Identifying the latent failures underpinning medication administration errors: an exploratory study.

Area of Science:

• Healthcare quality and safety
• Medication safety research
• Organizational psychology in healthcare

Background:

• Medication errors pose a significant threat to patient safety.
• Understanding the root causes of medication errors is crucial for effective prevention.
• Latent failures within healthcare systems are often implicated in adverse events.

Purpose of the Study:

• To systematically identify latent failures perceived to underlie medication errors.
• To explore organizational factors contributing to medication errors in a UK hospital setting.

Main Methods:

• Cross-sectional qualitative study design.
• Semi-structured interviews with 12 nurses and 8 managers across three UK hospital wards.
• Thematic content analysis of transcribed interviews with inter-rater reliability testing.

Main Results:

• Ten latent failures were identified: ward climate, local working environment, workload, human resources, team communication, routine procedures, bed management, written policies and procedures, supervision and leadership, and training.
• Ward climate emerged as the most prevalent theme, interacting with failures in other organizational structures and processes.

Conclusions:

• This research provides a systematic identification of latent failures contributing to medication errors.
• Findings can inform the development of organization-level patient safety interventions.
• The study supports the design of proactive error management tools and incident reporting systems.