Technical rationality and the decentring of patients and care delivery: a critique of 'unavoidable' in the context of patient harm. | PSNet

Provide Feedback |

Submit a Case

Register

Commentary

Technical rationality and the decentring of patients and care delivery: a critique of 'unavoidable' in the context of patient harm.

July 25, 2018

Hutchinson M, Jackson D, Wilson S. Nurs Inq. 2018;25(2):e12225.

View more articles from the same authors.

Lack of consensus regarding whether some types of health care–acquired harm are unavoidable influences design and implementation of patient safety initiatives. This commentary spotlights concerns that normalizing harm as unavoidable can hinder investigation of incidents.

PubMed citation

Related Resources From the Same Author(s)

Towards international consensus on patient harm: perspectives on pressure injury policy.

June 8, 2016

A concept analysis of undergraduate nursing students speaking up for patient safety in the patient care environment.

August 3, 2016

Three missed critical nursing care processes on labor and delivery units during the COVID-19 pandemic.

May 31, 2023

An integrative review exploring the perceptions of patients and healthcare professionals towards patient involvement in promoting hand hygiene compliance in the hospital setting.

September 12, 2018

Intentional rounding—an integrative literature review.

August 7, 2019

The wicked problem of patient misidentification: how could the technological revolution help address patient safety?

May 1, 2019

Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration.

September 23, 2015

Medical device-related pressure ulcers: a systematic review and meta-analysis.

March 6, 2019

Hierarchy and medical error: speaking up when witnessing an error.

April 8, 2020

Nurse interrupted: development of a realistic medication administration simulation for undergraduate nurses.

August 26, 2015

Exploring leadership within a systems approach to reduce health care–associated infections: a scoping review of one work system model.

April 17, 2019

Understanding whistleblowing: qualitative insights from nurse whistleblowers.

September 29, 2010

The role of feedback in emergency ambulance services: a qualitative interview study.

April 6, 2022

Residents' perspective on the impact of the 80-hour workweek policy.

June 11, 2008

Reducing medication errors by using applied technology.

August 23, 2006

We're all in this together: how COVID-19 revealed the co-construction of mindful organising and organisational reliability.

February 9, 2022

Diagnostic overshadowing in dentistry.

September 11, 2019

Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement.

December 14, 2022

Nurses' role in medication safety.

November 3, 2010

Barriers and enablers to nurses' use of harm prevention strategies for older patients in hospital: a cross-sectional survey.

May 11, 2022

Accidents, claiming, and regional subcultures: are medical errors and malpractice lawsuits related to social capital?

July 9, 2008

Communicating, coordinating, and cooperating when lives depend on it: tips for teamwork.

May 28, 2008

Patient perceptions of deterioration and patient and family activated escalation systems—a qualitative study.

April 4, 2018

Rapid response teams: what's the latest?

March 14, 2018

Surgical site verification: A through Z.

November 22, 2006

Promoting health care safety through training high reliability teams.

August 24, 2005

Evidence summary and recommendations for improved communication during care transitions.

June 8, 2016

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

October 17, 2018

Interprofessional education in team communication: working together to improve patient safety.

March 27, 2013

The right and wrong way to talk to patients about adverse events.

June 25, 2014

Safety during night shifts: a cross-sectional survey of junior doctors' preparation and practice.

October 23, 2013

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

July 4, 2007

Effect of social influences on pharmacists' intention to report adverse drug events.

October 17, 2012

A strategic approach for managing conflict in hospitals: responding to The Joint Commission leadership standard—part 1 and part 2.

January 26, 2011

Using simulation training to improve perioperative patient safety.

April 17, 2013

Bullying: a hidden threat to patient safety.

May 28, 2014

Nurses' perceptions and experiences of communication in the operating theatre: a focus group interview.

February 22, 2006

Keeping an eye on patient safety using human factors engineering (HFE): a family affair for the hospitalized child.

February 3, 2010

Resident and family engagement in medication management in aged care facilities: a systematic review.

July 7, 2021

Nurses' harm prevention practices during admission of an older person to the hospital: a multi-method qualitative study.

