Commentary Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. Citation Text: Dekker SWA. Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. J Law Med Ethics. 2007;35(3):463-70. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL October 3, 2007 Dekker SWA. J Law Med Ethics. 2007;35(3):463-70. View more articles from the same authors. The author analyzes one Swedish medication error incident that resulted in criminal charges against the nurse involved and discusses how the media contorted the assignment of blame for the failure. PubMed citation Available at Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Dekker SWA. Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. J Law Med Ethics. 2007;35(3):463-70. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) A systems approach to analyzing and preventing hospital adverse events. June 24, 2020 Obstacles to research on the effects of interruptions in healthcare. February 10, 2016 The systems approach to medicine: controversy and misconceptions. September 3, 2014 Just culture: who gets to draw the line? October 14, 2009 A just culture after Mid Staffordshire. March 26, 2014 Benefactor or burden: exploring the professional identity of safety professionals. October 24, 2018 Intervening in interruptions: what exactly is the risk we are trying to manage? October 11, 2017 Laparoscopic bile duct injury: understanding the psychology and heuristics of the error. February 11, 2009 Doctors are more dangerous than gun owners: a rejoinder to error counting. April 4, 2007 Criminalization of medical error: who draws the line? September 19, 2007 A qualitative survey of factors shaping the role of a safety professional. October 19, 2022 'Just culture': improving safety by achieving substantive, procedural and restorative justice. May 25, 2016 ‘Ladder’-based safety culture assessments inversely predict safety outcomes. February 8, 2023 Compensation of chief executive officers at nonprofit US hospitals. October 30, 2013 Adaptive design: adaptation and adoption of patient safety practices in daily routines, a multi-site study. August 12, 2020 Detach yourself: the positive effect of psychological detachment on patient safety in long-term care. September 29, 2021 What do we really know about crew resource management in healthcare?: An umbrella review on crew resource management and its effectiveness. March 2, 2022 The impact of transition to a digital hospital on medication errors (TIME study). August 16, 2023 Safety culture in long-term care: a cross-sectional analysis of the Safety Attitudes Questionnaire in nursing and residential homes in the Netherlands. August 12, 2015 Interventions to improve team effectiveness: a systematic review. November 18, 2009 Discrepant perceptions of communication, teamwork and situation awareness among surgical team members. March 23, 2011 Teamwork and Teamwork Training in Healthcare. July 25, 2018 Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021 Measures of patient safety in developing and emerging countries: a review of the literature. March 17, 2010 A randomized trial of a multifactorial strategy to prevent serious fall injuries. July 29, 2020 ACR guidance document on MR safe practices: 2013. March 21, 2013 Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017 Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative. May 18, 2022 Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital. March 29, 2012 Impact of teamwork and communication training interventions on safety culture and patient safety in emergency departments: a systematic review. January 26, 2022 Core competencies for patient safety research: a cornerstone for global capacity strengthening. February 2, 2011 Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures. May 25, 2011 Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. May 10, 2017 Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports. June 10, 2009 Implementation of peer messengers to deliver feedback: an observational study to promote professionalism in nursing. January 18, 2023 Errors, incidents and accidents in anaesthetic practice. March 6, 2005 Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020 The effect of computerised decision support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring: a cluster randomised stepped-wedge trial. February 14, 2024 Adverse drug events caused by three high-risk drug-drug interactions in patients admitted to intensive care units: a multicentre retrospective observational study. October 18, 2023 World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. May 23, 2018 Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals. April 25, 2018 Outcomes with overlapping surgery at a large academic medical center. February 21, 2018 The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. August 24, 2005 Drug-induced hypoglycaemia--new insight into an old problem. October 25, 2006 Effect of reducing interns' work hours on serious medical errors in intensive care units. March 27, 2005 Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. February 9, 2011 Locating errors through networked surveillance: a multimethod approach to peer assessment, hazard identification, and prioritization of patient safety efforts in cardiac