Reporting drug errors in a British acute hospital trust

Clinical Governance

Volumn 12, Issue 2, 2007, Pages 102-114

  Armitage, Gerry ^a   Newell, Rob ^a   Wright, John ^b  

^a UNIVERSITY OF BRADFORD   (United Kingdom)

^b BRADFORD TEACHING HOSPITALS NHS FOUNDATION TRUST   (United Kingdom)

Author keywords

Drugs; Hospitals; Quality control; Risk management; United Kingdom

Indexed keywords

DRUG;

ARTICLE; CONTENT ANALYSIS; CONTINUING EDUCATION; DRUG ADMINISTRATION ROUTE; DRUG DOSE REGIMEN; DRUG LABELING; DRUG SAFETY; HEALTH CARE ORGANIZATION; HEALTH PERSONNEL ATTITUDE; HUMAN; INCIDENT REPORT; INTERNAL BIAS; INTERPERSONAL COMMUNICATION; KNOWLEDGE; MEDICATION ERROR; PRIORITY JOURNAL; PROFESSIONAL COMPETENCE; PSYCHOLOGICAL ASPECT; RELIABILITY; RISK MANAGEMENT; SCORING SYSTEM; STRESS; TAXONOMY; UNITED KINGDOM; VALIDITY; VOLUNTARY REPORTING;

EID: 34247333364     PISSN: 14777274     EISSN: None     Source Type: Journal    
DOI: 10.1108/14777270710741465     Document Type: Article

References (54)

