A human error taxonomy for analysing healthcare incident reports: Assessing reporting culture and its effects on safety performance

Journal of Risk Research

Volumn 12, Issue 3-4, 2009, Pages 485-511

  Itoh, K ^a   Omata, N ^a   Andersen, H B ^b  

^a TOKYO INSTITUTE OF TECHNOLOGY   (Japan)

^b TECHNICAL UNIVERSITY OF DENMARK   (Denmark)

Author keywords

Human error taxonomy; Incident reporting; Inter rater reliability; Organisational learning; Patient safety; Reporting culture

Indexed keywords

HUMAN ERROR TAXONOMY; HUMAN ERRORS; INCIDENT REPORTS; MISS DETECTION; ORGANISATIONAL LEARNING; PATIENT SAFETY; SAFETY PERFORMANCE; SAFETY PROCEDURE;

ERRORS; HEALTH CARE; HOSPITALS; KNOWLEDGE MANAGEMENT; RELIABILITY; RISK ANALYSIS; RISK MANAGEMENT;

TAXONOMIES;

EID: 71149083705     PISSN: 13669877     EISSN: 14664461     Source Type: Journal    
DOI: 10.1080/13669870903047513     Document Type: Article

References (49)

1. Aspden, P., J.M. Corrigan, J. Wolcott, and S.M. Erickson, eds. 2004. Patient safety: Achieving a new standard for care. Committee on data standards for patient safety: Board on health care services. Washington, DC: The National Academic Press.
2. Barach, P., and S.D. Small. 2000. Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems British Medical Journal 320: 753-763
3. Battles, J.B., and R.J. Lilford. 2003. Organizing patient safety research to identify risks and hazards. Quality and Safety in Health Care 12, suppl. 2: ii2-ii7.
4. Beckmann, U., L.F. West, G.J. Groombridge, I. Baldwin, G.K. Hart, D.G. Clayton, R.K.Webb, and W.B. Runciman. 1996. The Australian incident monitoring study in intensive care: AIMS-ICU. The development and evaluation of an incident reporting system in intensive care. Anaesthesia and Intensive Care 24, no.3: 314-319 (Pubitemid 26189701)
5. Bove, T. 2002. Development and validation of a human error management taxonomy in air traffic control. Risø-R-1378(EN). Roskilde: Risø National Laboratory.
6. Chang, A., P.M. Schyve, R.J. Croteau, D.S. O'Leary, and J.M. Loeb. 2005. The JCAHO patient safety event taxonomy: A standardized terminology and classification schema for near misses and adverse events. International Journal for Quality in Health Care 17, no.2: 95-105.
7. Cohen, J. 1960. A coefficient of agreement for nominal scales. Educational and Psychological Measurements 20: 37-46.
8. Department of Health. 2000. An organisation with a memory: Report of an expert group on learning from adverse events in the National Health Service chaired by the chief medical officer. London: HMSO.
9. Dovey, S.M., D.S. Meyers, R.L. Phillips, Jr., L.A. Green, G.E. Fryer, J.M. Galliher, J. Kappus, and P. Grob. 2002. A preliminary taxonomy of medical errors in family practice. Quality and Safety in Health Care 11: 233-238
10. Edmondson, A.C. 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, no.1: 5-28.
11. ---. 2004. Learning from failure in health care: Frequent opportunities, pervasive barriers. Quality and Safety in Health Care 13, suppl. 2: ii3-ii9.
12. Hammons, T., N.F. Piland, S.D. Small, M.J. Hatlie, and H.R. Burstin. 2003. Ambulatory patient safety: What we know and need to know. Journal of Ambulatory Care Management 26: 63-82.
13. Helmreich, R.L., and A.C. Merritt. 1998. Culture at work in aviation and medicine: National, organizational and professional influences. Aldershot, UK: Ashgate.
14. Hollnagel, E. 1998. Cognitive reliability and error analysis method (CREAM). London: Elsevier Science.
15. Isaac, A., S.T. Shorrock, R. Kennedy, B. Kirwan, H.B. Andersen, and T. Bove. 2001. The human error in ATM (HERA) technique. Brussels: Eurocontrol Headquarters.
16. Isaac, A., S.T. Shorrock, and B. Kirwan. 2002. Human error in European air traffic management: The HERA project. Reliability Engineering and System Safety 75, no.2: 257-272
17. Itoh, K. 2003. Safety culture and its correlation with patient safety in Japanese hospitals: Proceedings of the 7th International Symposium on Human Factors in Organizational Design and Management (ODAM 7), Aachen, Germany, October 2003. In Human factors in organizational design and management. Vol.4: ed. H. Luczak, and K.J. Zink, 35-45. Santa Monica, CA: IEA Press.
18. Itoh, K., and H.B. Andersen. 2004. Analysing medical incident reports by use of a human error taxonomy adapted from air traffic management: Proceedings of the 7th International Conference on Probabilistic Safety Assessment and Management -PSAM7-ESREL'04, Berlin, Germany, June 2004. In Probabilistic safety assessment and management. Vol.5: ed. C. Spitzer, U. Schmocker, and V.N. Dang, 2714-2719 London: Springer.
19. Itoh, K., H.B. Andersen, and M.D. Madsen. 2006. Safety culture in healthcare. In Handbook of human factors and ergonomics in healthcare and patient safety, ed. P. Carayon, 199-216. Mahwah, NJ: Lawrence Erlbaum Associates.
20. Itoh, K., H.B. Andersen, M.D. Madsen, and T. Abe. 2005. Comparative results of crossnational surveys on hospital safety culture: The views and attitudes of healthcare staff towards safety-related issues and reporting of adverse events and errors. Technical Report No.2005-1. Tokyo: Tokyo Institute of Technology.
