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

2017 ◽  
Vol 26 (4) ◽  
pp. 272-277 ◽  
Author(s):  
Elizabeth A. Henneman
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Eye Tracking ◽  
Medical Errors ◽  
Improve Patient Safety ◽  
Safety Net ◽  
Near Miss ◽  
The Impact ◽  
Risk Processes ◽  
Insight Into

The Institute of Medicine (now National Academy of Medicine) reports “To Err is Human” and “Crossing the Chasm” made explicit 3 previously unappreciated realities: (1) Medical errors are common and result in serious, preventable adverse events; (2) The majority of medical errors are the result of system versus human failures; and (3) It would be impossible for any system to prevent all errors. With these realities, the role of the nurse in the “near miss” process and as the final safety net for the patient is of paramount importance. The nurse’s role in patient safety is described from both a systems perspective and a human factors perspective. Critical care nurses use specific strategies to identify, interrupt, and correct medical errors. Strategies to identify errors include knowing the patient, knowing the plan of care, double-checking, and surveillance. Nursing strategies to interrupt errors include offering assistance, clarifying, and verbally interrupting. Nurses correct errors by persevering, being physically present, reviewing/confirming the plan of care, or involving another nurse or physician. Each of these strategies has implications for education, practice, and research. Surveillance is a key nursing strategy for identifying medical errors and reducing adverse events. Eye-tracking technology is a novel approach for evaluating the surveillance process during common, high-risk processes such as blood transfusion and medication administration. Eye tracking has also been used to examine the impact of interruptions to care caused by bedside alarms as well as by other health care personnel. Findings from this safety-related eye-tracking research provide new insight into effective bedside surveillance and interruption management strategies.

scholarly journals Teamwork Conflicts; Medical Errors and Patient Safety as Perceived by Nurses: A Cross-Sectional Study of Selected Hospitals in Hail City; Saudi Arabia

2021 ◽  
pp. 35-45
Author(s):  
Hamoud F. Alshammari ◽  
Fahad D. Algahtan ◽  
Bandar Alsaedi ◽  
Badr K. Aldhmadi ◽  
Richard D. Dayrit
Keyword(s):  
Risk Factors ◽  
Saudi Arabia ◽  
Patient Safety ◽  
Medical Errors ◽  
Medical Staff ◽  
Improve Patient Safety ◽  
Health Care Systems ◽  
Rank Correlation ◽  
Cross Sectional ◽  
The Impact

Patient safety is a global problem and one of the key elements of the quality of health care systems. The human factor is a major risk factor leading to medical errors that affect patient safety. To explore the impact of this factor on patient safety in the hospitals located in the Ha'il city in Saudi Arabia; the perceptions of nurses working in governmental hospitals were assessed using a self-structured questionnaire. Descriptive statistics were presented for the studied variables. Significant differences between the categories of the respondents’ characteristics in relation to risk factors were assessed using the Mann-Whitney test; the Kruskal-Wallis and the Spearman rank correlation test. Only 50% of the factors tested were perceived as moderate risk factors that were negatively affecting patient safety in Ha'il hospitals; namely: ‘Poor teamwork among medical staff’; ‘Unqualified medical staff’ and ‘Miscommunication among medical staff’. The substantial differences among demographic characteristics of the study sample in relation to the human resources risk factors causing medical errors was identified at P<0.05. Although the human risk factors were ranked as low to moderate; attention to and concern for all risk factors is needed by policymakers and hospital managers in order to improve patient safety in the healthcare settings in the Ha'il city in KSA.

Hospital Nurses’ Intention to Report Near Misses, Patient Safety Culture and Professional Seniority

2021 ◽  
Author(s):  
Orly Toren ◽  
Dokhi Mohanad ◽  
Freda DeKeyser Ganz
Keyword(s):  
Patient Safety ◽  
Safety Culture ◽  
Medical Errors ◽  
Improve Patient Safety ◽  
Patient Safety Culture ◽  
Team Work ◽  
Near Miss ◽  
Institute Of Medicine ◽  
Near Misses ◽  
The Relationship

