The need for organizational change in patient safety initiatives

Anderson, James G.; Ramanujam, Rangaraj; Hensel, Devon J.; Anderson, Marilyn A.; Sirio, Carl A.

doi:10.1016/j.ijmedinf.2006.05.043

Cited by 50 publications

(28 citation statements)

References 35 publications

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“…To understand the functioning of the healthcare system and to successfully address medical errors, it is necessary to study those components whose complex relationships constitute the system -humans, technologies and their interactions [5][6][7][8][9]. The study of human factors is an integral part of current safety research [10].…”

Section: Introductionmentioning

confidence: 99%

The nature and occurrence of registration errors in the emergency department

Hakimzada

Green

Sayan

et al. 2008

International Journal of Medical Informatics

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Research into the nature and occurrence of medical errors has shown that these often result from a combination of factors that lead to the breakdown of workflow. Nowhere is this more critical than in the emergency department (ED), where the focus of clinical decision is on the timely evaluation and stabilization of patients. This paper reports on the nature of errors and their implications for patient safety in an adult ED, using methods of ethnographic observation, interviews, and think-aloud protocols. Data were analyzed using modified "grounded theory," which refers to a theory developed inductively from a body of data. Analysis revealed four classes of errors, relating to errors of misidentification, ranging from multiple medical record numbers, wrong patient identification or address, and in one case, switching of one patient's identification information with those of another. Further analysis traced the root of the errors to ED registration.These results indicate that the nature of errors in the emergency department are complex, multilayered and result from an intertwined web of activity, in which stress of the work environment, high patient volume and the tendency to adopt shortcuts play a significant role. The need for information technology (IT) solutions to these problems as well as the impact of alternative policies is discussed.

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Section: Introductionmentioning

confidence: 99%

The nature and occurrence of registration errors in the emergency department

Hakimzada

Green

Sayan

et al. 2008

International Journal of Medical Informatics

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“…Develop and execute a sound organizational change management plan with the help of clinicians [27]. "The level of change involved with CPOE is much greater than hospitals have faced in the past, and success requires that the organization become expert at accomplishing and sustaining change."…”

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confidence: 99%

Assessing the anticipated consequences of Computer-based Provider Order Entry at three community hospitals using an open-ended, semi-structured survey instrument

Sittig¹,

Ash²,

Guappone³

et al. 2008

International Journal of Medical Informatics

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Objective-To determine what "average" clinicians in organizations that were about to implement Computer-based Provider Order Entry (CPOE) were expecting to occur, we conducted an openended, semi-structured survey at three community hospitals. Methods-We created an open-ended, semi-structured, interview survey template that we customized for each organization. This interview-based survey was designed to be administered orally to clinicians and take approximately five minutes to complete, although clinicians were allowed to discuss as many advantages or disadvantages of the impending system roll-out as they wanted to.Results-Our survey findings did not reveal any overly negative, critical, problematic, or striking sets of concerns. However, from the standpoint of unintended consequences, we found that clinicians were anticipating only a few of the events, emotions, and process changes that are likely to result from CPOE. Conclusions-The resultsof such an open-ended survey may prove useful in helping CPOE leaders to understand user perceptions and predictions about CPOE, because it can expose issues about which more communication, or discussion, is needed. Using the survey, implementation strategies and management techniques outlined in this paper, any chief information officer (CIO) or chief medical information officer (CMIO) should be able to adequately assess their organization's CPOE readiness, make the necessary mid-course corrections, and be prepared to deal with the currently identified unintended consequences of CPOE should they occur. Keywords

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“…Reversely, McFadden and colleagues (2006a,b) showed that doi:10.3926/jiem.2008.v1n2.p240-268 ©© JIEM, 2008-01(02): 240-268 -ISSN: 2013 Pragmatic Evaluation of the Toyota Production System (TPS) Analysis Procedure for Problem Solving with Entry-level Nurses lack of top management support, lack of resources, lack of incentives and lack of knowledge can significantly hinder the implementation of any improvement strategies. A computer simulation model (Anderson, Ramanujam, Hensel, Anderson, & Sirio, 2006) that has been developed to explore organizational changes required to improve patient safety based on a medication error reporting system predicted that the number of medication errors reported by hospital staff would increase over time. The simulation model also found that organizational actions needed to reduce the risks of future errors occurred less than 46% of the time and found that 96% of the actions taken in response to reported errors involved individual staff.…”

Section: Current Challenges For Problem Solving In Healthcarementioning

confidence: 99%

“…The simulation model also found that organizational actions needed to reduce the risks of future errors occurred less than 46% of the time and found that 96% of the actions taken in response to reported errors involved individual staff. However, organizational actions that only affect individual staff are likely to have little effect in reducing future errors (Anderson et al, 2006).…”

Section: Current Challenges For Problem Solving In Healthcarementioning

confidence: 99%

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Pragmatic evaluation of the Toyota Production System (TPS) analysis procedure for problem solving with entry-level nurses

Mazur

Chen

Prescott³

2008

JIEM

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Medication errors occurring in hospitals are a growing national concern. These medication errors and their related costs (or wastes) are seen as major factors leading to increased patient safety risks and increased waste in the hospital setting. This article presents a study in which sixteen entry-level nurses utilized a Toyota Production System (TPS) analysis procedure to solve medication delivery problems at one community hospital. The objective of this research was to study and evaluate the TPS analysis procedure for problem solving with entry-level nurses. Personal journals, focus group discussions, and a survey study were used to collect data about entry-level nurses' perceptions of using the TPS problem solving approach to study medication delivery. A regression analysis was used to identify characteristics that enhance problem solving efforts. In addition, propositions for effective problem solving by entry-level nurses to aid in the reduction of medication errors in healthcare delivery settings are offered.

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The need for organizational change in patient safety initiatives

Cited by 50 publications

References 35 publications

The nature and occurrence of registration errors in the emergency department

The nature and occurrence of registration errors in the emergency department

Assessing the anticipated consequences of Computer-based Provider Order Entry at three community hospitals using an open-ended, semi-structured survey instrument

Pragmatic evaluation of the Toyota Production System (TPS) analysis procedure for problem solving with entry-level nurses

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