This research explores how group- and organizational-level factors affect errors in administering drugs to hospitalized patients. Findings from patient care groups in two hospitals show systematic differences not just in the frequency of errors, but also in the likelihood that errors will be detected and learned from by group members. Implications for learning in and by work teams in general are discussed.
Get full access to this article
View all access options for this article.
References
1.
Alderfer, C.
(1987). An intergroup perspective on group dynamics. In J. W. Lorsch (Ed.), Handbook of organizational behavior. Englewood Cliffs, NJ: Prentice Hall.
2.
Argyris, C.
(1985). Strategy, change, and defensive routines. Boston: Ballinger.
3.
Barker, K. N.
, & McConnell, W. E. (1962). Detecting errors in hospitals. American Journal of Hospital Pharmacy, 19, 361-369.
4.
Bates, D. W.
, Boyle, D. L., Vander Vliet, M. B., Schneider, J., & Leape, L. L. (1995). Relationship between medication errors and adverse drug events. Journal of General Internal Medicine, 10, 199-205.
5.
Bates, D. W.
, Leape, L. L., & Petrycki, S. (1993). Incidence and preventability of adverse drug events in hospitalized patients. Journal of General Internal Medicine, 8, 289-294.
6.
Classen, D. C.
, Pestotnik, S. L., Evans, R. S., & Burke, J. P. (1991). Computerized surveillance of adverse drug events in hospital patients. Journal of the American Medical Association, 266(20), 2847-2851.
7.
Cohen, M. R.
(1977). Medication error reports. American Journal of Hospital Pharmacy, 12(1), 42-44.
8.
Evans, R. S.
, Pestotnik, S. L., Classen, D. C., Bass, S. B., Menlove, R. L., Gardner, R. M., & Burke, J. P. (1992). Development of a computerized adverse drug event monitor. In Proceedings of the Annual Symposium on Computerized Applications for Medical Care, pp. 23-27.
9.
Fiske, S. T.
, & Taylor, S. E. (1991). Social cognition. New York: McGraw-Hill.
10.
Forrester, J. W.
(1971). Counterintuitive behavior of social systems. Technology Review, 73(3), 52-68.
11.
Foushee, H. C.
, Lauber, J. K., Baetge, M. M., & Acomb, D. B. (1986). Crew factors in flight operations III: The operational significance of exposure to short-haul air transport operations (Technical Memorandum No. 88342). Moffett Field, CA: NASA-Ames Research Center.
12.
Goleman, D.
(1985). Vital lies simple truths: The psychology of self-deception. New York: Simon & Schuster.
13.
Hackman, J. R.
(1987). The design of work teams. In J. W. Lorsch (Ed.), Handbook of organizational behavior. Englewood Cliffs, NJ: Prentice Hall.
14.
Hackman, J. R.
(1990). New directions in crew-oriented flight training. Unpublished proceedings of the ICAO Human Factors Seminar, Leningrad.
15.
Hackman, J. R.
(1993). Teams, leaders, and organizations: New directions for crew-oriented flight training. In E. L. Wiener, B. G. Kanki, & R. L. Helmreich (Eds.), Cockpit resource management. Orlando, FL: Academic Press.
16.
Hackman, J. R.
, & Morris, C. G. (1975). Group tasks, group interaction process, and group performance effectiveness. In H. H. Blumberg, A. P. Hard, V. Kent, & M. Davies (Eds.), Small groups and social interaction (Vol. 1). Chichester, UK: Wiley.
17.
Helmreich, R. L.
, & Foushee, H. C. (1993). Why crew resource management? Empirical and theoretical bases of human factors training in aviation. In E. L. Wiener, B. G. Kanki, & R. L. Helmreich (Eds.), Cockpit resource management. Orlando, FL: Academic Press.
18.
James, L. R.
, Demaree, R. G., & Wolf, G. (1984). Estimating within-group interrater reliability with and without response bias. Journal of Applied Psychology, 69(1), 85-98.
19.
Kenny, D. A.
, & LaVoie, L. (1985). Separating individual and group effects. Journal of Personality and Social Psychology, 48(2), 339-448.
20.
Leape, L. L.
, Brennan, T. A., Laird, N., Lawthers, A. G., Localio, A. R., Barnes, B. A., Hebert, L., Newhouse, J. P., Wyler, P. C., & Hiatt, H. (1991). The nature of adverse events in hospitalized patients: Results of the Harvard Medical Practice Study II. New England Journal of Medicine, 324(6), 377-384.
21.
Lesar, T. S.
, Briceland, L. L., Delcoure, K., Parmalee, J. C., Masta-Gornic, V., & Pohl, H. (1990). Medication prescribing errors in a teaching hospital. Journal of American Medicine, 263, 2329-2334.
22.
Lewin, K.
, Lippitt, R., & White, R. (1939). Patterns of aggressive behavior in experimentally created social climates. Journal of Social Psychology, 10, 271-299.
23.
Maier, N.R.F.
(1967). Assets and liabilities in group problem solving: The need for an integrative function. Psychological Review, 74, 239-249.
24.
Massaro, T. A.
(1992). Introducing physician order entry at a major academic medical center: II. Impact on medical education. Academic Medicine, 68, 25-30.
25.
Melmon, K. L.
(1971). Preventable drug reactions: Causes and cures. New England Journal of Medicine, 284(24), 1361-1368.
26.
Michael, D. N.
(1976). On learning to plan and planning to learn. San Francisco: Jossey-Bass.
27.
Norman, D. A.
(1980). Post-Freudian slips. Psychology Today, 13, 42-50.
28.
Norman, D. A.
(1981). Categorization of action slips. Psychological Review, 88, 1-15.
29.
Perrow, C.
(1984). Normal accidents. New York: Basic Books.
30.
Reason, J.
(1984). Lapses of attention in everyday life. In R. Parasuraman & D. R. Davies (Eds.), Varieties of attention (pp. 515-549). Orlando, FL: Academic Press.
31.
Rice, A. K.
(1958). Productivity and social organization: The Ahmedabad experiment. London: Tavistock.
32.
Roethlisberger, F. J.
, & Dickson, W. (1939). Management and the worker. Boston: Harvard University Press.
33.
Rumelhart, D. E.
(1980). Schemata: The building blocks of cognition. In R. J. Spiro, B. C. Bruce, & W. F. Brewer (Eds.), Theoretical issues in reading comprehension: Perspectives from cognitive psychology, linguistics, artificial intelligence and education (pp. 33-58). Hillsdale, NJ: Lawrence Erlbaum.
34.
Senge, P.
(1990). The fifth discipline: The art and practice of the learning organization. New York: Doubleday.
35.
Trist, E. A.
, & Bamforth, K. W. (1951). Some social and psychological consequences of the Longwall method of coal-getting. In D. S. Pugh (Ed.), Organization theory (pp. 393-419). London: Penguin. March 1996
