From a reactive to a proactive safety approach. Analysis of medication errors in chemotherapy using general failure types
(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:
https://lup.lub.lu.se/record/7853063
- author
- Fyhr, AnnSofie LU ; Ternov, Sven and Ek, Åsa LU
- organization
- publishing date
- 2015-08-04
- 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 Inc.
- external identifiers
-
- pmid:26239427
- scopus:84939237856
- pmid:26239427
- wos:000396455900001
- 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
- 2016-04-01 10:58:02
- date last changed
- 2022-04-28 03:14:12
@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}},
keywords = {{local characteristics; organisational weaknesses; resilience; proactive tool; chemotherapy; medication error}},
language = {{eng}},
month = {{08}},
publisher = {{John Wiley & Sons Inc.}},
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 = {{https://lup.lub.lu.se/search/files/2274487/7853080.pdf}},
doi = {{10.1111/ecc.12348}},
year = {{2015}},
}