Toward a theoretical approach to medical error reporting system research and design.

Ben-Tzion Karsh; Kamisha Hamilton Escoto; John W. Beasley; Richard J. Holden

Study

Toward a theoretical approach to medical error reporting system research and design.

October 12, 2005

Karsh B-T, Escoto KH, Beasley JW, et al. Appl Ergon. 2006;37(3):283-95.

View more articles from the same authors.

The authors integrate multiple theories to construct a reporting system model that manages barriers to and facilitates implementation.

PubMed citation

Available at

Related Resources From the Same Author(s)

A review of medical error reporting system design considerations and a proposed cross-level systems research framework.

April 4, 2007

Value of human factors to medication and patient safety in the intensive care unit.

July 7, 2010

Effects of mental demands during dispensing on perceived medication safety and employee well-being: a study of workload in pediatric hospital pharmacies.

May 5, 2010

Information chaos in primary care: implications for physician performance and patient safety.

November 30, 2011

Self-reported violations during medication administration in two paediatric hospitals.

May 16, 2012

Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety.

May 14, 2008

The science of human factors: separating fact from fiction.

May 22, 2013

A typology of electronic health record workarounds in small-to-medium size primary care practices.

August 21, 2013

Using a multi-method, user centred, prospective hazard analysis to assess care quality and patient safety in a care pathway.

July 4, 2007

A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions.

February 28, 2007

A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life.

February 2, 2011

A human factors engineering paradigm for patient safety: designing to support the performance of the healthcare professional.

December 20, 2006

Physicians' beliefs about using EMR and CPOE: in pursuit of a contextualized understanding of health IT use behavior.

February 3, 2010

Cognitive performance-altering effects of electronic medical records: an application of the human factors paradigm for patient safety.

January 30, 2005

What stands in the way of technology-mediated patient safety improvements? A study of facilitators and barriers to physicians' use of electronic health records.

December 21, 2011

Texting while doctoring: a patient safety hazard.

December 18, 2013

Interruptions in the wild: development of a sociotechnical systems model of interruptions in the emergency department through a systematic review.

October 28, 2015

SEIPS 101 and seven simple SEIPS tools.

June 9, 2021

Patient safety professionals as the third victims of adverse events.

June 26, 2019

Associations between self-reported healthcare disruption due to COVID-19 and avoidable hospital admission: evidence from seven linked longitudinal studies for England.

August 9, 2023

Hospital at night: an organizational design that provides safer care at night.

August 10, 2016

Interruptions and distractions in healthcare: review and reappraisal.

May 12, 2010

Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospitals.

December 20, 2017

Human factors systems approach to healthcare quality and patient safety.

August 14, 2013

Concordance with urgent referral guidelines in patients presenting with any of six ‘alarm’ features of possible cancer: a retrospective cohort study using linked primary care records.

August 10, 2022

How to avoid the 'seven deadly sins of surgery.'

March 14, 2012

SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients.

October 3, 2013

Meaningful use's benefits and burdens for US family physicians.

May 30, 2018

Reducing the risk of adverse drug events in older adults.

April 17, 2013

The electronic prescribing of subcutaneous infusions: a before-and-after study assessing the impact upon patient safety and service efficiency.

June 15, 2022

Creating a just culture: the Ottawa Hospital's experience.

August 21, 2019

eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.

June 16, 2021

Patient Safety Innovations

eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.

April 7, 2022

Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: business case for quality improvement.

October 13, 2010

Effect of short-term pretrial practice on surgical proficiency in simulated environments: a randomized trial of the "preoperative warm-up" effect.

February 18, 2009

The Quality in Australian Health Care Study.

March 27, 2005

Fallacious reasoning and complexity as root causes of clinical inertia.

August 29, 2007

Concerns regarding tablet splitting: a systematic review.

December 7, 2022

When should a multicampus hospital be considered a single entity for public reporting on patient safety issues?

June 6, 2007

The thinking doctor: clinical decision making in contemporary medicine.

