If only....: Failed, missed and absent error recovery opportunities in medication errors

Quality and Safety in Health Care

Volumn 19, Issue 1, 2010, Pages 37-41

  Habraken, Marieke Maria Petronella ^a   Van Der Schaaf, T W ^a,b  

^a EINDHOVEN UNIVERSITY OF TECHNOLOGY   (Netherlands)

^b HASSELT UNIVERSITY   (Belgium)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; HOSPITAL; HUMAN; MEDICATION ERROR; NETHERLANDS; PATIENT SAFETY; SAFETY; STANDARD;

HOSPITALS; HUMANS; MEDICATION ERRORS; NETHERLANDS; PATIENT SAFETY; SAFETY MANAGEMENT;

EID: 77649096722     PISSN: 14753898     EISSN: 14753901     Source Type: Journal    
DOI: 10.1136/qshc.2007.026187     Document Type: Article

References (20)

1. Aspden P, Corrigan JM, Wolcott J, et al. Patient safety: achieving a new standard for care. Washington DC: The National Academies Press, 2004:193.
2. Kanse L, Van der Schaaf TW, Vrijland ND, et al. Error recovery in a hospital pharmacy. Ergonomics 2006;49:503-16.
3. Parnes B, Fernald D, Quintela J, et al. Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. Qual Saf Health Care 2007;16:12-6.
4. Van der Schaaf TW. Introduction. In: Van der Schaaf TW, Lucas DA, Hale AR, eds. Near miss reporting as a safety tool. Oxford: Butterworth-Heinemann Ltd, 1991:1-8.
5. Van der Schaaf TW, Wright LB. Systems for near miss reporting and analysis. In: Wilson JR, Corlett EN, eds. Evaluation of human work. Boca Raton, FL: CRC Press, 2005:877-99.
6. Habraken MMP. Better care for incidents in health care [MSc thesis]. Eindhoven: Eindhoven University of Technology, 2005.
7. Habraken M, Van der Schaaf T. Biases in a medical incident causation database: a quantitative evaluation using PRISMA-Medical. In: Marmaras N, Kontogiannis T, Nathanael D, eds. Proceedings EACE'05, Annual Conference of the European Association of Cognitive Ergonomics; Chania, Greece, 29 Septembere1 October 2005:167e73. Also available via ACM Digital Library at http://portal.acm.org, ACM International Conference Proceedings Series, Volume 132.
8. Battles JB, Kaplan HS, Van der Schaaf TW, et al. The attributes of medical event-reporting systems: experience with a prototype medical event-reporting system for transfusion medicine. Arch Pathol Lab Med 1998;122:231-8.
9. Hollnagel E. Accidents and barriers. In: Hoc J M, Millot P, Hollnagel E, et al, eds. Proceedings CSAPC'99, Seventh European Conference on Cognitive Science Approaches to Process Control. Villeneuve d'Asq, France: Presses Universitaires de Valenciennes, 1999:175-80.
10. Svenson O. Accident and incident analysis based on the accident evolution and barrier function (AEB) model. Cogn Technol Work 2001;3:42-52.
11. Affonso D, Jeffs L. Near misses: lessons learned in the processes of care. Int Nurs Persp 2004;4:115-22.
12. Tamuz M, Thomas EJ, Franchois KE. Defining and classifying medical error: lessons for patient safety reporting systems. Qual Saf Health Care 2004;13:13-20.
13. Pronovost PJ, Weast B, Holzmueller CG, et al. Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center. Qual Saf Health Care 2003;12:405-10.
14. Henriksen K, Dayton E. Issues in the design of training for quality and safety. Qual Saf Health Care 2006;15:i17-24.
15. Shapiro MJ, Morey JC, Small SD, et al. Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? Qual Saf Health Care 2004;13:417-21.
16. Katz-Navon T, Naveh E, Stern Z. Safety climate in health care organizations: a multidimensional approach. Acad Manage J 2005;48:1075-89.
17. Henriksen K, Kaplan H. Hindsight bias, outcome knowledge and adaptive learning. Qual Saf Health Care 2003;12:ii46-50.
18. Henneman EA, Blank FSJ, Gawlinski A, et al. Strategies used by nurses to recover medical errors in an academic emergency department setting. Appl Nurs Res 2006;19:70-7.
19. Runciman WB, Williamson JAH, Deakin A, et al. An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification. Qual Saf Health Care 2006;15:i82-90.
20. Hogan H, Olsen S, Scobie S, et al. What can we learn about patient safety from information sources within an acute hospital: a step on the ladder of integrated risk management? Qual Saf Health Care 2008;17:209-15.