Error recovery in a hospital pharmacy

Ergonomics

Volumn 49, Issue 5-6, 2006, Pages 503-516

  Kanse, L ^a   Van Der Schaaf, T W ^b,c   Vrijland, N D ^b   Van Mierlo, H ^d  

^a UNIVERSITY OF QUEENSLAND   (Australia)

^b LEIDEN UNIVERSITY MEDICAL CENTER   (Netherlands)

^c EINDHOVEN UNIVERSITY OF TECHNOLOGY   (Netherlands)

^d ERASMUS UNIVERSITY ROTTERDAM   (Netherlands)

Author keywords

Error recovery; Hospital pharmacy; Incident analysis; Medication error; Near misses; Patient safety

Indexed keywords

ACCIDENT PREVENTION; HOSPITALS; MEDICAL COMPUTING; PATIENT MONITORING;

ERROR RECOVERY; HOSPITAL PHARMACY; PREVENTION-BASED SAFETY METHOD;

ERGONOMICS;

DRUG;

ARTICLE; CONFIDENTIALITY; DATA ANALYSIS; DOSE RESPONSE; DRUG ADMINISTRATION ROUTE; DRUG LABELING; FOLLOW UP; HARM REDUCTION; HEALTH CARE ORGANIZATION; HEALTH CARE QUALITY; HOSPITAL PHARMACY; HUMAN; INFORMATION PROCESSING; INTERVIEW; MEDICATION ERROR; PATIENT SAFETY; PHARMACIST; PRACTICE GUIDELINE; PRESCRIPTION; REINFORCEMENT; RESPONSIBILITY; VOLUNTARY REPORTING;

EFFICIENCY, ORGANIZATIONAL; GUIDELINES; HUMAN ENGINEERING; HUMANS; MEDICATION ERRORS; NETHERLANDS; ORGANIZATIONAL CULTURE; PHARMACY SERVICE, HOSPITAL; QUALITY ASSURANCE, HEALTH CARE; RISK MANAGEMENT; SAFETY MANAGEMENT; SYSTEMS ANALYSIS; TECHNOLOGY, PHARMACEUTICAL;

EID: 33744793505     PISSN: 00140139     EISSN: 13665847     Source Type: Journal    
DOI: 10.1080/00140130600568741     Document Type: Article

References (52)