1. Arah, O.A. and Klazinga, N.S. (2004), "How safe is the safety paradigm?", Quality and Safety in Health Care, Vol. 13 No. 3, pp. 226-32.
2. Bagian, J.P., Lee, C., Gosbee, J., DeRosier, J., Stalhandske, E., Eldridge, N., Williams, R. and Burkhardt, M. (2001), "Developing and deploying a patient safety program in a large health care delivery system", Joint Commission in Accreditation of Healthcare Organisations, Vol. 27 No. 10, pp. 522-32.
3. Barker, K.N., Flynn, E.A., Pepper, G.A., Bates, D.W. and Mikeal, R.L. (2002), "Medication errors observed in 36 health care facilities", Archives of Internal Medicine, Vol. 162, pp. 1897-903.
4. Battles, J.B. and Lilford, R. (2003), "Organizing patient safety research to identify risks and hazards", Quality and Safety in Health Care, Vol. 12, Suppl ll, pp. ii2-ii7.
5. Classen, D.C., Pestotnik, S.L., Scott Evans, R., Lloyd, J.F. and Burke, J.P. (1997), "Adverse drug events in hospitalised patients", Journal of the American Medical Association, Vol. 277 No. 4, pp. 301-5.
6. Cullen, D.J., Bates, D.W., Small, S.D., Cooper, J.B., Nemeskal, A.R. and Leape, L. (1995), "The incident reporting system does not detect adverse drug events: A problem for quality improvement", Journal of Quality Improvement, Vol. 21 No. 10, pp. 541-8.
7. Daniels, C. and Marlow, P. (2005), Literature Review on the Reporting of Workplace Injury Trends, Health & Safety Laboratory, Buxton.
8. Dean, B. (2003), "Adverse drug events: What's the truth?", Quality and Safety in Health Care, Vol. 12 No. 3, pp. 165-6.
9. Dean, B., Schacter, M., Vincent, C. and Barber, N. (2002), "Causes of prescribing errors in hospital inpatients: A prospective study", The Lancet, Vol. 359, pp. 1373-8.
10. Department of Health (2000), An Organisation with a Memory. Report of an Expert Group on Learning from Adverse Events in the NHS, HMSO, London.
11. Dineen, M. and Walshe, K. (1999), "Incident reporting in the NHS", Risk Management Health Care Risk Report, Vol. 5 No. 4, pp. 17-19.
12. Evans, S.M., Berry, J.G., Smith, B.J., Esterman, A., Selim, P., O'Shaugnessy, J. and DeWit, M. (2006), "Attitudes and barriers to incident reporting: A collaborative study", Quality and Safety in Health Care, Vol. 15 No. 1, pp. 39-43.
13. Firth-Cozens, J. (2002), "Barriers to incident reporting", Quality and Safety in Health Care, Vol. 11 No. 1, p. 7.
14. Flynn, E.A., Barker, K.N., Pepper, G.A., Bates, D.W. and Mikeal, R.L. (2002), "Comparisons of methods for detecting medication errors in 36 hospitals and skilled nursing facilities", American Journal of Health System Pharmacy, Vol. 59 No. 5, pp. 436-46.
15. Giles, S., Fletcher, M., Baker, M. and Thomson, R. (2006), "Incident reporting and analysis", in Maidenhead, W.K.B.R. (Ed.), Patient Safety: Research into Practice, Open University Press, Buckingham.
16. Holsti, O.R. (1969), Content Analysis for the Social Sciences and Humanities, Addison-Wesley, Reading, MA.
17. Kaplan, H. and Barach, P. (2002), "Incident reporting: Science or protoscience? Ten years later", Quality and Safety in Health Care, Vol. 11 No. 2, pp. 144-5.
18. Kaplan, H.S. and Fastman, B.R. (2003), "Organisation of event reporting data for sense making and system improvement", Quality and Safety in Health Care, Vol. 12, Suppl ll, pp. ii68-ii72.
19. Kaushal, R., Bates, D.W., Landrigan, C., McKenna, K.J., Clapp, M.D., Federico, F. and Goldmann, D.A. (2001), "Medication errors and adverse drug events in paediatric inpatients", Journal of the American Medical Association, Vol. 285 No. 16, pp. 2114-20.
20. Kennedy, I. (Chair) (2001) The Bristol Royal Infirmary Inquiry. Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984-1995, The Stationary Office, London.
21. Kostopoulou, O. (2006), "From cognition to the system: Developing a multi-level taxonomy of patient safety on general practice", Ergonomics, Vol. 49 Nos 5-6, Special Patient Safety Issue, pp. 486-502.
22. Lawton, R. and Parker, D. (2002), "Barriers to incident reporting in a healthcare system", Quality and Safety in Health Care, Vol. 11 No. 1, pp. 15-18.
23. Leape, L.L. (2002), "Reporting of adverse events", New England Journal of Medicine, Vol. 347 No. 20, pp. 1633-8.
24. Leape, L.L. et al. (1995), "Systems analysis of adverse drug events", Journal of the American Medical Association, Vol. 274 No. 1, pp. 35-43.
25. Lilford, R. (2003), "Patient safety research: Does it have legs?", Quality and Safety in Health Care, Vol. 11, pp. 113-4.
26. Malpass, A., Helps, S.C., Sexton, E.J., Maile, D. and Runciman, W.B. (1999), "A classification for adverse drug events", Journal of Quality in Clinical Practice, Vol. 19 No. 1, pp. 23-6.