surgery. April 23, 2014 Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. August 21, 2013 Toward improving patient safety through voluntary peer-to-peer assessment. January 25, 2012 Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022 The 2017 ACGME common work hour standards: promoting physician learning and professional development in a safe, humane environment. January 31, 2018 Incidence of adverse drug events and medication errors in intensive care units: a prospective multicenter study. February 18, 2009 Factors associated with workarounds in barcode-assisted medication administration in hospitals. August 26, 2020 Mitigating the July effect. July 7, 2021 'It depends': The complexity of allowing residents to fail from the perspective of clinical supervisors. November 24, 2021 The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study. March 16, 2016 Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. February 24, 2016 When a surgical colleague makes an error. February 24, 2016 A safe practice standard for barcode technology. June 3, 2015 Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems. May 1, 2019 The influence that electronic prescribing has on medication errors and preventable adverse drug events: an interrupted time-series study. December 2, 2009 Medication errors recovered by emergency department pharmacists. July 14, 2010 Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study. January 30, 2005 Guideline for opioid therapy and chronic noncancer pain. May 31, 2017 Innovative patient safety curriculum using iPad game (PASSED) improved patient safety concepts in undergraduate medical students. September 21, 2016 Failed spinal anaesthesia: mechanisms, management, and prevention. July 8, 2009 Recovery from medical errors: the critical care nursing safety net. January 31, 2006 A controlled trial of a rapid response system in an academic medical center. June 25, 2008 Organizational factors associated with high performance in quality and safety in academic medical centers. February 27, 2008 Crisis management during anaesthesia: the development of an anaesthetic crisis management manual. June 22, 2005 Effect of reducing interns' weekly work hours on sleep and attentional failures. March 27, 2005 Extended work shifts and neurobehavioral performance in resident-physicians. March 10, 2021 Implementation of a parent-centered approach to the preinduction checklist in pediatric surgery. February 3, 2021 Racial differences in antibiotic prescribing by primary care pediatricians. March 20, 2013 Cumulative effect of flexible duty-hour policies on resident outcomes: long-term follow-up results from the FIRST trial. July 15, 2020 Risk-adjusted cumulative sum for early detection of hospitals with excess perioperative mortality. December 13, 2023 Effect on patient safety of a resident physician schedule without 24-hour shifts. July 15, 2020 Prevalence and predictors of delayed clinical diagnosis of Type 2 diabetes: a longitudinal cohort study. November 14, 2018 Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems. January 28, 2015 Emergency department patient safety incident characterization: an observational analysis of the findings of a standardized peer review process. September 10, 2014 Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS). June 26, 2019 Practical challenges of introducing WHO surgical checklist: UK pilot experience. January 27, 2010 Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections. April 27, 2011 Errors during the preparation of drug infusions: a randomized controlled trial. August 22, 2012 Adverse drug events in surgical patients: an observational multicentre study. November 6, 2013 Development and evaluation of a 3-day patient safety curriculum to advance knowledge, self-efficacy and system thinking among medical students. April 18, 2012 Families as partners in hospital error and adverse event surveillance. March 8, 2017 Association of the Hospital Readmissions Reduction Program implementation with readmission and mortality outcomes in heart failure. November 22, 2017 Critical errors in infrequently performed trauma procedures after training. November 20, 2019 Improving transfusion safety: implementation of a comprehensive computerized bar code-based tracking system for detecting and preventing errors. April 9, 2008 Findings of the first consensus conference on medical emergency teams. August 16, 2006 Evaluation of policies limiting opioid exposure on opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large American health system. March 8, 2023 High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients. February 17, 2021 Increasing physician reporting of diagnostic learning opportunities. December 23, 2020 COVID-19: the dark side and the sunny side for patient safety. October 14, 2020 Prescription opioid dose reductions and potential adverse events: a multi-site observational cohort study in diverse US health systems. November 29, 2023 STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration. October 14, 2016 Clinician well-being assessment and interventions in Joint Commission-accredited hospitals and federally qualified health centers. October 4, 2023 Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study. June 