Reason's accident causation model: Application to adverse events in acute care

Contemporary Nurse

Volumn 43, Issue 1, 2012, Pages 22-28

  Elliott, Malcolm ^a,b   Page, Karen ^c   Worrall Carter, Linda ^a  

^a AUSTRALIAN CATHOLIC UNIVERSITY   (Australia)

^b Holmesglen Institute   (Australia)

^c NATIONAL HEART FOUNDATION OF AUSTRALIA   (Australia)

Author keywords

Accident causation; Adverse events; Quality and safety

Indexed keywords

ACUTE DISEASE; ARTICLE; EPIDEMIOLOGY; HUMAN; MEDICAL ERROR; THEORETICAL MODEL;

ACUTE DISEASE; CAUSALITY; HUMANS; MEDICAL ERRORS; MODELS, THEORETICAL;

EID: 84873185544     PISSN: 10376178     EISSN: None     Source Type: Journal    
DOI: 10.5172/conu.2012.43.1.22     Document Type: Article

References (37)

1. Baker, G., Norton, P., Flintoft, V., Blais, R., Brown, A., Cox, J.,... & Tamblyn, R. (2004). The Canadian adverse events study: The incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal, 170(11), 1678-1686.
2. Bates, K., & Schiller, J. (2007). Acute mental status changes, hypotension and bradycardia in a 15 year old boy. Hospital Physician, 43, 39-44.
3. Borbasi, S., Jackson, D., & Langford, R. (2008). Navigating the maze of nursing research-An interactive learning adventure (2nd ed.). Sydney, NSW: Mosby.
4. Brazil, K., Ozer, E., Cloutier, M., Levine, R., & Stryer, D. (2005). From theory to practice: Improving the impact of health services research. BMC Health Services Research, 5, 1.
5. Cohen, M. (2006). Medication errors-Unfamiliar syringe, wrong route. Nursing2006, 36(3), 14.
6. Dean, B., Schachter, M., Vincent, C., & Barber, N. (2002). Causes of prescribing errors in hospital inpatients: A prospective study. Lancet, 359(9328), 1373-1378.
7. De Vries, E., Ramrattan, M., Smorenburg, S., Gouma, D., & Boermeester, M. (2008). The incidence and nature of in-hospital adverse events: A systematic review. Quality & Safety in Health Care, 17(3), 216-223.
8. Ehsani, J., Duckett, S. & Jackson, T. (2007). The incidence and cost of cardiac surgery adverse events in Australian hospitals 2003-2004. European Journal of Health Economics, 8(4), 339-346.
9. Elliott, M. (2006). Readmission to intensive care: A review of the literature. Australian Critical Care, 19(3), 93-104.
10. Elliott, M., Crookes, P., Worrall-Carter, L., & Page, K. (2011). Readmission to intensive care: A qualitative analysis of nurses' perceptions and experiences. Heart & Lung, 40(4), 299-309.
11. Elliott, M., Worrall-Carter, L., & Page, K. (in press). Factors contributing to adverse events after ICU discharge: A survey of Liaison nurses. Australian Critical Care.
12. Fowler, F., Epstein, A., Weingart, S., Annas, C., Bolcic-Jankovic, D., Clarridge, B.,... Weissman J. (2008). Adverse events during hospitalization: Results of a patient survey. Joint Commission Journal on Quality and Patient Safety, 34, 583-590.
13. Green, A., & Edmonds, L. (2004). Bridging the gap between the intensive care unit and general wards-the ICU Liaison nurse. Intensive and Critical Care Nursing, 20(3), 133-143.
14. Griffi n, F., & Classen, D. (2008). Detection of adverse events in surgical patients using the Trigger Tool approach. Quality & Safety in Health Care, 17(4), 253-258.
15. Johnson, C., & Botting, R. (1999). Using Reason's model of organizational accidents in formalizing accident reports. Cognition, Technology & Work, 1, 107-118.
16. Johnson, C., McCarthy, J., & Wright, P. (1995). Using a formal language to support natural language in accident reports. Ergonomics, 38(6), 1264-1282.
17. Johnson, M., & Young, H. (2011). The application of Aronson's taxonomy to medication errors innursing. Journal of Nursing Care Quality, 26(2), 128-135.
18. Kohn, L., Corrigan, J., & Donaldson, M. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.
19. Mark, B., Hughes, L., Belyea, M., Bacon, C., Chang, Y., & Jones, C. (2008). Exploring organizational context and structure as predictors of medication errors and patient falls. Journal of Patient Safety, 4(2), 66-77.
20. Mark, B., Hughes, L., & Jones, C. (2004). The role of theory in improving patient safety and quality health care. Nursing Outlook, 52, 11-16.
21. Moody, L. (1990). Advancing nursing science through research. Newbury Park, CA: Sage.
22. O'Hare, D. (2000). The 'wheel of misfortune': A taxonomic approach to human factors in accident investigation and analysis in aviation and other complex systems. Ergonomics, 43, 2001-2019.
23. Parahoo, K. (2006). Nursing research-Principles, process and issues (2nd ed.). Hampshire, England: Palgrave.
24. Perin, C. (2005). Shouldering risks: The culture of control in the nuclear power industry. Princeton, NJ: Princeton University Press.
25. Perneger, T. (2005). The Swiss cheese model of safety incidents: Are there holes in the metaphor? BMC Health Services Research, 5(1), 71.
26. Polgar, S., & Thomas, S. (2008). Introduction to research in the health sciences (5th ed.). Edinburgh, Scotland: Churchill Livingstone.
27. Reason, J. (1990). Human error. Cambridge, England: Cambridge University Press.
28. Reason, J. (1997). Managing the risks of organizational accidents. Aldershot, England: Ashgate.
29. Reason, J. (2000). Human error: Models and management. British Medical Journal, 320, 768-770.
30. Reason, J. (2001). Understanding adverse events: The human factor. In C. Vincent (Ed.) Clinical risk management: Enhancing patient safety (2nd ed.). London, England: BMJ.
31. Reason, J., Carthey, J., & de Leval, M. (2001). Diagnosing 'vulnerable system syndrome': An essential prerequisite to effective risk management. Quality in Health Care, 10(Suppl 2), ii21-ii25.
32. Runciman, W., Webb, R., Lee, R., & Holland, R. (1993). System failure: An analysis of 2000 incident reports. Anaesthesia & Intensive Care, 21(5), 684-695.
33. Sharek, P., Horbar, J., Mason, W., Bisarya, H., Thurm, C., & Suresh, G. (2006). Adverse events in the neonatal intensive care unit: Development, testing, and fi ndings of an NICU-focused trigger tool to identify harm in North American NICUs. Pediatrics, 118(4), 1332-1340.
34. Sinopoli, D., Needham, D., Thompson, D., Holzmueller, C., Dorman, T., & Lubomski, L. (2007). Intensive care unit safety incidents for medical versus surgical patients: A prospective multicenter study. Journal of Critical Care, 22(3), 177-183.
35. Vincent, C., Neale, G., & Woloshynowych, M. (2001). Adverse events in British hospitals: Preliminary retrospective record review. British Medical Journal, 322(7299), 517-519.
36. Wagenaar, W., Hudson, P., & Reason, J. (1990). Cognitive failures and accidents. Applied Cognitive Psychology, 4(4), 273-294.
37. Woloshynowych, M., Rogers, S., Taylor-Adams, S., & Vincent, C. (2005). The investigation and analysis of critical incidents and adverse events in healthcare. Health Technology Assessment, 9(19), 1-143.