메뉴 건너뛰기




Volumn 27, Issue 1, 2015, Pages 1-9

What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system

Author keywords

Electronic prescribing; Incident reporting; Medication administration errors; Medication error; Safety

Indexed keywords

ARTICLE; AUSTRALIA; COMPARATIVE STUDY; HUMAN; INCIDENT REPORT; MEDICAL AUDIT; MEDICAL STAFF; MEDICATION ERROR; OBSERVATIONAL STUDY; PATIENT HARM; PRIORITY JOURNAL; TEACHING HOSPITAL; CLASSIFICATION; HEALTH CARE QUALITY; ORGANIZATION AND MANAGEMENT; PRESCRIPTION; RISK MANAGEMENT; SAFETY; STATISTICS AND NUMERICAL DATA;

EID: 84924629377     PISSN: 13534505     EISSN: 14643677     Source Type: Journal    
DOI: 10.1093/intqhc/mzu098     Document Type: Article
Times cited : (118)

References (43)
  • 1
    • 84857127727 scopus 로고    scopus 로고
    • A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths
    • de Feijter J, de Grave W, Muijtjens A et al. A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths. PLoS One 2012;7:e31125.
    • (2012) PLoS One , vol.7 , pp. e31125
    • de Feijter, J.1    de Grave, W.2    Muijtjens, A.3
  • 2
    • 84874818483 scopus 로고    scopus 로고
    • Irish staff nurses' perceptions of clinical incident reporting
    • Fitzgerald E, Cawley D, Rowan N. Irish staff nurses' perceptions of clinical incident reporting. Int J Nurs Midwifery 2011; 3:14-21.
    • (2011) Int J Nurs Midwifery , vol.3 , pp. 14-21
    • Fitzgerald, E.1    Cawley, D.2    Rowan, N.3
  • 3
    • 33847344617 scopus 로고    scopus 로고
    • Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place
    • Olsen S, Neale G, Schwab K et al. Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place. Qual Saf Health Care 2007; 16:40-4.
    • (2007) Qual Saf Health Care , vol.16 , pp. 40-44
    • Olsen, S.1    Neale, G.2    Schwab, K.3
  • 4
    • 61449183647 scopus 로고    scopus 로고
    • Adverse-event-reporting practices by US hospitals: results of a national survey
    • Farley DO, Haviland A, Champagne S et al. Adverse-event-reporting practices by US hospitals: results of a national survey. Qual Saf Health Care 2008; 17:416-23.
    • (2008) Qual Saf Health Care , vol.17 , pp. 416-423
    • Farley, D.O.1    Haviland, A.2    Champagne, S.3
  • 5
    • 84355162188 scopus 로고    scopus 로고
    • How event reporting by US hospitals has changed from 2005 to 2009
    • Farley DO, Haviland A, Haas A et al. How event reporting by US hospitals has changed from 2005 to 2009. BMJ Qual Saf 2012; 21:70-7.
    • (2012) BMJ Qual Saf , vol.21 , pp. 70-77
    • Farley, D.O.1    Haviland, A.2    Haas, A.3
  • 6
    • 80054764499 scopus 로고    scopus 로고
    • Reporting of sentinel events in Swedish hospitals: a comparison of severe adverse events reported by patients and providers
    • Ohrn A, Elfstrom J, Liedgren C et al. Reporting of sentinel events in Swedish hospitals: a comparison of severe adverse events reported by patients and providers. Jt Comm J Qual Patient Safety 2011; 37:495-501.
    • (2011) Jt Comm J Qual Patient Safety , vol.37 , pp. 495-501
    • Ohrn, A.1    Elfstrom, J.2    Liedgren, C.3
  • 7
    • 34249905609 scopus 로고    scopus 로고
    • Providing feedback to hospital doctors about prescribing errors; a pilot study
    • English
    • Franklin B, O'Grady K, Paschalides C et al. Providing feedback to hospital doctors about prescribing errors; a pilot study. Pharm World Sci 200729:213-20. English.
    • (2007) Pharm World Sci , vol.29 , pp. 213-220
    • Franklin, B.1    O'Grady, K.2    Paschalides, C.3
  • 8
    • 0027231164 scopus 로고