August 31, 2016

Technology induced error and usability: the relationship between usability problems and prescription errors when using a handheld application.

September 7, 2005

Usability and feasibility of consumer-facing technology to reduce unsafe medication use by older adults.

May 22, 2019

Beam me up Scotty! Impact of personal wireless communication devices in the emergency department.

November 24, 2010

Variation in quality of urgent health care provided during commercial virtual visits.

April 20, 2016

Handoffs and communication: the underappreciated roles of situational awareness and inattentional blindness.

September 1, 2010

John M. Eisenberg Patient Safety Awards. Safety, effectiveness, and efficiency: a Web-based virtual anticoagulation clinic.

March 6, 2005

Insulin pump risks and benefits: a clinical appraisal of pump safety standards, adverse event reporting, and research needs: a joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group.

May 6, 2015

Adoption of National Quality Forum safe practices by magnet hospitals.

October 19, 2011

Disclosing errors and adverse events in the intensive care unit.

April 5, 2006

Patient–doctor continuity and diagnosis of cancer: electronic medical records study in general practice.

May 13, 2015

Reducing delay in diagnosis: multistage recommendation tracking.

December 6, 2017

Novel telephone-based interactive voice response system for incident reporting.

November 17, 2021

Communication and collaboration: it's about the pharmacists, as well as the physicians and nurses.

February 17, 2010

Patient safety climate in primary care: age matters.

March 18, 2009

The effectiveness of interruptive prescribing alerts in ambulatory CPOE to change prescriber behaviour and improve safety.

May 5, 2021

A report of information technology and health deficiencies in U.S. nursing homes.

September 8, 2021

Winning the battle for standardization.

November 7, 2007

Unfinished nursing care, missed care, and implicitly rationed care: state of the science review.

April 8, 2015

Provider and pharmacist responses to warfarin drug–drug interaction alerts: a study of healthcare downstream of CPOE alerts.

January 30, 2005

Effect of pharmacists on medication errors in an emergency department.

February 27, 2008

Error disclosure: a new domain for safety culture assessment.

May 23, 2012

Methods used to obtain pediatric patient weights, their accuracy and associated drug dosing errors in 142 simulated prehospital pediatric patient encounters.

August 25, 2021

Who makes prescribing decisions in hospital inpatients? An observational study.

May 30, 2012

Association between limiting the number of open records in a tele-critical care setting and retract-reorder errors.

July 21, 2021

Preventing diagnostic errors in primary care.

October 12, 2016

Checklists to prevent diagnostic errors: a pilot randomized controlled trial.

July 8, 2015

Medication errors involving pediatric patients.

June 8, 2005

Errors prevented by and associated with bar-code medication administration systems.

May 2, 2007

MRSA Infections.

November 7, 2007

Patient perspectives on test result communication in primary care: a qualitative study.

April 29, 2015

Patient reports of preventable problems and harms in primary health care.

March 6, 2005

American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology.

December 7, 2005

The value of inking breast cores to reduce specimen mix-up.

January 24, 2007

Risk of adverse drug events by patient destination after hospital discharge.

September 21, 2005

Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase.

February 23, 2011

Medication errors resulting from computer entry by nonprescribers.

May 6, 2009

Dosing errors made by paramedics during pediatric patient simulations after implementation of a state-wide pediatric drug dosing reference.

July 24, 2019

Intralipid medication errors in the neonatal intensive care unit.

February 14, 2007

Adverse drug event reporting in intensive care units: a survey of current practices.

August 2, 2006

Contextual errors and failures in individualizing patient care: a multicenter study.

August 4, 2010

Costs and benefits of an early-alert surveillance system for hospital inpatients.

February 28, 2007

Deploying Six Sigma in a health care system as a work in progress.

November 2, 2005

Getting the whole story: integrating patient complaints and staff reports of unsafe care.

July 28, 2021

Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative exploration of patient and provider perspectives.

September 9, 2015

Test result communication in primary care: a survey of current practice.

August 19, 2015

The safety stand-down: a technique for improving and sustaining hand hygiene compliance among health care personnel.

