Managing medication errors—a qualitative study.

Pamela Stetina; Michael Groves; Leslie Pafford

Study

Managing medication errors—a qualitative study.

July 13, 2005

Stetina P, Groves M, Pafford L. Medsurg Nurs. 2005;14(3):174-8.

View more articles from the same authors.

The authors conducted interviews with practicing nurses regarding their experiences with medication errors.

PubMed citation

Related Resources From the Same Author(s)

The relationship between safety culture and patient outcomes: results from pilot meta-analyses.

July 24, 2013

Defining the incidence of cardiorespiratory instability in patients in step-down units using an electronic integrated monitoring system.

December 17, 2008

It's always something: hospital nurses managing risk.

January 30, 2013

Nurse bias and nursing care disparities related to patient characteristics: a scoping review of the quantitative and qualitative evidence

December 1, 2021

Keeping patients safe in healthcare organizations: a structuration theory of safety culture.

May 11, 2011

Applying ethnography to the study of context in healthcare quality and safety.

January 22, 2014

An ethnographic study of health information technology use in three intensive care units.

August 30, 2017

Interprofessional care in intensive care settings and the factors that impact it: results from a scoping review of ethnographic studies.

September 4, 2013

Strategies for detecting adverse drug events among older persons in the ambulatory setting.

March 6, 2005

A multiobserver study of the effects of including point-of-care patient photographs with portable radiography: a means to detect wrong-patient errors.

October 8, 2014

A mixed methods study examining teamwork shared mental models of interprofessional teams during hospital discharge.

January 8, 2020

Avoiding potential harm by improving appropriateness of urinary catheter use in 18 emergency departments.

July 16, 2014

Fostering patient safety competencies using multiple-patient simulation experiences.

December 9, 2009

Medical emergency team calls in the radiology department: patient characteristics and outcomes.

March 14, 2012

Nurse sensemaking for responding to patient and family safety concerns.

March 17, 2021

Achieving dialysis safety: the critical role of higher-functioning teams.

April 17, 2019

Patient voices in hospital safety during the COVID-19 pandemic.

November 2, 2022

Opioids for pain management in older adults: strategies for safe prescribing.

February 22, 2017

CPOE: strategies for success.

May 19, 2010

Peer support for clinicians: a programmatic approach.

July 20, 2016

The power of regret.

October 25, 2017

Healthcare management strategies: interdisciplinary team factors.

November 14, 2012

Off the record — avoiding the pitfalls of going electronic.

April 30, 2008

The key to CPOE.

December 12, 2007

Facilitating a safe transition from the pediatric emergency department to home with a post-discharge phone call: a quality-improvement initiative to improve patient safety.

July 9, 2014

Learning without borders: a review of the implementation of medical error reporting in Médecins Sans Frontières.

October 7, 2015

Do older patients' perceptions of safety highlight barriers that could make their care safer during organisational care transfers?

January 30, 2005

Improvement in detection of wrong-patient errors when radiologists include patient photographs in their interpretation of portable chest radiographs.

July 15, 2015

Nursing assessment of continuous vital sign surveillance to improve patient safety on the medical/surgical unit.

December 9, 2015

The mindful path to nursing accuracy: a quasi-experimental study on minimizing medication administration errors.

May 19, 2021

Formal medicine reconciliation within the emergency department reduces the medication error rates for emergency admissions.

November 24, 2010

Clinical nurse specialists as leaders in rapid response.

March 10, 2010

Using a network organisational architecture to support the development of Learning Healthcare Systems.

February 21, 2018

Tamper-resistant drugs cannot solve the opioid crisis.

January 18, 2017

The social cost of adverse medical events, and what we can do about it.

April 27, 2011

Perianesthesia nursing advocacy: an influential voice for patient safety.

June 11, 2008

Intrahospital transport to the radiology department: risk for adverse events, nursing surveillance, utilization of a MET and practice implications.

July 6, 2011

Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.

October 5, 2011

Rapid response team in a rural hospital.

May 23, 2012

How not to waste a crisis: a qualitative study of problem definition and its consequences in three hospitals.

March 13, 2019

Barriers and facilitators to implementing a process to enable parent escalation of care for the deteriorating child in hospital.

August 22, 2018

The impact of implementation of family-initiated escalation of care for the deteriorating patient in hospital: a systematic review.

