Australasian Emergency Nursing Journal
Volume 10, Issue 2 , Pages 80-85 , May 2007

Patient safety ethics and human error management in ED contexts Part II: Accountability and the challenge to change

Received 29 August 2006 ,Accepted 6 September 2006.

References 

  1. Brennan T, Leape L, Laird L, Hebert L, Localio R, Lawthers A, et al. Incidence of adverse events and negligence in hospitalised patients: results of the Harvard Medical practice Study I. N Engl J Med. 1991;324(6):370–376
  2. Leape L, Brennan T, Laird L, Lawthers A, Localio R, Barnes B, et al. The nature of adverse events in hospitalised patients: results of the Harvard Medical practice Study II. N Engl J Med. 1991;324(6):377–384
  3. Wilson R, Runciman W, Gibberd R, Harrison B, Newby L, Hamilton J. The quality in Australian health care study. Med J Aust. 1995;163:458–471
  4. Woolf A, Bourke J. Detecting and reducing adverse events in an Australian rural base hospital emergency department using medical record screening and review. Emerg Med J. 2002;19:35–40
  5. Cosby K. A framework for classifying factors that contribute to error in the Emergency Department. Ann Emerg Med. 2003;42(6):815–823
  6. Chamberlain J, Slonim A, Joseph J. Reducing errors and promoting patient safety in pediatric emergency care. Ambulat Pediatr. 2004;4(1):55–63
  7. Institute of Medicine (IOM). Hospital-based emergency care: at the breaking point. Washington DC: The National Academies Press; In press.
  8. In:  Kohn L,  Corrigan J,  Donaldson M editor. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000;
  9. In:  Sharpe E editors. Accountability: patient safety and policy reform. Washington, DC: Georgetown University Press; 2004;
  10. Sharpe N. Special supplement: promoting patient safety: an ethical basis for policy deliberations. Hast Center Rep. 2003;33(5):S1–S19
  11. In:  Rubin S,  Zoloth L editor. Margin of error: the ethics of mistakes in the practice of medicine,. Hagerstown, Maryland: University Publishing Group; 2000;
  12. In:  Rosenthal M,  Mulcahy L,  Lloyd-Bostock S editor. Medical mishaps: pieces of the puzzle. Buckinhgam: Open University Press; 1999;
  13. Hobgood C, Xie J, Weiner B, Hooker J. Error identification, disclosure, and reporting: practice patterns of three emergency medicine provider types. Acad Emerg Med. 2004;11(2):196–199
  14. Johnstone M, Kanitsaki O. The ethics and practical importance of defining, distinguishing and disclosing nursing errors: a discussion paper. Inter J Nurs Stud. 2006;43(3):367–376
  15. Secker-Walker J, Taylor-Adams S. Clinical incident reporting. In:  Vincent C editors. Clinical risk management: enhancing patient safety. 2nd ed.. London: BMJ Books; 2002;p. 419–438
  16. Amoore J, Ingram P. Quality improvement report: learning from adverse incidents involving medical devices. Br Med J. 2002;325:272–275
  17. Hart E, Hazelgrove J. Understanding the organisational context for adverse events in the health services: the role of cultural censorship. Qual Health Care. 2001;10(4):257–262
  18. Kingston M, Evans S, Smith B, Berry J. Attitudes of doctors and nurses towards incident reporting: a qualitative analysis. Med J Aust. 2004;181(1):36–39
  19. King G. Perceptions of intentional wrongdoing and peer reporting behaviour among registered nurses. J Busin Ethics. 2001;34(1):1–13
  20. Antonow J, Smith A, Silver M. Medication error reporting: a survey of nursing staff. J Nurs Care Qual. 2000;15(1):42–48
  21. Australian Council for Safety and Quality in Health Care. Open disclosure standard: a national standard for open communication in public and private hospitals, following an advised event in health care. Canberra: Commonwealth of Australia; 2003;
  22. Risser D, Rice M, Salisbury M, Simon R, Jay G, Berns S. The potential for improved teamwork to reduce medical errors in the emergency department. Ann Emerg Med. 1999;34(3):373–383
  23. Sharpe V. Taking responsibility for medical mistakes. In:  Rubin S,  Zoloth L editor. Margin of error: the ethics of mistakes in the practice of medicine. Hagerstown, Maryland: University Publishing Group; 2000;p. 183–192
  24. Wu A. Medical error: the second victim. Br Med J. 2000;320(7237):726–727
  25. Leape L. Error in medicine. J Am Med Assoc. 1994;272(23):1851–1857
  26. Johnstone M. Patient safety, ethics and whistleblowing: a nursing response to the events at the Campbelltown and Camden Hospitals. Austr Health Rev. 2004;28(1):13–19
  27. Freire P. Cultural action for freedom. Harmondsworth, Middlesex: Penguin Books; 1972;
  28. Johnstone M, Kanitsaki O. Clinical risk management and patient safety education for nurses. Nur Educ Today; In press.
