The potential role of organizational factors in enhanced patient safety and medical error prevention is highlighted in the systems approach advocated for by the Institute of Medicine and others. However, little is known about the extent to which these factors have been shown empirically to be associated with these favorable outcomes. The present study conducted an intensive review of the clinical and health services literatures in order to explore this issue. The results of this review support the general conclusion that there is little evidence for asserting the importance of any individual, group, or structural variable in error prevention or enhanced patient safety at the present time. Two major issues bearing on the development of future research in this area involve strengthening the theoretical foundations of organizational research on patient safety and overcoming definitional and observability problems associated with error-focused dependent variables.
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References
1.
Agency for Healthcare Research and Quality. 2001. Making health care safer: A critical analysis of patient safety practices. Prepared by University of California at San Francisco (UCSF)-Stanford University Evidence-based Practice Center under contract no. 290-97-0013.
2.
Anderson, James G. 2002. Evaluation in health informatics: Computer simulation. Computers and Biology in Medicine32 (3): 151-164.
3.
Berwick, D. M., A. B. Godfrey, and J. Roessner. 1990. Curing health care: New strategies for quality improvement. San Francisco: Jossey-Bass.
4.
Bogner, M. S. 1994. Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum.
5.
Collighan, G., A. Macdonald, J. Herzberg, M. Philpot, J. Lindesay. 1993. An evaluation of the multidisciplinary approach to psychiatric diagnosis in elderly people. British Medical Journal306 (6881): 821-824.
6.
Edge, W. E., R. K. Kanter, C. G. Weigle, R. F. Walsh. 1994. Reduction of morbidity in interhospital transport by specialized pediatric staff. Critical Care Medicine22 (7): 1186-1191.
7.
Ferlie, E. B., and S. M. Shortell. 2001. Improving the quality of health care in the United Kingdom and the United States: A framework for change. Milbank Quarterly79 (June): 281-315.
8.
Fetters, M. D. 2002. Medical error in primary care. In Medical error, edited by M. M. Rosenthal and K. M. Sutcliffe, 58-83. San Francisco: Jossey-Bass.
9.
Gaba, D. M. 1989. Human error in anesthetic mishaps. International Anesthesia Clinics27:137-147.
10.
Helmreich, R. L. 2000. On error management: Lessons from aviation. British Medical Journal320 (March): 781-785.
11.
Helmreich, R. L., A. C. Merritt, and J. A. Wilhelm. 1999. The evolution of crew resource management in commercial aviation. International Journal of Aviation Psychology9 (1): 19-32.
12.
Helmreich, R. L., and J. A. Wilhelm. 1991. Outcomes of crew resource management training. International Journal of Aviation Psychology1: 287-300.
13.
Institute of Medicine. 1999. To err is human: Building a safer health system. Washington, DC: National Academy Press.
14.
Institute of Medicine. 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
15.
Jones, B. 2002. Nurses and the “code of silence.” In Medical error, edited by M. M. Rosenthal and K. M. Sutcliffe, 84-100. San Francisco: Jossey-Bass.
16.
Joshi, M. S., J. F. Anderson, and S. Marwaha. 2002. A systems approach to improving error reporting. Journal of Healthcare Information Management16 (Winter): 40-45.
17.
Kuperman, G. J., J. M. Teich, T. K. Gandhi, and D. W. Bates. 2001. Patient safety and computerized medication ordering and Brigham and Women’s Hospital. Joint Commission Journal on Quality Improvement27 (10): 509-521.
18.
LaPorte, T. R. 1982. On the design and management of nearly error-free organizational control systems. In Accident at Three-Mile Island: The human dimensions, edited by D. L. Sills, C. P. Wolf, and V. B. Shelanski, 185-200. Boulder, CO: Westview.
19.
Leape, L. L. 1994a. Error in medicine. Journal of the American Medical Association272 (December): 1851-1857.
20.
Leape, L. L. 1994b. The preventability of medical injury. In Human error in medicine, edited by M. S. Bogner, 13-25. Hillsdale, NJ: Lawrence Erlbaum.
