Who is in charge of patient safety? Work practice, work processes and utopian views of automatic drug dispensing systems.

Ellen Balka; Nicki Kahnamoui; Kelsey Nutland

Commentary

Who is in charge of patient safety? Work practice, work processes and utopian views of automatic drug dispensing systems.

October 11, 2006

Balka E, Kahnamoui N, Nutland K. Int J Med Inform. 2007;76 Suppl 1:S48-57.

View more articles from the same authors.

The authors describe one hospital's implementation of an automatic drug dispensing system (ADS) and discuss the importance of recognizing social context when implementing ADS to minimize unintended consequences.

PubMed citation

Available at

Related Resources From the Same Author(s)

Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case studies.

February 12, 2014

Technology, governance and patient safety: systems issues in technology and patient safety.

October 11, 2006

Adverse drug event reporting systems: a systematic review.

September 14, 2016

Use of a computerized forcing function improves performance in ordering restraints.

August 6, 2008

Health disparities: impact of health disparities and treatment decision-making biases on cancer adverse effects among black cancer survivors.

November 10, 2021

Clinicians' insights on emergency department boarding: an explanatory mixed methods study evaluating patient care and clinician well-being.

August 23, 2023

Overreaction.

November 4, 2015

The pursuit of perfection: hospitals take heightened actions to reduce adverse events.

April 11, 2012

Safety in fragile, conflict-affected, and vulnerable settings: An evidence scanning approach for identifying patient safety interventions.

March 30, 2022

Adverse events and hospital-acquired conditions associated with potential low-value care in Medicare beneficiaries.

August 11, 2021

Five reasons for optimism on World Patient Safety Day.

October 23, 2019

Unacceptable behaviours between healthcare workers: just the tip of the patient safety iceberg.

June 15, 2022

DEEP SCOPE: a framework for safe healthcare design.

October 13, 2021

Roadmap for patient safety research: approaches and roadforks.

December 3, 2008

Bringing perioperative emergency manuals to your institution: a "How To" from concept to implementation in 10 steps.

April 3, 2019

Interruption handling strategies during paediatric medication administration.

August 29, 2012

Safety-I, Safety-II and resilience engineering.

November 6, 2015

'Doing the best we can': Registered nurses' experiences and perceptions of patient safety in intensive care during COVID-19.

September 7, 2022

Sustained impact of a pediatric resident-led patient safety council.

August 1, 2018

Improving standardization of paging communication using quality improvement methodology.

April 10, 2019

Using simulation to improve systems.

September 27, 2017

Psychosocial factors and safety in high-risk industries: a systematic literature review.

November 30, 2022

Disparities in patient safety voluntary event reporting: a scoping review.

December 20, 2023

Enhancing safety culture through improved incident reporting: a case study in translational research.

December 12, 2018

Performance-based payment incentives increase burden and blame for hospital nurses.

February 16, 2011

Medication dose calculation errors and other numeracy mishaps in hospitals: analysis of the nature and enablers of incident reports.

November 10, 2021

Minimizing surgical error by incorporating objective assessment into surgical education.

September 3, 2008

Using Six Sigma to reduce medication errors in a home-delivery pharmacy service.

June 1, 2005

Strategies to enhance adoption of ventilator-associated pneumonia prevention interventions: a systematic literature review.

August 6, 2014

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

June 6, 2018

Utilization of pharmacy technicians to increase the accuracy of patient medication histories obtained in the emergency department.

July 13, 2016

Can mindfulness in health care professionals improve patient care? An integrative review and proposed model.

June 12, 2019

Creating a safer health care system: finding the constraint.

December 21, 2005

Revitalizing an established rapid response team.

May 14, 2008

A review of the literature examining linkages between organizational factors, medical errors, and patient safety.

March 6, 2005

Assessment of overuse of medical tests and treatments at US hospitals using Medicare claims.

May 19, 2021

Assessment of patients' ability to review electronic health record information to identify potential errors: cross-sectional web-based survey.

March 10, 2021

Use and impact of virtual primary care on quality and safety: the public's perspectives during the COVID-19 pandemic.

January 12, 2022

Teaching quality improvement.

September 22, 2010

Why worry? Worry, risk perceptions, and willingness to act to reduce medical errors.

April 19, 2006

Can patients be part of the solution? Views on their role in preventing medical errors.

