The environmental context of patient safety and medical errors

Journal of Rural Health

Volumn 20, Issue 4, 2004, Pages 304-313

  Wholey, Douglas ^a   Moscovice, Ira ^a   Hietpas, Terry ^a   Holtzman, Jeremy ^a,b  

^a UNIVERSITY OF MINNESOTA   (United States)

^b UNIVERSITY OF MINNESOTA MEDICAL SCHOOL   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

CULTURAL ANTHROPOLOGY; EMERGENCY HEALTH SERVICE; ENVIRONMENTAL FACTOR; HEALTH CARE ORGANIZATION; HEALTH CARE QUALITY; HOSPITAL; INFORMATION PROCESSING; MEDICAL DECISION MAKING; MEDICAL ERROR; MEDICAL INFORMATION; MEDICAL TECHNOLOGY; PATIENT CARE; PATIENT TRANSPORT; REVIEW; RISK REDUCTION; RURAL AREA; RURAL HEALTH CARE; SAFETY; THEORETICAL MODEL;

HUMANS; MEDICAL ERRORS; MEDICALLY UNDERSERVED AREA; ORGANIZATIONAL CULTURE; ORGANIZATIONAL INNOVATION; PATIENT CARE TEAM; QUALITY ASSURANCE, HEALTH CARE; RURAL HEALTH; RURAL HEALTH SERVICES; SAFETY MANAGEMENT; UNITED STATES;

EID: 6344229313     PISSN: 0890765X     EISSN: None     Source Type: Journal    
DOI: 10.1111/j.1748-0361.2004.tb00044.x     Document Type: Review

References (51)

