Integrating data from the UK national reporting and learning system with work domain analysis to understand patient safety incidents in community pharmacy

Journal of Patient Safety

Volumn 13, Issue 1, 2017, Pages 6-13

  Phipps, Denham L ^a,b   Tam, W Vanessa ^a   Ashcroft, Darren M ^a,b  

^a UNIVERSITY OF MANCHESTER   (United Kingdom)

^b UNIVERSITY OF MANCHESTER   (United Kingdom)

Author keywords

Cognitive work analysis; Community pharmacy; Incident analysis; Incident reporting; National reporting and learning system; Sociotechnical system

Indexed keywords

ANALYTIC METHOD; DOCUMENTATION; ERROR; HEALTH PROMOTION; HUMAN; INCIDENT REPORT; INFORMATION PROCESSING; JOB ANALYSIS; LEARNING; MODEL; PATIENT SAFETY; PHARMACIST; PHARMACY; RETROSPECTIVE STUDY; STATISTICAL ANALYSIS; COMMUNITY CARE; COMPREHENSION; INCIDENCE; MEDICATION ERROR; RISK MANAGEMENT; UNITED KINGDOM; WORK;

COMMUNITY HEALTH SERVICES; COMPREHENSION; DOCUMENTATION; FOCUS GROUPS; HUMANS; INCIDENCE; MEDICATION ERRORS; PATIENT SAFETY; PHARMACIES; PHARMACISTS; PHARMACY; RETROSPECTIVE STUDIES; RISK MANAGEMENT; UNITED KINGDOM; WORK;

EID: 84894460706     PISSN: 15498417     EISSN: 15498425     Source Type: Journal    
DOI: 10.1097/PTS.0000000000000090     Document Type: Article

References (40)

