Eintrag weiter verarbeiten
A systems approach to the reduction of medication error on the hospital ward
Gespeichert in:
Zeitschriftentitel: | Journal of Advanced Nursing |
---|---|
Personen und Körperschaften: | , |
In: | Journal of Advanced Nursing, 35, 2001, 1, S. 34-41 |
Format: | E-Article |
Sprache: | Englisch |
veröffentlicht: |
Wiley
|
Schlagwörter: |
author_facet |
Anderson, David J. Webster, Craig S. Anderson, David J. Webster, Craig S. |
---|---|
author |
Anderson, David J. Webster, Craig S. |
spellingShingle |
Anderson, David J. Webster, Craig S. Journal of Advanced Nursing A systems approach to the reduction of medication error on the hospital ward General Nursing |
author_sort |
anderson, david j. |
spelling |
Anderson, David J. Webster, Craig S. 0309-2402 1365-2648 Wiley General Nursing http://dx.doi.org/10.1046/j.1365-2648.2001.01820.x <jats:p> <jats:bold>A systems approach to the reduction of medication error on the hospital ward</jats:bold> </jats:p><jats:p> <jats:bold>Aims.</jats:bold> To discuss a potentially powerful approach to safer medication administration on the hospital ward, based on principles of safety developed in other high‐risk industries, and consistent with recent national reports on safety in health care released in the United Kingdom (UK) and United States of America (USA). To discuss why punitive approaches to safety on the hospital ward and in the nursing literature do not work.</jats:p><jats:p> <jats:bold>Background.</jats:bold> Drug administration error on the hospital ward is an ever‐present problem and its occurrence is too frequent. Administering medication is probably the highest‐risk task a nurse can perform, and accidents can lead to devastating consequences for the patient and for the nurse’s career. Drug errors in nursing are often dealt with by unsystematic, punitive, and ineffective means, with little knowledge of the factors influencing error generation. Typically, individual nurses are simply blamed for their carelessness. By focusing on the individual, the complete set of contributing factors cannot be known. Instead, vain attempts will be made to change human behaviour – one of the most change‐resistant aspects of any system. A punitive, person‐centred approach therefore, severely hampers effective improvements in safety. By contrast, in other high‐risk industries, such as aviation and nuclear power, the systems‐centred approach to error reduction is routine.</jats:p><jats:p> <jats:bold>Conclusions.</jats:bold> Accidents or errors are only the tip of the incident iceberg. Through effective, nonpunitive incident reporting, which includes reports of near‐misses and system problems in addition to actual accidents, the systems‐approach allows the complete set of contributing factors underlying an accident to be understood and addressed. Feedback to participants and targeted improvement in the workplace is also important to demonstrate that incident data are being used appropriately, and to maintain high levels of on‐going reporting and enthusiasm for the scheme. Drug administration error is a serious problem, which warrants a well‐reasoned approach to its improvement.</jats:p> A systems approach to the reduction of medication error on the hospital ward Journal of Advanced Nursing |
doi_str_mv |
10.1046/j.1365-2648.2001.01820.x |
facet_avail |
Online |
format |
ElectronicArticle |
fullrecord |
blob:ai-49-aHR0cDovL2R4LmRvaS5vcmcvMTAuMTA0Ni9qLjEzNjUtMjY0OC4yMDAxLjAxODIwLng |
id |
ai-49-aHR0cDovL2R4LmRvaS5vcmcvMTAuMTA0Ni9qLjEzNjUtMjY0OC4yMDAxLjAxODIwLng |
institution |
DE-Gla1 DE-Zi4 DE-15 DE-Pl11 DE-Rs1 DE-105 DE-14 DE-Ch1 DE-L229 DE-D275 DE-Bn3 DE-Brt1 DE-D161 |
imprint |
Wiley, 2001 |
imprint_str_mv |
Wiley, 2001 |
issn |
0309-2402 1365-2648 |
issn_str_mv |
0309-2402 1365-2648 |
language |
English |
mega_collection |
Wiley (CrossRef) |
match_str |
anderson2001asystemsapproachtothereductionofmedicationerroronthehospitalward |
publishDateSort |
2001 |
publisher |
Wiley |
recordtype |
