International Journal of Medical Informatics
Volume 75, Issue 12 , Pages 809-817 , December 2006

The need for organizational change in patient safety initiatives

  • James G. Anderson

      Affiliations

    • Purdue University, West Lafayette, IN 47907, United States
    • Corresponding Author InformationCorresponding author at: Department of Sociology & Anthropology, Purdue University, 700 W. State Street, West Lafayette, IN 47907-2059, United States. Tel.: +1 765 494 4703; fax: +1 765 496 1476.
  • ,
  • Rangaraj Ramanujam

      Affiliations

    • Purdue University, West Lafayette, IN 47907, United States
  • ,
  • Devon Hensel

      Affiliations

    • Indiana University School of Medicine, Indianapolis, IN 46202, United States
  • ,
  • Marilyn M. Anderson

      Affiliations

    • Anderson Consulting, West Lafayette, IN 47907, United States
  • ,
  • Carl A. Sirio

      Affiliations

    • University of Pittsburgh, United States

Received 21 October 2005 ,Revised 8 February 2006 ,Accepted 24 May 2006.

References 

  1. In:  Kohn KT,  Corrigan JM,  Donaldson MS editor. To Err is Human: Building a Safer Health System.. Washington, DC: Institute of Medicine, National Academy Press; 2001;
  2. Phillips DP, Bredder CC. Morbidity and mortality from medical errors: an increasingly serious public health problem. Ann. Rev. Pub. Health. 2002;23:135–150
  3. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. J. Am. Med. Assoc. 1998;279:1200–1205
  4. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch. Intern. Med. 2002;162:1897–1903
  5. Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press, Washington, DC, 2001.
  6. Leape LL. Reporting of adverse events. New England J. Med. 2002;347(20):1633–1638
  7. Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events: a problem for quality improvement. J. Qual. Im. 1995;21:541–548
  8. Leape LL, Berwick DM. Five years after to err is human: what have we learned. J. Am. Med. Assoc. 2005;293:2384–2390
  9. Billings CE. Some hopes and concerns regarding medical event-reporting systems: lessons from the NASA aviation safety reporting system. Arch. Pathol. Lab. Med. 1998;122(3):214–215
  10. Veterans Administration Patient Safety reporting System (PSFS), http://www.psrs.arc.nasa.gov/.
  11. Mears D, White SV, James P. Bagian on patient safety initiative. J. Health Care Qual. 2002;24(15–16):24
  12. Institute for Safe Medication Practices Medication Error Program, http://www.ismp.org/pasgesd/communication.asp.
  13. Pronovost PJ, Wu AW, Dorman T, Morlock L. Building safety into ICU care. J. Crit. Care. 2002;17:78–85
  14. Mekhjian HS, Bentley TD, Ahmad A, Harsh G. Development of a web-based event reporting system in an academic environment. J. Am. Med. Inform. Assoc. 2004;11(1):11–18
  15. Fernald DH, Pace WD, et al. Event reporting to a primary care safety reporting system: A report from the ASIPS collaborative. Ann. Family Med. 2004;2:327–332
  16. Wu A, Pronovost P, Morlock L. ICU incident reporting systems. J. Crit. Care. 2002;17:86–94
  17. Kim J, Bates DW. Results of a survey on medical error reporting systems in Korean hospitals. Int. J. Med. Inform. 2006;75(2):148–155
  18. Furukawa H, Bunko H, Tsuchiya F, Miyamoto K. Voluntary medication error reporting program in a Japanese national university hospital. Ann. Pharmacother. 2003;37(11):1716–1722
  19. Le Duff F, Daniel S, Kamendje B, Le Beux P, Duvauferrier R. Monitoring incident report in the healthcare process to improve quality in hospitals. Int. J. Med. Inform. 2005;74(2–4):111–117
