Identifying the Latent Failures Underpinning Medication Administration Errors: An Exploratory Study
- 29 February 2012
- journal article
- research article
- Published by Wiley in Health Services Research
- Vol. 47 (4), 1437-1459
- https://doi.org/10.1111/j.1475-6773.2012.01390.x
Abstract
The primary aim of this article was to identify the latent failures that are perceived to underpin medication errors. The study was conducted within three medical wards in a hospital in the United Kingdom. The study employed a cross-sectional qualitative design. Interviews were conducted with 12 nurses and eight managers. Interviews were transcribed and subject to thematic content analysis. A two-step inter-rater comparison tested the reliability of the themes. Ten latent failures were identified based on the analysis of the interviews. These were ward climate, local working environment, workload, human resources, team communication, routine procedures, bed management, written policies and procedures, supervision and leadership, and training. The discussion focuses on ward climate, the most prevalent theme, which is conceptualized here as interacting with failures in the nine other organizational structures and processes. This study is the first of its kind to identify the latent failures perceived to underpin medication errors in a systematic way. The findings can be used as a platform for researchers to test the impact of organization-level patient safety interventions and to design proactive error management tools and incident reporting systems in hospitals.Keywords
This publication has 66 references indexed in Scilit:
- Characteristics of Work Interruptions During Medication AdministrationJournal of Nursing Scholarship, 2009
- Work system design for patient safety: the SEIPS modelPublished by BMJ ,2006
- How Many Interviews Are Enough?Field Methods, 2006
- Using thematic analysis in psychologyQualitative Research in Psychology, 2006
- What makes an error unacceptable? A factorial survey on the disclosure of medical errorsInternational Journal for Quality in Health Care, 2004
- Barriers to incident reporting in a healthcare systemQuality and Safety in Health Care, 2002
- Caregivers' Sensitivity to Conflict:Journal of Elder Abuse & Neglect, 1996
- A systems approach to organizational errorErgonomics, 1995
- Driving errors, driving violations and accident involvementErgonomics, 1995
- Errors and violations on the roads: a real distinction?Ergonomics, 1990