October 12, 2005

The relationship between professional burnout and quality and safety in healthcare: a meta-analysis.

April 19, 2017

Rolling out the rapid response team.

June 1, 2011

Epidemiology of and risk factors for harmful anti-infective medication errors in a pediatric hospital.

September 19, 2018

The relationship between registered nurses and nursing home quality: an integrative review (2008–2014).

November 18, 2015

Changes to supervision in community pharmacy: pharmacist and pharmacy support staff views.

June 26, 2013

Review: application of the Safety Attitudes Questionnaire (SAQ) in primary care - a systematic synthesis on validity, descriptive and comparative results, and variance across organisational units.

February 14, 2024

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

February 28, 2007

Opportunities for improvement in nursing homes: variance of six patient safety climate factor scores across nursing homes and wards—assessed by the Safety Attitudes Questionnaire.

July 17, 2019

The prescription opioid crisis: role of the anaesthesiologist in reducing opioid use and misuse.

July 24, 2019

Undertriage of elderly trauma patients to state-designated trauma centers.

October 8, 2008

The surgeon as the second victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) study.

March 22, 2017

Variation in surgical time-out and site marking within pediatric otolaryngology.

January 26, 2011

Explaining ethnic disparities in patient safety: a qualitative analysis.

March 3, 2010

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

August 12, 2015

Diagnostic error in pediatric cancer.

January 17, 2018

The association between patient-reported incidents in hospitals and estimated rates of patient harm.

January 14, 2015

Peer support by interprofessional health care providers in aftermath of patient safety incidents: a cross-sectional study.

June 9, 2021

Relevance of the Agency for Healthcare Research and Quality Patient Safety Indicators for children's hospitals.

March 6, 2005

Design and impact of a novel surgery-specific second victim peer support program.

January 29, 2020

Patient safety measures in burn care: do national reporting systems accurately reflect quality of burn care?

February 3, 2010

Results of a survey among GP practices on how they manage patient safety aspects related to point-of-care testing in every day practice.

April 22, 2015

Bridging the gap between hospital and primary care: the pharmacist home visit.

April 1, 2015

Patient–pharmacist communication during a post-discharge pharmacist home visit.

April 10, 2019

Missed diagnosis of cardiovascular disease in outpatient general medicine: insights from malpractice claims data.

August 16, 2017

Green Cross method in a postanaesthesia care unit: a qualitative study of the healthcare professionals' experiences after 3 years, including the COVID-19 pandemic period.

June 14, 2023

Common contributing factors of diagnostic error: a retrospective analysis of 109 serious adverse event reports from Dutch hospitals.

August 23, 2023

Disclosing adverse events to patients.

March 6, 2005

Structure and outcomes of interdisciplinary rounds in hospitalized medicine patients: a systematic review and suggested taxonomy.

September 28, 2016

A standardized handoff simulation promotes recovery from auditory distractions in resident physicians.

July 11, 2018

A contemporary medicolegal analysis of outpatient medication management in chronic pain.

November 8, 2017

An IDEA: safety training to improve critical thinking by individuals and teams.

April 10, 2019

The cost of opioid–related adverse drug events.

October 8, 2014

Confirming delivery: understanding the role of the hospitalized patient in medication administration safety.

May 28, 2014

The association between patient safety culture and adverse events - a scoping review.

May 17, 2023

High-risk medication in home care nursing: a Delphi study.

September 7, 2022

January 30, 2005

State legal restrictions and prescription-opioid use among disabled adults.

July 20, 2016

Wrong-site nerve blocks: a systematic literature review to guide principles for prevention.

August 8, 2018

Physician engagement in malpractice risk reduction: a UPHS case study.

August 29, 2018

The costs of developing, implementing, and operating a safety learning system in community practice.

December 11, 2013

Effectiveness of a course designed to teach handoffs to medical students.

September 8, 2010

Use of an appreciative inquiry approach to improve resident sign-out in an era of multiple shift changes.

January 25, 2012

A multidisciplinary, multifaceted improvement initiative to eliminate mislabelled laboratory specimens at a large tertiary care hospital.

July 9, 2014

Shift-to-shift handoff effects on patient safety and outcomes: a systematic review.

November 18, 2015

Factors that affect opioid quality improvement initiatives in primary care: insights from ten health systems.