Abstract Background Preventable medical errors are the third cause of death after cancer and heart disease. The first step in coping with medical errors in the healthcare system is to develop a culture of patient safety. Reporting medical errors, especially near misses, is one of the chosen methods of dealing with patient safety issues, recommended by the Institute of Medicine. Despite this recommendation, few studies examined the relationship between reporting near misses and improvements in patient safety culture. Intention to report a near miss event is another means to understand the phenomena of reporting, but no studies were found that included this variable and its relationship to safety culture. The aims of this study were to determine the extent nurses reported near miss events; to describe the relationship between patient safety culture, professional seniority and intention to report near misses; and to determine predictors of intention to report near miss events. Methods This was a descriptive cross-sectional study, based on the Hospital Survey on Patient Safety (HSOPS). The target population was ICU and inpatient ward nurses working in general hospitals. The sampling method was cluster convenience sampling. Statistical analysis included descriptive and predictive analyses. Results The sample included 227 nurses. Most nurses rated the patient safety culture components as moderately positive. Approximately 80% stated their intention to report a near miss, however 52.4% indicated that they did not report a near miss event in the past year. A positive correlation was found between all components of the patient safety culture and the intention to report a near miss event. Professional seniority was not related to any safety culture components or intention to report a near-miss event. Three variables predicted intention to report: team work, feedback and communication about errors, and the amount of near misses reported in the last year. Conclusions There is a discrepancy between what nurses describe as their intent to report a near miss event and their actual reporting of an event. Components of safety culture, especially communication openness, teamwork and reported near misses in the last year are significant predictors of the intent to report. Therefore, reinforcement of these components should be encouraged at the policy level to enable nurses to report near misses and thus improve patient safety.

scholarly journals Nurses’ perception of patient safety culture and its relationship with adverse events: a national questionnaire survey in Iran

BMC Nursing ◽  
2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Edris Kakemam ◽  
Hojatolah Gharaee ◽  
Mohamad Reza Rajabi ◽  
Milad Nadernejad ◽  
Zahra Khakdel ◽  
...  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Safety Culture ◽  
Improve Patient Safety ◽  
Patient Safety Culture ◽  
Teaching Hospitals ◽  
Management Support ◽  
Cross Sectional Survey ◽  
Nurses Perceptions ◽  
The Impact

Abstract Background Patient safety culture is an important factor in determining hospitals’ ability to address and reduce the occurrence of adverse events (AEs). However, few studies have reported on the impact of nurses’ perceptions of patient safety culture on the occurrence of AEs. Our study aimed to assess the association between nurses’ perception of patient safety culture and their perceived proportion of adverse events. Methods A cross-sectional survey was carried out among 2295 nurses employed in thirty-two teaching hospitals in Iran. Nurses completed the Persian version of the hospital survey of patients’ safety culture between October 2018 and September 2019. Results Positive Response Rates of overall patient safety culture was 34.1% and dimensions of patient safety culture varied from 20.9 to 43.8%. Also, nurses estimated that the occurrence of six adverse events varied from 51.2–63.0% in the past year. The higher nurses’ perceptions of “Staffing”, “Hospital handoffs and transitions”, “Frequency of event reporting”, “Non-punitive response to error”, “Supervisor expectation and actions promoting safety”, “Communication openness”, “Organizational learning continuous improvement”, “Teamwork within units”, and “Hospital management support patient safety” were significantly related to lower the perceived occurrence at least two out of six AEs (OR = 0.69 to 1.46). Conclusions Our findings demonstrated that nurses’ perception regarding patient safety culture was low and the perceived occurrence of adverse events was high. The research has also shown that the higher level of nurses’ perception of patient safety culture was associated with lowered occurrence of AEs. Hence, managers could provide prerequisites to improve patient safety culture and reduce adverse events through different strategies, such as encouraging adverse events’ reporting and holding training courses for nurses. However, further research is needed to assess how interventions addressing patient safety culture might reduce the occurrence of adverse events.

scholarly journals Assessment of patient safety culture in intensive care units and factors affecting it

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
M A Tlili ◽  
W Aouicha ◽  
H Lamine ◽  
E Taghouti ◽  
M B e n Dhiab ◽  
...  
Keyword(s):  
Patient Safety ◽  
Intensive Care ◽  
Adverse Events ◽  
Intensive Care Units ◽  
Safety Culture ◽  
Improve Patient Safety ◽  
Healthcare Quality ◽  
Patient Safety Culture ◽  
Cross Sectional ◽  
Learning From Errors

