Transcript Understanding and Preventing Medication Errors

Understanding and Preventing
Medication Errors
in the Critical Care Unit
designed specifically for the
CCU at St. Joseph Hospital
in Lexington, Ky by
Robin D. Dennison, RN, MSN, CCNS
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Objectives
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Describe how the risk of harm caused by medication
error is heightened when the patient is critically-ill,
when the route of administration is intravenous, and
when the medication is one categorized as a highalert medication.
Discuss evidence-based recommendations
regarding prevention of intravenous medication error
and/or reduction of harm caused by intravenous
medication error.
Identify crucial steps in the safe intravenous infusion
of high-alert medications.
What is a critically-ill patient?
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a patient who is
at high risk for
actual or potential
life-threatening
health problems
(AACN, 2002)
“The more critically ill the patient:
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the more likely he/she is to be
vulnerable, unstable, and complex,
thereby requiring intense and vigilant
nursing care.” (AACN, 2002)
Critical care units are busy, complex
environments where the margins of
error are narrow and the demands for
safety are crucial.
Patricia Benner, RN, PhD, 2001
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Why Critical Care Units are High-Risk
Areas for Medication Errors
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Clinical condition has been shown to be a
risk factor for adverse events; seriously ill
patients including those admitted to a critical
care unit, are more likely than an other
hospitalized patients to experience an
adverse event (Pronovost et al, 2002)
Why Critical Care Units are High-Risk
Areas for Medication Errors
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The Critical Care Unit work setting is intense,
with many interactions between patients and
caregivers (Pronovost et al, 2002)
Why Critical Care Units are High-Risk
Areas for Medication Errors
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Critically-ill patients
receive about twice as
many drugs as
patients in general
care units, which
increases their
exposure to potential
errors (Pronovost et al,
2002)
Why Critical Care Units are High-Risk
Areas for Medication Errors
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Serious illness reduces both the
patient's natural resilience and the
ability to rebound from the
consequences of human error
(Pronovost et al, 2002)
Why Critical Care Units are High-Risk
Areas for Medication Errors
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Communication barriers
for patients may increase
risk for an adverse event
(Pronovost et al, 2002)
Critically-ill patients
frequently can’t tell you:
–
–
10
that the infusion burns
that they have already had
that medication
Why Critical Care Units are High-Risk
Areas for Medication Errors
 Critically-ill
patients get most drugs
by either intravenous injection or
infusion and most of the drugs
administered to these patients are
considered “high-alert” drugs
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What are High-Alert Medications?
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drugs that bear a heightened risk of causing
significant patient harm when they are used
in error; note that although errors may or
may not be more common with these drugs,
the consequences of an error with these
medications are clearly more devastating to
patients (ISMP, 2003a)
High-Alert Medications
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The Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) has
compiled a list of high-risk medications
based on 130 drug-related sentinel event
reports (events of death or major permanent
loss of a bodily function) since 1995 (JCAHO,
2004)
Medications Most Frequently Involved
in Medication Errors
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Why Critical Care Units are High-Risk
Areas for Medication Errors
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In critical care units,
many IV infusions of
high-alert
medications are
titrated according to
the patient’s
responses (Brown,
2001)
Why Critical Care Units are High-Risk
Areas for Medication Errors

Medication errors are less detectable since
symptoms of errors may be hidden by a
variety of other conditions and symptoms,
with higher chance of repeated errors
–
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Sudden changes in clinical status, including
cardiac arrest, may actually be caused by
medication error but are assumed to be related to
deterioration of clinical condition
Why Critical Care Units are High-Risk
Areas for Medication Errors
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Medications are often
stocked directly on the
unit and frequently
given STAT and not
checked before
administration by a
pharmacist
–
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This elimination of a step
in the human safety net
increases the risk of
error reaching the patient
Peter Pronovost, MD, PhD
Institute for Healthcare Improvement
We need to work to move
away from blaming people
and start focusing on how
the system is organized.
 Improvements in safety represent the
greatest opportunity to improve patient
care.
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The Terrible Toll of Medication Errors
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Human error is expensive in terms of
mortality, patient/family suffering, injury,
and costs (Benner, 2001)
Nurses suffer feelings of guilt and
sadness from knowing that they injured a
patient (Serembus et al, 2001); some
never work again
Studies indicate that nurses remember
details of their medication errors for years
after they occur
Can you remember your
first medication error?
 Can you remember your
most serious medication
error?
 How would you feel if you
made an error that caused
a
patient’s
death?
20
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How Do Errors Occur?
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Defenses, barriers, and safeguards protect against potential
hazards
Most do this effectively but there are weakness (e.g., active and
latent failures)
These weakness are not static but are continually opening, shutting,
and shifting location
The presence of a weakness in one defensive layer does not
normally cause a bad outcome
However, when weaknesses occur in many layers occur at the same
time, an error is allowed to occur to reach the patient
Reason, 1995
A Medication Error Story
Patient receives
a medication to
which he
is allergic
Patient arrests and
death
22
Inadequate nurse
staffing
Fax system for ordering
medications
is broken
Tube system
for obtaining
medications
is broken
Nurse borrows
medication from
another patient
Reason’s Swiss
Cheese Model
The Nurse is at the “sharp end” of the
medication process
 Individual
professionals are the last
layer of defense against error
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Significance of the Nurse

