical Judgment How Expert Nurses Use Intuition American Journal of Nursing 1 23 31
8. Berenholtz SM PJ Pronovost PA Lipsett D Hobson K Earsing JE Farley S Milanovich EP Garrett-Mayer BD Winters HR Rubin T Dorman TM Perl 2004 Eliminating Catheter-Related Bloodstream Infections in the Intensive Care Unit Critical Care Medicine 32 10 2014 20
9. Billings CE 1984 Human Factors in Aircraft Incidents Results of a 7-Year Study Aviation Space and Environmental Medicine 55 960 5
10. Buerhaus PI DO Staiger DI Auerbach 2000 Implications of an Aging Registered Nurse Workforce Journal of American Medical Association 283 22 2948
11. Burke TA JR McKee HC Wilson RMJ Donahue AS Batenhorst DS Pathak 2000 A Comparison of Time-and-Motion and Self-Reporting Methods of Work Measurement Journal of Nursing Administration 30 3 118 25
12. Chassin MR EC Becher 2002 The Wrong Patient Annals of Internal Medicine 136 11 826 33
13. Cho S-H S Ketefian VH Barkauskas DG Smith 2003 The Effects of Nurse Staffing on Adverse Events, Morbidity, Mortality, and Medical Costs Nursing Research 52 2 71 9
14. Cleary PD 2003 A Hospitalization from Hell A Patient's Perspective on Quality Annals of Internal Medicine 138 33 9
15. Cook R D Woods 1994 Operating at the Sharp End The Complexity of Human Error In Human Error in Medicine edited by MS Bogner pp. 255 310 Hillsdale NJ Lawrence Erlbaum Associates
16. Flynn EA KN Barker JT Gibson RE Pearson BA Berger LA Smith 1999 Impact of Interruptions and Distractions on Dispensing Errors in an Ambulatory Care Pharmacy American Journal of Health-System Pharmacists 56 1319 25
17. Gerberding JL 2002 Hospital-Onset Infections A Patient Safety Issue Annals of Internal Medicine 137 8 665 70
18. Godinez G J Schweiger J Gruver P Ryan 2001 Role Transition from Graduate to Staff Nurse A Qualitative Analysis Journal of Nursing Staff Development 17 144 50
19. Gosbee JW 2002 Human Factors Engineering and Patient Safety Quality and Safety in Health Care 11 4 352 4
20. Gosbee JW 2004 Who Left the Defibrillator On? Joint Commission Journal on Quality and Patient Safety 30 5 282 5
21. Grout JR 2003 Preventing Medical Errors by Designing Benign Failures Joint Commission Journal on Quality and Safety 29 7 354 62
22. Hansten R M Washburn 2000 Intuition in Professional Practice Executive and Staff Perceptions Journal of Nursing Administration 30 4 185 9
23. Hendrickson G TM Doddato CT Kovner 1990 How Do Nurses Use Their Time? Journal of Nursing Administration 20 3 31 8
24. Hirano H B Talbot 1995 Five Pillars of the Visual Workplace: The Sourcebook for 5s Implementation Portland, OR Productivity Press
25. Hope HA 2004 Working Conditions of the Nursing Workforce Excerpts from a Policy Roundtable at AcademyHealth's 2003 Annual Research Meeting Health Services Research 39 3 445 61
26. Institute of Medicine 2004 Keeping Patients Safe: Transforming the Work Environment of Nurses Washington, DC The National Academies Press
27. Kahneman D 1973 Attention and Effort Englewood Cliffs, NJ Prentice-Hall
28. Ko J 2005 Anesthesia Equipment and Machines Oklahoma Center for Veterinary Health Sciences, Oklahoma State University
29. Kovner C C Jones C Zhan PJ Gergen J Basu 2002 Nurse Staffing and Postsurgical Adverse Events An Analysis of Administrative Data from a Sample of U.S. Hospitals, 1990-1996 Health Services Research 37 3 611 29
30. Kramer M 1974 Reality Shock: Why Nurses Leave Nursing St. Louis, MO Mosby
31. Leape LL 1994 Error in Medicine Journal of American Medical Association 272 23 1851 7
32. Linden L K English 1994 Adjusting the Cost-Quality Equation Utilizing Work Sampling and Time Study Data to Redesign Clinical Practice Journal of Nursing Care Quality 8 3 34 42
33. Lundgren S K Segesten 2001 Nurses' Use of Time in a Medical-Surgical Ward with All-RN Staffing Journal of Nursing Management 9 1 13 20
34. Mallak L 1998 Putting Organizational Resilience to Work Industrial Management 40 6 8
35. Mandler G 1982 Stress and Thought Processes In Handbook of Stress edited by S Goldberger S Breznitz pp. 88 164 New York Free Press
36. McCloskey JC GM Bulechek S Moorhead J Daly 1996 Nurses' Use and Delegation of Indirect Care Interventions Nursing Economics 14 1 22 33
37. McDaniel RR DJ Driebe 2001 Complexity Science and Health Care Management Advances in Health Care Management 2 11 36