June 27, 2018

Evaluating service delivery interventions to enhance patient safety.

January 14, 2009

Do professionalism lapses in medical school predict problems in residency and clinical practice?

June 17, 2020

Expanding what we know about off-peak mortality in hospitals.

May 26, 2010

Comorbid conditions delay diagnosis of colorectal cancer: a cohort study using electronic primary care records.

July 26, 2017

Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system.

January 27, 2016

Effect of illness severity and comorbidity on patient safety and adverse events.

November 9, 2011

From the flight deck to the operating room: an initial pilot study of the feasibility and potential impact of true interdisciplinary team training using high-fidelity simulation.

January 2, 2008

Work system design for patient safety: the SEIPS model.

October 12, 2011

Identifying hospital-wide harm: a set of ICD-9–CM-coded conditions associated with increased cost, length of stay, and risk of mortality.

December 17, 2014

Checklists to reduce diagnostic errors.

February 9, 2011

The impact of abbreviations on patient safety.

September 5, 2007

Using nurses and office staff to report prescribing errors in primary care.

May 7, 2008

Academic detailing to improve laboratory testing among outpatient medication users.

October 17, 2007

Relationship between preventability of death after coronary artery bypass graft surgery and all-cause risk-adjusted mortality rates.

July 9, 2008

Related Resources

Hospital Reporting Program: Annual Summary.

December 27, 2023

Serious Reportable Events in Massachusetts.

May 22, 2023

Patient Safety Authority Annual Reports.

May 1, 2023

Access to Clinical Information at the Bedside.

March 1, 2023

Inequity and Iatrogenic Harm.

August 31, 2022

4 actions to reduce medical errors in U.S. hospitals.

May 25, 2022

Leveraging a safety event management system to improve organizational learning and safety culture.

March 30, 2022

Family Input for Quality and Safety (FIQS): using mobile technology for in-hospital reporting from families and patients.

March 2, 2022

Harnessing event report data to identify diagnostic error during the COVID-19 pandemic.

December 15, 2021

Novel telephone-based interactive voice response system for incident reporting.

November 17, 2021

Algorithmic Bias Playbook.

June 30, 2021

Transformational improvement in quality care and health systems: the next decade.

November 25, 2020

Integrating adverse event reporting into a free-text mobile application used in daily workflow increases adverse event reporting by physicians.

January 8, 2020

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

November 13, 2019

Effect of an Electronic Medication Reconciliation Intervention on Adverse Drug Events: A Cluster Randomized Trial

October 16, 2019

A culture of openness is associated with lower mortality rates among 137 English National Health Service acute trusts.

May 22, 2019

NHS Improvement.

May 18, 2019

Americans' growing exposure to clinician quality information: insights and implications.

March 20, 2019

Healthcare scandals and the failings of doctors: do official inquiries hold the profession to account?

March 20, 2019

Improving Usability, Safety and Patient Outcomes With Health Information Technology.

February 27, 2019

Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety.

November 7, 2018

Introduction of a mobile adverse event reporting system is associated with participation in adverse event reporting.

July 25, 2018

Collaboration with regulators to support quality and accountability following medical errors: the communication and resolution program certification pilot.

September 21, 2016

The aging surgeon.

September 7, 2016

Electronic approaches to making sense of the text in the adverse event reporting system.

September 7, 2016

ACOG Committee Opinion #621: patient safety and health information technology.

April 1, 2015

Hospital patient safety grades may misrepresent hospital performance.

February 12, 2014

Conversations with...Lucian Leape, MD.

July 17, 2013

Slow progress on meeting hospital safety standards: learning from the Leapfrog Group's efforts.

January 23, 2013

National and local medication error reporting systems—a survey of practices in 16 countries.

December 5, 2012

See More About The Topic

Health Care Executives and Administrators

Policy Makers

Error Reporting

Technologic Approaches

Toward a theoretical approach to medical error reporting system research and design.

eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Toward a theoretical approach to medical error reporting system research and design.

eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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