To Err Is Human

Kohn, Linda T.; Corrigan, Janet M.; Donaldson, Molla S.

doi:10.17226/9728

Cited by 3,515 publications

(154 citation statements)

References 11 publications

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“…Over the years, there have been numerous reports of incidence, prevalence, and preventability of drug-related hospital admissions [1][2][3], medication error-related deaths [4], and adverse drug events in in-patient and out-patient settings [5][6][7]. Drug-related problems are common in hospitalized patients and can interfere with the achievements of desired therapeutic outcomes [8].…”

Section: Introductionmentioning

confidence: 99%

Evaluation of drug therapy problems among renal patients receiving care in some tertiary hospitals in Nigeria

Adibe¹,

Igboeli²,

Ukwe³

2017

Trop. J. Pharm Res

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Section: Introductionmentioning

confidence: 99%

Evaluation of drug therapy problems among renal patients receiving care in some tertiary hospitals in Nigeria

Adibe¹,

Igboeli²,

Ukwe³

2017

Trop. J. Pharm Res

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“…A common medical error is medication error, such as medication order, prescribing, or administration errors (Kawamura, 2003;Kohn, Corrigan, & Donaldson, 1999;Pham et al, 2012; Japan Council for Quality Health Care Division of Adverse Event Prevention, 2016). For prevention of a medication error, it has been strongly recommended that healthcare workers use finger-pointing toward drugs and prescriptions when they prepare and administer medicine to patients.…”

Section: Introductionmentioning

confidence: 99%

Accuracy of Discriminating between Similar Drug Names by Nurses: Effect of Finger-pointing on Error Prevention

Mitobe

Higuchi

2017

JSS

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Discriminating between similar drug names accurately is important in order to prevent medication error. To facilitate accurate discrimination, performing finger-pointing toward drug names to recognize them is recommended in Japan for healthcare workers. We investigate whether nurses would accurately recognize the difference between target and similar drug names and whether finger-pointing would lead to error prevention for drug names by using a choice reaction time task. Participants observed six drug names with or without pointing with the index finger and determined as quickly and accurately as possible whether the target drug name was present. Targets were real drug names, although distractors were pseudo names so as to strictly manipulate the degree of similarity. The results showed that error rates were significantly higher for nurses than for students. Due to their familiarity with the drug names, the nurses could misrecognize the pseudo words as target drug names when a quick response was requested. We also found that nurses did not receive a benefit from finger-pointing. Moreover, finger-pointing may have been inadequate to lead to accurate recognition of complex stimuli, such as drug names.

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“…The Institute of Medicine's landmark 1999 report, To Err Is Human, highlighted high adverse event rates in hospitals in the USA. 1 The likelihood that NHS hospitals also had high adverse event rates was raised in An Organisation With A Memory, published the following year. 2 The 2001 Kennedy report on high mortality rates in cardiac surgery at Bristol Royal Infirmary humanised the problem.…”

Section: Chapter 1 Introductionmentioning

confidence: 99%

Quality and safety between ward and board: a biography of artefacts study

Keen

Nicklin

Long

et al. 2018

Health Serv Deliv Res

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BackgroundThere have been concerns about the quality and safety of NHS hospital services since the turn of the millennium. This study investigated the progress that acute NHS hospital trusts have made in developing and using technology infrastructures to enable them to monitor quality and safety following the publication in 2013 of the second Francis report on the scandal at Mid Staffordshire NHS Foundation Trust (The Mid Staffordshire NHS Foundation Trust Public Inquiry. Chaired by Sir Robert Francis QC.Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. HC 898. London: The Stationery Office; 2013).MethodsA telephone survey of 15 acute NHS trusts in the Yorkshire and the Humber region, and a review of board papers of all acute NHS trusts in England for January 2015, were undertaken. The telephone survey was used to identify trusts for a larger field study, which was undertaken in four acute NHS trusts between April 2015 and September 2016. The methods included the direct observation of the use of whiteboards and other technologies on two wards in each trust, an observation of board quality committees, semistructured interviews and an analysis of the quality and safety data in board papers. Published sources about national and local agencies were reviewed to identify the trust quality and safety data that these agencies accessed and used. An interview programme was also undertaken with those organisations. The Biography of Artefacts approach was used to analyse the data.FindingsThe data and technology infrastructures within trusts had developed over many years. The overall design had been substantially determined by national agencies, and was geared to data processing: capturing and validating data for submission to national agencies. Trust boards had taken advantage of these data and used them to provide assurance about quality and safety. Less positively, the infrastructures were fragmented, with different technologies used to handle different quality and safety data. Real-time management systems on wards, including electronic whiteboards and mobile devices, were used and valued by nurses and other staff. The systems support the proactive management of clinical risks. These developments have occurred within a broad context, with trusts focusing on improving the quality and safety of services and publishing far more data on their performance than they did just 3 years earlier. Trust-level data suggest that quality and safety improved at all four trusts between 2013 and 2016. Our findings indicate that the technology infrastructures contributed to these improvements. There remains considerable scope to rationalise those infrastructures.LimitationsThe four trusts in the main study were, in part, purposively selected, and deliberately biased towards sites that had made progress with designing and deploying real-time ward management systems. This limits the generalisability of the study. The study focused more on the work of nurses and nurse managers, and has relatively little to say about the experiences of doctors or allied health professionals.Future workFuture research might focus on the effects of mobile technologies and electronic whiteboards on acute wards, the value of current national data returns, and the uses and value of trust data warehouses.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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To Err Is Human

Cited by 3,515 publications

References 11 publications

Evaluation of drug therapy problems among renal patients receiving care in some tertiary hospitals in Nigeria

Evaluation of drug therapy problems among renal patients receiving care in some tertiary hospitals in Nigeria

Accuracy of Discriminating between Similar Drug Names by Nurses: Effect of Finger-pointing on Error Prevention

Quality and safety between ward and board: a biography of artefacts study

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