1. Armitage, G. and Knapman, H. (2003) Adverse events in drug administration: A literature review Journal of Nursing Management, 11, pp. 130-140.
2. Ashcroft, D. and Quinlan, P. and Blenkinsopp, A. (2005) Prospective study of the incidence, nature and causes of dispensing errors in community pharmacies Pharmacoepidemiology and Drug Safety, 14, pp. 327-332.
3. Aspden, P., Corrigan, J.M., Wolcott, J. and Erickson, S.M. (Eds.), (2004) Patient Safety: Achieving a New Standard for Care. Washington DC: National Academies Press. 226-245
4. Bagnara, S. and Ferrante, D. and Rizzo, A. and Stablum, F.(1988) Causal analysis in error detection and recovery: When does it occur?. In Proceedings of International Conference on Joint Design of Technology, Organisation and People Growth. 12-14 October, Venice
5. Battles, J. and Kaplan, H. and Van der Schaaf, T. and Shea, C. (1998) The attributes of medical event-reporting systems: Experience with a prototype medical event-reporting system for transfusion medicine Archives of Pathology and Laboratory Medicine, 122, pp. 231-238.
6. Benjamin, D. (2003) Reducing medication errors and increasing patient safety: Case studies in clinical pharmacology Journal of Clinical Pharmacology, 43, pp. 768-783.
7. Bove, T.(2002) Development and validation of a human error management taxonomy in air traffic control. In. Risø National Laboratory and University of Roskilde. PhD thesis
8. Bove, T. and Andersen, H.(2001) Types of error recovery in air traffic management. In Third International Conference on Engineering Psychology and Cognitive Ergonomics. (pp. 171-180). Aldershot: Ashgate.
9. Crawford, S. and Cohen, M. and Tafesse, E. (2003) Systems factors in the reporting of serious medication errors in hospitals Journal of Medical Systems, 27, pp. 543-551.
10. Dean, B. and Schachter, M. and Vincent, C. and Barber, N. (2002) Prescribing errors in hospital inpatients: Their incidence and clinical significance Quality and Safety in Health Care, 11, pp. 340-344.
11. Duncan, K.(1987) Fault diagnosis training for advanced continuous process installations. In New Technologies and Human Error. (pp. 209-221). Chichester: John Wiley & Sons.
12. Edmondson, A. (1996) Learning from mistakes is easier said than done: Group and organizational influences on the detection and correction of human error Journal of Applied Behavioral Science, 32, pp. 5-28.
13. Flanagan, J. (1954) The critical incident technique Psychological Bulletin, 51, pp. 327-358.
14. Frese, M.(1991) Error management or error prevention: Two strategies to deal with errors in software design. In Human Aspects in Computing: Design and Use of Interactive Systems and Work With Terminals. (pp. 776-782). Amsterdam: Elsevier Science Publishers.
15. Helmreich, R. and Merritt, A. and Wilhelm, J. (1999) The evolution of crew resource management training in commercial aviation International Journal of Aviation Psychology, 9, pp. 19-32.
16. Hoffman, R. and Crandall, B. and Shadbolt, N. (1998) Use of the Critical Decision Method to elicit expert knowledge: A case study in the methodology of cognitive task analysis Human Factors, 40, pp. 254-276.
17. Hollnagel, E.(1999) Accidents and barriers. In Proceedings CSAPC '99, Seventh European Conference on Cognitive Science Approaches to Process Control. (pp. 175-180). Villeneuve d'Asq: Presses Universitaires de Valenciennes.
18. Kanse, L.(2004) Recovery uncovered: How people in the chemical process industry recover from failures. In. Eindhoven University of Technology. PhD thesis
19. Kanse, L. and Van der Schaaf, T.(2001a) Factors influencing recovery from failures. In CSAPC '01-8th Conference on Cognitive Science Approaches to Process Control. (pp. 123-136). Neubiberg: Universitat der Bunderwehr.
20. Kanse, L. and Van der Schaaf, T. (2001b) Recovery from failures in the chemical process industry International Journal of Cognitive Ergonomics, 5, pp. 199-211.
21. Kaplan, H. and Battles, J. and Van der Schaaf, T. and Shea, C. and Mercer, S. (1998) Identification and classification of the causes of events in transfusion medicine Transfusion, 38, pp. 1071-1081.
22. Kirwan, B.(1994) A Guide to Practical Human Reliability Assessment. London: Taylor & Francis.
23. Klein, G. and Pliske, R. and Crandall, B. and Woods, D. (2005) Problem detection Cognition, Technology and Work, 7, pp. 14-28.
24. Kohn, L.T., Corrigan, J.M. and Donaldson, M.S. (Eds.), (2000) To Err Is Human: Building a Safer Health System. Washington DC: National Academies Press.
25. Kontogiannis, T. (1999) User strategies in recovering from errors in man-machine systems Safety Science, 32, pp. 49-68.