“Critical care
nurses do the
majority of patient
assessment,
evaluation, and
care in critical
care units.”
(Brilli et al, 2001)
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Significance of the Nurse
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Nursing actions are
directly related to
better patient
outcomes (Kahn et
al, 1990, Mitchell
and Shortell, 1997,
Rubenstein et al,
1992)
Significance of the Nurse
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Nursing vigilance
defends patients
against error
(Page, 2004)
What we know
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Humans are fallible and
errors are inevitable
(Reason, 1990)
Nurses are human and
administer most
medications in a hospital
setting (Page, 2004)
What we know

Errors occurring during the administration
phase of the medication process are unlikely
to be detected and, therefore, are likely to
injure the patient (Bates et al, 1995)
–
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28
Less than 2% of administration errors are
intercepted
Nurses desire to prevent error and patient
injury (Wolf et al, 2000)
What we know
Safety is every patient’s right (Aspden
et al, 2004)
 Patient safety is every health care
professional’s responsibility (Page,
2004)
 Nurses are “indispensable to our
safety” (Page, 2004)
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29
What we know
 Calculation
and titration of these
intravenous infusions of high-alert
medications represents a
significant risk for error (ISMP,
2003)
30
What we know
 Critically-ill
patients are more likely
to receive high-alert medications
and frequently receive these drugs
by intravenous infusion with
titration to physiologic response
(Benner, 2001, Pronovost et al,
2002)
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What we know
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Intravenous medication
errors have the greatest
potential to harm the
patient (Cada, 2002;
Eskew, Jacobi, Buss,
Warhurst, & DeBord,
2002; Bates, Rothschild,
and Keohane, 2004)
Goal
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Since zero errors is not humanly
possible, our goal is to reduce the risk
for injury to the patient caused by
medication error
Evidence-Based Recommendations to
Reduce Risk of Injury to Patients Caused by
Medication Errors Involving the Intravenous
Infusion of High-Alert Medications
34
Confirm
order and
access
information
about the
patient and
drug as
necessary
Use
standardized
infusion
concentrations
Control the
environment:
adequate
lighting, noise
control,
distraction
avoidance
Know and
use
appropriate
equipment
such as
infusion
pumps with
free-flow
protection;
always use
the guardrails
function of
“smart”
pumps when
available
Identify
the
patient
in at
least 2
ways
Ensure that
bag is
labeled,
pump is
displaying
drug and
dose, and
tubing is
labeled
with the
drug being
infused
Independent
double check
by 2 nurses
of drug, dose,
calculation,
patient
identity,
infusion rate
settings, and
appropriate
line
Prevent Injury
Prevent Errors
Safe Administration of High-Alert Medication Infusion
Yes
Contact
pharmacist
and/or
physician for
consultation,
clarification,
and/or
confirmation
Concerns
allayed
No
Consider: is
there any
reason that
this patient
should not
get this drug,
at this time, at
this dose, or
by this route?
No
Yes
Notify
immediate
supervisor
Optimize Therapy
Identify and
communicat
e targets: is
this drug
being
titrated to
BP, HR, CI,
urine output,
or CPP and
what is the
desirable
range?
Monitor
response:
note
physiologic
response to
the drug, any
adverse
event, need
for additional
dose
adjustment
(titration)
Communicate
and document
any significant
changes
Legend: BP, blood pressure; HR, heart rate; CI, cardiac index; CPP, cardiac perfusion pressure
An Evidence-Based Practice Flowchart
by Dennison, 2005
35
Confirm the order and access information
about the patient and the drug as
necessary