    • Incidence and preventability of adverse drug events in hospitalized adults
    • Bates DW, Leape L, Petrvcki S. Incidence and preventability of adverse drug events in hospitalized adults. J Gen Intern Med 1993; 8:289-94.
    • (1993) J Gen Intern Med , vol.8 , pp. 289-294
    • Bates, D.W.1    Leape, L.2    Petrvcki, S.3
  • 10
    • 79959661552 scopus 로고    scopus 로고
    • Mapping the limits of safety reporting systems in health care- what lessons can we actually learn?
    • Thomas M, Shultz T, Hannaford N et al. Mapping the limits of safety reporting systems in health care- what lessons can we actually learn? Med J Aust 2011;194:635-9.
    • (2011) Med J Aust , vol.194 , pp. 635-639
    • Thomas, M.1    Shultz, T.2    Hannaford, N.3
  • 11
    • 28944453114 scopus 로고    scopus 로고
    • Mandatory state-based error-reporting systems: current and future prospects
    • Wood K, Nash D. Mandatory state-based error-reporting systems: current and future prospects. Am J Med Qual 2005; 20:297-303.
    • (2005) Am J Med Qual , vol.20 , pp. 297-303
    • Wood, K.1    Nash, D.2
  • 12
    • 33846289616 scopus 로고    scopus 로고
    • Incident reporting and patient safety
    • Vincent C. Incident reporting and patient safety. Br Med J 2007; 334:51.
    • (2007) Br Med J , vol.334 , pp. 51
    • Vincent, C.1
  • 13
    • 84869082137 scopus 로고    scopus 로고
    • Improving the value of patient safety reporting systems
    • Henriksen K, Battles J, Keyes M, Grady M, (eds), Rockville, MD: Agency for Healthcare Research and Quality
    • Pronovost P, Morlock L, Sexton J et al. Improving the value of patient safety reporting systems. In: Henriksen K, Battles J, Keyes M, Grady M, (eds). Advances in Patient Safety: New Directions and Alternative Approaches. Rockville, MD: Agency for Healthcare Research and Quality, 2008.
    • (2008) Advances in Patient Safety: New Directions and Alternative Approaches
    • Pronovost, P.1    Morlock, L.2    Sexton, J.3
  • 15
    • 61449150551 scopus 로고    scopus 로고
    • The frustrating case of incident-reporting systems
    • Shojania K. The frustrating case of incident-reporting systems. Qual Saf Health Care 2008; 17:400-2.
    • (2008) Qual Saf Health Care , vol.17 , pp. 400-402
    • Shojania, K.1
  • 17
    • 84872679157 scopus 로고    scopus 로고
    • Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit-based project
    • Fore A, Sculli G, Albee D et al. Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit-based project. J Nurs Manag 2013; 21:106-11.
    • (2013) J Nurs Manag , vol.21 , pp. 106-111
    • Fore, A.1    Sculli, G.2    Albee, D.3
  • 18
    • 84898656142 scopus 로고    scopus 로고
    • Are interventions to reduce interruptions and errors during medication administration effective? A systematic review
    • Raban M, Westbrook J. Are interventions to reduce interruptions and errors during medication administration effective? A systematic review. BMJ Qual Saf 2014; 23:414-21.
    • (2014) BMJ Qual Saf , vol.23 , pp. 414-421
    • Raban, M.1    Westbrook, J.2
  • 19
    • 84924585251 scopus 로고    scopus 로고
    • Audit of medication interruptions and effectiveness of drug round tabards in Aberdeen Royal Infirmary, NHS Grampian
    • Scott J, Williams D, MacKenzie F et al. Audit of medication interruptions and effectiveness of drug round tabards in Aberdeen Royal Infirmary, NHS Grampian. Br J Clin Pharmacol 2009; 68:291.
    • (2009) Br J Clin Pharmacol , vol.68 , pp. 291
    • Scott, J.1    Williams, D.2    MacKenzie, F.3
  • 20
    • 33846305099 scopus 로고    scopus 로고
    • Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review
    • Sari A, Sheldon T, Cracknell A et al. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. Br Med J 2007; 334:79.
    • (2007) Br Med J , vol.334 , pp. 79
    • Sari, A.1    Sheldon, T.2    Cracknell, A.3
  • 21
    • 0027369391 scopus 로고
    • Physician reporting compared with medical-record review to identify adverse medical events
    • O'Neil A, Petersen L, Cook E et al. Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med 1993; 119:370-6.
    • (1993) Ann Intern Med , vol.119 , pp. 370-376
    • O'Neil, A.1    Petersen, L.2    Cook, E.3
  • 24
    • 0035478255 scopus 로고    scopus 로고
    • Retrospective analysis of mortalities associated with medication errors
    • Phillips J, Beam S, Brinker A. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm 2001; 58:1835-41.
    • (2001) Am J Health Syst Pharm , vol.58 , pp. 1835-1841
    • Phillips, J.1    Beam, S.2    Brinker, A.3
  • 26
    • 33244493122 scopus 로고    scopus 로고
    • Attitudes and barriers to incident reporting: a collaborative hospital study
    • Evans S, Berry J, Smith B et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care 2006; 15:39-43.
    • (2006) Qual Saf Health Care , vol.15 , pp. 39-43
    • Evans, S.1    Berry, J.2    Smith, B.3
  • 27
    • 0032942425 scopus 로고    scopus 로고
    • Reasons for not reporting adverse incidents: an empirical study
    • Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Prac 1999; 5:13-21.
    • (1999) J Eval Clin Prac , vol.5 , pp. 13-21
    • Vincent, C.1    Stanhope, N.2    Crowley-Murphy, M.3
  • 28
    • 78650418398 scopus 로고    scopus 로고
    • Underreporting of patient safety incidents reduces health care's ability to quantify and accurately measure harm reduction
    • Noble DJ, Pronovost PJ. Underreporting of patient safety incidents reduces health care's ability to quantify and accurately measure harm reduction. J Patient Saf 2010; 6:247-50.
    • (2010) J Patient Saf , vol.6 , pp. 247-250
    • Noble, D.J.1    Pronovost, P.J.2
  • 29
    • 84924608850 scopus 로고    scopus 로고
    • (19 December 2014, date last accessed)
    • NSW Health. Incident Management Policy. 2014. p. http://www0.health. nsw.gov.au/policies/pd/2014/pdf/PD_004.pdf (19 December 2014, date last accessed).
    • (2014) Incident Management Policy
  • 30
    • 84924564992 scopus 로고    scopus 로고
    • RiskMan.Net, 19 December, date last accessed
    • RiskMan.Net. http://www.riskman.net.au/ (19 December 2014, date last accessed).
    • (2014)
  • 31
    • 44449160871 scopus 로고    scopus 로고
    • Attitudes toward the large-scale implementation of an incident reporting systems
    • Braithwaite J, Westbrook M, Travaglia J. Attitudes toward the large-scale implementation of an incident reporting systems. Int J Qual Health Care 2008; 20:184-91.
    • (2008) Int J Qual Health Care , vol.20 , pp. 184-191
    • Braithwaite, J.1    Westbrook, M.2    Travaglia, J.3
  • 32
    • 84856495580 scopus 로고    scopus 로고
    • Effects of two commercial electronic prescribing systems on prescribing error rates in hospital inpatients: a before and after study
    • Westbrook J, Reckmann M, Li L et al. Effects of two commercial electronic prescribing systems on prescribing error rates in hospital inpatients: a before and after study. PLoS Med 2012;9:e1001164. doi:10.1371/journal.pmed.
    • (2012) PLoS Med , vol.9 , pp. e1001164
    • Westbrook, J.1    Reckmann, M.2    Li, L.3
  • 33
    • 77951664144 scopus 로고    scopus 로고