14, 2023 Reducing pediatric emergency department prescription errors. June 22, 2022 View More Related Resources Systemic failures in health care oversight. March 20, 2024 How Columbia ignored women, undermined prosecutors and protected a predator for more than 20 years. September 20, 2023 Unstoppable: this doctor has been investigated at every level of government. How is he still practicing? August 23, 2023 Inside the preventable deaths that happened within a prominent transplant center. June 28, 2023 Annual Perspective Improving Diagnostic Safety and Quality April 26, 2023 Creating a stronger culture of safety within US community pharmacies. April 12, 2023 Minnesota lets nurses practice while disciplinary investigations drag on. Patients keep getting hurt. April 12, 2023 Crisis in the Lakeshore Hospital ER. March 8, 2023 Implementation of an online reporting system to identify unprofessional behaviors and mistreatment directed at trainees at an academic medical center. December 21, 2022 The prosecution of RaDonda Vaught: an ethical and legal mistake. December 21, 2022 National Plan for Health Workforce Well-Being. September 28, 2022 Physicians and cognitive decline: a challenge for state medical boards. September 7, 2022 Society for Maternal-Fetal Medicine Special Statement: a critique of postpartum readmission rate as a quality metric. May 18, 2022 How can regulatory authorities improve safety in organizations by influencing safety culture? A conceptual model of the relationships and a discussion of implications. July 14, 2021 Patient safety functions of state medical boards in the United States. April 21, 2021 The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul. October 7, 2020 Assessing and supporting late career practitioners: four key questions. September 30, 2020 Burnout in healthcare: the case for organisational change. August 28, 2019 Strengthening the medical error "meme pool." August 7, 2019 Zero Harm: How to Achieve Patient and Workforce Safety in Healthcare. July 31, 2019 Medication Safety in Key Action Areas. July 10, 2019 Patient Safety. May 1, 2019 Impact of nurse peer review on a culture of safety. October 3, 2018 Transformational leadership in nursing and medication safety education: a discussion paper. June 1, 2016 Conflict of interest, Dr Charles Denham and the Journal of Patient Safety. December 3, 2014 Patient safety is not elective: a debate at the NPSF Patient Safety Congress. December 3, 2014 Alcohol and drug testing of health professionals following preventable adverse events: a bad idea. November 19, 2014 Intolerance of error and culture of blame drive medical excess. October 29, 2014 Talking behind their backs: negative gossip and burnout in hospitals. September 24, 2014 What about doctors? The impact of medical errors. August 20, 2014 View More See More About The Topic Organizational Behaviorists Policy Makers Discontinuities, Gaps, and Hand-Off Problems Medication Safety Credentialing, Licensure, and Discipline View More
Laparoscopic bile duct injury: understanding the psychology and heuristics of the error. February 11, 2009
'Just culture': improving safety by achieving substantive, procedural and restorative justice. May 25, 2016
Adaptive design: adaptation and adoption of patient safety practices in daily routines, a multi-site study. August 12, 2020
Detach yourself: the positive effect of psychological detachment on patient safety in long-term care. September 29, 2021
What do we really know about crew resource management in healthcare?: An umbrella review on crew resource management and its effectiveness. March 2, 2022
Safety culture in long-term care: a cross-sectional analysis of the Safety Attitudes Questionnaire in nursing and residential homes in the Netherlands. August 12, 2015
Discrepant perceptions of communication, teamwork and situation awareness among surgical team members. March 23, 2011
Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021
Measures of patient safety in developing and emerging countries: a review of the literature. March 17, 2010
Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017
Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative. May 18, 2022
Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital. March 29, 2012
Impact of teamwork and communication training interventions on safety culture and patient safety in emergency departments: a systematic review. January 26, 2022
Core competencies for patient safety research: a cornerstone for global capacity strengthening. February 2, 2011
Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures. May 25, 2011
Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. May 10, 2017
Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports. June 10, 2009
Implementation of peer messengers to deliver feedback: an observational study to promote professionalism in nursing. January 18, 2023
Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020
The effect of computerised decision support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring: a cluster randomised stepped-wedge trial. February 14, 2024
Adverse drug events caused by three high-risk drug-drug interactions in patients admitted to intensive care units: a multicentre retrospective observational study. October 18, 2023
