The anatomy and physiology of error in adverse health care events

Palmieri, Patrick A.; DeLucia, Patricia R.; Peterson, Lori T.; Ott, Tammy; Green, Alexia

doi:10.1016/s1474-8231(08)07003-1

Cited by 30 publications

(25 citation statements)

References 44 publications

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“…While individual practitioners are indeed accountable for the quality of their work, patient safety is optimized by focusing on system processes rather than exclusively on individual performance [3,12,14,21]. Partners within a system approach include regulatory bodies, educational institutions, diverse practice organizations, and the individuals within these structures that provide and receive services.…”

Section: Literature Reviewmentioning

confidence: 99%

“…This complexity is defined by an interaction among variables such as economics, multi-level human resources, constant change, unpredictability, communication and relational challenges, advancing technology, and multifaceted health needs [12,20,27]. Such a practice context requires safety conscious health care providers to sustain a culture of safety.…”

Section: Literature Reviewmentioning

confidence: 99%

“…Researchers suggest that up to half of all reported adverse events which compromised patient safety are preventable [9,10]. This healthcare tragedy requires individuals, practice organizations, educational institutions, and systems to commit to actualizing a shared evidence-informed culture of patient safety by preventing, identifying, reporting and analyzing errors [11,12].…”

Section: Introductionmentioning

confidence: 99%

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Factors Affecting Nursing Students’ Perception on Pediatric Patient Safety Culture and Nursing Activity

Park¹,

Oh²,

Kim³

2017

Child Health Nurs Res

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Background: Nursing education necessitates vigilance for clinical safety, a daunting challenge given the complex interchanges between students, patients and educators. As active learners, students offer a subjective understanding concerning safety in the practice milieu that merits further study. This study describes the viewpoints of senior undergraduate nursing students about compromised safety in the clinical learning environment. Methods: Q methodology was used to systematically elicit multiple viewpoints about unsafe clinical learning from the perspective of senior students enrolled in a baccalaureate nursing program offered at multiple sites in Ontario, Canada. Across two program sites, 59 fourth year students sorted 43 theoretical statement cards, descriptive of unsafe clinical practice. Q-analysis identified similarities and differences among participant viewpoints yielding discrete and consensus perspectives. Results: A total of six discrete viewpoints and two consensus perspectives were identified. The discrete viewpoints at one site were Endorsement of Uncritical Knowledge Transfer, Non-student Centered Program and Overt Patterns of Unsatisfactory Clinical Performance. In addition, a consensus perspective, labelled Contravening Practices was identified as responsible for compromised clinical safety at this site. At the other site, the discrete viewpoints were Premature and Inappropriate Clinical Progression, Non-patient Centered Practice and Negating Purposeful Interactions for Experiential Learning. There was consensus that Eroding Conventions compromised clinical safety from the perspective of students at this second site. Conclusions: Senior nursing students perceive that deficits in knowledge, patient-centered practice, professional morality and authenticity threaten safety in the clinical learning environment. In an effort to eradicate compromised safety associated with learning in the clinical milieu, students and educators must embody the ontological, epistemological and praxis fundamentals of nursing.

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Section: Literature Reviewmentioning

confidence: 99%

Section: Literature Reviewmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Factors Affecting Nursing Students’ Perception on Pediatric Patient Safety Culture and Nursing Activity

Park¹,

Oh²,

Kim³

2017

Child Health Nurs Res

View full text Add to dashboard Cite

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“…Physicians can reduce the risk of such accidental error by investing in the expertise needed to properly diagnose patients and select treatments, as well as in systems, staffing and health care technology 21 needed to treat patients without excessive risk of preventable error (Mello and Studdert 2008;Palmieri et al 2008; see generally Arlen & MacLeod 2003;2005a). Medical institutions, like hospitals and MCOs, also can reduce the risk of accidental medical negligence through investment in superior systems, supervision, 18 Section 4 infra shows that this empirically grounded model undermines the economic justification for contractual malpractice liability (Arlen & MacLeod 2003;Arlen 2010).…”

Section: A Causes Of Medical Errormentioning

confidence: 99%

Economic Analysis of Medical Malpractice Liability and Its Reform

Arlen

2013

SSRN Journal

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“…According to this model, events must happen in a particular sequence for an adverse consequence to occur, much like lining up the holes in slices of Swiss cheese. 56 As such, the "average risks" quoted for a particular antithrombotic therapy may inaccurately define the actual risk facing a specific patient and care setting. For example, enoxaparin, a renally cleared anticoagulant, may not pose much risk when used in young persons with normal kidney function; however, if enoxaparin is given to an elderly patient with impaired renal clearance and the dose is not adjusted, the likelihood for bleeding quickly escalates.…”

Section: Drug- Patient- and Provider-associated Riskmentioning

confidence: 99%