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From a reactive to a proactive safety approach. Analysis of medication errors in chemotherapy using general failure types
Author(s) -
Fyhr A.,
Ternov S.,
Ek Å.
Publication year - 2017
Publication title -
european journal of cancer care
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.849
H-Index - 67
eISSN - 1365-2354
pISSN - 0961-5423
DOI - 10.1111/ecc.12348
Subject(s) - medicine , patient safety , work (physics) , process management , risk analysis (engineering) , medical emergency , health care , mechanical engineering , business , engineering , economics , economic growth
A better understanding of why medication errors (MEs) occur will mean that we can work proactively to minimise them. This study developed a proactive tool to identify general failure types ( GFT s) in the process of managing cytotoxic drugs in healthcare. The tool is based on Reason's Tripod Delta tool. The GFT s and active failures were identified in 60 cases of MEs reported to the Swedish national authorities. The most frequently encountered GFT s were defences, procedures, organisation and design. Working conditions were often the common denominator underlying the MEs. Among the active failures identified, a majority were classified as slips, one‐third as mistakes, and for a few no active failure or error could be determined. It was found that the tool facilitated the qualitative understanding of how the organisational weaknesses and local characteristics influence the risks. It is recommended that the tool be used regularly. We propose further development of the GFT tool. We also propose a tool to be further developed into a proactive self‐evaluation tool that would work as a complement to already incident reporting and event and risk analyses.