Rework and workarounds in nurse medication administration process: Implications for work processes and patient safety

Health Care Management Review

Volumn 35, Issue 2, 2010, Pages 124-133

  Halbesleben, Jonathon R B ^a   Savage, Grant T ^b   Wakefield, Douglas S ^b   Wakefield, Bonnie J ^b  

^a UNIVERSITY OF WISCONSIN EAU CLAIRE   (United States)

^b UNIVERSITY OF MISSOURI   (United States)

Author keywords

Medication safety; Nursing; Quality improvement; Rework; Workarounds

Indexed keywords

ARTICLE; DOCTOR NURSE RELATION; HOSPITAL ORGANIZATION; HUMAN; INFORMATION PROCESSING; INTENSIVE CARE UNIT; INTERVIEW; MEDICATION ERROR; NURSING PROCESS; NURSING STAFF; ORGANIZATION AND MANAGEMENT; PATIENT SAFETY;

AUTOMATIC DATA PROCESSING; HUMANS; INTENSIVE CARE UNITS; INTERVIEWS AS TOPIC; MEDICATION ERRORS; MEDICATION SYSTEMS, HOSPITAL; NURSING PROCESS; NURSING STAFF, HOSPITAL; PATIENT SAFETY; PHYSICIAN-NURSE RELATIONS;

EID: 77949592334     PISSN: 03616274     EISSN: None     Source Type: Journal    
DOI: 10.1097/HMR.0b013e3181d116c2     Document Type: Article

References (43)