26. Landis, J. and Koch, G. (1977) The measurement of observer agreement for categorical data Biometrics, 33, pp. 159-174.
27. Lawton, R. and Parker, D. (2002) Barriers to incident reporting in a healthcare system Quality and Safety in Health Care, 11, pp. 15-18.
28. Leape, L. and Brennan, T. and Laird, N. and Lawthers, A. and Localio, A. and Barnes, B. and Hebert, L. and Newhouse, J. and Weiler, P. and Hiatt, H. (1991) The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II New England Journal of Medicine, 324, pp. 377-384.
29. Nyst, C. and Van der Schaaf, T.(2001) The Near-miss Pilot Study in Anesthesia.
30. O'Shea, E. (1999) Factors contributing to medication errors: A literature review Journal of Clinical Nursing, 8, pp. 496-504.
31. Rasmussen, J.(1986) Information Processing and Human-Machine Interaction: An Approach to Cognitive Engineering. New York: Elsevier Science Publishing Company.
32. Reason, J.(1990) Human Error. Cambridge: Cambridge University Press.
33. Rizzo, A. and Ferrante, D. and Bagnara, S.(1995) Handling human error. In Expertise and Technology: Cognition and Human-computer Cooperation. Expertise: Research and Applications. (pp. 195-212). Hillsdale NJ: Lawrence Erlbaum Associates.
34. Rolland, P. (2004) Occurrence of dispensing errors and efforts to reduce medication errors at the Central Arkansas Veteran's Healthcare System Drug Safety, 27, pp. 271-282.
35. Safren, M. and Chapanis, A. (1960) A critical incident study of hospital medication errors Hospitals, 34, pp. 32-34. 57-66, 65-68
36. Sarter, N. and Alexander, H. (2000) Error types and related error detection mechanisms in the aviation domain: An analysis of Aviation Safety Reporting System incident reports International Journal of Aviation Psychology, 10, pp. 189-206.
37. Siegel, S. and Castellan, N., Jr.(1988) Nonparametric Statistics for the Behavioral Sciences. New York: McGraw-Hill.
38. Svenson, O. (2001) Accident and incident analysis based on the accident evolution and barrier function (AEB) model Cognition, Technology and Work, 3, pp. 42-52.
39. Van den Bemt, P. and Postma, M. and Van Roon, E. and Chow, M. and Fijn, R. and Brouwers, J. (2002) Cost-benefit analysis of the detection of prescribing errors by hospital pharmacy staff Drug Safety, 25, pp. 135-143.
40. Van der Schaaf, T.(1988) Critical incidents and human recovery: Some examples of research techniques. In COST A1 Seminar on Risk Analysis and Human Error. L.H.J. Goossens (Ed.) Delft: Delft University of Technology.
41. Van der Schaaf, T.(1992) Near miss reporting in the chemical process industry. In. Eindhoven University of Technology. PhD thesis
42. Van der Schaaf, T.(1996a) Human recovery of errors in man-machine systems. In Proceedings of International Conference and Workshop on Process Safety Management and Inherently Safer Processes. 8-11 October, New York: American Institute of Chemical Engineers. Orlando, FL
43. Van der Schaaf, T.(1996b) PRISMA: A risk management tool based on incident analysis. In Proceedings of International Conference and Workshop on Process Safety Management and Inherently Safer Processes. 8-11 October, Utrecht: Academy of the Dutch Health Inspectorate. Orlando, FL
44. Van der Schaaf, T.(2002) IGZ Course on Patient Safety.
45. Van Der Schaaf, T.W., Lucas, D.A. and Hale, A.R. (Eds.), (1991) Near Miss Reporting as a Safety Tool. Oxford: Butterworth Heinemann.
46. Van der Schaaf, T. and Wright, L.(2005) Systems for near miss reporting and analysis. In Evaluation of Human Work. (pp. 877-900). London: CRC Press.
47. Van Vuuren, W. and Kanse, L.(2003) Widening the scope of incident analysis in complex work environments. In Komplexes Handeln in der Anaesthesie (Complex Activity in Anesthesiology). (pp. 186-207). Berlin: Pabst Science Publishers.
48. Vrijland, N.(2004) PRISMA analyse van incidentmeldingen. In. Eindhoven University of Technology. PhD thesis
49. Wagenaar, W. and Groeneweg, J. (1987) Accidents at sea: Multiple causes and impossible consequences International Journal of Man-Machine Studies, 27, pp. 587-598.
50. Wioland, L. and Amalberti, R.(1998) Human error management: Towards an ecological safety model a case study in an air traffic control microworld. In Proceedings of 9th European Conference on Cognitive Ergonomics. 24-26 August, Limerick: Republic of Ireland.
51. Wong, B.(2004) Data analysis for the Critical Decision Method. In Task Analysis for Human-Computer Interaction. (pp. 327-346). Mahwah NJ: Lawrence Erlbaum Associates.
52. Zapf, D. and Reason, J. (1994) Introduction: Human errors and error handling Applied Psychology: An International Review, 43, pp. 427-432.