Medication error trends and effects of person-related, environment-related and communication-related factors on medication errors in a paediatric hospital
2019
Journal of Paediatrics and Child Health
Journal Article
Issue 3
Volume 55
Pages 320-326
Author(s): Manias, E., Cranswick, N., Newall, F., Rosenfeld, E., Weiner, C., Williams, A., Wong, I. C. K., Borrott, N., Lai, J., Kinney, S.
Previous studies have found that children receiving care in pediatric facilities can face a high risk of medication errors due to a combination of person-related, communication-related, or environment-related factors. This study further examines how environment-related factors specifically influence medication errors.
Added November 2019
A Novel ICU Hand-Over Tool: The Glass Door of the Patient Room
2017
Journal of Intensive Care Medicine
Journal Article
Issue 8
Volume 32
Pages 514-519
Author(s): Wessman, B. T., Sona, C., Schallom, M.
The Institute of Medicine has identified poor communication among the patient care team as one of the most common causes of serious errors in patient care. There was a desire in this organization to create a culture of team-oriented continuity of care by changing the mindset of handoff reporting to handover reporting communication among multidisciplinary care team members on key aspects of the patient’s daily plan of care. They developed a communication tool that included key areas of care (tests, care goals and progress toward those goals, treatments, and consultation recommendations) and printed the topic areas on the glass door of the patient room. The information was updated regularly throughout the day/night so that the most current information on patient status was available any time for rounding by various care providers, specialists, and consultants. The information was also available for viewing by the patient’s family.
Added November 2017
Separate Medication Preparation Rooms Reduce Interruptions and Medication Errors in the Hospital Setting: A Prospective Observational Study
2016
Journal of Patient Safety
Journal Article
Issue 3
Volume 17
Pages e161-e168
Author(s): Huckels-Baumgart, S., Baumgart, A., Buschmann, U., Schüpfer, G., Manser, T.
Errors and interruptions are commonplace during medication preparation procedures in healthcare environments. One study found that one interruption occurred for every 3.2 drugs administered during nurses’ medication rounds.
Added December 2016
Impact of the Physical Environment of Residential Health, Care, and Support Facilities (RHCSF) on Staff and Residents A Systematic Review of the Literature
2015
Environment and Behavior
Journal Article
Issue 10
Volume 48
Pages 1203-1241
Author(s): Joseph, A., Choi, Y.-S., Quan, X.
Strategies related to the design of the built environment should be considered within the context of the culture of the organization and the resident population. This study of the physical environment of residential health, care, and support facilities addresses the range of settings and population, where other studies have been lacking. The literature review strongly suggests that the built environment is an important component of care provided in residential care settings.
Added May 2016
Facility Design and Healthcare-Acquired Infections
2014
Journal of Nursing Administration
Journal Article
Issue 3
Volume 44
Pages 129-132
Author(s): Stichler, J. F.
This article outlines the relationship between select design elements and the pervasive problem of healthcare-acquired infections.
Added January 2016
Hospital Nurses’ Perceptions of Human Factors Contributing to Nursing Errors
2015
Journal of Nursing Administration
Journal Article
Author(s): Roth, C., Wieck, K. L., Fountain, R. & Haas, B. K.
This study built upon results from a previous study. The aim was to understand details about how human factors contribute to nursing errors.
Added January 2016
Light for Nurses’ Work in the 21st Century: A Review of Lighting, Human Vision Limitations, and Medication Administration
2014
Journal of Nursing Care Quality
Journal Article
Issue 3
Volume 29
Pages 287-294
Author(s): Graves, K., Symes, L., & Cesario, S. K.
While there has been previous documentation about the impact of the built environment on staff efficiency, little has been documented about the role of architectural lighting on staff’s ability to perform work tasks. The authors cite specific examples of how medications are often distributed on night shifts, sometimes when nurses use pen lights so as not to disturb patients.
Added January 2016
The Business Case for Building Better Neonatal Intensive Care Units
Journal of Perinatology
2014
Journal Article
Issue 11
Volume 34
Pages 811-815
Author(s): Shepley, M., Smith, J.A., Sadler, B.L. & White, R.D.
There is increasing evidence that the physical environment of the Neonatal Intensive Care Unit (NICU) has a tangible effect on the vulnerable infants who spend the first crucial weeks or months of their life there.
Added January 2016
Destination Bedside
2012
The Journal of Nursing Administration
Journal Article
Issue 5
Volume 42
Pages 256-265
Author(s): Watkins, N., Kennedy, M., Lee, N., O’Neill, M., Peavey, E., DuCharme, M., & Padula, C.
Patient-centered care (PCC) has been at the core of healthcare reform. Improvements and advancements in Healthcare Information Technology (HIT), Electronic Health Records and inpatient unit layout have been some means that aim to achieve PCC. Also key to PCC is the alleviation of medical errors, which HIT and related technology can help achieve.
Added January 2016
One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs
2015
BMJ Quality & Safety
Journal Article
Issue 4
Volume 25
Pages 241-256
Author(s): Maben, J., Griffiths, P., Penfold, C., Simon, M, Anderson, J. E., Robert, G., Pizzo, E., Hughes, J., Murrells, T., Barlow, J.
Authors indicate that despite the trend to adopt single-patient rooms, there is a dearth of strong evidence regarding its effect on healthcare quality and safety. When a hospital in England moved to a new building with 100% single rooms, a before-and-after move study was conducted on patient and staff experience, safety outcomes, and cost analysis. The study found that over two-thirds of the patients and one-fifth of the staff preferred single rooms.
Added September 2015
Luminous environment in healthcare buildings for user satisfaction and comfort: an objective and subjective field study
2015
Indoor and Built Environment
Journal Article
Issue 5
Volume 25
Pages 809-825
Author(s): Lo Verso, V. R.M., Caffaro, F., Aghemo, C.
