Book Review: To Do No Harm: Ensuring Patient Safety in Health Care Organizations

2005 ◽  
Vol 39 (9) ◽  
pp. 1584-1584
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Health Care Organizations ◽  
Do No Harm

Improving Patient Safety with Telemedicine

2013 ◽  
pp. 56-70 ◽  
Author(s):  
I. H. Monrad Aas
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Adverse Events ◽  
Potential Role ◽  
Professional Communities ◽  
Network Organization ◽  
Quality Problem ◽  
Do No Harm ◽  
Centralization And Decentralization

The patient safety and quality problem in health care are considerable. To err is human, but primum non nocere (first, do no harm) means work against the adverse events and work for good quality. The purpose of the chapter is to explore the potential role for patient safety of a telemedicine network organization with centralization and decentralization taken into consideration. Network organization is of importance for strengthening of professional communities and competence complementation. For the building of strong professional communities, some size can be necessary, and this can be promoted by centralization. In the telemedicine era, a new way of organizing can be network organization, combined with centralization and decentralization. Not to do anything with the significant patient safety and quality problem is fundamentally wrong and morally indefensible. To err is human, to continue to err is diabolic, and to forgive is divine.

Patient safety culture: finding meaning in patient experiences

2015 ◽  
Vol 28 (6) ◽  
pp. 595-610 ◽  
Author(s):  
Andrea C. Bishop ◽  
Brianna R. Cregan
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Safety Culture ◽  
Health Care Organizations ◽  
Patient Safety Culture ◽  
Patient Experiences ◽  
Qualitative Inquiry ◽  
Data Set ◽  
Content Type ◽  
Family Stories

Purpose – The purpose of this paper is to determine what patient and family stories can tell us about patient safety culture within health care organizations and how patients experience patient safety culture. Design/methodology/approach – A total of 11 patient and family stories of adverse event experiences were examined in September 2013 using publicly available videos on the Canadian Patient Safety Insitute web site. Videos were transcribed verbatim and collated as one complete data set. Thematic analysis was used to perform qualitative inquiry. All qualitative analysis was done using NVivo 10 software. Findings – A total of three themes were identified: first, Being Passed Around; second, Not Having the Conversation; and third, the Person Behind the Patient. Results from this research also suggest that while health care organizations and providers might expect patients to play a larger role in managing their health, there may be underlying reasons as to why patients are not doing so. Practical implications – The findings indicate that patient experiences and narratives are useful sources of information to better understand organizational safety culture and patient experiences of safety while hospitalized. Greater inclusion and analysis of patient safety narratives is important in understanding the needs of patients and how patient safety culture interventions can be improved to ensure translation of patient safety strategies at the frontlines of care. Originality/value – Greater acknowledgement of the patient and family experience provides organizations with an integral perspective to assist in defining and addressing deficiencies within their patient safety culture and to identify opportunities for improvement.

Involuntary automaticity: a work-system induced risk to safe health care

2005 ◽  
Vol 18 (4) ◽  
pp. 211-216 ◽  
Author(s):  
Brian Toft ◽  
Hugo Mascie-Taylor
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Health Care Professionals ◽  
Health Care Organizations ◽  
Negative Effects ◽  
Care Community ◽  
Work System ◽  
Skilled Action ◽  
Conscious Attention

Automaticity is the term given by psychologists to the skilled action that people develop through repeatedly practising the same activity, for example driving a car. Usually, automaticity is discussed in terms of the benefits it brings to people, such as the reduction in the degree of conscious attention a person needs to pay to such skilled activities. However, there is evidence to suggest that substantial costs may also be associated with such learned behaviour. Managing patient safety is a difficult task and one of the ways in which health-care professionals seek to accomplish it is through the use of verbal challenge-response protocols. However, it is argued in this paper that it is possible for the negative effects of automaticity to involuntarily capture those using such verbal checklist techniques and cause them to erroneously believe that the treatment that they are about to administer to a patient is safe when it is not. This phenomenon does not, however, seem to have been recognized by the health-care community nationally or internationally. We conclude that patient safety could be significantly improved worldwide if the organizational arrangements which appear to induce involuntary automaticity were to be robustly addressed by the management of all health-care organizations.

Anaesthetics

2016 ◽  
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Professional Practice ◽  
Health Care Organizations ◽  
Quality Care ◽  
Technical Skills ◽  
High Quality ◽  
Ventilatory Assistance ◽  
Applied Physiology

Current anaesthetic practice is provided using a combination of many different available techniques and drugs, with the primary aim of ensuring patient safety and high-quality care are provided for patients. Anaesthesia today is extremely safe, with mortality less than one death in 250 000 directly related to anaesthetic intervention alone. This is due to a continued focus on the principles of patient safety and quality of care, underpinned by continued innovation in pharmacology, applied physiology, physics, and engineering. These have yielded improved techniques and technologies to enhance airway management, provide ventilatory assistance and haemodynamic support, and monitor physiological parameters. Modern professional practice is continually seeking to improve by emphasizing the importance of individual non-technical skills in educational curricula and the workplace. In addition, anaesthetists are heavily involved in the integration of human factors science into health-care organizations.