ai |
record_format |
ai |
series |
Journal of Advanced Nursing |
source_id |
49 |
title |
A systems approach to the reduction of medication error on the hospital ward |
title_unstemmed |
A systems approach to the reduction of medication error on the hospital ward |
title_full |
A systems approach to the reduction of medication error on the hospital ward |
title_fullStr |
A systems approach to the reduction of medication error on the hospital ward |
title_full_unstemmed |
A systems approach to the reduction of medication error on the hospital ward |
title_short |
A systems approach to the reduction of medication error on the hospital ward |
title_sort |
a systems approach to the reduction of medication error on the hospital ward |
topic |
General Nursing |
url |
http://dx.doi.org/10.1046/j.1365-2648.2001.01820.x |
publishDate |
2001 |
physical |
34-41 |
description |
<jats:p> <jats:bold>A systems approach to the reduction of medication error on the hospital ward</jats:bold> </jats:p><jats:p> <jats:bold>Aims.</jats:bold> To discuss a potentially powerful approach to safer medication administration on the hospital ward, based on principles of safety developed in other high‐risk industries, and consistent with recent national reports on safety in health care released in the United Kingdom (UK) and United States of America (USA). To discuss why punitive approaches to safety on the hospital ward and in the nursing literature do not work.</jats:p><jats:p> <jats:bold>Background.</jats:bold> Drug administration error on the hospital ward is an ever‐present problem and its occurrence is too frequent. Administering medication is probably the highest‐risk task a nurse can perform, and accidents can lead to devastating consequences for the patient and for the nurse’s career. Drug errors in nursing are often dealt with by unsystematic, punitive, and ineffective means, with little knowledge of the factors influencing error generation. Typically, individual nurses are simply blamed for their carelessness. By focusing on the individual, the complete set of contributing factors cannot be known. Instead, vain attempts will be made to change human behaviour – one of the most change‐resistant aspects of any system. A punitive, person‐centred approach therefore, severely hampers effective improvements in safety. By contrast, in other high‐risk industries, such as aviation and nuclear power, the systems‐centred approach to error reduction is routine.</jats:p><jats:p> <jats:bold>Conclusions.</jats:bold> Accidents or errors are only the tip of the incident iceberg. Through effective, nonpunitive incident reporting, which includes reports of near‐misses and system problems in addition to actual accidents, the systems‐approach allows the complete set of contributing factors underlying an accident to be understood and addressed. Feedback to participants and targeted improvement in the workplace is also important to demonstrate that incident data are being used appropriately, and to maintain high levels of on‐going reporting and enthusiasm for the scheme. Drug administration error is a serious problem, which warrants a well‐reasoned approach to its improvement.</jats:p> |
container_issue |
1 |
container_start_page |
34 |
container_title |
Journal of Advanced Nursing |
container_volume |
35 |
format_de105 |
Article, E-Article |
format_de14 |
Article, E-Article |
format_de15 |
Article, E-Article |
format_de520 |
Article, E-Article |
format_de540 |
Article, E-Article |
format_dech1 |
Article, E-Article |
format_ded117 |
Article, E-Article |
format_degla1 |
E-Article |
format_del152 |
Buch |
format_del189 |
Article, E-Article |
format_dezi4 |
Article |
format_dezwi2 |
Article, E-Article |
format_finc |
Article, E-Article |
format_nrw |
Article, E-Article |
_version_ |
1792348821305425927 |
geogr_code |
not assigned |
last_indexed |
2024-03-01T18:17:04.28Z |
geogr_code_person |
not assigned |
openURL |
