Recognizing the Ordinary as Extraordinary: Insight Into the “Way We Work” to Improve Patient Safety Outcomes

2017 ◽  
Vol 26 (3) ◽  
pp. 183-183
Author(s):  
Elizabeth A. Henneman
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Safety Outcomes ◽  
Improve Patient ◽  
Insight Into ◽  
The Way

scholarly journals Mandatory reporting legislation in Canada: improving systems for patient safety?

2021 ◽  
pp. 1-16
Author(s):  
C. Milligan ◽  
S. Allin ◽  
M. Farr ◽  
E. Farmanova ◽  
A. Peckham ◽  
...  
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Patient Safety Culture ◽  
Mandatory Reporting ◽  
Safety Outcomes ◽  
System Improvement ◽  
Evidence Of Impact ◽  
Patient Safety Incidents ◽  
Improve Patient

Abstract Patient safety is a complex systems issue. In this study, we used a scoping review of peer-reviewed literature and a case study of provincial and territorial legislation in Canada to explore the influence of mandatory reporting legislation on patient safety outcomes in hospital settings. We drew from a conceptual model that examines the components of mandatory reporting legislation that must be in place as a part of a systems governance approach to patient safety and used this model to frame our results. Our results suggest that mandatory reporting legislation across Canada is generally designed to gather information about – rather than respond to and prevent – patient safety incidents. Overall, we found limited evidence of impact of mandatory reporting legislation on patient safety outcomes. Although legislation is one lever among many to improve patient safety outcomes, there are nonetheless several considerations for patient safety legislation to assist in broader system improvement efforts in Canada and elsewhere. Legislative frameworks may be enhanced by strengthening learning systems, accountability mechanisms and patient safety culture.

scholarly journals Writing’s on the wall: improving the WHO Surgical Safety Checklist

2021 ◽  
Vol 10 (1) ◽  
pp. e001086
Author(s):  
Claire Cushley ◽  
Tom Knight ◽  
Helen Murray ◽  
Lawrence Kidd
Keyword(s):  
Patient Safety ◽  
Online Survey ◽  
Improve Patient Safety ◽  
Surgical Safety Checklist ◽  
Surgical Safety ◽  
Time Out ◽  
Mandatory Requirement ◽  
Who Checklist ◽  
Improve Patient ◽  
Theatre Team

Background and problemThe WHO Surgical Safety Checklist has been shown to improve patient safety as well as improving teamwork and communication in theatres. In 2009, it was made a mandatory requirement for all NHS hospitals in England and Wales. The WHO checklist is intended to be adapted to suit local settings and was modified for use in Gloucestershire Hospitals NHS Foundation Trust. In 2018, it was decided to review the use of the adapted WHO checklist and determine whether improvements in compliance and engagement could be achieved.AimThe aim was to achieve 90% compliance and engagement with the WHO Surgical Safety Checklist by April 2019.MethodsIn April 2018, a prospective observational audit and online survey took place. The results showed compliance for the ‘Sign In’ section of the checklist was 55% and for the ‘Time Out’ section was 91%. Engagement by the entire theatre team was measured at 58%. It was proposed to move from a paper checklist to a wall-mounted checklist, to review and refine the items in the checklist and to change the timing of ‘Time Out’ to ensure it was done immediately prior to knife-to-skin.ResultsFollowing its introduction in September 2018, the new wall-mounted checklist was reaudited. Compliance improved to 91% for ‘Sign In’ and to 94% for ‘Time Out’. Engagement by the entire theatre team was achieved 100% of the time. Feedback was collected, adjustments made and the new checklist was rolled out in stages across all theatres. A reaudit in December 2018 showed compliance improved further, to 99% with ‘Sign In’ and to 100% with ‘Time Out’. Engagement was maintained at 100%.ConclusionsThe aim of the project was met and exceeded. Since April 2019, the new checklist is being used across all theatres in the Trust.

scholarly journals Understanding safety in healthcare: the system evolution, erosion and enhancement model

2013 ◽  
Vol 2 (3) ◽  
pp. 25 ◽  
Author(s):  
Jane Carthey
Keyword(s):  
Patient Safety ◽  
Complex Systems ◽  
Human Error ◽  
Improve Patient Safety ◽  
New Model ◽  
System Evolution ◽  
Accident Causation ◽  
System Migration ◽  
Improve Patient

The paper summarises previous theories of accident causation, human error, foresight, resilience and system migration. Five lessons from these theories are used as the foundation for a new model which describes how patient safety emerges in complex systems like healthcare: the System Evolution Erosion and Enhancement model. It is concluded that to improve patient safety, healthcare organisations need to understand how system evolution both enhances and erodes patient safety.

Atmung – Standardisierte Checkliste macht Intubation von Neugeborenen sicherer

2017 ◽  
Vol 22 (03) ◽  
pp. 124-125
Author(s):  
Maria Weiß
Keyword(s):  
Intensive Care Unit ◽  
Patient Safety ◽  
Intensive Care ◽  
Neonatal Intensive Care Unit ◽  
Neonatal Intensive Care ◽  
Improve Patient Safety ◽  
Improve Patient

Hatch LD. et al. Intervention To Improve Patient Safety During Intubation in the Neonatal Intensive Care Unit. Pediatrics 2016; 138: e20160069 Kinder auf der Neugeborenen-Intensivstation sind besonders durch Komplikationen während des Krankenhausaufenthaltes gefährdet. Dies gilt auch für die Intubation, die relativ häufig mit unerwünschten Ereignissen einhergeht. US-amerikanische Neonatologen haben jetzt untersucht, durch welche Maßnahmen sich die Komplikationsrate bei Intubationen in ihrem Perinatal- Zentrum senken lässt.

Allogeneic blood transfusion and AIS surgery: how the NSQIP database can improve patient safety

2021 ◽  
Author(s):  
Hady Eltayeby ◽  
Catherine Brown ◽  
Brendan T. Campbell ◽  
Craig Bonanni ◽  
Mark Indelicato ◽  
...  
Keyword(s):  
Patient Safety ◽  
Blood Transfusion ◽  
Improve Patient Safety ◽  
Allogeneic Blood Transfusion ◽  
Allogeneic Blood ◽  
Improve Patient
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