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Latent preconditions of medication administration errors:\ud development of a proactive error-management tool

By Samantha Jane Carruthers


latrogenic injury has been found to occur in around 10% of UK hospital admissions, equating to the harm of approximately 850,000 patients each year. The Department of Health has made repeated calls for NHS research to learn from proactive error management techniques (EMTs) employed\ud within other 'safety-critical' organisations (DOH 2000,2001). The aim of this research was to develop a valid and reliable proactive measure of latent organisational failures (EMT) for use in secondary care using a psychological theory of organisational accidents (Reason, 1990,1997). This theory purports that errors occur as a result of a complex interaction between unsafe acts and\ud systemic organisational weaknesses known as latent failures. This tool will be used to measure and monitor organisational safety in health care and predict the likelihood of medication administration errors (MAEs).\ud \ud \ud Twenty semi-structured interviews were conducted in study I with qualified nurses from several general medical wards and senior managers from Bradford Teaching Hospitals NHS Foundation Trust. Using error vignettes, participants were asked to discuss their perceptions of error causation.\ud Additional qualitative data was collected using clinical observations and incident report review. Using thematic content analysis, ten latent workplace and organisational causes of MAEs were identified, consistent with psychological error theory and error causes evidenced within other safety-critical industries (Reason, 1997; Groeneweg, 1992; Helmreich, 2000; Colla et al., 2005),\ud including team functioning, human resources, culture and training. In ternis of Reason's organisational accident model, combining three pools of independent qualitative data afforded an in-depth exploration of latent error causes at an individual (e. g. unsafe practices), workplace (e. g. team functioning) and organisational level (e. g. use of policies and protocols).\ud \ud \ud Study 2 was conducted to conceptualize identified latent preconditions of MAE within a proactive questionnaire measure; the Organisational Safety Questionnaire (OSQ). Revisiting qualitative data collected in Study 1, this study explored the ways in which each latent organisational failure would manifest at a hospital ward level. One hundred and forty-five safety indicators were generated\ud based on these manifestations of poor safety. Pilot studies to test the face validity of indicators and content analysis to remove less commonly endorsed items led to refinement of the tool to 82 items.\ud \ud \ud Given several notable drawbacks to using NHS formal incident reporting systems as an outcome measure, study 3 was conducted to develop an independent measure of MAEs against which to test the predictive validity of the OSQ (the Drug Round Behaviour questionnaire; DRBQ). This study\ud explored the types of MAEs which can arise in secondary care as a direct or indirect result of the ten latent preconditions. Using the qualitative data obtained in study 1, a 27-item measure of 10 types of MAE (NCC MERP, 1995) was developed which was not reliant upon adverse patient\ud outcomes and intended to also capture near misses. After a pilot study was conducted to improve the construct and face validity of the tool, 13 items which reflected 7 types of MAE had good face validity and were retained for study 4.\ud \ud \ud The final study was conducted to measure the validity and reliability of the OSQ. The 82-item OSQ was administered to qualified and unqualified nurses working in 54 clinical areas across 2 two Bradford hospitals. Analysis revealed that the OSQ was relevant for all qualified nurses working in 34 of these clinical areas. Although developed as 10 subscales representing 10 latent preconditions of MAE, factor analysis yielded only one overall construct from 28 items named 'organisational safety'. However, these items reflected 8 of the 10 proposed predictors of MAE which supports their role in the occurrence of MAE. The 28-item OSQ had good internal consistency and concurrent validity (with an independent 9-item measure of local safety culture; Vogus & Sutcliffe, 2007). While the OSQ was significantly predictive of MAEs measured by the DRBQ, it did not significantly predict formally reported incidents. However, this may have been an artefact of low statistical power which may have been improved with a larger sample. Finally, high safety risk wards said they were less likely to formally report their errors than lower risk wards, yet all wards reported a similar number of incidents. It is proposed that high risk wards report a comparatively\ud smaller percentage of the errors which actually occur compared to lower risk wards due to poorer safety cultures. Interestingly, high safety risk wards admitted making significantly more MAEs on the DRBQ than 'safer' wards suggesting the DRBQ was a more sensitive measure of the actual number of drug administration errors occurring on wards. The Organisational Safety Questionnaire represents a novel, valid and reliable proactive measure of safety which is not currently available in health care which would be useful in measuring the effects on systems interventions and other organisational changes.\ud \ud \ud This thesis has explored and identified latent organisational causes of medication administration errors in secondary care and used methodological techniques used in other safety-critical industries to develop a valid and reliable measure of organisational safety which was successful in predicting medication administration errors. Findings are discussed in terms of the benefit of rigorous\ud qualitative methods in this type of research and the direction of future research which could examine the generaliseability of the tool to other health care professionals or fields of medicin

Publisher: Institute of Psychological Sciences (Leeds)
Year: 2008
OAI identifier:

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