Abstract：
OBJECTIVES:The primary aim of this article was to identify the latent failures that are perceived to underpin medication errors. STUDY SETTING:The study was conducted within three medical wards in a hospital in the United Kingdom. STUDY DESIGN:The study employed a cross-sectional qualitative design. DATA COLLECTION METHODS:Interviews were conducted with 12 nurses and eight managers. Interviews were transcribed and subject to thematic content analysis. A two-step inter-rater comparison tested the reliability of the themes. PRINCIPAL FINDINGS:Ten latent failures were identified based on the analysis of the interviews. These were ward climate, local working environment, workload, human resources, team communication, routine procedures, bed management, written policies and procedures, supervision and leadership, and training. The discussion focuses on ward climate, the most prevalent theme, which is conceptualized here as interacting with failures in the nine other organizational structures and processes. CONCLUSIONS:This study is the first of its kind to identify the latent failures perceived to underpin medication errors in a systematic way. The findings can be used as a platform for researchers to test the impact of organization-level patient safety interventions and to design proactive error management tools and incident reporting systems in hospitals.
journal_name
Health Serv Resjournal_title
Health services researchauthors
Lawton R,Carruthers S,Gardner P,Wright J,McEachan RRdoi
10.1111/j.1475-6773.2012.01390.xsubject
Has Abstractpub_date
2012-08-01 00:00:00pages
1437-59issue
4eissn
0017-9124issn
1475-6773journal_volume
47pub_type
杂志文章,多中心研究abstract：:In late 1982, as an alternative to Medicaid, Arizona implemented a prepaid, competitively bid medical care program--the Arizona Health Care Cost Containment System (AHCCCS). Before its introduction, the poor had been cared for primarily by a network of county-supported centers. Impact of the AHCCCS initiative was exam...
journal_title：Health services research
pub_type： 杂志文章
doi：
更新日期：1985-08-01 00:00:00
abstract：:The National Long Term Care Demonstration (channeling) was designed to provide coordinated community-based long-term care services to those older persons at high risk of nursing home placement. A key component of the program was the process established to accomplish this targeting effort. In this article, the outreach...
journal_title：Health services research
pub_type： 杂志文章
doi：
更新日期：1988-04-01 00:00:00
abstract：OBJECTIVE:To examine the ways in which the costs of nonresidential mental health care depend on (1) the type of provider who initiates the treatment episode and (2) the level of cost sharing imposed on the patient. STUDY SETTING:The 1987 National Medical Expenditure Survey, a national probability sample of the U.S. ci...
journal_title：Health services research
pub_type： 杂志文章
doi：
更新日期：1998-12-01 00:00:00
abstract：:Limited information exists concerning lifetime use of nursing home services by the aged. This article examines the longitudinal experience, over four years, of elderly individuals at high risk of institutionalization, and develops a simple model of nursing home use based on these observations. This model allows us to ...
journal_title：Health services research
pub_type： 杂志文章
doi：
更新日期：1986-06-01 00:00:00
abstract：OBJECTIVE:To estimate the effects of competition for both Medicare and HMO patients on the quality decisions of hospitals in Southern California. DATA SOURCE:Secondary discharge data from the Office of Statewide Health Planning and Development for the State of California for the period 1989-1993. STUDY DESIGN:Outcome...
journal_title：Health services research
pub_type： 杂志文章
doi：10.1111/j.1475-6773.2003.00185.x
更新日期：2003-12-01 00:00:00
abstract：OBJECTIVE:To assess what is known about the relationship between patient experience measures and incentives designed to improve care, and to identify how public policy and medical practices can promote patient-valued outcomes in health systems with strong financial incentives. DATA SOURCES/STUDY SETTING:Existing liter...
journal_title：Health services research
pub_type： 杂志文章,评审
doi：10.1111/1475-6773.12420
更新日期：2015-12-01 00:00:00
abstract：OBJECTIVES:The Patient Activation Measure (PAM) quantifies the extent to which people are informed about and involved in their health care. Objectives were to determine the psychometric properties of PAM among multimorbid older adults and evaluate a theoretical, four-stage model of patient activation. Methods. A cross-...
journal_title：Health services research
pub_type： 杂志文章
doi：10.1111/j.1475-6773.2010.01210.x
更新日期：2011-04-01 00:00:00
abstract：OBJECTIVE:To examine facility variation in data quality of the level of pain documented in the minimum data set (MDS) as a function of level of hospice enrollment in nursing homes (NHs). DATA SOURCE:Clinical assessments on 3,469 nonhospice residents from 178 NHs were merged with On-line Survey Certification and Report...
