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8 - Violations and Medication Safety

Published online by Cambridge University Press:  09 April 2021

Alan Merry  and
Joyce Wahr
Alan Merry
Affiliation:
University of Auckland
Joyce Wahr
Affiliation:
University of Minnesota
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Summary

Much has been written about human error in the setting of medication safety; much less has been written about violations, which may be equally important and even more common. Violations may vary from and individual's failure to label a syringe to an organization's failure to invest in medication safety. Perhaps the most compelling challenge in this regard is lack of engagement by practitioners in the safety initiatives that exist within their organizations. This chapter includes a discussion of the 4 main reasons for violations: 1) rules must be violated in order for the work to be done; 2) a sense of powerfulness, that one can skillfully complete the job without needing rules; 3) violations represent short-cuts that allow the work to be done better or faster; 4) poor work planning, which results in having to invent the work process as one goes and solve problems as they arise. Reducing violations requires understanding why, and then fixing, the reasons for the violations. An understanding of violation in all its shades and a greater willingness to name this problem and to expect accountability for it within the context of a just culture may well be the key to improving medication safety in the future.

Keywords

Vilationssabotagefatiguehero mentalityduty hourscompliancehard engineeringsoft engineeringaffordancesoptimizing violations
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Chapter
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Medication Safety during Anesthesia and the Perioperative Period , pp. 130 - 155
Publisher: Cambridge University Press
Print publication year: 2021

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References

Merry, AF, Brookbanks, W. Merry and McCall Smith’s Errors, Medicine and the Law. 2nd ed. Cambridge, UK: Cambridge University Press; 2017.Google Scholar
Reason, J. Human Error. New York, NY: Cambridge University Press; 1990.CrossRefGoogle Scholar
Baker, R, Hurwitz, B. Intentionally harmful violations and patient safety: the example of Harold Shipman. J R Soc Med. 2009;102(6):223–227.CrossRefGoogle ScholarPubMed
Haines, D. The legacy of Dr. Harold Shipman. Med Leg J. 2015;83(3):115.Google Scholar
Stubbley, P. Frederic Pechier: doctor charged with killing nine patients by “poisoning them during surgery.” London: Independent; 2019. Accessed January 17, 2020. https://www.independent.co.uk/news/world/europe/frederic-pechier-doctor-poison-patients-france-surgery-besancon-a8917811.htmlGoogle Scholar
Wikipedia contributors. Firefighter arson. Wikipedia, The Free Encyclopedia; 2019. Accessed January 18, 2020. https://en.wikipedia.org/wiki/Firefighter_arsonGoogle Scholar
Wikipedia contributors. Harold Shipman. Wikipedia, The Free Encyclopedia; 2018. Accessed January 18, 2020. https://en.wikipedia.org/w/index.php?title=Harold_Shipman&oldid=848386767Google Scholar
Williams, LS. Anesthetist receives jail sentence after patient left in vegetative state. CMAJ. 1995;153:619–620.Google ScholarPubMed
International Taskforce on Anaesthesia Safety. International standards for a safe practice of anaesthesia. Eur J Anaesthesiol. 1993;10(suppl 7):12–15.Google Scholar
Gelb, AW, Morriss, WW, Johnson, W, Merry, AF, International Standards for a Safe Practice of Anesthesia Workgroup. World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. Anesth Analg. 2018;126(6):2047–2055.Google Scholar
Merry, AF, Webster, CS, Hannam, J, et al. Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation. BMJ. 2011;343:d5543.Google Scholar
Rowe, L, Galletly, DC, Henderson, RS. Accuracy of text entries within a manually compiled anaesthetic record. Br J Anaesth. 1992;68:381–387.Google Scholar