June 22, 2016

A qualitative study of speaking out about patient safety concerns in intensive care units.

October 25, 2017

Explaining Matching Michigan: an ethnographic study of a patient safety program.

August 21, 2013

From HRO to HERO: making health equity a core system capability.

November 24, 2021

Safeguarding patients: complexity science, high reliability organizations, and implications for team training in healthcare.

December 20, 2006

Incomplete EHR adoption: late uptake of patient safety and cost control functions.

September 19, 2007

Tips to reduce dangerous interruptions by healthcare staff.

February 6, 2013

Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay.

November 28, 2012

Teaching patient safety in simulated learning experiences.

June 22, 2011

Anticoagulation patient safety goal compliance at a university health system: methods for achieving the goal.

September 23, 2009

Surgeon agreement at the time of handover, a prospective cohort study.

April 27, 2016

Improving patient safety: patient-focused, high-reliability team training.

September 10, 2008

Developing a high value care programme from the bottom up: a programme of faculty-resident improvement projects targeting harmful or unnecessary care.

November 9, 2016

Healthcare professional and patient codesign and validation of a mechanism for service users to feedback patient safety experiences following a care transfer: a qualitative study.

October 5, 2016

Inpatient fall prevention: use of in-room Webcams.

January 9, 2013

Use of multidisciplinary rounds to simultaneously improve quality outcomes, enhance resident education, and shorten length of stay.

July 25, 2007

Missed breast cancer: effects of subconscious bias and lesion characteristics.

August 5, 2020

We need to talk: primary care provider communication at discharge in the era of a shared electronic medical record.

April 1, 2015

Between surveillance and subjectification: professionals and the governance of quality and patient safety in English hospitals.

March 5, 2014

Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.

July 25, 2012

PReSaFe: A model of barriers and facilitators to patients providing feedback on experiences of safety.

December 7, 2016

Patients' conceptualizations of responsibility for healthcare: a typology for understanding differing attributions in the context of patient safety.

June 5, 2019

Interdisciplinary team training identifies discrepancies in institutional policies and practices.

June 22, 2011

Implementing a survey for patients to provide safety experience feedback following a care transition: a feasibility study

October 9, 2019

Interruptions during the delivery of high-risk medications.

June 2, 2010

Nursing home patient safety culture perceptions among licensed practical nurses.

February 1, 2023

Medicaid markets and pediatric patient safety in hospitals.

September 26, 2007

Impact of professional interpreters on outcomes for hospitalized children from migrant and refugee families with limited English proficiency: a systematic review.

September 16, 2020

Predictors of completeness of patients' self-reported personal medication lists and discrepancies with clinic medication lists.

December 11, 2013

Frequency, types, and potential clinical significance of medication-dispensing errors.

February 11, 2009

Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit.

November 8, 2006

Disclosure coaching: an ask-tell-ask model to support clinicians in disclosure conversations.

July 25, 2018

Increasing patient–clinician concordance about medical error disclosure through the patient TIPS model.

July 12, 2017

Housestaff and medical student attitudes toward medical errors and adverse events.

August 1, 2007

Evaluating teamwork in a simulated obstetric environment.

May 9, 2007

Implications of the failure to identify high-risk electrocardiogram findings for the quality of care of patients with acute myocardial infarction: results of the Emergency Department Quality in Myocardial Infarction (EDQMI) study.

November 8, 2006

"Out of sight, out of mind": housestaff perceptions of quality-limiting factors in discharge care at teaching hospitals.

July 18, 2012

"Learning by Doing"—resident perspectives on developing competency in high-quality discharge care.

June 20, 2012

Getting by: underuse of interpreters by resident physicians.

January 28, 2009

Introduction of discharge plan to reduce adverse events within 72 hours of discharge from the ICU.

August 12, 2009

Perceptions of pediatric hospital safety culture in the United States: an analysis of the 2016 Hospital Survey on Patient Safety Culture.

April 24, 2019

Improving patient safety in public hospitals: developing standard measures to track medical errors and process breakdowns.

April 4, 2018

Supporting a psychiatric hospital culture of safety.

November 21, 2012

Twenty-four/seven: a mixed-method systematic review of the off-shift literature.

August 29, 2012

Learning from error: identifying contributory causes of medication errors in an Australian hospital.

March 19, 2008

Improving quality and safety of care using "technovigilance": an ethnographic case study of secondary use of data from an electronic prescribing and decision support system.