21. Itoh, K., M. Seki, and H.B. Andersen. 2003. Approaches to transportation safety: Methods and case studies applying to track maintenance train operations. In Handbook of cognitive task design, ed. E. Hollnagel, 603-632 Mahwah, NJ: Lawrence Erlbaum Associates.
22. Kohn, L.T., J.M. Corrigan, and M.S. Donaldson, eds. 1999. To err is human: Building a safer health system. Washington DC: National Academy Press.
23. Kostopoulou, O. 2006. From cognition to the system: Developing a multilevel taxonomy of patient safety in general practice. Ergonomics 49, no.5: 486-502.
24. Kostopoulou, O., and B. Delaney. 2007. Confidential reporting of patient safety events in primary care: Results from a multilevel classification of cognitive and system factors. Quality and Safety in Health Care 16: 95-100.
25. Kunac, D.L., D.M. Reith, J. Kennedy, N.C. Austin, and S.M. Williams. 2006. Inter- and intra-rater reliability for classification of medication related events in paediatric inpatients. Quality and Safety in Health Care 15: 196-201.
26. Landis, J., and G.G. Koch. 1977. The measurement of observer agreement for categorical data. Biometrics 33: 327-347
27. Madsen, M.D., H.B. Andersen, and K. Itoh. 2006. Assessing safety culture in healthcare. In Handbook of human factors and ergonomics in healthcare and patient safety, ed. P. Carayon, 693-713. Mahwah, NJ: Lawrence Erlbaum Associates.
28. Makeham, M.A.B., S.M. Dovey, M. County, and M.R. Kidd. 2002. An International taxonomy for errors in general practice: A pilot study. The Medical Journal of Australia 177: 68-72.
29. Mason, S. 1997. Procedural violations: Causes, costs and cues. In Human factors in safety critical systems, ed. F. Redmill, and K.J. Rajan, 287-318. Oxford, UK: Butterworth-Heinemann.
30. Pedrali, P., H.B. Andersen, and P. Trucco. 2002. Are maritime accident causation taxonomies reliable? An experimental study of the human factors classification of the IMO, MAIB and CASMET Systems. In Proceedings of the RINA Conference on Human Factors in Ship Design and Operation, 117-129. London: RINA.
31. Rasmussen, J. 1980. What can be learned from human error reports? In Changes in working life, ed. K. Duncan, M. Gruneberg, and D. Wallis, 97-113. London: Wiley.
32. Rasmussen, J. 1986. Information processing and human-machine interaction: An approach to cognitive engineering. New York: North-Holland.
33. Reason, J. 1990. Human error. New York: Cambridge University Press.
34. ---. 1993. Managing the management risk: New approaches to organisational safety. In Reliability and safety in hazardous work systems, ed. B. Wilpert, and T. Qvale. Hove, UK: Lawrence Erlbaum Associates.
35. ---. 1997. Managing the risk of organizational accidents. Aldershot, UK: Ashgate.
36. Reason, J., and A. Hobbs. 2003. Managing maintenance error: A practical guide. Aldershot, UK: Ashgate.
37. Runciman, W.B., S.C. Helps, E.J. Sexton, and A. Malpass. 1998. A classification for incidents and accidents in the health-care system. Journal of Quality in Clinical Practice 18: 199-211.
38. Runciman, W.B., J.A.H. Williamson, A. Deakin, K.A. Benveniste, K. Bannon, and P.D. Hibbert. 2006. An integrated framework for safety, quality and risk management: An information and incident management system based on a universal patient safety classification. Quality and Safety in Health Care 15, suppl. 1: i482-i490.
39. Salo, I., and O. Svenson. 2003. Mental causal models of incidents communicated in licensee event reports in a process industry. Cognition, Technology & Work 5: 211-217
40. Shorrock, S.T., and B. Kirwan. 2002. Development and application of a human error identification tool for air traffic control. Applied Ergonomics 33, no.4: 319-336
41. Shoukri, M.M. 2004. Measures of interobserver agreement. Boca Raton, FL: Chapman & Hall/CRC.
42. Swain, A.D., and H.E. Guttmann. 1983. A handbook of human reliability analysis with emphasis on nuclear power plant applications. NUREG/CR-1278; SAND-80-0200. Albuquerque, NM: Sandia National Laboratories.
43. Taylor-Adams, S.E., and B. Kirwan. 1995. Human reliability data requirements. Journal of Quality and Reliability Management 12, no.1: 24-46.
44. Van Der Schaaf, T.W. 1996. PRISMA: A risk management tool based on incident analysis. Paper presented at the International Conference and Workshop on Process Safety Management and Inherently Safer Processes, 8-11 October, in Orlando, FL.
45. Van Der Schaaf, T.W., and M.N.P. Habraken. 2005. PRISMA-medical: A brief description. Eindhoven: Eindhoven University of Technology.
46. WHO. 2005. WHO draft guidelines for adverse event reporting and learning systems. Geneva: World Alliance for Patient Safety, WHO.
47. ---. 2006. The conceptual framework of an international patient safety event classification. Geneva: World Alliance for Patient Safety, WHO.
48. Woods, D.M., J. Johnson, J.L. Holl, M. Mehra, E.J. Thomas, E.S. Ogata, and C. Lannon. 2005. Anatomy of a patient safety event: A pediatric patient safety taxonomy. Quality and Safety in Health Care 14: 422-427
49. Zhang, J., V.L. Patel, T.R. Johnson, and E.H. Shortliffe. 2004. A cognitive taxonomy of medical errors. Journal of Biomedical Informatics 37, no.3: 193-204.