If only....: failed, missed and absent error recovery opportunities in medication errors

Kessels-Habraken, Mmp Marieke; Schaaf, van der Tw Tjerk

doi:10.1136/qshc.2007.026187

Cited by 33 publications

(28 citation statements)

References 18 publications

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“…The first three consist of the 3-tiered hierarchy of risk controls. The remaining two, detection/situational awareness and preparedness help users consider risk controls to reduce the severity of harm or prevent harm in the midst of an on-going systems breakdown; they are aimed at promoting resilience [29][30][31], as opposed to focusing solely on preventing systems breakdowns in the first place. This two-pronged approach is based on the model, widely accepted in the risk management community, of risk as the product of likelihood and consequences [32].…”

Section: The Go-arc Promptsmentioning

confidence: 99%

Use of the Generating Options for Active Risk Control (GO-ARC) Technique can lead to more robust risk control options

Card¹,

Simsekler

Clark

et al. 2014

International Journal of Risk &Amp; Safety in Medicine

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BACKGROUND: Risk assessment is widely used to improve patient safety, but healthcare workers are not trained to design robust solutions to the risks they uncover. This leads to an overreliance on the weakest category of risk control recommendations: administrative controls. Increasing the proportion of non-administrative risk control options (NARCOs) generated would enable (though not ensure) the adoption of more robust solutions. OBJECTIVES: Experimentally assess a method for generating stronger risk controls: The Generating Options for Active Risk Control (GO-ARC) Technique. METHODS: Participants generated risk control options in response to two patient safety scenarios. Scenario 1 (baseline): All participants used current practice (unstructured brainstorming). Scenario 2: Control group used current practice; intervention group used the GO-ARC Technique. To control for individual differences between participants, analysis focused on the change in the proportion of NARCOs for each group. RESULTS: Control group: Proportion of NARCOs decreased from 0.18 at baseline to 0.12. Intervention group: Proportion increased from 0.10 at baseline to 0.29 using the GO-ARC Technique. Results were statistically significant. There was no decrease in the number of administrative controls generated by the intervention group. CONCLUSION: The Generating Options for Active Risk Control (GO-ARC) Technique appears to lead to more robust risk control options. A.J. Card et al. / Use of the Generating Options for Active Risk Control (GO-ARC) Techniqueof these approaches is that they are exclusively focused on problem exploration (risk assessment). They provide no direct support for the process of translating this problem-focused learning into solutionsfocused interventions (risk control) [2,9,13,14].The unexamined assumption behind this state of affairs is that successful risk assessment will necessarily lead to successful risk control. This approach may be successful in the industrial settings where these techniques were developed (the chemical process industry, for instance [15]), but recent evidence suggests that this success does not extend to the fields of healthcare [2] or occupational health and safety [16]. This may reflect that fact that the tools of operational risk assessment were created both by and for engineers, who are specifically trained to develop high-quality, robust solutions in response to identified requirements [17]. Healthcare workers are not trained in these skills [18], nor are they supported by risk management policies and procedures that provide adequate support for this function [14]. As a result, they face significant challenges in generating (and recognizing) high-quality risk controls [2,19,20].The strength of risk controls can be assessed using the three-tiered hierarchy of risk control [2]. The most effective and robust (i.e., prone to continue working over time) category is Elimination of the Hazard or the Target. The intermediate level is made up of Design Controls (aka Engineering Controls [16]), inter...

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Section: The Go-arc Promptsmentioning

confidence: 99%

Use of the Generating Options for Active Risk Control (GO-ARC) Technique can lead to more robust risk control options

Card¹,

Simsekler

Clark

et al. 2014

International Journal of Risk &Amp; Safety in Medicine

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“…He notes how the current system sets patients up for dissatisfaction and medical error. Habraken and Van der Schaaf 6 Investigated 53 medication errors that resulted in patient injury or death. While the study focused on classification or errors, results showed 55% of the medication errors occurred during administration-usually a domain of nursing.…”

Section: Makarymentioning

confidence: 99%

Tracking medical errors and near misses in the new graduate registered nurse

Africa¹,

Shinners

2019

Nurs Forum

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This article provides a narrative that describes the current state of medical errors and near misses in the general health care setting and for new graduate registered nurses specifically. It then proposes a "wild idea" to create a national database for the reporting of errors that would act as a call to action to change our current reporting system to one of transparency and shared information for the purpose of creating needed education in both academic and practice settings. K E Y W O R D S adverse events, medical errors, near misses, new graduate registered nurses, transition-to-practice

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“…Because not all errors may be prevented, HFE researchers have developed models to understand how errors can be detected, corrected, mitigated, and dealt with by operators 25. Strategies for error detection and recovery have been explored among nurses,26 in particular critical care nurses,27 and among pharmacists 28 29.…”

Section: Hfe Approaches and Contributions To Patient Safetymentioning

confidence: 99%

Human factors and ergonomics as a patient safety practice

2013

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BackgroundHuman factors and ergonomics (HFE) approaches to patient safety have addressed five different domains: usability of technology; human error and its role in patient safety; the role of healthcare worker performance in patient safety; system resilience; and HFE systems approaches to patient safety.MethodsA review of various HFE approaches to patient safety and studies on HFE interventions was conducted.ResultsThis paper describes specific examples of HFE-based interventions for patient safety. Studies show that HFE can be used in a variety of domains.ConclusionsHFE is a core element of patient safety improvement. Therefore, every effort should be made to support HFE applications in patient safety.

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If only....: failed, missed and absent error recovery opportunities in medication errors

Cited by 33 publications

References 18 publications

Use of the Generating Options for Active Risk Control (GO-ARC) Technique can lead to more robust risk control options

Use of the Generating Options for Active Risk Control (GO-ARC) Technique can lead to more robust risk control options

Tracking medical errors and near misses in the new graduate registered nurse

Human factors and ergonomics as a patient safety practice

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