  29. Johnstone M, Kanitsaki O. Culture, language and patient safety: making the link. Inter J Qual Health Care. 2006;18(5):383–388
  30. Beauchamp T, Childress J. Principles of biomedical ethics. 5th ed.. New York: Oxford University Press; 2001;
  31. Hobbes T. Leviathan (reprinted from 1651 edition with notes by CB Macpherson). Harmondsworth, Middlesex: Pelican Books; 1968;
  32. Johnstone M-J. Patient safety ethics and human error management in ED contexts. Part I: Development of the global patient safety movement. Aus. Emerg Nurs J. 2007;10(1):13–20
  33. Wachter R. The end of the beginning: patient safety five years after ‘To err is human’. Qual Care, Health Affairs Web Exclus. 2004;W4-534–W4-545
  34. Berwick D. Crossing the boundary: changing mental models in the service of improvement. Inter J Qual Health Care. 1998;10(5):435–441
  35. Leape L, Woods D, Hatlie M, Kizer K, Schroeder S, Lundberg G. Promoting patient safety by preventing medical error. J Am Med Assoc. 1998;280(16):1444–1447
  36. Van Der Weyden M. The healthcare complaints system needs reform, and politicians must accept ultimate responsibility. Med J Aust. 2004;180:365–366
  37. Adams J, Bohan J. System contributions to error. Acad Emerg Med. 2000;7(11):1189–1193
  38. Pellegrino E. Prevention of medical error: where professional and organizational ethics meet. In:  Sharpe E editors. Accountability: patient safety and policy reform,. Washington, DC: Georgetown University Press; 2000;p. 83–98
  39. Andrus C, Villasenor E, Kettelle J, Roth R, Sweeney A, Matolo N. To err is human”: uniformly reporting medical errors and near misses, a naïve, costly, and misdirected goal. J Am Coll Surg. 2003;196(6):911–918
  40. Bovbjerg R, Miller R, Shapiro D. Paths to reducing medical injury: professional liability and discipline vs. patient safety – and the need for a third way. J Law Med Ethics. 2001;29(3/4):369–380
  41. Dickens B. Medical errors: legal and ethical responses. Inter J Gynecol Obstetr. 2003;81(1):109–114
  42. Liang B. The adverse event of unaddressed medical error: identifying and filling the holes in the health-care and legal systems.. J Law Med Ethics. 2001;29(3/4):346–368
  43. May T, Aulisio M. Medical malpractice, mistake prevention, and compensation. Kennedy Instit Ethics J. 2001;11(2):135–146
  44. Morey J, Simon R, Jay G, Wears R, Salisbury M, Dukes K, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams Project. Health Serv Res. 2002;37(6):1553–1581
  45. Harris K, Treanor C, Salisbury M. Improving patient safety with team coordination: challenges and strategies for implementation. JOGNN. 2006;35:557–566
  46. Dong S, Bullard M, Meurer D, Colman I, Blitz S, Holroyd B, et al. Emergency triage: comparing a novel computer triage program with standard triage. Acad Emerg Med. 2005;12(6):502–507
  47. Iomedex Corporation. MobileIRIS™ (Wireless Patient Tracking in Disaster Management). Available at: http://www/iomedex.com/index-4.html. Accessed August 22, 2006.
  48. Feied C, Handler JU, Smith M, Gillam M, Kanhouwa M, Rothenhaus T, et al. Clinical information systems: instant ubiquitous clinical data for error reduction and improved clinical outcomes. Acad Emerg Med. 2004;11(11):1162–1169
  49. Bullard M, Meurer D, Colman I, Holroyd B, Rowe B. Supporting clinical practice at the bedside using wireless technology. Acad Emerg Med. 2004;11(11):1186–1192
  50. Johnstone M, Kanitsaki O. The moral imperative of designating patient safety and quality care a national nursing research priority. Collegian. 2006;13(1):5–9
  51. Johnstone M, Kanitsaki O. Processes for disciplining nurses for unprofessional conduct of a ‘serious’ nature: a critique. J Adv Nurs. 2005;50(4):363–371
  52. Firth-Cozens J, Cording H, Ginsburg R. Can we select health professionals who provide safer care. Qual Safety Health Care. 2005;12(Suppl. 1):i16–i20
  53. Maschke P. Personality evaluation of applicants in aviation. In:  Goeters K editors. Aviation psychology: practice and research. Hampshire: Ashgate; 2004;p. 141–151
  54. Mussen D, Sandal G, Helmreich R. Personality characteristics and trait clusters in final stage astronaut selection. Aviat Space Environ Med. 2004;75(4):342–349
  55. Butcher J. Assessing pilots with ‘the wrong stuff’: a call for research on emotional health factors in commercial aviators. Inter J Select Assess. 2002;10(1/2):168–184

 An earlier version of this paper was presented as an invited paper at the College of Emergency Nursing Australasia (CENA) 2nd National Emergency Nursing Conference, 25 August 2006, Hobart, Tasmania.

PII: S1574-6267(06)00125-X

doi: 10.1016/j.aenj.2006.11.001

Australasian Emergency Nursing Journal
Volume 10, Issue 2 , Pages 80-85 , May 2007