Edwards, KE, Hagen, SM, Hannam, J, et al.. A randomized comparison between records made with an anesthesia information management system and by hand, and evaluation of the Hawthorne effect. Can J Anaesth. 2013;60(10):990–997.Google Scholar
Van Schalkwyk, JM, Lowes, D, Frampton, C, Merry, AF. Does manual anaesthetic record capture remove clinically important data? Br J Anaesth. 2011;107(4):546–552.Google Scholar
Dawson, D, Reid, K. Fatigue, alcohol and performance impairment. Nature. 1997;388:235.Google Scholar
Ferguson, SA, Thomas, MJ, Dorrian, J, et al.. Work hours and sleep/wake behavior of Australian hospital doctors. Chronobiol Int. 2010;27(5):997–1012.Google Scholar
Asch, DA, Parker, RM. The Libby Zion case. One step forward or two steps backward? N Engl J Med. 1988;318(12):771–775.Google Scholar
Bhananker, SM, Cullen, BF. Resident work hours. Curr Opin Anaesthesiol. 2003;16(6):603–609.CrossRefGoogle ScholarPubMed
Spritz, N. Oversight of physicians’ conduct by state licensing agencies. Lessons from New York’s Libby Zion case. Ann Intern Med. 1991;115(3):219–222.CrossRefGoogle ScholarPubMed
Patel, N. Learning lessons: the Libby Zion case revisited. J Am Coll Cardiol. 2014;64(25):2802–2804.Google Scholar
Savill, R. Tired doctor cleared over patient's death. The Daily Telegraph. May 20, 1995.Google Scholar
Gander, PH, Merry, A, Millar, MM, Weller, J. Hours of work and fatigue-related error: a survey of New Zealand anaesthetists. Anaesth Intensive Care. 2000;28(2):178–183.Google Scholar
Dement, WC. The perils of drowsy driving [editorial]. N Engl J Med. 1997;337(11):783–784.Google Scholar
Smetzer, J, Baker, C, Byrne, FD, Cohen, MR. Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Jt Comm J Qual Patient Saf. 2010;36(4):152–163.Google ScholarPubMed
Parsa-Parsi, RW. The revised declaration of Geneva: a modern-day physician’s pledge. JAMA. 2017;318(20):1971–1972.CrossRefGoogle Scholar
WMA Declaration of Geneva. Ferney-Voltaire, France: World Medical Association; 2017. Accessed January 18, 2020. https://www.wma.net/policies-post/wma-declaration-of-geneva/Google Scholar
Maisonneuve, JJ, Lambert, TW, Goldacre, MJ. UK doctors’ views on the implementation of the European Working Time Directive as applied to medical practice: a quantitative analysis. BMJ Open. 2014;4(2):e004391.Google Scholar
Clarke, RT, Pitcher, A, Lambert, TW, Goldacre, MJ. UK doctors’ views on the implementation of the European Working Time Directive as applied to medical practice: a qualitative analysis. BMJ Open. 2014;4(2):e004390.Google Scholar
Trew, A, Searles, B, Smith, T, Darling, EM. Fatigue and extended work hours among cardiovascular perfusionists: 2010 Survey. Perfusion. 2011;26(5):361–370.Google Scholar
Howard, SK, Gaba, DM, Smith, BE, et al. Simulation study of rested versus sleep-deprived anesthesiologists. Anesthesiology. 2003;98(6):1345–1355.CrossRefGoogle ScholarPubMed
Landrigan, CP, Rothschild, JM, Cronin, JW, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351(18):1838–1848.Google Scholar
Lockley, SW, Cronin, JW, Evans, EE, et al. Effect of reducing interns’ weekly work hours on sleep and attentional failures. N Engl J Med. 2004;351(18):1829–1837.CrossRefGoogle ScholarPubMed
Chu, MW, Stitt, LW, Fox, SA, et al. Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures. Arch Surg. 2011;146(9):1080–1085.Google Scholar
Ellman, PI, Kron, IL, Alvis, JS, et al. Acute sleep deprivation in the thoracic surgical resident does not affect operative outcomes. Ann Thorac Surg. 2005;80(1):60–64.Google Scholar
Ellman, PI, Law, MG, Tache-Leon, C, et al. Sleep deprivation does not affect operative results in cardiac surgery. Ann Thorac Surg. 2004;78(3):906–911.Google Scholar
Howard, SK, Gaba, DM, Rosekind, MR, Zarcone, VP. The risks and implications of excessive daytime sleepiness in resident physicians. Acad Med. 2002;77(10):1019–1025.Google Scholar
