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From a reactive to a proactive safety approach. Analysis of medication errors in chemotherapy using general failure types

Fyhr, AnnSofie LU ; Ternov, Sven and Ek, Åsa LU (2015) In European Journal of Cancer Care
Abstract
A better understanding of why medication errors (MEs) occur will mean that we can work proactively to minimise them. This study developed a proactive tool to identify general failure types (GFTs)in the process of managing cytotoxic drugs in healthcare. The tool is based on Reason’s Tripod Delta tool. The GFTs and active failures were identified in 60 cases of MEs reported to the Swedish national authorities. The most frequently encountered GFTs were defences, procedures, organisation and design. Working conditions were often the common denominator underlying the MEs. Among the active failures identified, a majority were classified as slips,one-third as mistakes, and for a few no active failure or error could be determined. It was found... (More)
A better understanding of why medication errors (MEs) occur will mean that we can work proactively to minimise them. This study developed a proactive tool to identify general failure types (GFTs)in the process of managing cytotoxic drugs in healthcare. The tool is based on Reason’s Tripod Delta tool. The GFTs and active failures were identified in 60 cases of MEs reported to the Swedish national authorities. The most frequently encountered GFTs were defences, procedures, organisation and design. Working conditions were often the common denominator underlying the MEs. Among the active failures identified, a majority were classified as slips,one-third as mistakes, and for a few no active failure or error could be determined. It was found that the tool facilitated the qualitative understanding of how the organisational weaknesses and local characteristics influence the risks. It is recommended that the tool be used regularly. We propose further development of the GFT tool. We also propose a tool to be further developed into a proactive self-evaluation tool that would work as a complement to already incident reporting and event and risk analyses. (Less)
Please use this url to cite or link to this publication:
author
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
local characteristics, organisational weaknesses, resilience, proactive tool, chemotherapy, medication error
in
European Journal of Cancer Care
publisher
John Wiley & Sons
external identifiers
  • pmid:26239427
  • scopus:84939237856
ISSN
1365-2354
DOI
10.1111/ecc.12348
language
English
LU publication?
yes
id
ed3f9e5a-206a-4aeb-9bfd-b9267f257e38 (old id 7853063)
date added to LUP
2015-09-04 11:38:45
date last changed
2017-11-12 03:14:17
@article{ed3f9e5a-206a-4aeb-9bfd-b9267f257e38,
  abstract     = {A better understanding of why medication errors (MEs) occur will mean that we can work proactively to minimise them. This study developed a proactive tool to identify general failure types (GFTs)in the process of managing cytotoxic drugs in healthcare. The tool is based on Reason’s Tripod Delta tool. The GFTs and active failures were identified in 60 cases of MEs reported to the Swedish national authorities. The most frequently encountered GFTs were defences, procedures, organisation and design. Working conditions were often the common denominator underlying the MEs. Among the active failures identified, a majority were classified as slips,one-third as mistakes, and for a few no active failure or error could be determined. It was found that the tool facilitated the qualitative understanding of how the organisational weaknesses and local characteristics influence the risks. It is recommended that the tool be used regularly. We propose further development of the GFT tool. We also propose a tool to be further developed into a proactive self-evaluation tool that would work as a complement to already incident reporting and event and risk analyses.},
  author       = {Fyhr, AnnSofie and Ternov, Sven and Ek, Åsa},
  issn         = {1365-2354},
  keyword      = {local characteristics,organisational weaknesses,resilience,proactive tool,chemotherapy,medication error},
  language     = {eng},
  month        = {08},
  publisher    = {John Wiley & Sons},
  series       = {European Journal of Cancer Care},
  title        = {From a reactive to a proactive safety approach. Analysis of medication errors in chemotherapy using general failure types},
  url          = {http://dx.doi.org/10.1111/ecc.12348},
  year         = {2015},
}