Social aspects of clinical errors: a discussion paper.

Joel Richman; Tom Mason; Elizabeth Mason-Whitehead; Annette McIntosh; Dave Mercer

Commentary

Social aspects of clinical errors: a discussion paper.

March 25, 2009

Richman J, Mason T, Mason-Whitehead E, et al. Int J Nurs Stud. 2009;46(8).

View more articles from the same authors.

This article engages with issues of clinical errors by examining how their histories relate to today's compensation culture. The piece also provides a definition of clinical error and reviews strategies for managing these mistakes.

Available at

PubMed citation

Related Resources From the Same Author(s)

Interventions to improve follow-up of laboratory test results pending at discharge: a systematic review.

March 14, 2018

Examining medication errors in a tertiary hospital.

December 20, 2006

A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety.

January 28, 2015

High-reliability emergency response teams in the hospital: improving quality and safety using in situ simulation training.

May 1, 2013

Why do GDPs fail to recognise oral cancer? The argument for an oral cancer checklist.

April 10, 2013

Adverse event reporting tool to standardize the reporting and tracking of adverse events during procedural sedation: a consensus document from the World SIVA International Sedation Task Force.

January 25, 2012

The evolving role of health educators in advancing patient safety: forging partnerships and leading change.

April 11, 2007

Accuracy of medication documentation in hospital discharge summaries: a retrospective analysis of medication transcription errors in manual and electronic discharge summaries.

November 4, 2009

Widespread misinterpretation of advance directives and Portable Orders for Life-Sustaining Treatments threatens patient safety and causes undertreatment and overtreatment.

July 12, 2023

Estimating breast cancer overdiagnosis after screening mammography among older women in the United States.

August 30, 2023

Use of complex adaptive systems metaphor to achieve professional and organizational change.

August 31, 2005

Creating a distraction simulation for safe medication administration.

September 3, 2014

Improving the quality of written prescriptions in a general hospital: the influence of 10 years of serial audits and targeted interventions.

April 30, 2008

A new category of "never events"-ending harmful hospital policies.

November 9, 2022

Giving voice to quality and safety matters at board level: a qualitative study of the experiences of executive nurses working in England and Wales.

August 24, 2016

Assessing the impact of a new pediatric healthcare facility on medication administration: a human factors approach.

July 12, 2023

Threats to safety during sedation outside of the operating room and the death of Michael Jackson.

April 20, 2016

A review of medical error taxonomies: a human factors perspective.

June 29, 2011

Comparing the usability and reliability of a generic and a domain-specific medical error taxonomy.

July 25, 2012

Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.

April 19, 2017

An assessment of the quality and impact of NPSA medication safety outputs issued to the NHS in England and Wales.

April 13, 2011

Including the reason for use on prescriptions sent to pharmacists: scoping review.

January 26, 2022

Care transition of trauma patients: processes with articulation work before and after handoff.

February 16, 2022

Stakeholder safety communication: patient and family reports on safety risks in hospitals.

October 12, 2022

Why patients need leaders: introducing a ward safety checklist.

September 26, 2012

Workplace training for senior trainees: a systematic review and narrative synthesis of current approaches to promote patient safety.

September 16, 2015

Causes of use errors in ventilation devices--systematic review.

November 10, 2021

Paediatric nurses' understanding of the process and procedure of double-checking medications.

March 17, 2010

Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy.

November 25, 2009

E-prescribing first step to improved safety.

January 24, 2007

Medication order errors at hospital admission among children with medical complexity

July 8, 2020

Are more experienced clinicians better able to tolerate uncertainty and manage risks? A vignette study of doctors in three NHS emergency departments in England.

February 27, 2019

Understanding preventable deaths in the geriatric trauma population: analysis of 3,452,339 patients from the Center of Medicare and Medicaid Services Database.

December 1, 2021

Competencies for patient safety and quality improvement: a synthesis of recommendations in influential position papers.

April 6, 2016

A review of the evidence of harm from self-tests.

September 17, 2014

Prioritising recommendations following analyses of adverse events in healthcare: a systematic review.

