Although fully recognizing that they represent "only the tip of the iceberg," published case reports/series of these errors were reviewed in detail with the aim of estimating the frequency and the nature of these errors. Obstetric Neuraxial Drug Administration Errors: A Quantitative and Qualitative Analytical Review.ĭrug administration errors in obstetric neuraxial anesthesia can have devastating consequences. The development, sharing, and use of error taxonomies, and the refinement of approaches for increased fidelity of qualitative modeling is offered as a means to help direct useful data collection strategies.« less In a recent NASA Advanced Human Support Technology grant FRANCIE was refined, and two new taxonomies for use on space missions were developed. Performance shaping factors and error types from such detailed approaches can be used to structure error reporting schemes. The assignment of performance shaping factors to generic errors by experts proved to be valuable to qualitative modeling. A result was the development of the FRamework Assessing Notorious Contributing Influences for Error (FRANCIE) with a taxonomy for airline maintenance tasks. Other needs identified included developing comprehensive taxonomies to support detailed qualitative modeling and to structure meaningful data collection efforts across domains. Identified needs included the need for a method to identify and prioritize task and contextual characteristics affecting human reliability. In the mid 90s Boeing, America West Airlines, NASA Ames Research Center and INEEL partnered in a NASA sponsored Advanced Concepts grant to: assess the state of the art in human error analysis, identify future needs for human errormore » analysis, and develop an approach addressing these needs. This was likely due to the lack of comprehensive error and performance shaping factor taxonomies, and the limited data available on observed error rates and their relationship to specific contextual variables. However, detailed qualitative modeling with comprehensive representation of contextual variables often was lacking. The experienced nurses were more prone to "Practice beyond scope of practice" and to make errors in spite of "Lack of adequateįRamework Assessing Notorious Contributing Influences for Error (FRANCIE): Perspective on Taxonomy Development to Support Error Reporting and Analysisīeginning in the 1980s a primary focus of human reliability analysis was estimation of human error probabilities. The errors "Wrong patient due to mix-up of patients" and "Wrong route" and the contributory factors "Lack of knowledge" and "Negligence, forgetfulness or lack of attentiveness" were more common in less experienced nurses. In 78 % of the cases, an average of 1.7 system contributory factors was found the most common being "Role overload" (36 %), "Unclear communication or orders" (30 %) and "Lack of adequate access to guidelines or unclear organisational routines" (30 %). In 95 % of the cases, an average of 1.4 individual contributory factors was found the most common being "Negligence, forgetfulness or lack of attentiveness" (68 %), "Proper protocol not followed" (25 %), "Lack of knowledge" (13 %) and "Practice beyond scope" (12 %). There were a total of 613 medication errors in the 585 cases, the most common being "Wrong dose" (41 %), "Wrong patient" (13 %) and "Omission of drug" (12 %). In order to test for possible differences between nurses' work experience and associations within and between the errors and contributory factors, Fisher's exact test was used, and Cohen's kappa (k) was performed to estimate the magnitude and direction of the associations. A qualitative content analysis and classification according to the type and the individual and system contributory factors was made. All medication errors where a nurse was held responsible for malpractice (n = 585) during 11 years in Sweden were included. Nurses have a key role in medication administration, and there are contradictory reports on the nurses' work experience in relation to the risk and type for medication errors. Other studies have analyzed the individual and system contributory factor leading to a medication error. Many studies address the prevalence of medication errors but few address medication errors serious enough to be regarded as malpractice. Medication errors as malpractice-a qualitative content analysis of 585 medication errors by nurses in Sweden.ījörkstén, Karin Sparring Bergqvist, Monica Andersén-Karlsson, Eva Benson, Lina Ulfvarson, Johanna
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