Gander, P, Millar, M, Webster, C, Merry, A. Sleep loss and performance of anaesthesia trainees and specialists. Chronobiol Int. 2008;25(6):1077–1091.Google Scholar
Garden, AL, Currie, M, Gander, PH. Sleep loss, performance and the safe conduct of anaesthesia. In: Keneally, J, Jones, M, eds. Australasian Anaesthesia. Melbourne: Australian and New Zealand College of Anaesthetists; 1996:43–51.Google Scholar
Saleh, A, Awadalla, N, El-masri, Y, Sleem, W. Impacts of nurses’ circadian rhythm sleep disorders, fatigue, and depression on medication administration errors. Egypt J Chest Dis Tuberc. 2014;63:145–153.Google Scholar
Valentin, A, Capuzzo, M, Guidet, B, et al. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ. 2009;338:b814.CrossRefGoogle ScholarPubMed
Zhao, J, Warman, GR, Cheeseman, JF. The functional changes of the circadian system organization in aging. Ageing Res Rev. 2019;52:64–71.Google Scholar
Webster, CS, Merry, AF, Larsson, L, McGrath, KA, Weller, J. The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care. 2001;29(5):494–500.CrossRefGoogle ScholarPubMed
Cheeseman, JF, Webster, CS, Pawley, MDM, et al. Use of a new task-relevant test to assess the effects of shift work and drug labelling formats on anesthesia trainees’ drug recognition and confirmation. Can J Anaesth. 2011;58(1):38–47.CrossRefGoogle ScholarPubMed
Silbert, BS, Maruff, P, Evered, LA, et al. Detection of cognitive decline after coronary surgery: a comparison of computerized and conventional tests. Br J Anaesth. 2004;92(6):814–820.Google Scholar
Griffiths, JD, McCutcheon, C, Silbert, BS, Maruff, P. A prospective observational study of the effect of night duty on the cognitive function of anaesthetic registrars. Anaesth Intensive Care. 2006;34(5):621–628.Google Scholar
Merry, AF, Warman, GR. Fatigue and the anaesthetist. Anaesth Intensive Care. 2006;34(5):577–578.Google Scholar
Huffmyer, JL, Kleiman, AM, Moncrief, M, et al. Impact of caffeine ingestion on the driving performance of anesthesiology residents after 6 consecutive overnight work shifts. Anesth Analg. 2020;130(1):66–75.CrossRefGoogle ScholarPubMed
Norman, DA. The Psychology of Everyday Things. New York, NY: Basic Books; 1998.Google Scholar
Shadwell, T. Jaywalk and you could be in court. Dominion Post. February 10, 2014.Google Scholar
Norman, D. Things That Make Us Smart: Defending Human Attributes in the Age of the Machine. Reading, MA: Perseus; 1993.Google Scholar
Eichhorn, JH, Cooper, JB, Cullen, DJ, et al. Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA. 1986;256(8):1017–1020.Google Scholar
Braun, AR, Skene, L, Merry, AF. Informed consent for anaesthesia in Australia and New Zealand. Anaesth Intensive Care. 2010;38(5):809–822.Google Scholar
Braun, AR, Leslie, K, Merry, AF, Story, D. What are we telling our patients? A survey of risk disclosure for anaesthesia in Australia and New Zealand. Anaesth Intensive Care. 2010;38(5):935–938.Google Scholar
Wahr, JA, Prager, RL, Abernathy, JH 3rd, et al. Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. Circulation. 2013;128(10):1139–1169.CrossRefGoogle ScholarPubMed
Pedersen, T, Nicholson, A, Hovhannisyan, K, et al. Pulse oximetry for perioperative monitoring. Cochrane Database Syst Rev. 2014;(3):CD002013.Google Scholar
Merry, AF, Eichhorn, JH, Wilson, IH. Extending the WHO “Safe Surgery Saves Lives” project through global oximetry. Anaesthesia. 2009;64(10):1045–1048.Google Scholar
Iszatt-White, M. Catching them at it: an ethnography of rule violation. Ethnography. 2007;8(4):445–465.Google Scholar
Reason, J. The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Burlington, VT: Ashgate Publishing; 2008.Google Scholar
Anonymous. Costa Concordia: Captain Schettino tried to “impress.” BBC News. December 2, 2014. Accessed January 18, 2020. https://www.bbc.com/news/world-europe-30297395Google Scholar
Janssen, W. Seat-belt wearing and driving behavior: an instrumented-vehicle study. Accid Anal Prev. 1994;26(2):249–261.Google Scholar