November 4, 2020

Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience.

July 13, 2011

Team resource management and patient safety: a team focused approach to clinical governance.

May 10, 2006

Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years?

February 26, 2014

Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals.

April 16, 2008

Identifying and encouraging high-quality healthcare: an analysis of the content and aims of patient letters of compliment.

August 5, 2020

Stakeholders in safety: patient reports on unsafe clinical behaviors distinguish hospital mortality rates.

May 20, 2020

Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety.

September 26, 2018

The Healthcare Complaints Analysis Tool: development and reliability testing of a method for service monitoring and organisational learning.

February 24, 2016

Guilty, afraid, and alone — struggling with medical error.

October 31, 2007

Online patient feedback as a safety valve: an automated language analysis of unnoticed and unresolved safety incidents.

September 14, 2022

Enhancing patient safety by integrating ethical dimensions to critical incident reporting systems.

April 28, 2021

Rapid response systems in the Netherlands.

March 9, 2011

A structured judgement method to enhance mortality case note review: development and evaluation.

December 4, 2013

Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review.

May 12, 2021

Disclosure of harmful medical errors in out-of-hospital care.

August 29, 2012

Interventions targeted at reducing diagnostic error: systematic review.

September 8, 2021

Nurses' attitudes to a medical emergency team service in a teaching hospital.

December 20, 2006

Effectiveness of a graduate medical education program for improving medical event reporting attitude and behavior.

October 12, 2005

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

May 7, 2014

Fixed-dose combination antihypertensives and risk of medication errors.

October 3, 2018

Teamwork and team training in the ICU: where do the similarities with aviation end?

December 21, 2011

Doctors' perceived working conditions and the quality of patient care: a systematic review.

July 17, 2019

Using portable digital technology for clinical care and critical incidents: a new model.

August 17, 2005

Artificial intelligence in health care: accountability and safety.

June 3, 2020

Making patients safer: nurses' responses to patient safety alerts.

September 24, 2008

Applying aviation factors to oral and maxillofacial surgery—the human element.

February 1, 2012

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

October 17, 2018

Patient complaints in healthcare systems: a systematic review and coding taxonomy.

June 18, 2014

Improving the patient, family, and clinician experience after harmful events: the "When Things Go Wrong" curriculum.

June 16, 2010

Teaching but not learning: how medical residency programs handle errors.

October 25, 2006

Physician perception of hospital safety and barriers to incident reporting.

May 31, 2006

CHaMP: A model for building a center to support health care worker well-being after experiencing an adverse event.

April 5, 2023

Triggers, bundles, protocols, and checklists—what every maternal care provider needs to know.

April 13, 2016

Physician assistants and the disclosure of medical error.

June 18, 2014

A national physician survey of diagnostic error in paediatrics.

October 26, 2016

The problem with 'My Five Moments for Hand Hygiene'.

August 25, 2021

Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System.

February 25, 2009

A qualitative exploration of the impact of a distressed family member on pediatric resuscitation teams.

October 7, 2020

Walking the plank: an experimental paradigm to investigate safety voice.

July 31, 2019

Communication skills and error in the intensive care unit.

November 28, 2007

Improving patient safety in the ICU by prospective identification of missing safety barriers using the Bow-Tie prospective risk analysis model.

October 2, 2013

Epidemiology of and risk factors for coronavirus infection in health care workers: a living rapid review.

May 27, 2020

What do healthcare staff think about the quality and safety of care provided to children and young people with an intellectual disability? A qualitative study using the framework method of analysis.

September 6, 2023

A virtual breakthrough series collaborative to support deprescribing interventions across Veterans Affairs healthcare settings.

October 4, 2023

Modification of potentially inappropriate prescribing following fall-related hospitalizations in older adults.

July 10, 2019

Diagnostic error in the emergency department: follow up of patients with minor trauma in the outpatient clinic.

April 26, 2017

The next step in learning from sentinel events in healthcare.

April 15, 2020

Medication safety teams' guided implementation of electronic medication administration records in five nursing homes.

January 14, 2009

Nursing home error and level of staff credentials.

