From a reactive to a proactive safety approach. Analysis of medication errors in chemotherapy using general failure types
Author
Summary, in English
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.
Department/s
Publishing year
2015-08-04
Language
English
Publication/Series
European Journal of Cancer Care
Full text
- Available as PDF - 165 kB
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Document type
Journal article
Publisher
John Wiley & Sons Inc.
Topic
- Other Engineering and Technologies not elsewhere specified
- Cancer and Oncology
Keywords
- local characteristics
- organisational weaknesses
- resilience
- proactive tool
- chemotherapy
- medication error
Status
Published
ISBN/ISSN/Other
- ISSN: 1365-2354