21.
Leape, L. L., A. I. Kabcenell, T. K. Gandhi, P. Carver, T. W. Nolan, and D. M. Berwick. 2000. Reducing adverse drug events: Lessons froma breakthrough series collaborative. Joint Commission Journal on Quality Improvement26 (6): 321-331.
22.
Meyer, G. S., and M. P. Massagli. 2001. The forgotten component of the quality triad: Can we still learn something from “structure”? Joint Commission on Accreditation of Health Care Organizations27 (September): 484-493.
23.
Miles, M. B., and A. M. Huberman. 1994. Qualitative data analysis. Thousand Oaks, CA: Sage.
24.
Moray, N. 1994. Error reduction as a systems problem. In Human error in medicine, edited by M. S. Bogner, 67-91. Hillsdale, NJ: Lawrence Erlbaum.
25.
Perrow, C. 1994. Accidents in high-risk systems. Technology Studies1 (1): 1-38.
26.
Perrow, C. 1984. Normal accidents: Living with high-risk technologies. New York: Basic Books.
27.
Perrow, C. 1999. Organizing to reduce the vulnerabilities of complexity. Journal of Contingencies and Crisis Management7 (3): 150-155.
28.
Rasmussen, J. 1982. Human errors: A taxonomy for describing human malfunction in industrial installations. Journal of Occupational Accidents4:311-335.
29.
Reason, J. 1990. Human error. Cambridge, UK: Cambridge University Press.
30.
Risser, D. T., M. M. Rice, M. L. Salisbury, R. Simon, G. D. Jay, and S. D. Berns. 1999. The potential for improved teamwork to reduce medical errors in the emergency department. Annals of Emergency Medicine34 (3): 373-382.
31.
Roberts, K. H. 1990. Some characteristics of high-reliability organizations. Organization Science1:160-177.
32.
Rochlin, G. I. 1993. Defining “high reliability” organizations in practice: A taxonomic prologue. In New challenges to understanding organizations, edited by K. H. Roberts, 11-32. New York: Macmillan.
33.
Rosenthal, M.M., and K. M. Sutcliffe. 2002. Medical error. San Francisco: Jossey-Bass.
34.
Sexton, J. B., E. J. Thomas, and R. L. Helmrich. 2000. Error, stress, and teamwork in medicine and aviation: Cross sectional surveys. British Medical Journal320 (March): 745-749.
35.
Schulman, P. R. 1993. The analysis of high reliability organizations: A comparative framework. In New challenges to understanding organizations, edited by K. H. Roberts, 33-54. New York: Macmillan.
36.
Shaughnessy, A. F., F. A. D’ Amico, and R. O. Nickel. Improving prescription-writing skills in a family practice residency. DICP, Annals of Pharmacotherapy25:17-25.
37.
Simpson, J. 2001. A unique approach for reducing specimen labeling errors. Clinical Leader Management Review15 (6): 401-405.
38.
Surdulescu, S., D. Utamsingh, R. Shekar. 1998. Phlebotomy teams reduce blood-culture contamination rate and save money. Clinical Performance and Quality Health Care6 (2): 60-62.
39.
Thomas, E. J., and R. L. Helmreich. 2002. Will airline safety models work in medicine? In Medical error, edited by M. M. Rosenthal and K. M. Sutcliffe, 217-234. San Francisco: Jossey-Bass.
40.
Weber, R. P. 1990. Basic content analysis. Newbury Park, CA: Sage.
41.
Weick, K. E., and K. H. Roberts. 1993. Collective mind in organizations: Heedful inter-relating on flight decks. Administrative Science Quarterly38 (September): 357-381.
42.
Weick, K. E., K. M. Sutcliffe, and D. Obstfeld. 1999. Organizing for high reliability: Processes of collective mindfulness. In Research in organizational behavior, edited by B. Staw and R. Sutton, 81-123. Greenwich, CT: JAI.