August 10, 2022

Nursing guidelines for comprehensive harm prevention strategies for adult patients in acute hospitals: an integrative review and synthesis.

February 23, 2022

How long does it take to train a surgeon?

November 18, 2009

Hospital safety climate surveys: measurement issues.

October 20, 2010

Adverse event rates as measures of hospital performance.

September 21, 2011

Impact of hospital accreditation on quality improvement in healthcare: a systematic review.

January 17, 2024

Signal and noise: applying a laboratory trigger tool to identify adverse drug events among primary care patients.

August 1, 2012

Measuring safety in older adult care homes: a scoping review of the international literature.

May 19, 2021

Home health agency patient experience measures and their relationship to Joint Commission accreditation.

June 7, 2023

Prevalence and characteristics of interruptions and distractions during surgical counts.

July 28, 2021

Predictors of medication errors among elderly hospital patients.

March 19, 2008

Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm.

November 16, 2022

Patient perspectives of patient–provider communication after adverse events.

August 10, 2005

The development of a patient safety program across the continuum of care.

November 16, 2005

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

December 4, 2013

Use of an audit with feedback implementation strategy to promote medication error reporting by nurses.

November 25, 2020

Interruptions and medication administration in critical care.

July 29, 2015

Just culture: the foundation of staff safety in the perioperative environment.

May 12, 2021

Prevalence and sources of duplicate information in the electronic medical record.

October 12, 2022

Rural inpatient telepharmacy consultation demonstration for after-hours medication review.

October 3, 2012

The effect of collaboration on obstetric patient safety in three academic facilities.

December 4, 2013

Patient safety climate strength: a concept that requires more attention.

August 31, 2016

Examining the diagnostic justification abilities of fourth-year medical students.

November 7, 2012

Error training: missing link in surgical education.

April 11, 2012

Sample to sample carryover: a source of analytical laboratory error and its relevance to integrated clinical chemistry/immunoassay systems.

July 5, 2006

Path to safety: benefits of the 2005 Patient Safety and Quality Improvement Act.

June 28, 2006

One intensive care nursery's experience with enhancing patient safety.

June 28, 2006

A realist synthesis of pharmacist-conducted medication reviews in primary care after leaving hospital: what works for whom and why?

December 2, 2020

Measuring team hierarchy during high-stakes clinical decision making: development and validation of a new behavioral observation method.

April 12, 2023

Measurement of adverse events using "incidence flagged" diagnosis codes.

February 8, 2006

The incidence and cost of adverse events in Victorian hospitals 2003-04.

June 28, 2006

Emotional impact of patient safety incidents on family physicians and their office staff.

March 21, 2012

Requirements for implementing a 'just culture' within healthcare organisations: an integrative review.

June 21, 2023

Characteristics of unsafe undergraduate nursing students in clinical practice: an integrative literature review.

January 30, 2005

Nurses' knowledge and teaching of possible postpartum complications.

August 30, 2017

Patient safety education: what was, what is, and what will be?

December 18, 2013

Cultural diversity: what role does it play in patient safety?

August 25, 2010

Role of nursing home quality on COVID-19 cases and deaths: evidence from Florida nursing homes.

September 22, 2021

Problems and solutions arising during a study in visual semantics of the medical emergency team system.

September 10, 2008

How is medication prescribing ceased? A systematic review.

November 24, 2010

Surrogate decision makers' perspectives on preventable breakdowns in care among critically ill patients: a qualitative study.

May 25, 2016

Racial/ethnic inequities in pregnancy-related morbidity and mortality.

March 10, 2021

What are the critical success factors for team training in health care?

August 5, 2009

Clinical deterioration and hospital‐acquired complications in adult patients with isolation precautions for infection control: a systematic review.

October 14, 2020

Reporting of Clinical Adverse Events Scale: a measure of doctor and nurse attitudes to adverse event reporting.

October 22, 2008

Year 1 medical undergraduates' knowledge of and attitudes to medical error.

December 16, 2009

Case report of a medication error: in the eye of the beholder.