Knowledge of the patient as well as
knowledge regarding the drug being
administered is important in
preventing medication administration
errors from occurring and injuring the patient (Pepper,
1995, Leape et al, 1995)
–
–
36
Access the patient’s chart, laboratory data, physiologic
parameters as needed; electronic patient record is preferred
Access drug information from current drug references, such as
Gahart and Nazareno’s 2005 Intravenous Medications, Micro Medex,
Epocrates, or the pharmacist
Allow the Pharmacist to Help Us
Protect the Patient from Error
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37
Prescriptions: run
all orders through
the pharmacy if
possible
Admixtures: always
use either premixed or
pharmacy-mixed
solutions
Use standardized infusion
concentrations
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38
Standardization eliminates unnecessary
complexity of care processes so that patients
receive the correct medications in a safer
environment (Rozich et al., 2004, JCAHO,
2004, ISMP, 2003b)
Restriction of the formulary and access to some
high-alert medications, such as concentrated
electrolytes, is also recommended (ISMP,
2003b)
StandardIZE
 Use
standard
concentrations
 Consistency
improves safety
39
Control the environment: ensure
adequate lighting, noise control, and
avoidance of distraction
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Environmental factors, such as poor lighting, cluttered work spaces,
noise, interruptions, high patient acuity, and non-stop unit activity
contribute to medication errors (Buchanan et al, 1991, National
Quality Forum, 2003, Pape, 2002)
Know and use appropriate equipment such
as infusion pumps with free-flow
protection; always use the guardrails
function of “smart” pumps when available
Misuse of infusion pumps and
other parenteral device systems
and malfunction of these devices
are a significant cause of error
(Leape et al., 1995, ISMP, 2003,
JCAHO, 2003, Kohn et al, 2000)
41
-Guard
Your
Always Use Guardrails!
42
Identify the patient in at least 2 ways
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43
Use of 2 patient identifiers
will significantly reduce the
risk of wrong patient errors
(JCAHO, 2004)
– name
– social security number
– hospital ID number
– telephone number
– address
– birth date
– barcode
Ensure that the bag is labeled with the patient’s name
and added drug(s), the pump is displaying the drug and
dose, and tubing is labeled near the distal end with the
drug being infused through that line and the site
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44
Tubing mix-up may
be prevented by
labeling the tubing
(ISMP, 2004)
Label
1. The IV Bag with Patient’s
Name, Drug, Amount
Added, Date, Time
2. Distal Tubing with Drug
Being Infused and Site
3. Pump (using Guardrails or
Channel Labels)
James Smith
Dopamine 800 mg
3/15/05 10:15 am
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Independent double-check by 2 nurses of
drug, dose, calculation, patient identity,
infusion rate setting, and appropriate line
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Because errors can occur when
the wrong drug or drug
concentration is selected, flow rates
are improperly set, or the infusion line
is mixed-up with another, errors can be
made visible, and patient injury can be
prevented, through double-checks and
redundancy and these double-checks
are more effective if they are performed
independently (ISMP, 2003)
Independent double-check
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An independent doublecheck means that two
nurse do the checks
(order, drug, dose,
patient, line) and
calculations separately
and then compare
Checking with another
nurses increases the
risk of confirmation bias
“check this with me”
Confirmation Bias
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48
The nurse selects the wrong medication with
a label or package similar to the correct drug
and believes that she (he) read the label to
verify the right drug
We see what we expect to see especially
when enough things match the picture in our
mind
Miscalculation: a contributing
factor to medication errors
Ability to calculate
micrograms/kilogram/minute
is very important in
critical care areas
49
If you know the rate:
(micrograms/ml) x (ml/hr)
--------------------------------------------------= micrograms/kg/minute
(60 min/hour) x (kg of body weight)
50
If you know the prescription:
(dose in micrograms/kg/min) x (60 min/hr) x (wt in kg)
----------------------------------------------------------------- = ml/hr
micrograms/ml of the solution
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Consider: is there any reason
that this patient should not get
this drug, at this dose, at this
time, and by this route?