1. Ash, J. S., Berg, M., & Coiera, E. (2004). Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. Journal of the American Medical Informatics Association, 11, 104-112.
2. Ash, J. S., Gorman, P. N., Lavelle, M., Payne, T. H, Massaro, T. A., Frantz, G. L., et al. (2003). A cross-site qualitative study of physician order entry. Journal of the American Medical Informatics Association, 10, 188-200.
3. Bates, D. W. (2000). Using information technology to reduce rates of medication errors in hospitals. British Medical Journal, 320, 788-791.
4. Bond, C. A., Raehl, C. L., & Franke, T. (2001). Medication errors in United States hospitals. Pharmacotherapy, 21, 1023-1036.
5. Carayon, P., & Gürses, A. P. (2005). A human factors engineering conceptual framework of nursing workload and patient safety in intensive care units. Intensive and Critical Care Nursing, 21, 284-301.
6. Catchpole, K. R., Giddings, A. E., Wilkinson, M., Dale, T., & de Leval, M. R. (2007). Improving patient safety by identifying latent failures in successful operations. Surgery, 142, 102-110.
7. Edmondson, A. (2004). Learning from failure in health care: Frequent opportunities, pervasive barriers. Quality and Safety in Health Care, 13, ii3-ii9.
8. Godfrey, M. M., Nelson, E. C.,Wasson, J. H., Mohr, J. J., Batalden, P. B. (2003). Microsystems in health care: Part 3. Planning patient-centered services. Joint Commission Journal on Quality and Patient Safety, 29, 159-170.
9. Gurwitz, J. H., Field, T. S., Judge, J., Rochon, P., Harrold, L. R., Cadoret, C., et al. (2005). The incidence of adverse drug events in two large academic long-term care facilities. American Journal of Medicine, 118, 251-258.
10. Halbesleben, J. R. B., & Rathert, C. (2008). The role of continuous quality improvement and psychological safety in predicting workarounds. Health Care Management Review, 33, 134-144.
11. Halbesleben, J. R. B., Wakefield, D. S., & Wakefield, B. J. (2008). Workarounds in health care settings: Literature review and research agenda. Health Care Management Review, 33, 2-12.
12. Halpern, N. A., Pastores, S. M., & Greenstein, R. J. (2004). Critical care medicine in the United States 1985-2000: An analysis of bed numbers, use, and costs. Critical Care Medicine, 32, 1254-1259.
13. Harrison, M. I., Koppel, R., & Bar-Lev, S. (2007). Unintended consequences of information technologies in health care: An interactive sociotechnical analysis. Journal of the American Medical Informatics Association, 14, 542-549.
14. Hofmann, D. A., Lei, Z., & Grant, A. M. (2009). Seeking help in the shadow of doubt: The sensemaking process underlying how nurses decide whom to ask for advice. Journal of Applied Psychology, 94, 1261-1274.
15. Hunter, K., Hari, S., Egbu, C., & Kelly, J. (2005). Grounded theory: Its diversification and application through two examples from research studies on knowledge and value management. The Electronic Journal of Business ResearchMethodology, 3, 57-68.
16. Institute of Medicine. (2006). Preventing medication errors. Washington, DC: National Academies Press.
17. Kane, S. L., Weber, R. J., & Dasta, J. F. (2003). The impact of critical care pharmacists on enhancing patient outcomes. Intensive Care Medicine, 29, 691-698.
18. Kenagy, J. W., Berwick, D. M., Shore, M. F. (1999). Service quality in health care. JAMA, 281, 661-665.
19. Kobayashi, M., Fussell, S. R., Xiao, Y., & Seagull, J. (2005). Work coordination, workflow, and workarounds in a medical context. CHI Late Breaking Results (pp. 1561-1564). New York: ACM Press.
20. Koppel, R., Metlay, J. P., Cohen, A., Abaluck, B., Localio, A. R., Kimmel, S. E., et al. (2005). Role of computerized physician order entry systems in facilitating medical errors. Journal of the American Medical Association, 293, 1197-1203.
21. Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B. (2008). Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15, 408-423.
22. Krähenbühl-Melcher, A., Schlienger,R., Lampert, M., Haschke, M., Drewe, J.,& Krähenbühl, S. (2007).Drug-related problems in hospitals: A review of the recent literature. Drug Safety, 30, 379-407.
23. Mazur, L. M., & Chen, S. -J. (2008). Understanding and reducing the medication delivery waste via systems mapping and analysis. Health Care Management Science, 11, 55-65.
24. Mazur, L. M., & Chen, S. -J. (2009). An empirical study for medication delivery improvement based on healthcare professionals' perceptions of medication delivery system. Health Care Management Science, 12, 56-66.
25. McDonald, C. J. (2006). Computerization can create safety hazards: A bar-coding near miss. Annals of Internal Medicine, 144, 510-516.
26. Morath, J. M., & Turnbull, J. E. (2005). To do no harm. San Francisco: Jossey-Bass.
27. Morse, J. M. (1994). Designing funded qualitative research. In N. K. Denzin, & Y. S. Lincoln (Eds.). Handbook of Qualitative Research (pp. 220-235). Thousand Oaks, CA: Sage.
28. Patterson, E. S., Rogers, M. L., Chapman, R. J., & Render M. (2006). Compliance with intended use of bar code medication administration in acute and long-term care: An observational study. Human Factors, 48, 15-22.
29. Pennsylvania Patient Safety Authority. (2008). Medication errors occurring with the use of bar-code administration technology. Pennsylvania Patient Safety Advisory, 5(4), 122-126.
30. Russell, C. K., & Gregory, D. M. (2003). Evaluation of qualitative research studies. Evidence Based Nursing, 6, 36-40.
31. Sandelowski, M. (1995). Sample size in qualitative research. Research in Nursing & Health, 18, 179-183.
32. Spear, S. J., & Schmidhofer, M. (2005). Ambiguity and workarounds as contributors to medical error. Annals of Internal Medicine, 142, 627-630.
33. Thomas, E. J., Studdert, D. M., Burstin, H. R., Orav, E. J., Zeena, T., Williams, E. J., et al. (2000). Incidence and types of adverse events and negligent care in Utah and Colorado. Medical Care, 38, 261-271.
34. Thompson, D. N., Wolf, G. A., & Spear, S. J. (2003). Driving improvement in patient care: Lessons from Toyota. Journal of Nursing Administration, 33, 585-595.
35. Tucker, A. L., & Edmondson, A. C. (2003). Why hospitals don't learn from failures: Organizational and psychological dynamics that inhibit system change. California Management Review, 45(2), 1-18.
36. Uhlig, P. N., Brown, J., Nason,A. K., Camelio,A.,& Kendall, E. (2002). System innovation: Concord Hospital. Joint Commission Journal of Quality Improvement, 28, 666-672.
37. Unruh, L. (2003). Licensed nurse staffing and adverse events in hospitals. Medical Care, 41, 142-152.
38. Vogelsmeier, A. A., Halbesleben, J. R. B., & Scott-Cawiezell, J. R. (2008). Technology implementation and workarounds in the nursing home. Journal of the American Medical Informatics Association, 15, 114-119.
39. Volpp, K. G. M., & Grande, D. (2003). Residents' suggestions for reducing errors in teaching hospitals. New England Journal of Medicine, 348, 851-855.
40. Wakefield, D. S., Halbesleben, J. R. B.,Ward, M. M., Qiu, Q., Brokel, J., & Crandall, D. (2007). Development of a measure of clinical information systems expectations and experiences. Medical Care, 45, 884-890.
41. Ward, M. M., Jaana, M., Bahensky, J. A.,Vartak, S., & Wakefield, D. S. (2006). Clinical information system availability and use in urban and rural hospitals. Journal of Medical Systems, 30, 429-438.
42. Wideman, M., Whittler, M., & Anderson, T. (2005). Barcode medication administration: Lessons learned from an intensive care unit implementation. In K. Henriksen, J. B. Battles, E. Marks, & D. I. Lewin (Eds.), Advances in patient safety: from research to implementation. Vol.3, Implementation issue. Rockville, MD: Agency for Healthcare Research and Quality. AHRQ Publication No. 05-0021-23
43. Wilson, K., & Sullivan, M. (2004). Preventing medication errors with smart infusion technology. American Journal of Health-System Pharmacy, 61, 177-183.