August 31, 2016

Operational rounds: a practical administrative process to improve safety and clinical services in radiology.

November 26, 2008

A concept analysis of systems thinking.

January 18, 2017

Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: a systematic review.

June 1, 2016

Trainee autonomy and patient safety.

December 6, 2017

Development and implementation of a pediatric patient safety program.

June 21, 2006

Driving improvement in patient care: lessons from Toyota.

March 6, 2005

An ethical framework for allocating scarce life-saving chemotherapy and supportive care drugs for childhood cancer.

February 17, 2016

Assessment of fidelity in interventions to improve hand hygiene of healthcare workers: a systematic review.

March 16, 2016

Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists.

October 31, 2007

Surgical safety checklists: do they improve outcomes?

June 20, 2012

Realizing e-prescribing's potential to reduce outpatient psychiatric medication errors.

January 31, 2018

Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta-analysis.

July 12, 2023

The safety of Australian healthcare: 10 years after QAHCS.

April 15, 2005

Pursuing professional accountability: an evidence-based approach to addressing residents with behavioral problems.

August 1, 2012

View More

Related Resources

Towards a unified model of accident causation: refining and validating the systems thinking safety tenets.

May 10, 2023

Speaking up as an extension of socio-cultural dynamics in hospital settings: a study of staff experiences of speaking up across seven hospitals.

February 22, 2023

An evidence and consensus-based definition of second victim: a strategic topic in healthcare quality, patient safety, person-centeredness and human resource management.

February 15, 2023

Medication-related medical emergency team activations: a case review study of frequency and preventability.

July 20, 2022

Leadership: an effective human factor during COVID-19.

September 1, 2021

Planning for a pandemic: mitigating risk to radiation therapy service delivery in the COVID-19 era.

July 22, 2020

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

June 19, 2019

Understanding the healthcare workplace learning culture through safety and dignity narratives: a UK qualitative study of multiple stakeholders' perspectives.

June 12, 2019

Ten principles for more conservative, care-full diagnosis.

October 10, 2018

Does the perception of severity of medical error differ between varying levels of clinical seniority?

October 3, 2018

Active-shooter response at a health care facility.

September 19, 2018

Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews.

September 19, 2018

Using co-design to develop a collective leadership intervention for healthcare teams to improve safety culture.

September 12, 2018

Reframing and addressing horizontal violence as a workplace quality improvement concern.

August 22, 2018

Measurement of harms in community care: a qualitative study of use of the NHS Safety Thermometer.

August 1, 2018

A multi-stakeholder consensus-driven research agenda for better understanding and supporting the emotional impact of harmful events on patients and families.

July 11, 2018

Interventions to improve employee health and well-being within health care organizations: a systematic review.

June 20, 2018

A piece of my mind. The art of constructive worrying.

June 20, 2018

Focus on the Quadruple Aim: development of a resiliency center to promote faculty and staff wellness initiatives.

June 6, 2018

Resolving the productivity paradox of health information technology: a time for optimism.

June 6, 2018

Clinicians' perceptions of medication errors with opioids in cancer and palliative care services: a priority setting report.

May 30, 2018

Governing the quality and safety of healthcare: a conceptual framework.

May 30, 2018

Workplace bullying in risk and safety professionals.

May 30, 2018

Physician resiliency and wellness for transforming a health system.

May 30, 2018

Disruptive physician behavior: the importance of recognition and intervention and its impact on patient safety.

May 16, 2018

Serious incidents after death: content analysis of incidents reported to a national database.

May 16, 2018

'Broken hospital windows': debating the theory of spreading disorder and its application to healthcare organizations.

May 9, 2018

Leadership Survey: Immunization Against Burnout: Insights Report.

May 9, 2018

Physician burnout in the electronic health record era: are we ignoring the real cause?

May 9, 2018

A framework for operationalizing risk: a practical approach to patient safety.

May 2, 2018

View More

See More About The Topic

Facility and Group Administrators

Psychological and Social Complications

Epidemiology of Errors and Adverse Events

To sign up for updates or to access your subscriber preferences, please enter your email address below.

5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364