A Model for Risk Assessment in Health Care Using a Health Care Failure Method and Effect Analysis

1. World Health Organization. Conceptual Framework for the International Classification for Patient Safety Version 1.1, 2009. Available Feb 10, 2013 from: http://www.who.int/patientsafety/taxonomy/icps_full_report.pdf.Search in Google Scholar

2. Kohn LT, Corrigan JM, Donaldson MS. To err Is human: building a safer health system. Washington DC: National Academy Press, 2000.Search in Google Scholar

3. De Rosier J, Stalhandske E, Bagian JP, Nudell T. Using health care failure: mode and effect analysis. The VA National Center for Patient Safety’s Prospective Risk Analysis System. JCJQI 2002; 27: 248-267.Search in Google Scholar

4. Council of Europe. Recommendation Rec (2006) of the Committee of Ministers to member states on management of patient safety and prevention of adverse events in health care. Available Jan 09, 2013 from: https://wcd.coe.int/ViewDoc.jsp?id=1005439&Site=CM.Search in Google Scholar

5. Robida A. (prev). Konceptualni okvir za mednarodno klasifikacijo za varnost pacientov: končno tehnično poročilo. Ljubljana: Ministrstvo za zdravje, 2010.Search in Google Scholar

6. Kiauta M, Poldrugovac M, Rems M, Robida A, Simčič B, Miholič P. (ur). Nacionalna strategija kakovosti in varnosti v zdravstvu (2010 - 2015). Ljubljana: Ministrstvo za zdravje, 2010.Search in Google Scholar

7. Joint Commission. Patient safety. Available Jan 07, 2013 from: http://www.jointcommission.org/topics/patient_safety.aspx.Search in Google Scholar

8. Robida, A. Pot do odlične zdravstvene prakse: vodnik za izboljševanje kakovosti in presojo lastne zdravstvene prakse. 1. natis. Ljubljana: Planet GV, 2009.Search in Google Scholar

9. Zhang J, Patel VL, Johnson TR. Medical error: is the solution medical or cognitive? JAMIA 2002; 9 (Suppl 1): S75-S77.10.1197/jamia.M1232Search in Google Scholar

10. Ministrstvo za zdravje. Priporočilo Rec (2006) Obora ministrov državam članicam o ravnanju z varnostjo pacientov in preprečevanju neželenih dogodkov v zdravstvu, 2006. Available Jan 02, 2013 from: http://www.mz.gov.si/fileadmin/mz.gov.si/pageuploads/mz_dokumenti/delovna_podrocja/zdravstveno_varstvo/kakovost/VARNOST/SEVarnost_Pacientov_2007.pdf.Search in Google Scholar

11. Benner P, Sheets V, Uris P, Malloch K, Schwed K, Jamison D. Individual, practice, and system causes of errors in nursing: a taxonomy. J Nurs Admin 2002; 32: 509-523.10.1097/00005110-200210000-00006Search in Google Scholar

12. Potter P, Wolf L, Boxerman S, Grayson D, Sledge J, Dunagan C. Understanding the cognitive work of nursing in the acute care environment. J Nurs Admin 2005; 35: 327-335.10.1097/00005110-200507000-00004Search in Google Scholar

13. Flin R. Measuring safety culture in healthcare: a case for accurate diagnosis. Safety Sci 2007; 45: 653-667.10.1016/j.ssci.2007.04.003Search in Google Scholar

14. Portwood B, Reising L. Root cause analysis and quantitative methods - Yin and Yang? 2007. Available Jan 17, 2013 from: http://www.realitycharting.com/_public/site/files/pdf/RCA-and-Quantitative-Methods.pdf.Search in Google Scholar

15. Dimenstein I.B. Root cause analysis of specimen misidentification in surgical pathology accession and grossing. LabMed 2008; 39: 497-502.Search in Google Scholar

16. Karl R, Karl MC. Adverse events: root causes and latent factors. Surg Clin North Am 2012; 92: 89-100.10.1016/j.suc.2011.12.003Search in Google Scholar

17. Agrawal A. Counting matters: lessons from the root cause analysis of a retained surgical item. Jt Comm J Qual Patient Saf 2012; 38: 566-574.10.1016/S1553-7250(12)38074-4Search in Google Scholar

