Catching and correcting near misses: The collective vigilance and individual accountability trade-off

Journal of Interprofessional Care

Volumn 26, Issue 2, 2012, Pages 121-126

  Jeffs, Lianne Patricia ^a   Lingard, Lorelei ^b   Berta, Whitney ^c   Baker, G Ross ^c  

^a ST MICHAEL'S HOSPITAL   (Canada)

^b UNIVERSITY OF WESTERN ONTARIO   (Canada)

^c UNIVERSITY OF TORONTO   (Canada)

Author keywords

Grounded theory; Interprofessional practice; Interviews; Professional boundaries; Qualitative method

Indexed keywords

ARTICLE; CANADA; HEALTH PERSONNEL ATTITUDE; HUMAN; INTERVIEW; MEDICAL ERROR; PATIENT SAFETY; PSYCHOLOGICAL ASPECT; PUBLIC RELATIONS; QUALITATIVE RESEARCH; SOCIAL BEHAVIOR; STANDARD; TEACHING HOSPITAL;

ATTITUDE OF HEALTH PERSONNEL; CANADA; HOSPITALS, TEACHING; HUMANS; INTERPROFESSIONAL RELATIONS; INTERVIEWS AS TOPIC; MEDICAL ERRORS; PATIENT SAFETY; QUALITATIVE RESEARCH; SOCIAL RESPONSIBILITY;

EID: 84858022637     PISSN: 13561820     EISSN: 14699567     Source Type: Journal    
DOI: 10.3109/13561820.2011.642424     Document Type: Article

References (22)

1. Amalberti, R., Vincent, C., Auroy, Y., & de Saint Maurice, G. (2006). Violations and migrations in health care: A framework for understanding and management. Quality and Safety in Health Care, 15(Suppl. 1), i66-i71.
2. Barr, H. (2002). Interprofessional education: Today, yesterday, and tomorrow. London: Learning and Support Network: Centre for Health Sciences and Practice.
3. Careau, E., Vincent, C., & Swaine, B.R. (2011). Consensus group session of experts to describe interprofessional collaboration processes in team meetings. Journal of Interprofessional Care, 25(4), 299-301.
4. 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(1), 102-110.
5. Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. Thousand Oaks, CA: Sage Publications.
6. Cook, R., & Rasmussen, J. (2005). "Going solid": A model of systems dynamics and consequences of patient safety. Quality and Safety in Health Care, 14(2), 130-134.
7. Espin, S., Levinson, W., Regehr, G., Baker, G.R., & Lingard, L. (2006). Error or "act of God"? A study of patients' and operating team members' perceptions of error definition, reporting, and disclosure. Surgery, 139(1), 6-14.
8. 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, 3(1), 2-12.
9. Halbesleben, J.R.B., Savage, G.T., Wakefield, D.S., & Wakefield, B.J. (2010). Rework and workarounds in nurse medication administration process: Implications for work processes and patient safety. Health Care Management Review, 35(2), 124-133.
10. Henneman, E.A., & Gawlinski, A. (2004). A "near-miss" model for describing the nurse's role in the recovery of medical errors. Journal of Professional Nursing, 20(3), 196-201.
11. Iedema, R. (2009). New approaches to researching patient safety. Social Science & Medicine, 69(12), 1701-1704.
12. Kanse, L., van der Schaaf, T.W., Vrijland, N., & van Mierlo, H. (2006). Error recovery in a hospital pharmacy. Ergonomics, 49(5/6), 503-526.
13. Kessels-Habraken, M., van der Schaaf, T., De Jonge, J., & Rutte, C. (2010). Defining near misses: Towards a sharpened definition based on empirical data about error handling processes. Social Science Medicine, 70(9), 1301-1308.
14. Reeves, S., Lewin, S., Espin, S., & Zwarenstein, M. (2010). Interprofessional teamwork for health and social care. Oxford, UK:Wiley-Blackwell.
15. Reeves, S., Goldman, J., Gilbert, J., Tepper, J., Silver, I., Suter, E., & Zwarenstein, M. (2011). A scoping review to improve conceptual clarity around interprofessional interventions. Journal of Interprofessional Care, 25(3), 167-174.
16. Rogers, A.E., Dean, G., Hwang, W.-T., & Scott, L.D. (2008). The role of registered nurses in error prevention, discovery, and correction. Quality and Safety in Health Care, 17(2), 117-121.
17. Tucker, A.L., & Edmondson, A.C. (2002). Managing routine exceptions: A model of nurse problem solving behaviour. Adv Health Care Manage, 3, 87-113.
18. Tucker, A.L., & Edmondson, A.C. (2003). Why hospitals don't learn from failures: Organizational and psychological dynamics that inhibit system change. Calif Manage Rev, 45, 55-72.
19. Van der Schaaf, T.W. (1992). Near miss reporting in the chemical process industry. Eindhoven: Technische Universiteit Eindhoven. Vaughan, D. (1996). The Challenger launch decisions: Risky technology, culture and deviance of NASA. Chicago, IL: Chicago University Press.
20. Vincent, C. (2009). Social scientists and patient safety: Critics or contributors? Social Science & Medicine, 69(12), 1777-1779.
21. Waring, J.J. (2009). Constructing and re-constructing narratives of patient safety. Social Science & Medicine, 69(12), 1722-1731.
22. Way, D., Jones, L., & Busing, N. (2000). Implementation strategies: Collaboration in primary care-family doctors & nurse practitioners delivering shared care. Toronto: The Ontario College of Family Physicians. Available at: http://www.ocfp.on.ca/english/ocfp/ communications/publications/ default.asp?s1.