December 14, 2022

Organisational factors associated with safety climate, patient satisfaction and self-reported medicines adherence in community pharmacies.

June 17, 2020

Identifying modifiable barriers to medication error reporting in the nursing home setting.

December 5, 2007

Duration of second victim symptoms in the aftermath of a patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands.

July 31, 2019

Impact of altering referral threshold from out-of-hours primary care to hospital on patient safety and further health service use: a cohort study.

January 11, 2023

Racial inequality in receipt of medications for opioid use disorder.

May 31, 2023

Bedside shift-to-shift handoffs: a systematic review of the literature.

August 26, 2015

Trends in opioid use in commercially insured and Medicare Advantage populations in 2007–16: retrospective cohort study.

August 29, 2018

Use of high-fidelity simulation to enhance interdisciplinary collaboration and reduce patient falls.

May 10, 2017

The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care.

March 21, 2012

Significant reduction in preanalytical errors for nonphlebotomy blood draws after implementation of a novel integrated specimen collection module.

December 14, 2016

Opioid prescribing for opioid-naive patients in emergency departments and other settings: characteristics of prescriptions and association with long-term use.

October 25, 2017

Incivility and patient safety: a longitudinal study of rudeness, protocol compliance, and adverse events.

April 10, 2019

Patient activation related to fall prevention: a multisite study

February 19, 2020

Estimation of breast cancer overdiagnosis in a U.S. breast screening cohort.

March 16, 2022

Related Resources

A "Do No Harm" novel safety checklist and research approach to determine whether to launch an artificial intelligence-based medical technology: introducing the Biological-Psychological, Economic, and Social (BPES) Framework.

July 5, 2023

Interview

In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Perspective

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

November 16, 2022

Interview

In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD

November 16, 2022

ASHP guidelines on the safe use of automated dispensing devices.

August 29, 2021

Crossing academic boundaries for diagnostic safety: 10 complex challenges and potential solutions from clinical perspectives and high-reliability organizing principles.

March 24, 2021

From fable to reality at Parkland Hospital: the impact of evidence-based design strategies on patient safety, healing, and satisfaction in an adult inpatient environment.

February 10, 2021

Patient Safety Primers

COVID-19: Team and Human Factors to Improve Safety

July 30, 2020

An integrative total worker health framework for keeping workers safe and healthy during the COVID-19 pandemic.

July 1, 2020

Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety.

September 11, 2019

Advances in Human Factors and Ergonomics in Healthcare and Medical Devices.

September 11, 2019

Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.

January 23, 2019

Understanding models of error and how they apply in clinical practice.

July 20, 2016

Human factors in healthcare: welcome progress, but still scratching the surface.

June 29, 2016

Adverse events in robotic surgery: a retrospective study of 14 years of FDA data.

June 8, 2016

The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study.

March 16, 2016

Debriefing in the emergency department after clinical events: a practical guide.

December 17, 2014

Changing our culture: adopting the military aviation safety system.

July 16, 2014

Sound the alarm.

June 25, 2014

Addressing the taboo of medical error through IGBOs: I got burnt once!

June 4, 2014

Redesigning hospital alarms for patient safety: alarmed and potentially dangerous.

March 12, 2014

A unified model of patient safety (or "Who froze my cheese?").

January 15, 2014

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

December 4, 2013

Using good design to eliminate medical errors.

November 20, 2013

Reasons for the persistence of adverse events in the era of safer surgery―a qualitative approach.

November 20, 2013

'Not another safety culture survey': using the Canadian patient safety climate survey (Can-PSCS) to measure provider perceptions of PSC across health settings.

November 13, 2013

The contribution of prescription chart design and familiarity to prescribing error: a prospective, randomised, cross-over study.

October 9, 2013

Spreading human factors expertise in healthcare: untangling the knots in people and systems.

October 9, 2013

Approaches to decreasing medication and other care errors in the ICU.

September 25, 2013

See More About The Topic

Quality and Safety Professionals

Organizational Behaviorists

Safety Scientists

Engineers

Automatic drug dispensers

Who is in charge of patient safety? Work practice, work processes and utopian views of automatic drug dispensing systems.

COVID-19: Team and Human Factors to Improve Safety

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Who is in charge of patient safety? Work practice, work processes and utopian views of automatic drug dispensing systems.

COVID-19: Team and Human Factors to Improve Safety

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