Sagberg, F, Fosser, S, Saetermo, IA. An investigation of behavioural adaptation to airbags and antilock brakes among taxi drivers. Accid Anal Prev. 1997;29(3):293–302.Google Scholar
Ebstein, RP, Novick, O, Umansky, R, et al. Dopamine D4 receptor (D4DR) exon III polymorphism associated with the human personality trait of Novelty Seeking. Nat Genet. 1996;12(1):78–80.Google Scholar
Ham, BJ, Lee, YM, Kim, MK, et al. Personality, dopamine receptor D4 exon III polymorphisms, and academic achievement in medical students. Neuropsychobiology. 2006;53(4):203–209.Google Scholar
Uzefovsky, F, Shalev, I, Israel, S, et al. The dopamine D4 receptor gene shows a gender-sensitive association with cognitive empathy: evidence from two independent samples. Emotion. 2014;14(4):712–721.Google Scholar
Reiner, I, Spangler, G. Dopamine D4 receptor exon III polymorphism, adverse life events and personality traits in a nonclinical German adult sample. Neuropsychobiology. 2011;63(1):52–58.Google Scholar
Brickhill, P. Reach for the Sky: The Story of Douglas Bader DSO, DFC. London: Odhams Press Ltd; 1954.Google Scholar
Reason, J. Managing the Risks of Organizational Accidents. London: Routledge; 1997.Google Scholar
Alper, SJ, Holden, RJ, Scanlon, MC, et al. Self-reported violations during medication administration in two paediatric hospitals: A systematic review of safety violations in industry. BMJ Qual Saf. 2012;21:408–415.Google Scholar
Weick, KE, Sutcliffe, KM. Managing the Unexpected: Resilient Performance in an Age of Uncertainty. 2nd ed. San Francisco, CA: Jossey-Bass; 2007.Google Scholar
Zimlichman, E, Henderson, D, Tamir, O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039–2046.Google Scholar
Donaldson, LJ, Panesar, SS, Darzi, A. Patient-safety-related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010–2012. PLoS Med. 2014;11(6):e1001667.CrossRefGoogle ScholarPubMed
Allegranzi, B, Pittet, D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect. 2009;73(4):305–315.Google Scholar
Allegranzi, B, Gayet-Ageron, A, Damani, N, et al. Global implementation of WHO’s multimodal strategy for improvement of hand hygiene: a quasi-experimental study. Lancet Infect Dis. 2013;13(10):843–851.Google Scholar
Huang, GKL, Stewardson, AJ, Grayson, ML. Back to basics: hand hygiene and isolation. Curr Opin Infect Dis. 2014;27(4):379–389.Google Scholar
Pittet, D, Allegranzi, B, Storr, J. The WHO Clean Care is Safer Care programme: field-testing to enhance sustainability and spread of hand hygiene improvements. J Infect Public Health. 2008;1(1):4–10.Google Scholar
Allegranzi, B, Pittet, D. Healthcare-associated infection in developing countries: simple solutions to meet complex challenges. Infect Control Hosp Epidemiol. 2007;28(12):1323–1327.Google Scholar
Clean Care is Safer Care Team. WHO Guidelines on Hand Hygiene in Health Care: a Summary. Geneva: World Health Organization; 2009. Accessed January 18, 2020. https://apps.who.int/iris/bitstream/handle/10665/70126/WHO_IER_PSP_2009.07_eng.pdf;jsessionid=427B1CDF65656AAC96D50E4329449EE3?sequence=1Google Scholar
Lau, T, Tang, G, Mak, KL, Leung, G. Moment-specific compliance with hand hygiene. Clin Teach. 2014;11(3):159–164.Google Scholar
Munoz-Price, LS, Bowdle, A, Johnston, BL, et al. Infection prevention in the operating room anesthesia work area. Infect Control Hosp Epidemiol. 2018;11:1–17.Google Scholar
Lucas, NC, Hume, CG, Al-Chanati, A, et al. Student-led intervention to inNOvate hand hygiene practice in Auckland Region’s medical students (the No HHARMS study). N Z Med J. 2017;130(1448):54–63.Google Scholar
Koff, MD, Loftus, RW, Burchman, CC, et al. Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device. Anesthesiology. 2009;110(5):978–985.Google Scholar
Stone, SP, Fuller, C, Savage, J, et al. Evaluation of the national Cleanyourhands campaign to reduce Staphylococcus aureus bacteraemia and Clostridium difficile infection in hospitals in England and Wales by improved hand hygiene: four year, prospective, ecological, interrupted time series study. BMJ. 2012;344:e3005.Google Scholar