27. Nash, D.B. (2003), "Tracking medical errors: Enter the private sector", Health Policy Newsletter, Vol. 16, pp. 1-3.
28. National Audit Office (2005), A Safer Place for Patients, National Audit Office, London.
29. National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) (1998), Taxonomy of Medication Errors, NCCMERP, Rockville, MD.
30. National Patient Safety Agency (2005), National Reporting and Learning System, NPSA, London.
31. Pope, C., Ziebland, S. and Mays, N. (2000), "Qualitative research in healthcare: Analysing qualitative data", British Medical Journal, Vol. 320 No. 7227, pp. 114-6.
32. Reason, J. (1990a), Human Error, Cambridge University Press, Cambridge.
33. Reason, J.T. (1990b), "The contribution of latent human failures to the breakdown of complex systems", Philosophical Transactions of the Royal Society of London, Vol. 327, pp. 475-84.
34. Ross, L.M., Wallace, J. and Paton, J.Y. (2000), "Medication errors in a paediatric teaching hospital in the UK: Five years operational experience", Archives of Disease in Childhood, Vol. 83 No. 6, pp. 492-7.
35. Runciman, W. (2001), "Improving patients' safety by gathering information", British Medical Journal, Vol. 323 No. 7308, p. 298.
36. Runciman, W.B., Merry, A.F. and Tito, F. (2003), "Error, blame, and the law in health care - an Antipodean perspective", Annals of Internal Medicine, Vol. 138 No. 12, pp. 974-9.
37. Scott, J.A. (1990), Matter of Record: Documentary Sources in Social Research, Polity Press, Cambridge.
38. Selbst, S., Fein, J.A., Osterhoudt, K. and Ho, W. (1999), "Medication errors in a paediatric emergenecy department", Paediatric Emergency Care, Vol. 15 No. 1, pp. 1-4.
39. Shaw, R., Drever, F., Hughes, H., Osborn, S. and Williams, S. (2005), "Adverse events and near miss reporting in the NHS", Quality and Safety in Health Care, Vol. 14 No. 4, pp. 279-83.
40. Simpson, J.H., Lynch, R., Grant, J. and Alroomi, L. (2004), "Reducing medication errors in the neonatal intensive care unit", Archives of Disease in Childhood Fetal Neonatology, No. 89, pp. F480-2.
41. Sutcliffe, K., Lewton, E. and Rosenthal, M. (2004), "Communication failures: An insidious contributor to medical mishaps", Academic Medicine, Vol. 79 No. 2, pp. 186-94.
42. Tamuz, M., Thomas, E.J. and Franchois, K.E. (2004), "Defining and classifying medical error: Lessons for patient safety reporting systems", Quality and Safety in Health Care, Vol. 13 No. 1, pp. 13-20.
43. Thomas, E.J. and Peterson, L.A. (2003), "Measuring errors and adverse events", Journal of General Internal Medicine, Vol. 18 No. 1, pp. 61-7.
44. Tuttle, D., Holloway, R., Baird, T., Sheehan, B. and Skelton, W.K. (2004), "Electronic reporting to improve patient safety", Quality and Safety in Health Care, Vol. 13, pp. 281-6.
45. Uribe, C.L., Schweikhart, S.B. and Pathak, D.S. (2002), "Perceived barriers to medical error reporting: An exploratory investigation", Journal of Healthcare Management, Vol. 47 No. 4, pp. 263-79.
46. Vere-Jones, E. (2005), "Doctors loathe to report slip-ups", Hospital Doctor, No. 7.
47. Vincent, C., Ennis, M. and Audley, R.J. (2004), "Analysis of clinical incidents: A window on the system not a search for root causes", Quality and Safety in Health Care, Vol. 13 No. 4, pp. 242-3.
48. Vincent, C., Stanhope, N. and Crowley-Murphy, M. (1999), "Reasons for not reporting adverse events: An empirical study", Journal of Evaluation in Clinical Practice, Vol. 5 No. 1, pp. 13-21.
49. Wald, H. and Shojania, K.G. (2003), "Incident reporting", Patient Safety Initiative: Building Foundations, Reducing Risk, AHRQ, Rockville, MD.
50. Waring, J. (2005), "Beyond blame: Cultural barriers to medical incident reporting", Social Science and Medicine, Vol. 60 No. 9, pp. 1927-35.
51. Wilson, R.M., Runciman, W.B., Gibberd, R.W., Harrison, B.T., Newby, L. and Hamilton, J.D. (1995), "The quality in Australian health care study", Medical Journal of Australia, Vol. 163, pp. 458-71.
52. World Health Organisation (WHO) (2004), World Alliance for Patient Safety: Forward Programme for 2005, WHO, Geneva.
53. Yu, K.H., Nation, R.L. and Dooley, M.J. (2005), "Multiplicity of medication safety terms: DefiniWions and functional meanings: when is enough enough?", Quality and Safety in Health Care, Vol. 14, pp. 358-63.
54. Zhang, J., Patel, V.L., Todd, R.J. and Shortliffe, E.H. (2004), "A cognitive taxonomy of medical errors", Journal of Biomedical Informatics, Vol. 37 No. 6, pp. 193-204.