18. Middleton S, Chapman B, Griffiths R, Chester R. Reviewing recommendations of root cause analyses. Aust Health Rev 2007; 31: 288-295.10.1071/AH07028817470051Search in Google Scholar

19. DeMarco T. Structured analysis and system specification. NJ, USA: Prentice Hall PTR Upper Saddle River, 1979.Search in Google Scholar

20. Abrahamsson P, Salo O, Ronkainen J, Warsta J. Agile software development methods: review and analysis. Finland: VTT Publications 478, 2002.Search in Google Scholar

21. Aspden P, Wolcott JA, Bootman JL, Cronenwett LR. Preventing medical errors. Washington DC: National Academy Press, 2006:108-118.Search in Google Scholar

22. Poon EG, Keohane CA, Yoon CS, Ditmore M, Bane A, Levtzion- Korach O, et al. Effect of bar-code technology on the safety of medication administration. NEJM 2010; 362:1698-1707.10.1056/NEJMsa090711520445181Search in Google Scholar

23. Young J, Slebodnik M, Sands L. Bar code technology and medication administration error. J Patient Safety 2010; 6:115-120.10.1097/PTS.0b013e3181de35f722130354Search in Google Scholar

24. NCC MERP - National Coordinating Council for Medication Errors Reporting and Prevention. Taxonomy of Medication Errors, 2011. Available Jan 17, 2013 from: http://www.nccmerp.org/medErrorTaxonomy.html.Search in Google Scholar

25. Tam V, Knowles S, Cornish P, Fine N, Marchesano R, Etchells E. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ 2005; 173: 510-515.10.1503/cmaj.045311118819016129874Search in Google Scholar

26. Nerat T, Kos M. Analiza neprimernega predpisovanja zdravil starostnikom v Sloveniji na podlagi Beersovih in Larochevih meril. Zdrav Var 2011; 50: 34-44.Search in Google Scholar

27. Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA 1995; 274: 35-43.10.1001/jama.1995.03530010049034Search in Google Scholar

28. Phillips J, Beam S, Brinker A, Holquist C, Honig P, Lee LY, et al. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm 2001; 58: 1835-1841.10.1093/ajhp/58.19.183511596700Search in Google Scholar

29. Grasso BC, Genest R, Jordan CW, Bates DW. Use of chart and record reviews to detect medication errors in a state psychiatric hospital. Psychiatr Serv 2003; 54: 677-681.10.1176/appi.ps.54.5.67712719497Search in Google Scholar

30. Balas MC, Scott LD, Rogers AE. The prevalence and nature of errors reported by hospital staff nurses. Appl Nurs Res 2004;17: 224-230.10.1016/j.apnr.2004.09.00215573330Search in Google Scholar

31. Massachusetts Nurses Association. Position on Medication Error, 2011. Available Jan 17, 2013 from: http://www.massnurses.org/nursing-resources/position-statements/mederrors.Search in Google Scholar

32. Prijatelj V. Organizational information model for preventing errors in the process of nursing (PhD dissertation). Kranj: University of Maribor, 2012.Search in Google Scholar

33. Toussaint PJ, Verhoef J, Vliet Vlieland TP, Zwetsloot-Schonk JH. The impact of ICT on communication in healthcare. Stud Health Technol Inform 2004; 107: 988-991.Search in Google Scholar

34. Georgiou A, Westbrook J, Braithwaite J, Iedema R, Ray S, Forsyth R, Dimos A, Germanos T. When requests become orders a formative investigation into the impact of a computerized physician order entry system on a pathology laboratory service. Int J Med Inform 2007; 76: 583-591.10.1016/j.ijmedinf.2006.04.00216702022Search in Google Scholar

35. Ammenwerth E, Schnell-Inderst P, Machan C, Siebert U. The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. JAMIA 2008 ;15: 585-600.10.1197/jamia.M2667252804018579832Search in Google Scholar

36. Julie Li. A Sociotechnical approach to evaluating the impact of ICT on clinical care environments. Open Med Inform J 2010; 4: 202-205.10.2174/1874431101004010202309688221594005Search in Google Scholar