Nurses are the last link in the
drug therapy chain and commit
the act that marks the transition
between a preventable error and
an actual error (Pepper, 1995)
While the prescribed drug, dose, route, and
frequency may have been appropriate at the
time of prescription, it may not be appropriate at
the time of administration
52
McGovern, 1988
If you determine that the drug, dose,
route is not appropriate for this patient
at this time:

53
Contact the physician and/or pharmacist
for consultation, clarification, and/or
confirmation
– Open discussion of differences
enhances teamwork and a safer
atmosphere (Watson, 2003)
If your concerns can not be allayed,
notify your immediate supervisor

Because patient safety is everyone’s
responsibility, the nurse should never
administer a drug that she feels is unsafe
after consultation with the physician and/or
pharmacist
–
–
54
Speak up when you have a concern
Listen when others have a concern
Identify and communicate targets: is this drug
being titrated to BP, HR, CI, urine output, or
CPP and what is the desirable range?

55
High-alert drugs
used with critically-ill
patients are
frequently titrated to
the desired
physiologic effect
(Brown, 2001)
Monitor response: note physiologic response to
the drug, any adverse event, need for additional
dose adjustment (titration)

56
The nurse’s role in
pharmacotherapeutics
includes drug
administration, assessment
of therapeutic response,
early detection of adverse
events, and patient
education (Pepper, 1995).
Communicate and document any
administration of a drug and any significant
changes in the patient’s condition

57
Patterns of
communication in
effective safety cultures
are not hierarchical
(Page, 2004) and
effective
communication
between and within
disciplines is necessary
for patient safety
Remember the 7 rights of
medication administration
 Right
patient
 Right drug
 Right dose
 Right route
 Right time
 Right reason
 Right documentation
58
Pape, 2003
But these “rights” can not stand alone in
our efforts to prevent medication errors
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These are the goals of safe medication
practices but even with all 7 rights met, a
medication error can occur (such as the error
of omission)
These rights focus on the individual
performance of the nurse but do not reflect
the role of multidisciplinary efforts and
reliable systems
These rights do not take into account human
factors such as confirmation bias
Consider how you can avert these
common causes of medication errors
60
Incorrect infusion rates programmed
on an infusion pump
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61
Use of guardrails on smart pumps
Independent double-checks
Miscalculations

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62
Standardization to minimize drug calculations
Use of premix or pharmacy admixed
infusions
Use of smart pumps
Independent double-checks
Lack of availability of patient data

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63
Electronic patient record
Computerized access to laboratory data
Pharmacy review of all prescriptions before
administration
Lack of knowledge regarding new
drugs

Look it up
–
Drug Reference Books

–
Electronic Drug References: such as Micro
Medex on the hospital intranet or Epocrates on a
PDA

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64
Must be current
Be sure to scroll down to the end of the screen for the
drug since important alerts may be missed if it is at the
end of the drug description
Phone the pharmacist
Consider this:

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Our profession’s greatest challenge is to
provide quality care based on available
evidence with constrained resources
while ensuring patient safety
Let’s get them home safely!
66
References:
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American Association of Critical-Care Nurses. (2002). About
critical care nursing. Retrieved November 15, 2002, from
www.aacn.org/AACN/mrkt.nsf
Aspden, P., Corrigan, J. M., Wolcott, J., & Erickson, S. (Eds.).
(2004). Patient Safety. Achieving a New Standard for
Care.Washington, DC: The National Academies Press.
Bates, D. W., Boyle, D. L., Vander Bliet, M. B., & et al. (1995).
Relationship between medication errors and adverse drug
events. Journal of General Internal Medicine, 10, 199-205.
Bates, D. W., Rothschild, J. M., & Keohane, C. (2004,
November 7, 2003). Intravenous medication safety errors.
Paper presented at the Infusion Safety: Addressing Harm with
High-Risk Drug Administration, San Diego, CA.
Benner, P. (2001). Creating a culture of safety and
improvement: a key to reducing medical error. American
Journal of Critical Care, 10(4), 281-284.
References:




68
Brilli, R. J., Spevetz, A., Branson, R. D., & Campbell, G. M.
(2001). Critical care delivery in the intensive care unit: Defining
clinical roles and the best practice model. Critical Care
Medicine, 29(10), 2007-2019.
Brown, B. A. (2001). Calculating doses, flow rates, and
administration of continuous intravenous infusions. In D. J.
Lynn-McHale & K. K. Carlson (Eds.), AACN Procedure Manual
for Critical Care (Vol. 4th). Philadelphia: W. B. Saunders
Company.
Buchanan, T. L., Barker, K. N., Gibson, J. T., Jiang, B. C., &
Pearson, R. A. (1991). Illumination and errors in dispensing.
American Journal of Hospital Pharmacy, 48, 2137-2145.
Cada, D. J. (2002). Preventing IV medication errors. Hospital
Pharmacy, 37(11), 1.
References:




69
Eskew, J. A., Jacobi, J., Buss, W. F., Warhurst, H. M., &
DeBord, C. L. (2002). Using innovative technologies to set new
safety standards for the infusion of intravenous medications.
Hospital Pharmacy, 37(11), 1179-1189.
Institute for Safe Medication Practices. (2003a). ISMP's List of
High-Alert Medications. Retrieved April 1, 2004, from
www.ismp.org/MSAarticles/HighAlertPrint.htm
Institute for Safe Medication Practices. (2003b). Key Elements
of Medication Use. Retrieved April 1, 2004, from www.ismp.org
Institute for Safe Medication Practices. (2004). Confusion
reported between Aggrastat (tirofiban) and heparin while using
a two-channel pump. Retrieved November 7, 2004, from
www.ismp.org/msaarticles/aggratatprint.htm
References:




70
Joint Commission on the Accreditation of Healthcare
Organizations. (2004). Accreditation Manual for
Hospitals.Oakbrook Terrace, IL: Joint Commission on the
Accreditation of Healthcare Organizations.
Kahn, K., Rogers, W., Rubenstein, L., Sherwood, M., Reinisch,
E., Keeler, E., et al. (1990). Measuring quality of care with
explicit process criteria before and after implementation of the
DRG-based prospective payment system. Journal of the
American Medical Association, 264(15), 1969-1973.
Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000).
To Err is Human. Building a Safer Health System.Washington,
DC: National Academy Press.
Leape, L. L., Bates, D. W., Cullen, D. J., Cooper, J., Demonaco,
H. J., Gallivan, T., et al. (1995). System analysis of adverse
drug events. Journal of American Medical Association, 274(1),
35-43.
References:





71
McGovern, K. (1988). Ten golden rules for administering drug
safely. Nursing, 18(8), 34-42.
Mitchell, P. (2002). Nursing is essential to improving patient
safety. Journal of Advanced Nursing, 38(2), 109-110.
Mitchell, P., & Shortell, S. (1997). Adverse outcomes and
variations in organization of care delivery. Medical Care,
35(NS), 19-32.
National Quality Forum. (2003). Safe Practices for Better
Healthcare. A Consensus Report. Washington, DC: National
Quality Forum.
Page, A. (Ed.). (2004). Keeping Patients Safe. Transforming the
Work Environment for Nurses. Washington, DC: The National
Academies Press.
References:





72
Pape, T. M. (2002). The Effect of Nurses' Use of a Focused
Protocol to Decrease Distractions during Medication
Administration.Denton, TX: Texas Woman's University.
Pepper, G. A. (1995). Errors in drug administration by nurses.
American Journal of Health-System Pharmacy, 52, 390-395.
Pronovost, P., Wu, A. W., Dorman, T., & Morlock, L. (2002).
Building safety into ICU care. Journal of Critical Care, 17(2), 7885.
Reason, J. (2000). Human error: models and management.
British Medical Journal, 320, 768-770.
Reason, J. (1995). Understanding adverse events: human
factors. In C. Vincent (Ed.), Clinical Risk Management (pp. 3154). London: BMJ Pubishing Group.
References:



73
Reason, J. (1990). Human Error. Cambridge: Cambridge
University Press.
Rozich, J. D., Howard, R. J., Justeson, J. M., Macken, P. D.,
Lindsay, M. E., & Resar, R. K. (2004). Standardization as a
mechanism to improve safety in health care. Joint Commission
Journal on Quality and Safety, 30(1), 5-14.
Rubenstein, L., Chang, B., Keeler, E., & Kahn, K. (1992).
Measuring the quality of nursing surveillance activities for five
diseases before and after implementation of the disease-based
prospective payment system. Paper presented at the Patient
Outcomes Research: Examining the Effectiveness of Nursing
Practice, Bethesda, MD.
References:



74
Serembus, J. F., Wolf, Z. R., & Youngblood, N. (2001).
Consequences of fatal medication errors for health care
providers: A secondary analysis study. MEDSURG Nursing,
10(4), 193-201.
Watson, D. (2003). Creating the culture of safety. AORN Journal,
77(2), 268-271.
Wolf, Z. R., Serembus, J. F., Smetzer, J., Cohen, H., & Cohen, M.
(2000). Responses and concerns of healthcare providers to
medication errors. Clinical Nurse Specialist, 14(6), 278-290.