1. Department of Health, Design Council. Design for Patient Safety: A system-wide design-led approach to tackling patient safety in the NHS. London, UK: Department of Health; 2003.
2. Wiegmann DA, Eggman AA, Elbardissi AW, et al. Improving cardiac care: A work systems approach. Appl Ergon. 2010; 41: 701-712.
3. Monroe K, Wang D, Vincent C, et al. Patient safety factors in children dying in a paediatric intensive care unit (PICU): A case notes review study. BMJ Qual Saf. 2011; 20: 863-868.
4. Goodman PS, Ramanujam R, Carroll JS, et al. Organizational errors: Directions for future research. Res Org Behav. 2011; 21: 151-176.
5. Garfield S, Barber N, Walley P, et al. Quality of medication use in primary care Y mapping the problem, working to a solution: A systematic review of the literature. BMC Med. 2009; 7: 50.
6. Howard R, Avery A, Bisssell P. Causes of preventable drug-related hospital admissions: A qualitative study. Qual Saf Health Care. 2008; 17: 109-116.
7. Sauer BC, Hepler CD. Application of system-level root cause analysys for drug quality and safety problems: A case study. Res Soc Adm Pharm. 2013; 9: 49-59.
8. Waterson P. A critical review of the systems approach within patient safety research. Ergonomics. 2009; 52: 1185-1195.
9. Taylor-Adams S, Vincent C, Stanhope N. Applying human factors methods to the investigation and analysis of clinical adverse events. Saf Sci. 1999; 31: 143-159.
10. Armitage GA, Newell R, Wright J. Improving the quality of drug error reporting. J Eval Clin Pract. 2010; 16: 1189-1197.
11. Vincent C. Patient Safety. 2nd ed. Oxford, UK: BMJ Books; 2010.
12. Benn J, Koutantji M, Wallace L, et al. Feedback from incident reporting: Information and action to improve patient safety. Qual Saf Health Care. 2009; 18: 11-21.
13. Vicente KJ. Cognitive Work Analysis. Hillsdale, NJ: Lawrence Erlbaum; 1999.
14. Xu W. Identifying problems and generating recommendations for enhancing complex systems: Applying the abstraction hierarchy framework as an analytical tool. Hum Factors. 2007; 49: 975-994.
15. Lim RHM. A systems approach to medication safety in care homes: Understanding the medication system, investigating medication errors and identifying the requirements of a safe medication system. PhD thesis, University of Surrey, 2008.
16. Lim R, Anderson J, Buckle P. Analysing care home medication errors using work domain analysis. Presented at the Improving Patient Safety Conference, Cambridge, 16-18 July 2008.
17. Lim R, Anderson J, Buckle P. Analysing care home medication errors: A comparison of the London Protocol and work domain analysis. Presented at the 52nd Human Factors and Ergonomics Society Annual Meeting, New York, September 22-26 2008.
18. Phipps DL, Noyce PR, Parker D, et al. Medication safety in community pharmacy: A qualitative study of the sociotechnical context. BMC Health Serv Res. 2009; 9: 158.
19. James KL, Barlow D, McARtney R, et al. Incidence,type and causes of dispensing errors: A review of the literature. Int J Pharm Pract. 2009; 17: 9-30.
20. Williams SK, Osborn SS. The development of the National Reporting and Learning System in England and Wales, 2001-2005. Med J Aust. 2006; 184: S65-S68
21. Naikar N, Hopcroft R, Moylan A. Work domain analysis: Theoretical concepts and methodology. Report DSTO-TR-1665, Defence Science and Technology Organisation, 2005.
22. Rasmussen J. The role of hierarchical knowledge representation in decisionmaking and system management. IEEE Trans Sys Man Cybernetics. 1985; SMC-12: 234-243.
23. Farmilo A, Hone G, Whitworth I. The CWA Tool version 0.95 beta [Computer program]. Shrivenham: Human Factors Integration Defence Technology Centre; 2006.
24. Langley C, Belcher D. Pharmaceutical Compounding and Dispensing. 2nd ed. London, UK: Pharmaceutical Press; 2008.
25. Stone P, Curtis SJ. Pharmacy Practice. 3rd ed. London, UK: Pharmaceutical Press; 2002.
26. National Patient Safety Agency. Design for Patient Safety: A Guide to the Design of the Dispensing Environment. London, UK: NPSA; 2007.
27. Hollnagel E. The ETTO Principle: Efficiency-Thoroughness Trade-off. Farnham, UK: Ashgate; 2009.
28. Jacobs S, Hassell K, Ashcroft DM. Culture in community pharmacy organisations: What can we glean from the literature? J Health Organ Manag. 2011; 25: 420-454.
29. Phipps DL, Ashcroft DM. An investigation of occupational subgroups with respect to patient safety culture. Saf Sci. 2012; 50: 1290-1298.
30. Irwin A, Mearns K, Watson M, et al. The effect of proximity, tall-man lettering and time pressure on accurate visual perception of drug names. Hum Fact. 2013; 55: 253-266.
31. Phipps DL, Parker D, Pals EJM, et al. Identifying violation-provoking conditions in a healthcare setting. Ergonomics. 2008; 51: 1625-1642.
32. Lipczak H, Knudsen JL, Nissen A. Safety hazards in cancer care: Findings using three different methods. BMJ Qual Saf. 2011; 20: 1052-1056.
33. Woloshynowych M, Rogers S, Taylor-Adams S, et al. The investigation and analysis of critical incidents and adverse events in healthcare. Health Technol Assess. 2005; 9: 1-143.
34. Martinez EA, Shore A, Colantuoni E, et al. Cardiac surgery errors: Results from the UK National Reporting and Learning System. Int J Qual Health Care. 2011; 23: 151-158.
35. Catchpole K, Bell MDD, Johnson S. Safety in anaesthesia: A study of 12606 reported incidents from the UK National Reporting and Learning System. Anaesthesia. 2008; 63: 340-346.
36. Hogan H, Healey F, Neale G, et al. Preventable deaths due to problems in care in English acute hospitals: A retrospective case record review study. BMJ Qual Saf. 2012; 21: 737-745.
37. Boyle TA, Scobie AC, MacKinnon NJ, et al. Implications of process characteristics on quality-related event reporting in community pharmacy. Res Soc Adm Pharm. 2012; 8: 76-86.
38. Williams SD, Phipps DL, Ashcroft DM. Understanding the attitudes of hospital pharmacists to reporting medication incidents: A qualitative study. Res Soc Adm Pharm. 2013; 9: 80-89.
39. Anderson JE, Kodate N,Walters R, et al. Can incident reporting improve safety? Healthcare practitioners' views of the effectiveness of incident reporting. Int J Qual Health Care. 2013; 25: 141-150.
40. Waring J, Currie G. The politics of learning: The dilemma for patient safety. In: Rowley E, Waring J, eds. A Socio-Cultural Perspective on Patient Safety. Farnham, UK: Ashgate; 2011: 133-150.