Qual Saf Health Care
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Qual Saf Health Care · Jun 2006
Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room.
This paper explores the factors that influence the persistence of unsafe practice in an interprofessional team setting in health care, towards the development of a descriptive theoretical model for analyzing problematic practice routines. Using data collected during a mixed method interview study of 28 members of an operating room team, participants' approaches to unsafe practice were analyzed using the following three theoretical models from organizational and cognitive psychology: Reason's theory of "vulnerable system syndrome", Tucker and Edmondson's concept of first and second order problem solving, and Amalberti's model of practice migration. ⋯ However, the relational factors underlying unsafe practice routines are poorly accounted for in these theoretical approaches. Incorporating an additional theoretical construct such as "relational coordination" to account for the emotional human features of team practice would provide a more comprehensive theoretical approach for use in exploring unsafe practice routines and the forces that sustain them in healthcare team settings.
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Qual Saf Health Care · Apr 2006
Unscheduled returns to the emergency department: an outcome of medical errors?
The causes of unscheduled returns to the emergency department (ED) within 72 hours of discharge are unclear. A study was undertaken to identify factors associated with this quality care indicator. ⋯ Unscheduled returns are associated with medical errors in prognosis, treatment, follow up care, and information. A worse post-ED destination is associated with these medical errors and patient factors (dyspnoea and advanced age). Patient dissatisfaction is associated with medical errors, level of triage or care zone, patient educational level and ED time work shift. Most of these factors are modifiable.
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Qual Saf Health Care · Apr 2006
Reconcilable differences: correcting medication errors at hospital admission and discharge.
Medication errors at the time of hospital admission and discharge are common and can lead to preventable adverse drug events. The objective of this study was to describe the potential impact of a medication reconciliation process to identify and rectify medication errors at the time of hospital admission and discharge. ⋯ Unintended medication variances at the time of hospital admission and discharge are common and clinically important. The medication reconciliation process identified and addressed most of these unintended variances before harm occurred. In this small study, medication reconciliation was a useful method for identifying and rectifying medication errors at times of transition. Reconciliation warrants broader evaluation.