Abstract Background The intensive care units are a high-risk environments for the occurrence of adverse events with serious consequences. The development of patient safety culture is a strategic focus to prevent these adverse events and improve patient safety and healthcare quality. This study aimed to assess patient safety culture in Tunisian intensive care units and to determine its associated factors. Methods It is a multicenter, descriptive cross-sectional study, among healthcare professionals of the intensive care units in the Tunisian center. The data collection was spread over a period of 2 months (October-November 2017). The measuring instrument used is the validated French version of the Hospital Survey On Patient Safety Culture questionnaire. Data entry and analysis was carried out by the Statistical Package for Social Sciences (SPSS 20.0) and Epi Info 6.04. Chi-square test was used to explore factors associated with patient safety culture. Results A total of 404 professionals participated in the study with a participation rate of 81.94%, spread over 10 hospitals and 18 units. All dimensions were to be improved. The overall perception of safety was 32.35%. The most developed dimension was teamwork within units with a score of 47.87% and the least developed dimension was the non-punitive response to error (18.6%). The patient safety culture was significantly more developed in private hospitals in seven of the 10 dimensions. Participants working in small units had a significantly higher patient safety culture. It has been shown that when workload is reduced the patient safety culture was significantly increased. Conclusions This study has shown that the patient safety culture still needs to be improved and allowed a clearer view of the safety aspects requiring special attention. Thus, improving patient safety culture. by implementing the quality management and error reporting systems could contribute to enhance the quality of healthcare provided to patients. Key messages The culture of culpability is the main weakness in the study. Encouraging event reporting and learning from errors s should be priorities in hospitals to enhance patient safety and healthcare quality.

scholarly journals Second life in healthcare education: Virtual environment's potential to improve patient safety

2011 ◽  
pp. 17-23
Keyword(s):  
Patient Safety ◽  
Virtual Environments ◽  
Virtual Environment ◽  
Medical Errors ◽  
Second Life ◽  
Healthcare Professionals ◽  
Improve Patient Safety ◽  
Healthcare Education ◽  
Healthcare Profession ◽  
Improve Patient

Research has shown that a large portion of healthcare cost is due to medical errors. There are many factors that cause medical errors but one major factor is linked to healthcare professionals who are not adequately trained with the appropriate skills. Virtual environments and simulations are being used to help improve training in many different areas, including the healthcare profession. This paper explores the usage of Second Life in healthcare education and its ability to improve patient safety. The conclusion is that much progress and development still needs to be made before Second Life will make a significant impact on improved patient safety through healthcare education. There is a need to make the virtual environment more realistic to adequately train healthcare professionals.

scholarly journals The Impact of Patient Safety Climate on Medical Errors in a Sample of Nurses: Creating Safer Health Care.

Health Scope ◽  
2013 ◽  
Vol 1 (4) ◽  
Author(s):  
Seyed Bagher Mortazavi ◽  
Morteza Oostakhan ◽  
Amirabbas Mofidi ◽  
Aliakbar Babaei
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Medical Errors ◽  
Safety Climate ◽  
Patient Safety Climate ◽  
The Impact

Application of Bow-tie methodology to improve patient safety

2016 ◽  
Vol 29 (4) ◽  
pp. 425-440 ◽  
Author(s):  
Zhaleh Abdi ◽  
Hamid Ravaghi ◽  
Mohsen Abbasi ◽  
Bahram Delgoshaei ◽  
Somayeh Esfandiari
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Blood Stream Infection ◽  
Improve Patient Safety ◽  
Blood Stream ◽  
Clinical Settings ◽  
Content Type ◽  
Clinical Risks ◽  
Improve Patient ◽  
Bow Tie

Purpose – The purpose of this paper is to apply Bow-tie methodology, a proactive risk assessment technique based on systemic approach, for prospective analysis of the risks threatening patient safety in intensive care unit (ICU). Design/methodology/approach – Bow-tie methodology was used to manage clinical risks threatening patient safety by a multidisciplinary team in the ICU. The Bow-tie analysis was conducted on incidents related to high-alert medications, ventilator associated pneumonia, catheter-related blood stream infection, urinary tract infection, and unwanted extubation. Findings – In total, 48 potential adverse events were analysed. The causal factors were identified and classified into relevant categories. The number and effectiveness of existing preventive and protective barriers were examined for each potential adverse event. The adverse events were evaluated according to the risk criteria and a set of interventions were proposed with the aim of improving the existing barriers or implementing new barriers. A number of recommendations were implemented in the ICU, while considering their feasibility. Originality/value – The application of Bow-tie methodology led to practical recommendations to eliminate or control the hazards identified. It also contributed to better understanding of hazard prevention and protection required for safe operations in clinical settings.

Research Methods, Statistics, Patient Safety, and Quality Improvement

2020 ◽  
pp. 521-530
Author(s):  
Carlos Lerner
Keyword(s):  
Patient Safety ◽  
Quality Improvement ◽  
Adverse Events ◽  
Research Methods ◽  
Confidence Intervals ◽  
Medical Errors ◽  
Likelihood Ratios ◽  
Predictive Values ◽  
Analysis Of Variation ◽  
Answer Format

The chapter on research methods, statistics, patient safety, and quality improvement (QI) uses a question-and-answer format to make concepts in these areas relevant and accessible to general pediatricians. Research topics covered include study design and study types, validity, sources of bias, types of errors, sensitivity and specificity, positive and negative predictive values, likelihood ratios, incidence and prevalence, p values and confidence intervals. The patient safety questions focus on medical errors and adverse events, including their categorization, detection, prevention, and disclosure. Finally, the QI questions address key QI principles and methods, including tools to understand systems (e.g. fishbone diagrams and Pareto charts), analysis of variation, and the Langley Model for Improvement.