  20. Holzmueller CG, Pronovost PJ, Dickman F, Thompson DA, Wu AW, Lubomski LH, et al. Creating the web-based intensive care unit safety reporting system. J. Am. Med. Inform. Assoc. 2005;12(2):130–139
  21. Sirio CA, Segel KT, Keyser DJ, Harrison EI, Lloyd JC, Weber RJ, et al. Pittsburgh regional healthcare initiative: a systems approach for achieving perfect patient care. Health Affairs. 2003;22(5):157–165
  22. R.W. Hicks, J.P. Santell, D.D. Cousins, R.L. Williams, MEDMARX Fifth Anniversary Data Report: A Chartbook of 2003 Findings and Trends 1999–2003, 2004.
  23. National Coordinating Council for Medication Error Reporting and Prevention, What is a Medication Error?, 1998.
  24. Patel VL, Currie LM. Clinical cognition and biomedical informatics: Issues of patient safety. Int. J. Med. Inform. 2005;74(11–12):559–561
  25. Simpson RL. Managing the three ‘P's to improve patient safety: Nursing administration's role in managing information technology. Int. J. Med. Inform. 2004;73(7–8):111–117
  26. R. Ramanujam, D.J. Keyser, C.A. Sirio, Missing: The logic of organizational change in patient safety initiatives, Unpublished manuscript, 2004.
  27. Cook R, Render M, Woods D. Gaps in the continuity of care and progress on patient safety. Br. Med. J. 2000;320:791–794
  28. Anderson JG. A system's approach to preventing adverse drug events. In:  Krishna S,  Balas EA,  Boren SA editor. Information Technology Business Models for Quality Health Care: An EU/US Dialogue. The Netherlands: IOS Press; 2003;p. 95–102
  29. Hayard RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. J. Am. Med. Assoc. 2001;286(4):415–420
  30. Anderson JG, Jay SJ, Anderson M, Hunt TJ. Evaluating the capability of information technology to prevent adverse drug events: A computer simulation approach. J. Am. Med. Inform. Assoc. 2002;9:479–490
  31. Anderson JG. Information technology for detecting medication errors and adverse drug events. Expert Opin. Drug Saf. 2004;3(5):449–455
  32. Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. J. Am. Med. Assoc. 1999;272:267–270
  33. Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J. Am. Med. Inform. Assoc. 2004;11(2):104–112
  34. Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, et al. Role of computerized physician order entry systems in facilitating medication errors. J. Am. Med. Assoc. 2005;293:1197–1203
  35. Hannon B, Ruth M. Dynamic Modeling. New York: Springer-Verlag; 1994;
  36. Behal R. Organizational development framework for transformational change in patient safety: a guide for hospital senior leaders. In:  Youngberg BJ,  Hatlie MJ editor. The Patient Safety Handbook. Boston: Jones and Bartlett Publishers; 2004;
  37. Classen DC, Pestotnik SL, Evans RS, Burke JP. Computerized surveillance of adverse drug events in hospital patients. J. Am. Med. Assoc. 1991;266:2847–2851
  38. Jha AK, Kuperman GJ, Teich JM, Leape L, Shea B, Rittenberg E, et al. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J. Am. Med. Inform. Assoc. 1998;5:305–314
  39. Oliven A, Michalake I, Zalman D, Dorman E, Yeshurun D, Odeh M. Prevention of prescription errors by computerized, on-line surveillance of drug order entry. Int. J. Med. Inform. 2005;74(5):377–386
  40. Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. J. Am. Med. Assoc. 1998;280:1311–1316
  41. Nebeker JR, Hoffman JM, Weir CR, Bennett CL, Hurdle JF. High rates of adverse drug events in a highly computerized hospital. Arch. Intern. Med. 2005;165:1111–1116
  42. Donaldson L. Keep the patients safe. Qual. World. 2003;29(2):10–12

PII: S1386-5056(06)00156-0

doi: 10.1016/j.ijmedinf.2006.05.043

International Journal of Medical Informatics
Volume 75, Issue 12 , Pages 809-817 , December 2006