1. Bogner M, ed. Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates Inc; 1994.
2. Sharpe V, Faden A. Medical Harm: Historical, Conceptual and Ethical Dimensions of Iatrogenic Illness. New York, NY: Cambridge University Press; 1998.
3. Spath P, ed. Error Reduction in Health Care: A Systems Approach for Improving Patient Safety. Chicago, IL: Health Forum Inc; 2000.
4. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Institute of Medicine Committee on Quality of Healthcare in America. Washington, DC: National Academy Press; 1999.
5. Quality Interagency Coordination Task Force. Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. Available at: http://www.quic.gov/report. Accessed August 20, 2002.
6. Institute of Medicine Committee on Quality of Healthcare in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
7. Wakefield M. Patient safety and medical errors. Implications for rural health care. J Leg Med. 2002;23(1):43-56.
8. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370-376.
9. Coombs J. Quality of care in rural settings: bringing the "new quality" to rural practice. In: Geyman J, Norris T, Hart L, eds. Textbook of Rural Medicine. New York, NY: McGraw-Hill; 2001:325-340.
10. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med. 2002;346:1715-1722.
11. Feldman MS. Organizational routines as a source of continuous change. Organ Sci. 2000;11:611-629.
12. Feldman MS, Rafaeli A. Organizational routines as sources of connections and understandings. J Manage Stud. 2002;39:309-331.
13. Feldman MS, Pentland BT. Reconceptualizing organizational routines as a source of flexibility and change. Admin Sci Q. 2003;48:94-118.
14. Ricketts T, Johnson-Webb K, Randolph R. Populations and places in rural America. In: Ricketts T, ed. Rural Health in the United States. New York, NY: Oxford University Press; 1999:7-24.
15. Gurwitz JH, Field TS, Avorn J, et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med. 2000;109:87-94.
16. Rothschild JM, Bates DW, Leape LL. Preventable medical injuries in older patients. Arch Intern Med. 2000;160:2717-2728.
17. Wachter RM, McDonald KM, eds. Patient Safety Practices Rated by Strength of Evidence. Addendum to Summary. AHRQ publication no. 01-E057b. Agency for Healthcare Research and Quality, Rockville, MD. July 2001. Available at http://www.ahrq.gov/clinic/ptsafety/addend.htm.
18. Weick KE, Sutcliffe KM. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco, Calif: Jossey-Bass; 2001.
19. Veenema KR, Rodewald LE. Stabilization of rural multiple-trauma patients at level III emergency departments before transfer to a level I regional trauma center. Ann Emerg Med. 1995;25:175-181.
20. Rogers FB, Osler TM, Shackford SR, Cohen M, Camp L, Lesage M. Study of the outcome of patients transferred to a level I hospital after stabilization at an outlying hospital in a rural setting. J Trauma. 1999;46:328-333.
21. Sampalis JS, Denis R, Frechette P, Brown R, Fleiszer D, Mulder D. Direct transport to tertiary trauma centers versus transfer from lower level facilities: impact on mortality and morbidity among patients with major trauma. J Trauma. 1997;43:288-295; discussion 295-296.
22. Reilly BM, Evans AT, Schaider JJ, et al. Impact of a clinical decision rule on hospital triage of patients with suspected acute cardiac ischemia in the emergency department. JAMA. 2002;288:342-350.
23. Mann NC, Hedges JR, Mullins RJ, Helfand M, Worrall W, Zechnich AD. Rural hospital transfer patterns before and after implementation of a statewide trauma system. OHSU Rural Trauma Research Group. Acad Emerg Med. 1997;4:764-771.
24. Narad RA, Becker JL, Frecceri C. A decentralized trauma system design for a rural area. Prehosp Disaster Med. 1996;11:134-139;discussion 139-140.
25. Durkheim E. The Division of Labor in Society. Glencoe, Ill: Free Press; 1947.
26. Guldenmund FW. The nature of safety culture: a review of theory and research. Safe Sci. 2000;34:215-257.
27. Zohar D. Safety climate: conceptual and measurement issues. In: Quick JC, Tetrick LE, eds. Handbook of Occupational Health Psychology. Washington, DC: American Psychological Association; 2003:123-142.
28. Reason JT. Achieving a safe culture: Theory and practice. Work Stress. 1998;12:293-306.
29. Wald H, Shojania KG. Incident reporting. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, Markowitz AJ, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Washington, DC: Agency for Healthcare Research and Quality, AHRQ Publication No. 01-E058; 2001:41-50.
30. Collins R, Makowsky M. The Discovery of Society. 6th ed. New York, NY: McGraw-Hill; 1998.
31. Teich JM, Merchia PR, Schmiz JL, Kuperman GJ, Spurr CD, Bates DW. Effects of computerized physician order entry on prescribing practices. Arch Intern Med. 2000;160:2741-2747.
32. March JG. Exploration and exploitation in organizational learning. Organ Sci. 1991;2:71-87.
33. Levitt B, March JG. Organizational learning. Annu Rev Sociol. 1988;14:319-340.
34. Reason JT. Human Error. Cambridge, England: Cambridge University Press; 1990.
35. Reason J. Human error: models and management. Br Med J. 2000;320(7237):768-770.
36. Barley SR. Technicians in the workplace: ethnographic evidence for bringing work into organization studies. Admin Sci Q. 1996;41:404-441.
37. Barley SR. The alignment of technology and structure through roles and networks. Admin Sci Q. 1990;35:61-103.
38. Wald H, Shojania KG. Root cause analysis. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, Markowitz AJ, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Washington, DC: Agency for Healthcare Research and Quality, AHRQ Publication No. 01-E058; 2001:51-56.
39. Morrissey J. State probe shows Dana-Farber failed to follow basic protocols. Mod Healthcare. 1995(June 19);82.
40. March JG, Sproull LS, Tamuz M. Learning from samples of one or fewer. Organ Sci. 1991;2:1-13.
41. Leape LL. A systems analysis approach to medical error. J Eval Clin Pract. 1997;3:213-222.
42. Tamuz M. Defining away dangers: a study in the influence of managerial cognition on information systems. In: Lant T, Shapira Z, eds. Managerial and Organizational Cognition. Mahwah, NJ: Lawrence Erlbaum; 2000:157-183.
43. Thompson JD. Organizations in Action. New York, NY: McGraw-Hill; 1967.
44. Balestracci DJ, Barlow JL. Quality Improvement: Practical Applications for Medical Group Practice. Englewood, Colo: Center for Research in Ambulatory Care Administration; 1996.
45. O'Neil AC, Petersen LA, Cook EF, Bates DW, Lee TH, Brennan TA. Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med. 1993;119:370-376.
46. Welsh CH, Pedot R, Anderson RJ. Use of morning report to enhance adverse event detection. J Gen Intern Med. 1996;11:454-460.
47. Weingart SN, Ship AN, Aronson MD. Confidential clinician-reported surveillance of adverse events among medical inpatients. J Gen Intern Med. 2000;15:470-477.
48. Weinberg N. Using performance measures to identify plans of action to improve care. Joint Commit J Qual Improv. 2001;27:683-688.
49. Weinberg NS, Stason WB. Managing quality in hospital practice. Int J Qual Health Care. 1998;10:295-302.
50. Ioannidis JP, Lau J. Evidence on interventions to reduce medical errors: an overview and recommendations for future research. J Gen Intern Med. 2001;16:325-334.
51. Coburn AF, Wakefield M, Casey M, Moscovice I, Payne S, Loux S. Assuring rural hospital safety: what should the priorities be? J Rural Health. 2004; 20:314-325.