Description of a pharmacist-driven safety algorithm in Staphylococcus aureus bacteremia: Compliance, interventions, and good saves

2020 ◽  
Vol 41 (8) ◽  
pp. 921-925
Author(s):  
Tara H. Lines ◽  
Whitney J. Nesbitt ◽  
Matthew H. Greene ◽  
George E. Nelson
Keyword(s):  
Staphylococcus Aureus ◽  
Adverse Events ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
Safety Net ◽  
Definitive Therapy ◽  
Before And After ◽  
Bundle Compliance ◽  
The Impact ◽  
Major Adverse Events

AbstractObjective:To evaluate the impact of a pharmacist-driven Staphylococcus aureus bacteremia (SAB) safety bundle supported by leadership and to compare compliance before and after implementation.Design:Retrospective cohort study with descriptive and before-and-after analyses.Setting:Tertiary-care academic medical center.Patients:All patients with documented SAB, regardless of the source of infection, were included. Patients transitioned to palliative care were excluded from before-and-after analysis.Methods:A pharmacist-driven safety bundle including documented clearance of bacteremia, echocardiography, removal of central venous catheters, and targeted intravenous therapy of at least 2 weeks duration was implemented in November 2015 and was supported by leadership with stepwise escalation for nonresponse. A descriptive analysis of all patients with SAB during the study period included pharmacy interventions, acceptance rates, and escalation rates. A pre–post implementation analysis of 100 sequential patients compared bundle compliance and descriptive parameters.Results:Overall, 391 interventions were made in the 20-month period following implementation, including 20 “good saves” avoiding potentially major adverse events. No statistically significant differences in complete bundle compliance were detected between the periods (74% vs 84%; P = .08). However, we detected a significant increase in echocardiography after the bundle was implemented (83% vs 94%; P = .02) and fewer patients received suboptimal definitive therapy after the bundle was implemented (10% vs 3%; P = .045).Conclusions:This pharmacist-driven SAB safety bundle with leadership support showed improvement in process measures, which may have prevented major adverse events, even with available infectious diseases (ID) consultation. It provides a critical safety net for institutions without mandatory ID consultation or with limited antimicrobial stewardship resources.

scholarly journals Responding to adverse patient safety events in Viet Nam

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Reema Harrison ◽  
Anurag Sharma ◽  
Merrilyn Walton ◽  
Esmond Esguerra ◽  
Seinyenede Onobrakpor ◽  
...  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Physical Health ◽  
Psychological Health ◽  
Health Professionals ◽  
Incident Reporting ◽  
Near Miss ◽  
Viet Nam ◽  
Organisational Support ◽  
Doctors And Nurses

Abstract Background The psychological and professional impact of adverse events on doctors and nurses is well-established, but limited data has emerged from low- and middle-income. This article reports the experiences of being involved in a patient safety event, incident reporting and organisational support available to assist health professionals in Viet Nam to learn and recover. Method Doctors and nurses (1000) from all departments of a 1500-bed surgical and trauma hospital in Viet Nam were invited to take part in a cross-sectional survey. The survey explored respondents’ involvement in adverse events and/or near miss, their emotional, behavioural and coping responses, experiences of organisational incident reporting, and the learning and/or other consequences of the event. Survey items also assessed the availability of organisational support including peer support and mentorship. Results Of the 497 respondents, 295 (59%) experienced an adverse event in which a patient was harmed, of which 86 (17%) resulted in serious patient harm. 397 (80%) of respondents experienced a near miss, with 140 of these (28%) having potential for serious harm. 386 (77%) reporting they had been affected professionally or personally in some way, with impacts to psychological health (416; 84%), physical health (388; 78%), job satisfaction (378; 76%) and confidence in their ability (276; 56%) commonly reported. Many respondents were unable to identify local improvements (373; 75%) or organisation-wide improvements following safety events (359; 72%) and 171 (34%) admitted that they had not reported an event to their organisation or manager that they should have. Conclusions Health professionals in Viet Nam report impacts to psychological and physical health as a result of involvement in safety events that reflect those of health professionals internationally. Reports of limited organisational learning and improvement following safety events suggest that patient safety culture is underdeveloped in Viet Nam currently. In order to progress work on patient safety cultures and incident reporting in Viet Nam, health professionals will need to be convinced not only that they will not be exposed to punitive action, but that learning and positive changes will occur as a result of reporting safety events.

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