Errors and failures in complex health-care systems: Individual, team, system and cultural contributors.

摘要

This study examined three error-events in two community hospitals in the Northwest and Midwest United States which resulted in patient harm and/or potential patient harm. This study sought to answer the following questions: "What are the individual, team, and system characteristics and behaviors that contribute to error in community hospitals?" and "How does organizational culture contribute to error in health-care organizations?" Two sets of data were collected---(1) root-cause analyses, medical records, and staffing schedules from the two respective databases of the two hospitals; and (2) interview data from the persons who were identified as contributors to errors in the three error-events selected for study. The Taxonomy of Error Root Cause Analysis Protocol (TERCAP) tool, which was created by the National Council of State Boards of Nursing Practice Breakdown Research Advisory Council (2002) for retrospective error-categorization of nursing errors, was adapted by the researcher to categorize and analyze the individual errors of nurses and other health-care professionals and workers. The interdisciplinary team dynamics within the system and organizational culture were analyzed after an extensive review of the related research and literature. Findings revealed that multiple people in multiple professions and positions committed a variety of errors during the course of routine and emergent work that resulted in patient harm. Four patterns of behavior were identified involving individuals, team, systems, and cultures which contributed to six categories of error across the three error-events. The four patterns of behavior were: cultures of blame, fear, self protection and a hierarchical status-consciousness; difficult interpersonal relations; difficulty managing conflict, coping with stress, and confronting ones weaknesses; and feedback delays related to error discovery and reporting. The four patterns of behavior led to the following six categories of error that resulted in patient harm: (1) Failure to anticipate and be attentive secondary to unclear expectations and distractions; (2) Inappropriate judgment secondary to simplification and/or self aggrandizement; (3) Ineffective teamwork related to status consciousness and conflict; (4) Lack of agency/fiduciary responsibility in cultures that normalize intimidation and blame; (5) Inadequate system controls for critical operations; and (6) Inadequate and delayed feedback for learning.