url_ver=Z39.88-2004&ctx_ver=Z39.88-2004&ctx_enc=info%3Aofi%2Fenc%3AUTF-8&rfr_id=info%3Asid%2Fvufind.svn.sourceforge.net%3Agenerator&rft.title=A+systems+approach+to+the+reduction+of+medication+error+on+the+hospital+ward&rft.date=2001-07-01&genre=article&issn=1365-2648&volume=35&issue=1&spage=34&epage=41&pages=34-41&jtitle=Journal+of+Advanced+Nursing&atitle=A+systems+approach+to+the+reduction+of+medication+error+on+the+hospital+ward&aulast=Webster&aufirst=Craig+S.&rft_id=info%3Adoi%2F10.1046%2Fj.1365-2648.2001.01820.x&rft.language%5B0%5D=eng |
SOLR | |
_version_ | 1792348821305425927 |
author | Anderson, David J., Webster, Craig S. |
author_facet | Anderson, David J., Webster, Craig S., Anderson, David J., Webster, Craig S. |
author_sort | anderson, david j. |
container_issue | 1 |
container_start_page | 34 |
container_title | Journal of Advanced Nursing |
container_volume | 35 |
description | <jats:p> <jats:bold>A systems approach to the reduction of medication error on the hospital ward</jats:bold> </jats:p><jats:p> <jats:bold>Aims.</jats:bold> To discuss a potentially powerful approach to safer medication administration on the hospital ward, based on principles of safety developed in other high‐risk industries, and consistent with recent national reports on safety in health care released in the United Kingdom (UK) and United States of America (USA). To discuss why punitive approaches to safety on the hospital ward and in the nursing literature do not work.</jats:p><jats:p> <jats:bold>Background.</jats:bold> Drug administration error on the hospital ward is an ever‐present problem and its occurrence is too frequent. Administering medication is probably the highest‐risk task a nurse can perform, and accidents can lead to devastating consequences for the patient and for the nurse’s career. Drug errors in nursing are often dealt with by unsystematic, punitive, and ineffective means, with little knowledge of the factors influencing error generation. Typically, individual nurses are simply blamed for their carelessness. By focusing on the individual, the complete set of contributing factors cannot be known. Instead, vain attempts will be made to change human behaviour – one of the most change‐resistant aspects of any system. A punitive, person‐centred approach therefore, severely hampers effective improvements in safety. By contrast, in other high‐risk industries, such as aviation and nuclear power, the systems‐centred approach to error reduction is routine.</jats:p><jats:p> <jats:bold>Conclusions.</jats:bold> Accidents or errors are only the tip of the incident iceberg. Through effective, nonpunitive incident reporting, which includes reports of near‐misses and system problems in addition to actual accidents, the systems‐approach allows the complete set of contributing factors underlying an accident to be understood and addressed. Feedback to participants and targeted improvement in the workplace is also important to demonstrate that incident data are being used appropriately, and to maintain high levels of on‐going reporting and enthusiasm for the scheme. Drug administration error is a serious problem, which warrants a well‐reasoned approach to its improvement.</jats:p> |
doi_str_mv | 10.1046/j.1365-2648.2001.01820.x |
facet_avail | Online |
format | ElectronicArticle |
format_de105 | Article, E-Article |
format_de14 | Article, E-Article |
format_de15 | Article, E-Article |
format_de520 | Article, E-Article |
format_de540 | Article, E-Article |
format_dech1 | Article, E-Article |
format_ded117 | Article, E-Article |
format_degla1 | E-Article |
format_del152 | Buch |
format_del189 | Article, E-Article |
format_dezi4 | Article |
format_dezwi2 | Article, E-Article |
format_finc | Article, E-Article |
format_nrw | Article, E-Article |
geogr_code | not assigned |
geogr_code_person | not assigned |
id | ai-49-aHR0cDovL2R4LmRvaS5vcmcvMTAuMTA0Ni9qLjEzNjUtMjY0OC4yMDAxLjAxODIwLng |
imprint | Wiley, 2001 |
imprint_str_mv | Wiley, 2001 |