    • Association of interruptions with increased risk and severity of medication administration errors
    • Westbrook J, Woods A, Rob MI et al. Association of interruptions with increased risk and severity of medication administration errors. Arch Intern Med 2010; 170:683-90.
    • (2010) Arch Intern Med , vol.170 , pp. 683-690
    • Westbrook, J.1    Woods, A.2    Rob, M.I.3
  • 35
    • 0036500042 scopus 로고    scopus 로고
    • Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities
    • Flynn EA, Barker KN, Pepper GA et al. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm 2002; 59:436-46.
    • (2002) Am J Health Syst Pharm , vol.59 , pp. 436-446
    • Flynn, E.A.1    Barker, K.N.2    Pepper, G.A.3
  • 36
    • 17144413786 scopus 로고    scopus 로고
    • Insights from the sharp end of intravenous medication errors: implications for infusion pump technology
    • Husch M, Sullivan C, Rooney D et al. Insights from the sharp end of intravenous medication errors: implications for infusion pump technology. Qual Saf Health Care 2005;14:80-6.
    • (2005) Qual Saf Health Care , vol.14 , pp. 80-86
    • Husch, M.1    Sullivan, C.2    Rooney, D.3
  • 37
    • 0032813705 scopus 로고    scopus 로고
    • The impact of computerized physician order entry on medication error prevention
    • Bates D, Teich J, Lee J et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999; 6:313-21.
    • (1999) J Am Med Inform Assoc , vol.6 , pp. 313-321
    • Bates, D.1    Teich, J.2    Lee, J.3
  • 38
    • 34249780150 scopus 로고    scopus 로고
    • The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff-time: a before-and-after study
    • Franklin D, O'Grady K, Donyai P et al. The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff-time: a before-and-after study. Qual Saf Health Care 2007; 16:279-84.
    • (2007) Qual Saf Health Care , vol.16 , pp. 279-284
    • Franklin, D.1    O'Grady, K.2    Donyai, P.3
  • 39
    • 79960348429 scopus 로고    scopus 로고
    • Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error?
    • Coleman JJ, Hemming K, Nightingale PG et al. Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error? J R Soc Med 2011;104:208-18.
    • (2011) J R Soc Med , vol.104 , pp. 208-218
    • Coleman, J.J.1    Hemming, K.2    Nightingale, P.G.3
  • 40
    • 84885098475 scopus 로고    scopus 로고
    • Missed medication doses in hospitalised patients: a descriptive account of quality improvement measures and time series analysis
    • Coleman JJ, Hodson J, Brooks HL et al. Missed medication doses in hospitalised patients: a descriptive account of quality improvement measures and time series analysis. Int J Qual Health Care 2013; 25:564-72.
    • (2013) Int J Qual Health Care , vol.25 , pp. 564-572
    • Coleman, J.J.1    Hodson, J.2    Brooks, H.L.3
  • 41
  • 42
    • 0346147013 scopus 로고    scopus 로고
    • Improving medication safety: the measurement conundrum and where to start
    • Classen DC, Metzger J. Improving medication safety: the measurement conundrum and where to start. Int J Qual Health Care 2003;15(suppl 1):i41-i7.
    • (2003) Int J Qual Health Care , vol.15 , pp. i41-i47
    • Classen, D.C.1    Metzger, J.2
  • 43
    • 0038482206 scopus 로고    scopus 로고
    • The quality of health care delivered to adults in the United States
    • McGlynn EA, Asch SM, Adams J et al. The quality of health care delivered to adults in the United States. NEJM 2003; 348:2635-45.
    • (2003) NEJM , vol.348 , pp. 2635-2645
    • McGlynn, E.A.1    Asch, S.M.2    Adams, J.3


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.