World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. May 23, 2018
Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals. April 25, 2018
The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. August 24, 2005
Effect of reducing interns' work hours on serious medical errors in intensive care units. March 27, 2005
Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. February 9, 2011
Locating errors through networked surveillance: a multimethod approach to peer assessment, hazard identification, and prioritization of patient safety efforts in cardiac surgery. April 23, 2014
Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. August 21, 2013
Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022
The 2017 ACGME common work hour standards: promoting physician learning and professional development in a safe, humane environment. January 31, 2018
Incidence of adverse drug events and medication errors in intensive care units: a prospective multicenter study. February 18, 2009
Factors associated with workarounds in barcode-assisted medication administration in hospitals. August 26, 2020
'It depends': The complexity of allowing residents to fail from the perspective of clinical supervisors. November 24, 2021
The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study. March 16, 2016
Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. February 24, 2016
Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems. May 1, 2019
The influence that electronic prescribing has on medication errors and preventable adverse drug events: an interrupted time-series study. December 2, 2009
Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study. January 30, 2005
Innovative patient safety curriculum using iPad game (PASSED) improved patient safety concepts in undergraduate medical students. September 21, 2016
Organizational factors associated with high performance in quality and safety in academic medical centers. February 27, 2008
Crisis management during anaesthesia: the development of an anaesthetic crisis management manual. June 22, 2005
Implementation of a parent-centered approach to the preinduction checklist in pediatric surgery. February 3, 2021
Cumulative effect of flexible duty-hour policies on resident outcomes: long-term follow-up results from the FIRST trial. July 15, 2020
Risk-adjusted cumulative sum for early detection of hospitals with excess perioperative mortality. December 13, 2023
Prevalence and predictors of delayed clinical diagnosis of Type 2 diabetes: a longitudinal cohort study. November 14, 2018
Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems. January 28, 2015
Emergency department patient safety incident characterization: an observational analysis of the findings of a standardized peer review process. September 10, 2014
Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS). June 26, 2019
Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections. April 27, 2011
Development and evaluation of a 3-day patient safety curriculum to advance knowledge, self-efficacy and system thinking among medical students. April 18, 2012
Association of the Hospital Readmissions Reduction Program implementation with readmission and mortality outcomes in heart failure. November 22, 2017
Improving transfusion safety: implementation of a comprehensive computerized bar code-based tracking system for detecting and preventing errors. April 9, 2008
Evaluation of policies limiting opioid exposure on opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large American health system. March 8, 2023
High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients. February 17, 2021
Prescription opioid dose reductions and potential adverse events: a multi-site observational cohort study in diverse US health systems. November 29, 2023
STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration. October 14, 2016
Clinician well-being assessment and interventions in Joint Commission-accredited hospitals and federally qualified health centers. October 4, 2023
Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study. June 14, 2023
How Columbia ignored women, undermined prosecutors and protected a predator for more than 20 years. September 20, 2023
Unstoppable: this doctor has been investigated at every level of government. How is he still practicing? August 23, 2023
Minnesota lets nurses practice while disciplinary investigations drag on. Patients keep getting hurt. April 12, 2023
Implementation of an online reporting system to identify unprofessional behaviors and mistreatment directed at trainees at an academic medical center. December 21, 2022
Society for Maternal-Fetal Medicine Special Statement: a critique of postpartum readmission rate as a quality metric. May 18, 2022
How can regulatory authorities improve safety in organizations by influencing safety culture? A conceptual model of the relationships and a discussion of implications. July 14, 2021
The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul. October 7, 2020
Transformational leadership in nursing and medication safety education: a discussion paper. June 1, 2016
Alcohol and drug testing of health professionals following preventable adverse events: a bad idea. November 19, 2014