Lighting is important in healthcare, and the authors indicate its relevance to patient recovery and staff satisfaction. According to the authors, luminous environmental quality affects visual comfort, which is related to both natural and artificial lighting.
Added June 2015
Healing environment: A review of the impact of physical environmental factors on users
2012
Building and Environment
Journal Article
Author(s): Huisman, E. R. C. M., Morales, E., van Hoof, J., Kort, H. S. M.
According to the authors, research that examines the physical environment and its impact on the healing and well-being of human beings has been growing in the last several years. There is increasing availability of literature on evidence-based design.
Added March 2015
Realizing improved patient care through human-centered operating room design: A human factors methodology for observing flow disruptions in the cardiothoracic operating room
2013
Anesthesiology
Journal Article
Issue 5
Volume 119
Pages 1066-1077
Author(s): Palmer, G., Abernathy, J. H., Swinton, G., Allison, D., Greenstein, J., Shappell, S., Juang, K., Reeves, S. T.
The authors indicate that disruptions in the workflow of surgeries can extend surgery times and contribute to the escalation of healthcare costs.
Added March 2015
Patient Safety in the Cardiac Operating Room: Human Factors and Teamwork A Scientific Statement From the American Heart Association
2013
Circulation
Journal Article
Issue 10
Volume 128
Pages 1139-1169
Author(s): Wahr, J. A., Prager, R. L., Abernathy, J. H., Martinez, E. A., Salas, E., Seifert, P. C., Groom, R. C., Spiess, B. D., Searles, B. E., Sundt, T. M., Sanchez, J. A., Shappell, S. A., Culig, M. H., Lazzara, E. H., Fitzgerald, D. C., Thourani, V. H., Eghtesady, P., Ikonomidis, J. S., England, M. R., Sellke, F. W., Nussmeier, N. A.
The cardiac surgical operating room is a complex environment, where patient lives are saved or considerably improved with the help of sophisticated equipment and skilled personnel. Although outcomes are improving, adverse events still occur, many of which are preventable. This statement is the result of a review of literature that presented evidence on patient safety and interventions that worked in enhancing patient safety in the cardiac OR.
Added March 2015
Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station
2012
BMJ Quality & Safety
Journal Article
Issue 11
Volume 21
Pages 939-947
Author(s): Colligan, L., Guerlain, S., Steck, S. E., Hoke, T. R.
According to the authors, literature indicates that interruptions during the administration of medication in healthcare settings can lead to errors, and that such errors are likely to cause more harm in pediatric settings. The medication station in the study hospital is centrally located with an open design targeted to reduce nurse walking and increase time with patients.
Added December 2014
Conveniently located “napping rooms” provide opportunity for night- and extended-shift providers to rest, leading to less fatigue and better performance.
2008, last updated October 23, 2013
US Department of Health and Human Services; AHRQ (Agency for Healthcare Research and Quality) website
Journal Article
Author(s):
Healthcare providers are known for working unacceptably long hours and being chronically sleep deprived. Often, physicians and nurses work 24+ hour shifts, leading to fatigue and avoidable errors that put both caregivers and patients at risk of serious injury or death. Acute and chronic sleep deprivation can mimic the effects of drunkenness.
Added November 2014
The effects of physical environments in medical wards on medication communication processes affecting patient safety
2014
Health & Place
Journal Article
Author(s): Liu, W., Manias, E., Gerdtz, M.
The physical environment of a hospital has a wide range of effects on the quality of care administered to patients. In the context of medication distribution, seamless communication among healthcare professionals of different backgrounds is imperative, and in many cases the physical environment itself can have positive or negative effects on this complex process.
Added November 2014
Medication Dispensing Errors and Potential Adverse Drug Events before and after Implementing Bar Code Technology in the Pharmacy
2006
Annals of Internal Medicine
Journal Article
Issue 6
Volume 145
Pages 426-434
Author(s): Poon, E. G., Cina, J. L., Churchill, W., Patel, N., Featherstone, E., Rothschild, J. M., Keohane, C. A., Whittemore, A. D., Bates, D. W., Gandhi, T. K.
Medication errors are errors that occur while ordering, transcribing, dispensing, administering, or monitoring medications. Medication dispensing errors refer to discrepancies between a prescription and the medication dispensed by a pharmacist.
Added November 2014
The Effect of Hospital Unit Layout on Nurse Walking Behavior
2012
HERD: Health Environments Research & Design Journal
Journal Article
Issue 1
Volume 6
Pages 66-82
Author(s): Yi, L., Seo, H.-B.
Over the course of a typical shift, nurses spend a lot of time on their feet, walking back and forth on the unit to take care of patients' needs. The long distances that nurses walk is a topic of concern in the industry. Some believe it may potentially impact the amount of time spent with patients and also because of the physical toll on nurses, day after day. Researchers are attempting to understand whether unit layout and design might be revised to reduce walking distances and create efficiencies that enhance patient care.
Added September 2014
Effect of noise on auditory processing in the operating room
2013
Journal of the American College of Surgeons
Journal Article
Issue 5
Volume 216
Pages 933-8
Author(s): Way, T. J., Long, A., Weihing, J., Ritchie, R., Jones, R., Bush, M., Shinn, J. B.
Noise in operating rooms (ORs), defined as any unwanted sound impeding on normal hearing, can be grouped into two categories: equipment-related noise and staff-created noise. Equipment-related noise can come from anesthesia equipment and alarms, suction devices, or surgical instruments such as cautery devices, dissection tools, and drills. Staff-created noise can come from opening and closing doors, conversations, overhead pages, and music. All of these noise sources contribute to the average ambient noise in ORs, which is 65 dBA with peak levels reaching120 dBA.
Added September 2014