April 18, 2007

War games and diagnostic errors.

January 18, 2017

The business case for investing in physician well-being.

October 18, 2017

Association of cataract surgical outcomes with late surgeon career stages: a population-based cohort study.

October 24, 2018

Team situation awareness and the anticipation of patient progress during ICU rounds.

August 10, 2011

Avoidable iatrogenic complications of urethral catheterization and inadequate intern training in a tertiary-care teaching hospital.

May 13, 2009

Developing a team performance framework for the intensive care unit.

May 6, 2009

Intraoperative patient information handover between anesthesia providers.

November 5, 2014

The effect of workload reduction on the quality of residents' discharge summaries.

January 19, 2011

In-home medication reviews: a novel approach to improving patient care through coordination of care.

May 11, 2011

Use of a safety climate questionnaire in UK health care: factor structure, reliability and usability.

November 22, 2006

Strengthening leadership as a catalyst for enhanced patient safety culture: a repeated cross-sectional experimental study.

June 22, 2016

Risk factors for i.v. compounding errors when using an automated workflow management system.

July 27, 2016

Aviation and healthcare: a comparative review with implications for patient safety.

February 3, 2016

Ensuring primary care diagnostic quality in the era of telemedicine.

October 27, 2021

Errors, omissions, and outliers in hourly vital signs measurements in intensive care.

October 26, 2016

Related Resources

Disclosing medical errors: prioritising the needs of patients and families.

July 5, 2023

Support for healthcare workers and patients after medical error through mutual healing: another step towards patient safety.

January 18, 2023

How do hospital inpatients conceptualise patient safety? A qualitative interview study using constructivist grounded theory.

October 19, 2022

Notes on healing after a missed diagnosis.

October 19, 2022

Nurse well-being: a concept analysis.

August 17, 2022

Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS.

May 4, 2022

Caring for Those Who Care: Guide for the Development and Implementation of Occupational Health and Safety Programmes for Health Workers.

March 9, 2022

Honesty and transparency, indispensable to the clinical mission--Parts I-III.

December 15, 2021

To err Is human, to apologize is hard.

August 4, 2021

It’s time to consider national culture when designing team training initiatives in healthcare.

January 27, 2021

How U.S. teams advanced communication and resolution program adoption at local, state and national levels.

January 13, 2021

COVID-19 has united patients and providers against institutional betrayal in health care: a battle to be heard, believed, and protected.

August 19, 2020

Impact of providing patients access to electronic health records on quality and safety of care: a systematic review and meta-analysis.

July 8, 2020

Apology laws and malpractice liability: what have we learned?

July 8, 2020

The views and experiences of patients and health-care professionals on the disclosure of adverse events: a systematic review and qualitative meta-ethnographic synthesis.

April 8, 2020

Whistleblowing over patient safety and care quality: a review of the literature.

November 13, 2019

Medical error in the care of the unrepresented: disclosure and apology for a vulnerable patient population.

September 25, 2019

Individual and team-based medical error disclosure: dialectical tensions among health care providers.

August 28, 2019

Failure to report poor care as a breach of moral and professional expectation.

June 19, 2019

Interview

In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD

April 1, 2019

Interview

In Conversation With… Susan Haas, MD, MSc

March 1, 2019

Three laws for paperlessness.

February 20, 2019

Drs Bramhall and Bawa-Garba and the rightful domain of the criminal law.

February 20, 2019

Taking the blame: appropriate responses to medical error.

January 30, 2019

"Saying sorry": some strategies for effective apology within the workplace.

January 23, 2019

Can communication-and-resolution programs achieve their potential? Five key questions.

December 19, 2018

Holding out for an apology.

December 5, 2018

Mistakes were made (by me).

September 13, 2017

Just Culture: Restoring Trust and Accountability in Your Organization, Third Edition.

March 5, 2017

Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis.

December 21, 2016

See More About The Topic

Organizational Behaviorists

Psychological and Social Complications

Legal and Policy Approaches

Patient Disclosure

Social aspects of clinical errors: a discussion paper.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Social aspects of clinical errors: a discussion paper.

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