References
- 1. World Health Organization. Conceptual Framework for the International Classification for Patient Safety Version 1.1, 2009. Available Feb 10, 2013 from: http://www.who.int/patientsafety/taxonomy/icps_full_report.pdf.
- 2. Kohn LT, Corrigan JM, Donaldson MS. To err Is human: building a safer health system. Washington DC: National Academy Press, 2000.
- 3. De Rosier J, Stalhandske E, Bagian JP, Nudell T. Using health care failure: mode and effect analysis. The VA National Center for Patient Safety’s Prospective Risk Analysis System. JCJQI 2002; 27: 248-267.
- 4. Council of Europe. Recommendation Rec (2006) of the Committee of Ministers to member states on management of patient safety and prevention of adverse events in health care. Available Jan 09, 2013 from: https://wcd.coe.int/ViewDoc.jsp?id=1005439&Site=CM.
- 5. Robida A. (prev). Konceptualni okvir za mednarodno klasifikacijo za varnost pacientov: končno tehnično poročilo. Ljubljana: Ministrstvo za zdravje, 2010.
- 6. Kiauta M, Poldrugovac M, Rems M, Robida A, Simčič B, Miholič P. (ur). Nacionalna strategija kakovosti in varnosti v zdravstvu (2010 - 2015). Ljubljana: Ministrstvo za zdravje, 2010.
- 7. Joint Commission. Patient safety. Available Jan 07, 2013 from: http://www.jointcommission.org/topics/patient_safety.aspx.
- 8. Robida, A. Pot do odlične zdravstvene prakse: vodnik za izboljševanje kakovosti in presojo lastne zdravstvene prakse. 1. natis. Ljubljana: Planet GV, 2009.
- 9. Zhang J, Patel VL, Johnson TR. Medical error: is the solution medical or cognitive? JAMIA 2002; 9 (Suppl 1): S75-S77.
- 10. Ministrstvo za zdravje. Priporočilo Rec (2006) Obora ministrov državam članicam o ravnanju z varnostjo pacientov in preprečevanju neželenih dogodkov v zdravstvu, 2006. Available Jan 02, 2013 from: http://www.mz.gov.si/fileadmin/mz.gov.si/pageuploads/mz_dokumenti/delovna_podrocja/zdravstveno_varstvo/kakovost/VARNOST/SEVarnost_Pacientov_2007.pdf.
- 11. Benner P, Sheets V, Uris P, Malloch K, Schwed K, Jamison D. Individual, practice, and system causes of errors in nursing: a taxonomy. J Nurs Admin 2002; 32: 509-523.
- 12. Potter P, Wolf L, Boxerman S, Grayson D, Sledge J, Dunagan C. Understanding the cognitive work of nursing in the acute care environment. J Nurs Admin 2005; 35: 327-335.
- 13. Flin R. Measuring safety culture in healthcare: a case for accurate diagnosis. Safety Sci 2007; 45: 653-667.
- 14. Portwood B, Reising L. Root cause analysis and quantitative methods - Yin and Yang? 2007. Available Jan 17, 2013 from: http://www.realitycharting.com/_public/site/files/pdf/RCA-and-Quantitative-Methods.pdf.
- 15. Dimenstein I.B. Root cause analysis of specimen misidentification in surgical pathology accession and grossing. LabMed 2008; 39: 497-502.
- 16. Karl R, Karl MC. Adverse events: root causes and latent factors. Surg Clin North Am 2012; 92: 89-100.
- 17. Agrawal A. Counting matters: lessons from the root cause analysis of a retained surgical item. Jt Comm J Qual Patient Saf 2012; 38: 566-574.
- 18. Middleton S, Chapman B, Griffiths R, Chester R. Reviewing recommendations of root cause analyses. Aust Health Rev 2007; 31: 288-295.
- 19. DeMarco T. Structured analysis and system specification. NJ, USA: Prentice Hall PTR Upper Saddle River, 1979.
- 20. Abrahamsson P, Salo O, Ronkainen J, Warsta J. Agile software development methods: review and analysis. Finland: VTT Publications 478, 2002.
- 21. Aspden P, Wolcott JA, Bootman JL, Cronenwett LR. Preventing medical errors. Washington DC: National Academy Press, 2006:108-118.
- 22. Poon EG, Keohane CA, Yoon CS, Ditmore M, Bane A, Levtzion- Korach O, et al. Effect of bar-code technology on the safety of medication administration. NEJM 2010; 362:1698-1707.
- 23. Young J, Slebodnik M, Sands L. Bar code technology and medication administration error. J Patient Safety 2010; 6:115-120.
- 24. NCC MERP - National Coordinating Council for Medication Errors Reporting and Prevention. Taxonomy of Medication Errors, 2011. Available Jan 17, 2013 from: http://www.nccmerp.org/medErrorTaxonomy.html.
- 25. Tam V, Knowles S, Cornish P, Fine N, Marchesano R, Etchells E. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ 2005; 173: 510-515.
- 26. Nerat T, Kos M. Analiza neprimernega predpisovanja zdravil starostnikom v Sloveniji na podlagi Beersovih in Larochevih meril. Zdrav Var 2011; 50: 34-44.
- 27. Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA 1995; 274: 35-43.
- 28. Phillips J, Beam S, Brinker A, Holquist C, Honig P, Lee LY, et al. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm 2001; 58: 1835-1841.
- 29. Grasso BC, Genest R, Jordan CW, Bates DW. Use of chart and record reviews to detect medication errors in a state psychiatric hospital. Psychiatr Serv 2003; 54: 677-681.
- 30. Balas MC, Scott LD, Rogers AE. The prevalence and nature of errors reported by hospital staff nurses. Appl Nurs Res 2004;17: 224-230.
- 31. Massachusetts Nurses Association. Position on Medication Error, 2011. Available Jan 17, 2013 from: http://www.massnurses.org/nursing-resources/position-statements/mederrors.
- 32. Prijatelj V. Organizational information model for preventing errors in the process of nursing (PhD dissertation). Kranj: University of Maribor, 2012.
- 33. Toussaint PJ, Verhoef J, Vliet Vlieland TP, Zwetsloot-Schonk JH. The impact of ICT on communication in healthcare. Stud Health Technol Inform 2004; 107: 988-991.
- 34. Georgiou A, Westbrook J, Braithwaite J, Iedema R, Ray S, Forsyth R, Dimos A, Germanos T. When requests become orders a formative investigation into the impact of a computerized physician order entry system on a pathology laboratory service. Int J Med Inform 2007; 76: 583-591.
- 35. Ammenwerth E, Schnell-Inderst P, Machan C, Siebert U. The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. JAMIA 2008 ;15: 585-600.
- 36. Julie Li. A Sociotechnical approach to evaluating the impact of ICT on clinical care environments. Open Med Inform J 2010; 4: 202-205.