Pronovost, P, Needham, D, Berenholtz, S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725–2732.Google Scholar
Gray, J, Proudfoot, S, Power, M, et al. Target CLAB Zero: a national improvement collaborative to reduce central line-associated bacteraemia in New Zealand intensive care units. N Z Med J. 2015;128(1421):13–21.Google Scholar
Gargiulo, DA, Sheridan, J, Webster, CS, et al. Anaesthetic drug administration as a potential contributor to healthcare-associated infections: a prospective simulation-based evaluation of aseptic techniques in the administration of anaesthetic drugs. BMJ Qual Saf. 2012;21(10):826–834.Google Scholar
Birnbach, DJ, Rosen, LF, Fitzpatrick, M, et al. Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room. Anesth Analg. 2015;120(4):848–852.Google Scholar
Loftus, RW, Brown, JR, Koff, MD, et al. Multiple reservoirs contribute to intraoperative bacterial transmission. Anesth Analg. 2012;114(6):1236–1248.Google Scholar
Loftus, RW, Koff, MD, Birnbach, DJ. The dynamics and implications of bacterial transmission events arising from the anesthesia work area. Anesth Analg. 2015;120(4):853–860.Google Scholar
Wachter, RM, Pronovost, PJ. Balancing “no blame” with accountability in patient safety. N Engl J Med. 2009;361(14):1401–1406.Google Scholar
Merry, AF, Shipp, DH, Lowinger, JS. The contribution of labelling to safe medication administration in anaesthetic practice. Best Pract Res Clin Anaesthesiol. 2011;25(2):145–159.Google Scholar
Australian and New Zealand College of Anaesthetists. Guidelines for the Safe Administration of Injectable Drugs in Anaesthesia. Melbourne: Australian and New Zealand College of Anaesthetists; 2009. Policy document PS 51.Google Scholar
Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001 .Google Scholar
Morris, ZS, Wooding, S, Grant, J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med. 2011;104(12):510–520.Google Scholar
Eichhorn, J. APSF hosts medication safety conference: consensus group defines challenges and opportunities for improved practice. APSF Newsletter. 2010;25(1):1–7. Accessed January 3, 2020. www.apsf.org/article/apsf-hosts-medication-safety-conference/Google Scholar
Hudson, P, Verschuur, W, Parker, D, Lawton, R, van der Graaf, G. Bending the rules: managing violation in the workplace. Leiden: Centre for Safety Science, Leiden University; 1998. Accessed January 21, 2020. https://www.naris.com/wp-content/uploads/2016/10/Bending-the-rules.pdfGoogle Scholar
Hudson, P, Verschuur, W, Lawton, R, Parker, D, Reason, J.Bending the rules II: the violation manual. Leiden: Centre for Safety Science, Leiden University; 1997. Accessed January 21, 2020. https://www.academia.edu/21944364/Bending_the_Rules_Managing_Violation_in_the_WorkplaceGoogle Scholar

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  • Violations and Medication Safety
  • Alan Merry, University of Auckland, Joyce Wahr, University of Minnesota
  • Book: Medication Safety during Anesthesia and the Perioperative Period
  • Online publication: 09 April 2021
  • Chapter DOI: https://doi.org/10.1017/9781108151702.008
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  • Violations and Medication Safety
  • Alan Merry, University of Auckland, Joyce Wahr, University of Minnesota
  • Book: Medication Safety during Anesthesia and the Perioperative Period
  • Online publication: 09 April 2021
  • Chapter DOI: https://doi.org/10.1017/9781108151702.008
Available formats
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  • Violations and Medication Safety
  • Alan Merry, University of Auckland, Joyce Wahr, University of Minnesota
  • Book: Medication Safety during Anesthesia and the Perioperative Period
  • Online publication: 09 April 2021
  • Chapter DOI: https://doi.org/10.1017/9781108151702.008
Available formats
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