This research constitutes the first Australian study to use Coronial reports to analyse nurse-related adverse events resulting in the deaths of patients. As nurses represent the largest group in the health care workforce, providing 24-hour care, they are in a key position to contribute to improving patient safety. James Reason’s theory of accident prevention, including his Swiss cheese model (1990), provided a conceptual framework for the research and underpinned the Human Factors Analysis and Classification (HFACS) methodology used for the study. HFACS was used to categorise and analyse active and latent failures at each level of the organisations and to understand the interrelationships between these layers of influence that resulted in the deaths. Contributions to original knowledge derived from this research include the evidence that unsafe acts are not single, isolated events but the result of an error trajectory with influencing factors at all levels of an organisation; nurse-related errors are generally preventable; communication problems exist from the top layers of organisations down to the frontline; balancing the skill-mix and number of nursing staff matters; and routine violations are preventable. Latent factors contributing to error can be identified and mitigated which can then prevent errors from occurring. The findings from this research provide an evidence base for developing focussed policy and other strategies across health provider organisations to improve the safety of patients.
|Date of Award
|Mary Finlayson (Supervisor) & Marilynne Kirshbaum (Supervisor)