Please use this identifier to cite or link to this item: http://hdl.handle.net/1942/10717
Title: If only .... : failed, missed and absent error recovery opportunities in medication errors
Authors: Habraken, M. M. P.
VAN DER SCHAAF, Tjerk 
Issue Date: 2010
Publisher: B M J PUBLISHING GROUP
Source: QUALITY & SAFETY IN HEALTH CARE, 19(1). p. 37-41
Abstract: Background Systematic analysis of error recovery can provide hospitals with important information to help them improve their ability to detect and correct errors. Because errors will always crop up and 100% safety can never be achieved, hospitals should be able to prevent patient harm by timely and effective error recovery. Methods In this study, failed, missed and absent recovery opportunities were identified in 52 medication errors which all resulted in severe patient harm or patient death. For all identified recovery opportunities, the underlying failure factors were identified and classified according to the Eindhoven classification model. Those failure factors represent negative influences on error recovery. Results The number of recovery opportunities per error ranged from 0 to 11; on average, 2.4 recovery opportunities were identified. Of 127 identified recovery opportunities, 94 (74%) were planned and 33 (26%) were unplanned or ad hoc. Most failure factors underlying the planned recovery opportunities were organisational failure factors; most failure factors underlying the unplanned recovery opportunities were human failure factors. Conclusions From this study, it can be concluded that actual accidents can be used as an alternative data source to near misses for the analysis and understanding of error recovery. By using both sources, hospitals can enhance their resilience by reinforcing the positive influences on error recovery as well as reducing the negative ones. Together with traditional error reduction methodologies, which only concentrate on eliminating failure factors, hospitals thus have numerous opportunities to improve patient safety.
Notes: [Habraken, M. M. P.; van der Schaaf, T. W.] Eindhoven Univ Technol, NL-5600 MB Eindhoven, Netherlands. [van der Schaaf, T. W.] Hasselt Univ, Hasselt, Belgium. m.m.p.habraken@tue.nl
Document URI: http://hdl.handle.net/1942/10717
ISSN: 1475-3898
DOI: 10.1136/qshc.2007.026187
ISI #: 000274641500008
Category: A1
Type: Journal Contribution
Validations: ecoom 2011
Appears in Collections:Research publications

Files in This Item:
File Description SizeFormat 
vds.pdf
  Restricted Access
Published version116.46 kBAdobe PDFView/Open    Request a copy
Show full item record

SCOPUSTM   
Citations

13
checked on Sep 2, 2020

WEB OF SCIENCETM
Citations

13
checked on May 21, 2022

Page view(s)

88
checked on May 27, 2022

Download(s)

88
checked on May 27, 2022

Google ScholarTM

Check

Altmetric


Items in DSpace are protected by copyright, with all rights reserved, unless otherwise indicated.