October 16, 2013

Healthcare Utilizing Deliberate Discussion Linking Events (HUDDLE): a systematic review.

August 12, 2015

Cracking the code for quality: the interrelationships of culture, nurse demographics, advocacy, and patient outcomes.

March 11, 2020

A patient safety dilemma: obesity in the surgical patient.

February 15, 2017

Opportunities to enhance laboratory professionals' role on the diagnostic team.

November 16, 2016

Quality improvement through implementation of discharge order reconciliation.

June 12, 2013

Patient safety, error reduction, and pediatric nurses' perceptions of smart pump technology.

May 7, 2014

Association of note quality and quality of care: a cross-sectional study.

April 23, 2014

Changing hospital organisational culture for improved patient outcomes: developing and implementing the Leadership Saves Lives intervention.

August 12, 2020

Variability in the measurement of hospital-wide mortality rates.

March 19, 2014

Delivering the truth: challenges and opportunities for error disclosure in obstetrics.

February 26, 2014

Decreasing handoff-related care failures in children's hospitals.

August 13, 2014

Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency.

May 31, 2017

Management of arterial lines and blood sampling in intensive care: a threat to patient safety.

January 8, 2014

Related Resources

Understanding the peer, manager, and system influence on patient safety.

February 10, 2021

Nurse burnout predicts self-reported medication administration errors in acute care hospitals.

January 20, 2021

We Want to Know-a mixed methods evaluation of a comprehensive program designed to detect and address patient-reported breakdowns in care.

May 20, 2020

Evaluating horizontal violence and bullying in the nursing workforce of an oncology academic medical center.

September 25, 2019

Association of registered nurse and nursing support staffing with inpatient hospital mortality.

September 25, 2019

When safety climate is not enough: examining the moderating effects of psychosocial hazards on nurse safety performance.

August 28, 2019

Ensuring effective care transition communication: implementation of an electronic medical record-based tool for improved cancer treatment handoffs between clinic and infusion nurses.

August 21, 2019

The courage to speak out: a study describing nurses' attitudes to report unsafe practices in patient care.

August 14, 2019

Nurses' safety motivation: examining predictors of nurses' willingness to report medication errors.

August 7, 2019

Just culture: it's more than policy.

August 7, 2019

Incivility and clinical performance, teamwork, and emotions: a randomized controlled trial.

May 22, 2019

Using incident reports to assess communication failures and patient outcomes.

April 17, 2019

Impact of patient safety culture on missed nursing care and adverse patient events.

March 20, 2019

Implementation of bar-code medication administration to reduce patient harm.

February 20, 2019

Formative evaluation of the video reflexive ethnography method, as applied to the physician–nurse dyad.

February 6, 2019

Manifestations of high-reliability principles on hospital units with varying safety profiles: a qualitative analysis.

January 30, 2019

Relationship of staff information sharing and advice networks to patient safety outcomes.

January 30, 2019

Balancing patient-centered and safe pain care for nonsurgical inpatients: clinical and managerial perspectives.

January 16, 2019

The association of the nurse work environment and patient safety in pediatric acute care.

January 16, 2019

An electronic health record–based real-time analytics program for patient safety surveillance and improvement.

December 5, 2018

Developing an intervention to reduce harm in hospitalized patients: patients and families in research.

December 5, 2018

Effect of changes in hospital nursing resources on improvements in patient safety and quality of care: a panel study.

November 28, 2018

Nurses' and patients' appraisals show patient safety in hospitals remains a concern.

November 21, 2018

Bachelor's degree nurse graduates report better quality and safety educational preparedness than associate degree graduates.

November 14, 2018

Reducing treatment errors through point-of-care glucometer configuration.

October 31, 2018

Peer training using cognitive rehearsal to promote a culture of safety in health care.

October 31, 2018

Effects of individual nurse and hospital characteristics on patient adverse events and quality of care: a multilevel analysis.

October 24, 2018

Description and factors associated with missed nursing care in an acute care community hospital.

October 17, 2018

Impact of high-reliability education on adverse event reporting by registered nurses.

October 10, 2018

Association of nurse engagement and nurse staffing on patient safety.

August 29, 2018

See More About The Topic

Nurses

Nurse Managers

Nursing

Managing medication errors—a qualitative study.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Managing medication errors—a qualitative study.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site