journal_title：Health services research
pub_type： 杂志文章,多中心研究
doi：10.1111/j.1475-6773.2005.00400.x
更新日期：2005-08-01 00:00:00
abstract：OBJECTIVE:This study examines whether parents' reports and ratings of pediatric health care vary by race/ethnicity and language in Medicaid managed care. DATA SOURCES:The data analyzed are from the National Consumer Assessment of Health Plans (CAHPS) Benchmarking Database 1.0 and consist of 9,540 children enrolled in ...
journal_title：Health services research
pub_type： 杂志文章,多中心研究
doi：
更新日期：2001-07-01 00:00:00
abstract：OBJECTIVE:We study the association between the timing of the Great Recession (GR) and health spending among uninsured adults distinguishing by citizenship/nativity status and time of U.S. residence. DATA SOURCE:Uninsured U.S. citizens and noncitizens from the 2005-2006 and 2008-2009 Medical Expenditure Panel Survey. ...
journal_title：Health services research
pub_type： 杂志文章
doi：10.1111/1475-6773.12193
更新日期：2014-12-01 00:00:00
abstract：OBJECTIVE:To test the effectiveness of financial incentives for smoking cessation in the Medicaid population. DATA SOURCES:Secondary data from the Medicaid Incentives for Prevention of Chronic Disease (MIPCD) program and Medicaid claims/encounter data from 2010 to 2015 for five states. STUDY DESIGN:Beneficiaries were...
journal_title：Health services research
pub_type： 杂志文章
doi：10.1111/1475-6773.12994
更新日期：2018-12-01 00:00:00
abstract：STUDY QUESTION:Continuous quality improvement (CQI) has been implemented at least to some degree in many health care settings, yet randomized controlled trials (RCTs) of CQI are rare. We ask whether, when, and how RCTs of CQI might be designed. STUDY DESIGN:We consider two applications of CQI: as a general philosophy ...
journal_title：Health services research
pub_type： 评论,杂志文章
doi：
更新日期：2000-08-01 00:00:00
abstract：OBJECTIVE:To investigate factors affecting willingness to pay (WTP) for health insurance of older adults in a longitudinal setting in Germany. DATA SOURCES:Survey data from a cohort study in Saarland, Germany, from 2008-2010 and 2011-2014 (n1 = 3,124; n2 = 2,761) were used. STUDY DESIGN:Panel data were taken at two...
journal_title：Health services research
pub_type： 杂志文章
doi：10.1111/1475-6773.12522
更新日期：2017-06-01 00:00:00
abstract：OBJECTIVE:To assess the effects of an alternative method of paying home health agencies for services to Medicare beneficiaries, based on a demonstration program. DATA SOURCES/STUDY SETTING:Primary and secondary data collected on participating home health agencies in five states and their patients during the three-year...
journal_title：Health services research
pub_type： 临床试验,杂志文章,随机对照试验
doi：
更新日期：1997-10-01 00:00:00
abstract：OBJECTIVE:To determine whether difficulty walking and the strategies persons use to compensate for this deficit influenced downstream Medicare expenditures. DATA SOURCE:Secondary data analysis of Medicare claims data (1999-2000) for age-eligible Medicare beneficiaries (N=4,997) responding to the community portion of t...
journal_title：Health services research
pub_type： 杂志文章
doi：10.1111/j.1475-6773.2006.00509.x
更新日期：2006-06-01 00:00:00
abstract：OBJECTIVE:The rate of coronary artery bypass surgery (CABG) has been shown to vary greatly across geographic regions. This study examined whether these rates were associated with the rate of coronary artery angioplasty (PTCA) and with other community characteristics. DATA SOURCES/STUDY SETTING:The health care financin...
journal_title：Health services research
pub_type： 杂志文章
doi：
更新日期：1995-08-01 00:00:00
abstract：OBJECTIVE:To evaluate the effects of depression treatment in primary care on patients' clinical status and employment, over six months. DATA SOURCES/STUDY SETTING:Data are from a randomized controlled trial of quality improvement for depression that included 938 adults with depressive disorder in 46 managed primary ca...
journal_title：Health services research
pub_type： 临床试验,杂志文章,多中心研究,随机对照试验
doi：10.1111/1475-6773.01086
更新日期：2002-10-01 00:00:00
abstract：OBJECTIVE:To examine the source of observed lower risk-adjusted mortality for blacks than whites within the Veterans Affairs (VA) system by accounting for hospital site where treated, potential under-reporting of black deaths, discretion on hospital admission, quality improvement efforts, and interactions by age group....
journal_title：Health services research
pub_type： 杂志文章
doi：10.1111/j.1475-6773.2006.00688.x
更新日期：2007-08-01 00:00:00
abstract：OBJECTIVE:To determine if the availability of public ambulatory clinics affects preventable hospitalization (PH) rates of low-income and elderly populations. DATA SOURCES:PH rates were calculated using elderly and low-income discharges from 1995-97 Virginia hospital discharge data. Other data sources include the 1990 ...