38. McNeese-Smith DK 1999 A Content Analysis of Staff Nurse Descriptions of Job Satisfaction and Dissatisfaction Journal of Advanced Nursing 29 6 1332 41
39. Miller ET C Deets RV Miller 1997 Nurse Call Systems Impact on Nursing Performance Journal of Nursing Care Quality 11 3 36 43
40. Minyard K J Wall R Turner 1986 RNs May Cost Less Than You Think Journal of Nursing Administration 16 5 28 34
41. Needleman J PI Buerhaus S Mattke M Stewart K Zelevinsky 2002 Nurse-Staffing Levels and Quality of Care in Hospitals New England Journal of Medicine 346 22 1415 22
42. Page A 2004 Keeping Patients Safe: Transforming the Work Environment of Nurses B. o. H. C. S. Committee on the Work Environment for Nurses and Patient Safety, Washington, DC The National Academies Press
43. Perlow LA 1999 The Time Famine Toward a Sociology of Work Time Administrative Science Quarterly 44 1 57 81
44. Perrow C 1984 Normal Accidents: Living with High-Risk Technologies Princeton, NJ Princeton University Press
45. Potter P S Boxerman L Wolf J Marshall D Grayson J Sledge B Evanoff 2004 Mapping the Nursing Process A New Approach for Understanding the Work of Nursing Journal of Nursing Administration 34 2 101 9
46. Quist BD 1992 Work Sampling Nursing Units Nursing Management 23 9 50 1
47. Reason J 1990 Human Error New York Cambridge University Press
48. Roberts BJ C Jones M Lynn 2004 Job Satisfaction of New Baccalaureate Nurses 34 9 428 35
49. Roethlisberger FJ WJ Dickson 1939 Management and the Worker Cambridge, MA Harvard University Press
50. Rogers A W-T Hwang LD Scott LH Aiken DF Dinges 2004 The Working Hours of Hospital Staff Nurses and Patient Safety Health Affairs 23 4 202 12
51. Rudolph JW NP Repenning 2002 Disaster Dynamics Understanding the Role of Stress and Interruptions in Organizational Collapse Administrative Science Quarterly 47 1 30
52. Sorra J V Nieva 2004 Hospital Survey on Patient Safety Culture Rockville, MD Agency for Healthcare Research and Quality
53. Spear SJ M Schmidhofer 2005 Ambiguity and Workarounds as Contributors to Medical Error Annals of Internal Medicine 142 8 627 30
54. Spector PE 1994 Using Self-Report Questionnaires in OB Research A Comment on the Use of a Controversial Method Journal of Organizational Behavior 15 385 92
55. Speier C J Valacich I Vessey 1999 The Influence of Task Interruption on Individual Decision Making An Information Overload Perspective Decision Sciences 30 2 337 60
56. Staniszewska S L Ahmed 1998 Patient Expectations and Satisfaction with Health Care Nursing Standard 12 18 34 8
57. Taylor C 1997 Problem Solving in Clinical Nursing Practice Journal of Advanced Nursing 26 329 36
58. Thompson DN GA Wolf SJ Spear 2003 Driving Improvement in Patient Care Lessons from Toyota Journal of Nursing Administration 33 11 585 95
59. Tucker AL 2004 The Impact of Operational Failures on Hospital Nurses and Their Patients Journal of Operations Management 22 2 151 69
60. Tucker AL AC Edmondson 2003 Why Hospitals Don't Learn from Failures Organizational and Psychological Dynamics that Inhibit System Change California Management Review 45 2 1 18
61. Tucker AL AC Edmondson S Spear 2002 When Problem Solving Prevents Organizational Learning Journal of Organizational Change Management 15 2 122 37
62. Uhlig PN J Brown AK Nason A Camelio E Kendall 2002 System Innovation Concord Hospital Joint Commission Journal of Quality Improvement 28 12 666 72
63. Volpp KGM D Grande 2003 Residents' Suggestions for Reducing Errors in Teaching Hospitals New England Journal of Medicine 348 9 851 5
64. Weick KE 1993 The Collapse of Sense-Making in Organizations The Mann Gulch Disaster Administrative Science Quarterly 38 628 52
65. Weick KE KH Roberts 1993 Collective Mind in Organizations Heedful Interrelating on Flight Decks Administrative Science Quarterly 38 357 81
66. Weick KE KM Sutcliffe D Obstfeld 1999 Organizing for High Reliability Processes of Collective Mindfulness Research in Organizational Behavior 21 81 123
67. Wiklund ME 2002 Eleven Keys to Designing Error-Resistant Medical Devices Medical Device and Diagnostic Industry 24 5 86 94
68. Wilson P 2004 The Costs and Benefits of Safe Staffing Ratios Washington, DC Department for Professional Employees