Application of a human factors classification framework for patient safety to identify precursor and contributing factors to adverse clinical incidents in hospital

Source:  Applied Ergonomics Jan/52 pp. 185-95

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Date of publication: January 2016

Publication type:  Journal article

In a nutshell:  This study aimed to identify temporal precursor and associated contributing factors for adverse clinical incidents in a hospital setting using the Human Factors Classification Framework (HFCF) for patient safety. A random sample of 498 clinical incidents were reviewed. The framework identified key precursor events (PE), contributing factors (CF) and the prime causes of incidents. Descriptive statistics and correspondence analysis were used to examine incident characteristics. Staff action was the most common type of PE identified. Correspondence analysis for all PEs that involved staff action by error type showed that rule-based errors were strongly related to performing medical or monitoring tasks or the administration of medication. Skill-based errors were strongly related to misdiagnoses. Factors relating to the organisation (66.9%) or the patient (53.2%) were the most commonly identified CFs. The HFCF for patient safety was able to identify patterns of causation for the clinical incidents, highlighting the need for targeted preventive approaches, based on an understanding of how and why incidents occur.

Length of publication:  11 pages

Some important notes:  Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library

Reducing unacceptable missed doses: pharmacy assistant-supported medicine administration

Source: International Journal of Pharmacy Practice 23/5 pp. 327-332

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Date of publication: October 2015

Publication type:  Journal article

In a nutshell: The potential harm from omitted and delayed medicines for hospital inpatients was highlighted by the National Patient Safety Agency (NPSA). This study aimed to assess the impact on omitted doses when medicine administration was supported by pharmacy assistants (PAs).  The authors concluded that PA-supported medication rounds can significantly reduce the rate of omitted doses. This study provides evidence for a potential solution to the problem of omitted doses for hospital inpatients.

Length of Publication:  7 pages

Some important notes:  Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library

Scheme to improve patient safety is on track to save 6,000 lives

Source:  Department of Health, 24 June 2015

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Date of publication: June 2015

Publication type:  News item

In a nutshell: A year after the launch of Sign up to Safety, 260 NHS organisations have now set out plans to save lives by reducing avoidable harm. The figure far exceeds the campaign’s target to get 180 organisations to sign up in the first year. It means that Sign up to Safety is in a good position to reach its aim of saving up to 6,000 lives over 3 years through the reduction of preventable harm such as medication errors, blood clots and bed sores.

Length of Publication:  1 web page

Factors contributing to registered nurse medication administration error: a narrative review

Source:  International Journal of Nursing Studies 52/1 pp. 403-20

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Date of publication:  January 2015

Publication type:  Journal article

In a nutshell: The authors explored the factors contributing to medication administration incidents amongst registered nurses. A number of factors, including the environment and characteristics of the nurse, were found to influence medication administration incidents. In terms of environment, clinical workload and work setting were important. In terms of nurse characteristics, nurses’ lived experience of work and their demographics were significant. More studies have focused on environmental issues than on how personal characteristics may contribute to incidents. Any inter-relationship between factors was not explored.

Length of Publication:  17 pages

Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library

Causes of Medication Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative Evidence

Source:  Drug Safety vol/iss 36/11 pp. 1045-1067

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Date of publication:  November 2013

Publication type:  Journal article

In a nutshell:  The causes of medication administration errors in hospital were examined in this article. Medication lapses were the most commonly reported medication administration errors, followed by mistakes-based on inaccurate knowledge or deliberate violations. Factors potentially leading to medication administration errors included inadequate written communication, problems with medicines supply and storage such as pharmacy dispensing errors and ward stock management, perceived high workload, problems with access to or functioning of ward equipment, patient availability or acuity, fatigue or stress amongst professionals and distractions during drug administration. Medication administration errors are influenced by multiple systems factors so managers and clinicians need to take a system-wide approach to minimise errors.

Length of Publication:  23 pages

Predictors of health care professionals’ attitudes towards involvement in safety-relevant behaviours

Source:  Journal of Evaluation in Clinical Practice [Epub ahead of print]

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Date of publication:  August 2013

Publication type:  Journal article

In a nutshell:  This study examined factors that influence health professionals’ attitudes towards patient participation in patient safety activities. Doctors and nurses from four hospitals in England were surveyed about their attitudes towards patient involvement in two error scenarios regarding hand hygiene and medication safety. Professionals were more in favour of patients intervening about a medication error than about hand hygiene. If a professional hypothetically responded negatively to a patient when they pointed out a potential error, staff thought that this could have a negative effect on the patient-professional relationship. Doctors were less likely than nurses to think it was good for patients to intervene.

Length of Publication:  Unknown

Some important notes:  Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library.

Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study.

Source:  Research in Social and Administrative Pharmacy Vol/iss 9/1 pp.80-89

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Date of publication:  January 2013

Publication type:  Journal article

In a nutshell:  In England, hospital pharmacists said that medication errors are common and that they are often not reported. Error reporting forms are thought to be cumbersome and time consuming. It could be useful to simplify reporting forms, ensure staff are praised for reporting and make sure that any issues are addressed quickly so that staff feel that reporting is worthwhile.

Length of Publication:  10 pages

Some important notes:  Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library.

Reducing prescribing errors

Source:  The Health Foundation

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Date of publication: March 2012

Publication type:  Evidence scan/review

In a nutshell:  Prescribing accounts for a large proportion of medication errors. This review examined strategies to reduce prescribing errors.

Length of publication:  36 pages