journal_title：Health services research
pub_type： 杂志文章
doi：
更新日期：2001-06-01 00:00:00
abstract：OBJECTIVE:To demonstrate how a researcher can investigate the appropriateness of a published comorbidity summary measure for use with a given sample. DATA SOURCE:Surveillance, Epidemiology, and End Results linked to Medicare claims data. STUDY DESIGN:We examined Kaplan-Meier estimated survival curves for four disease...
journal_title：Health services research
pub_type： 杂志文章
doi：10.1111/1475-6773.12276
更新日期：2015-08-01 00:00:00
abstract：OBJECTIVE:To explain variation in direct care resource use (RU) of nursing home residents based on the Resource Utilization Groups III (RUG-III) classification system and other resident- and unit-level explanatory variables. DATA SOURCES/STUDY SETTING:Primary data were collected on 5,314 nursing home residents in 156 ...
journal_title：Health services research
pub_type： 杂志文章
doi：10.1111/j.1475-6773.2006.00627.x
更新日期：2007-04-01 00:00:00
abstract：OBJECTIVE:This study describes the derivation and validation of the Patient Management Category (PMC) Severity Scale, which provides a method of assessing the overall severity of a hospitalized patient's illnesses, based on the patient's unique clinical conditions, their interaction, and the resultant, combined risk of...
journal_title：Health services research
pub_type： 杂志文章
doi：
更新日期：1994-08-01 00:00:00
abstract：:Can Medicare beneficiaries make rational and informed decisions about their coverage under the Medicare program? Recent policy developments in the Medicare program have been based on the theory of competition in medical care. One of the key assumptions of the competitive model is the free flow of adequate information,...
journal_title：Health services research
pub_type： 杂志文章
doi：
更新日期：1988-12-01 00:00:00
abstract：OBJECTIVE:Pay-for-performance (P4P) is commonly used to improve health care quality in the United States and is expected to be frequently implemented under the Affordable Care Act. However, evidence supporting its use is mixed with few large-scale, rigorous evaluations of P4P. This study tests the effect of P4P on qual...
journal_title：Health services research
pub_type： 杂志文章
doi：10.1111/1475-6773.12035
更新日期：2013-08-01 00:00:00
abstract：:Alternative delivery systems, such as HMOs, PPOs, and primary care case-management programs, have a long history in rural America despite significant impediments to their development. However, little is known about the effect of these systems on rural communities and their medical care delivery systems. Existing studi...
journal_title：Health services research
pub_type： 历史文章,杂志文章,评审
doi：
更新日期：1989-02-01 00:00:00
abstract：OBJECTIVE:This study evaluates the relationship between hospital and regional characteristics and the prevalence of mobile computed tomography in rural hospitals. DATA SOURCES AND STUDY SETTING:Primary data were gathered from all rural hospitals in eight northwestern states (n = 471) in 1991. Secondary data sources in...
journal_title：Health services research
pub_type： 杂志文章
doi：
更新日期：1996-06-01 00:00:00
abstract：OBJECTIVE:To examine whether parental beliefs about routine checkups are associated with children's receipt of timely preventive care. DATA SOURCES:The 2001 United Way Outcomes and Community Impact Program telephone survey of San Diego County, including 918 households with children between 3 and 19 years of age, where...
journal_title：Health services research
pub_type： 杂志文章
doi：10.1111/j.1475-6773.2007.00759.x
更新日期：2008-02-01 00:00:00
abstract：OBJECTIVE:To examine reported experiences of gender discrimination and harassment among US women. DATA SOURCE AND STUDY DESIGN:Data come from a nationally representative, probability-based telephone survey of 1596 women, conducted January-April 2017. METHODS:We calculated the percentages of women reporting gender dis...
journal_title：Health services research
pub_type： 杂志文章
doi：10.1111/1475-6773.13217
更新日期：2019-12-01 00:00:00
abstract：OBJECTIVE:To review two indirect methods, geocoding and surname analysis, for estimating race/ethnicity as a means for health plans to assess disparities in care. STUDY DESIGN:Review of published articles and unpublished data on the use of geocoding and surname analyses. PRINCIPAL FINDINGS:Few published studies have ...
journal_title：Health services research
pub_type： 杂志文章,评审
doi：10.1111/j.1475-6773.2006.00551.x
更新日期：2006-08-01 00:00:00
abstract：:De-hospitalization of cancer treatment, particularly for those with advanced disease, can complicate adjustment and strain the capacity of caregiver networks to meet patients' daily needs. Outpatient staff should be able to recognize patients who need help to meet their daily needs as well as those who are not getting...
journal_title：Health services research
pub_type： 杂志文章
doi：
更新日期：1992-08-01 00:00:00