scholarly journals Guidelines for the Safe Preparation of Sterile Compounds: Results of the ISMP Sterile Preparation Compounding Safety Summit of October 2011

2013 ◽  
Vol 48 (4) ◽  
pp. 282-301 ◽  
Author(s):  
Darryl S. Rich ◽  
Matthew P. Fricker ◽  
Michael R. Cohen ◽  
Stuart R. Levine
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Health Care Organizations ◽  
Health Care Organization ◽  
Care Organization ◽  
Record Keeping ◽  
Policies And Procedures ◽  
Causative Factors ◽  
Mandatory Standard ◽  
Patient Safety Incidents

Significant patient safety incidents related to sterile drug compounding have occurred for many years. Previous guidelines have focused on ensuring sterility, but serious compounding errors have occurred as well. National efforts are needed to identify and reduce the potential for such errors and their causative factors. In response, the Institute for Safe Medication Practices (ISMP) convened in October 2011 a summit of 60 invited experts in the field for the purpose of establishing by consensus guidelines, safe practices, and standard operating procedures needed to ensure the safe preparation of compounded sterile preparations, especially intravenous admixtures. The resulting guidelines were categorized into 14 core processes: policies and procedures, order entry and verification, drug storage, assembling products and supplies, compounding, drug conservation during drug shortages, preparation of source/bulk containers, technology/automation used, IV workflow software, automated IV compounding devices, quality control/final verification, product labeling, record keeping, and staff management. They were also classified into 3 levels: mandatory, standard, and recommendation. The guidelines presented in this article were felt to be applicable to any health care organization that prepares sterile compounded products. The consensus of the group was that adherence to these guidelines will improve the safety of sterile product compounding and reduce harmful errors in patients receiving these products. Incorporation of these guidelines into sterile compounding practices of health care organizations is an important component of improving patient safety.

The effects of organizational commitment and structural empowerment on patient safety culture

2017 ◽  
Vol 31 (1) ◽  
pp. 10-27 ◽  
Author(s):  
Sujin K. Horwitz ◽  
Irwin B. Horwitz
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Organizational Commitment ◽  
Safety Culture ◽  
Affective Commitment ◽  
Health Care Organizations ◽  
Patient Safety Culture ◽  
Structural Empowerment ◽  
Content Type ◽  
The Relationship

Purpose The purpose of this paper is to investigate the relationship between patient safety culture and two attitudinal constructs: affective organizational commitment and structural empowerment. In doing so, the main and interaction effects of the two constructs on the perception of patient safety culture were assessed using a cohort of physicians. Design/methodology/approach Affective commitment was measured with the Organizational Commitment Questionnaire, whereas structural empowerment was assessed with the Conditions of Work Effectiveness Questionnaire-II. The abbreviated versions of these surveys were administered to a cohort of 71 post-doctoral medical residents. For the data analysis, hierarchical regression analyses were performed for the main and interaction effects of affective commitment and structural empowerment on the perception of patient safety culture. Findings A total of 63 surveys were analyzed. The results revealed that both affective commitment and structural empowerment were positively related to patient safety culture. A potential interaction effect of the two attitudinal constructs on patient safety culture was tested but no such effect was detected. Research limitations/implications This study suggests that there are potential benefits of promoting affective commitment and structural empowerment for patient safety culture in health care organizations. By identifying the positive associations between the two constructs and patient safety culture, this study provides additional empirical support for Kanter’s theoretical tenet that structural and organizational support together helps to shape the perceptions of patient safety culture. Originality/value Despite the wide recognition of employee empowerment and commitment in organizational research, there has still been a paucity of empirical studies specifically assessing their effects on patient safety culture in health care organizations. To the authors’ knowledge, this study is the first empirical study to examine the relationship between structural empowerment as proposed by Kanter and the culture of patient safety using physicians.

Understanding Clinical Alarm Safety

2015 ◽  
Vol 35 (4) ◽  
pp. 45-57 ◽  
Author(s):  
Carol L. Lukasewicz ◽  
Elizabeth Andersson Mattox
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Health Care Organizations ◽  
Nonprofit Organization ◽  
Contributing Factors ◽  
Alarm Management ◽  
High Acuity ◽  
National Patient ◽  
Health Care Accreditation

Patient safety organizations and health care accreditation agencies recognize the significance of clinical alarm hazards. The Association for the Advancement of Medical Instrumentation, a nonprofit organization focused on development and use of safe and effective medical equipment, identifies alarm management as a major issue for health care organizations. ECRI Institute, a nonprofit organization that researches approaches for improving patient safety and quality of care, identifies alarm hazards as the most significant of the “Top Ten Health Technology Hazards” for 2014. A new Joint Commission National Patient Safety Goal focusing on clinical alarm safety contains new requirements for accredited hospitals to be fully implemented by 2016. Through a fictional unfolding case study, this article reviews selected contributing factors to clinical alarm hazards present in inpatient, high-acuity settings. Understanding these factors improves contributions by nurses to clinical alarm safety practice.

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