institution | DE-Gla1, DE-Zi4, DE-15, DE-Pl11, DE-Rs1, DE-105, DE-14, DE-Ch1, DE-L229, DE-D275, DE-Bn3, DE-Brt1, DE-D161 |
issn | 0309-2402, 1365-2648 |
issn_str_mv | 0309-2402, 1365-2648 |
language | English |
last_indexed | 2024-03-01T18:17:04.28Z |
match_str | anderson2001asystemsapproachtothereductionofmedicationerroronthehospitalward |
mega_collection | Wiley (CrossRef) |
physical | 34-41 |
publishDate | 2001 |
publishDateSort | 2001 |
publisher | Wiley |
record_format | ai |
recordtype | ai |
series | Journal of Advanced Nursing |
source_id | 49 |
spelling | Anderson, David J. Webster, Craig S. 0309-2402 1365-2648 Wiley General Nursing http://dx.doi.org/10.1046/j.1365-2648.2001.01820.x <jats:p> <jats:bold>A systems approach to the reduction of medication error on the hospital ward</jats:bold> </jats:p><jats:p> <jats:bold>Aims.</jats:bold> To discuss a potentially powerful approach to safer medication administration on the hospital ward, based on principles of safety developed in other high‐risk industries, and consistent with recent national reports on safety in health care released in the United Kingdom (UK) and United States of America (USA). To discuss why punitive approaches to safety on the hospital ward and in the nursing literature do not work.</jats:p><jats:p> <jats:bold>Background.</jats:bold> Drug administration error on the hospital ward is an ever‐present problem and its occurrence is too frequent. Administering medication is probably the highest‐risk task a nurse can perform, and accidents can lead to devastating consequences for the patient and for the nurse’s career. Drug errors in nursing are often dealt with by unsystematic, punitive, and ineffective means, with little knowledge of the factors influencing error generation. Typically, individual nurses are simply blamed for their carelessness. By focusing on the individual, the complete set of contributing factors cannot be known. Instead, vain attempts will be made to change human behaviour – one of the most change‐resistant aspects of any system. A punitive, person‐centred approach therefore, severely hampers effective improvements in safety. By contrast, in other high‐risk industries, such as aviation and nuclear power, the systems‐centred approach to error reduction is routine.</jats:p><jats:p> <jats:bold>Conclusions.</jats:bold> Accidents or errors are only the tip of the incident iceberg. Through effective, nonpunitive incident reporting, which includes reports of near‐misses and system problems in addition to actual accidents, the systems‐approach allows the complete set of contributing factors underlying an accident to be understood and addressed. Feedback to participants and targeted improvement in the workplace is also important to demonstrate that incident data are being used appropriately, and to maintain high levels of on‐going reporting and enthusiasm for the scheme. Drug administration error is a serious problem, which warrants a well‐reasoned approach to its improvement.</jats:p> A systems approach to the reduction of medication error on the hospital ward Journal of Advanced Nursing |
spellingShingle | Anderson, David J., Webster, Craig S., Journal of Advanced Nursing, A systems approach to the reduction of medication error on the hospital ward, General Nursing |
title | A systems approach to the reduction of medication error on the hospital ward |
title_full | A systems approach to the reduction of medication error on the hospital ward |
title_fullStr | A systems approach to the reduction of medication error on the hospital ward |
title_full_unstemmed | A systems approach to the reduction of medication error on the hospital ward |
title_short | A systems approach to the reduction of medication error on the hospital ward |
title_sort | a systems approach to the reduction of medication error on the hospital ward |
title_unstemmed | A systems approach to the reduction of medication error on the hospital ward |
topic | General Nursing |
url | http://dx.doi.org/10.1046/j.1365-2648.2001.01820.x |