A system-oriented analysis model to enhance patient safety in healthcare organizations

2009 ◽  
Vol 12 (3) ◽  
pp. 218-232 ◽  
Author(s):  
Sheu-Wen Chuang ◽  
Chung-Yu Pan ◽  
Chin-Yin Huang
Keyword(s):  
Patient Safety ◽  
Analysis Model ◽  
Healthcare Organizations ◽  
Enhance Patient Safety

scholarly journals Malpractice Claimed Calls within the Swedish Healthcare Direct: A Descriptive – Comparative Case Study

2020 ◽  
Author(s):  
Annica Bjorkman ◽  
Maria Engström ◽  
Ulrika Winblad ◽  
Inger K Holmström
Keyword(s):  
Patient Safety ◽  
Medical Errors ◽  
Work Groups ◽  
Healthcare Providers ◽  
Total Sample ◽  
Comparative Case Study ◽  
Healthcare Organizations ◽  
Computerized Decision Support ◽  
Malpractice Claims ◽  
Enhance Patient Safety

Abstract Background: Medical errors are reported as a malpractice claim, and it is of uttermost importance to learn from the errors to enhance patient safety. The Swedish national telephone helpline SHD is staffed by registered nurses; its aim is to provide qualified healthcare advice for all residents of Sweden; it handles about 5 million calls annually. The aim of the present study was twofold: to describe all malpractice claims and healthcare providers’ reported measures regarding calls to Swedish Healthcare Direct (SHD) during the period January 2011-December 2018 and to compare these findings with results from a previous study covering the period 2003-2010.Methods: The study used a descriptive and comparative design. A total sample of all reported malpractice claims regarding calls to SHD (n=35) made during the period 2011-2018 was retrieved. Data were analysed and compared with all reported medical errors during the period 2003-2010 (n=33). Results: Telephone nurses’ failure to follow the computerized decision support system (CDSS) (n=18) was identified as the main reason for error during the period 2011-2018, while failure to listen to the caller (n=12) was the main reason during the period 2003-2010. Staff education (n=21) and listening to one’s own calls (n=16) were the most common measures taken within the organization during the period 2011-2018, compared to discussion in work groups (n=13) during the period 2003-2010.Conclusion: The proportion of malpractice claims in relation to all patient contacts to SHD is still very low; it seems that only the most severe patient injuries are reported. The fact that telephone nurses’ failure to follow the CDSS is the most common reason for error is notable, as SHD and healthcare organizations stress the importance of using the CDSS to enhance patient safety. The healthcare organizations seem to have adopted a more systematic approach to handling malpractice claims regarding calls, e.g., allowing telephone nurses to listen to their own calls instead of having discussions in work groups in response to events. This enables nurses to understand the latent factors contributing to error and provides a learning opportunity.

scholarly journals Malpractice claimed calls within the Swedish Healthcare Direct: a descriptive – comparative case study

BMC Nursing ◽  
2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Annica Björkman ◽  
Maria Engström ◽  
Ulrika Winblad ◽  
Inger K. Holmström
Keyword(s):  
Patient Safety ◽  
Medical Errors ◽  
Work Groups ◽  
Healthcare Providers ◽  
Total Sample ◽  
Comparative Case Study ◽  
Healthcare Organizations ◽  
Computerized Decision Support ◽  
Malpractice Claims ◽  
Enhance Patient Safety

Abstract Background Medical errors are reported as a malpractice claim, and it is of uttermost importance to learn from the errors to enhance patient safety. The Swedish national telephone helpline SHD is staffed by registered nurses; its aim is to provide qualified healthcare advice for all residents of Sweden; it handles normally about 5 million calls annually. The ongoing Covid-19 pandemic have increased call volume with approximate 30%. The aim of the present study was twofold: to describe all malpractice claims and healthcare providers’ reported measures regarding calls to Swedish Healthcare Direct (SHD) during the period January 2011–December 2018 and to compare these findings with results from a previous study covering the period January 2003–December 2010. Methods The study used a descriptive, retrospective and comparative design. A total sample of all reported malpractice claims regarding calls to SHD (n = 35) made during the period 2011–2018 was retrieved. Data were analysed and compared with all reported medical errors during the period 2003–2010 (n = 33). Results Telephone nurses’ failure to follow the computerized decision support system (CDSS) (n = 18) was identified as the main reason for error during the period 2011–2018, while failure to listen to the caller (n = 12) was the main reason during the period 2003–2010. Staff education (n = 21) and listening to one’s own calls (n = 16) were the most common measures taken within the organization during the period 2011–2018, compared to discussion in work groups (n = 13) during the period 2003–2010. Conclusion The proportion of malpractice claims in relation to all patient contacts to SHD is still very low; it seems that only the most severe patient injuries are reported. The fact that telephone nurses’ failure to follow the CDSS is the most common reason for error is notable, as SHD and healthcare organizations stress the importance of using the CDSS to enhance patient safety. The healthcare organizations seem to have adopted a more systematic approach to handling malpractice claims regarding calls, e.g., allowing telephone nurses to listen to their own calls instead of having discussions in work groups in response to events. This enables nurses to understand the latent factors contributing to error and provides a learning opportunity.

Cybersecurity in healthcare: Comparing cybersecurity maturity and experiences across global healthcare organizations (Preprint)

2020 ◽  
Author(s):  
Niki O'Brien ◽  
Guy Martin ◽  
Emilia Grass ◽  
Mike Durkin ◽  
Ara Darzi ◽  
...  
Keyword(s):  
Patient Safety ◽  
Electronic Health Records ◽  
Digital Technology ◽  
Data Security ◽  
Healthcare Organizations ◽  
Health Records ◽  
Cyber Threats ◽  
Raising Awareness ◽  
The World ◽  
Service Disruption

BACKGROUND Health systems around the world are increasingly reliant on digital technology. Such reliance requires that healthcare organizations consider effective cybersecurity and digital resilience as a fundamental component of patient safety, with recent cyberattacks highlighting the risks to patients and targeted organizations. OBJECTIVE The purpose of this study was to explore the current global cybersecurity landscape and maturity in healthcare. METHODS We developed and administered a survey to examine the current cybersecurity landscape and preparedness level across global healthcare organizations. RESULTS Cyber threats were a common concern for the 17 healthcare organizations who participated. The principal concerns highlighted were data security, including the manipulation or loss of electronic health records; loss of trust in the organization; and risks of service disruption. Cybersecurity maturity scoring showed that despite the majority of organizations having established cybersecurity practices, levels of awareness and education were universally poor. CONCLUSIONS Policymakers should consider raising awareness and improving education/training on cybersecurity as a fundamental tenet of patient safety.

scholarly journals Acute care nurses’ perceptions of leadership, teamwork, turnover intention and patient safety – a mixed methods study

BMC Nursing ◽  
2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Shahram Zaheer ◽  
Liane Ginsburg ◽  
Hannah J. Wong ◽  
Kelly Thomson ◽  
Lorna Bain ◽  
...  
Keyword(s):  
Patient Safety ◽  
Mixed Methods ◽  
Turnover Intention ◽  
Interactive Effect ◽  
Mixed Methods Study ◽  
Senior Leadership ◽  
Healthcare Organizations ◽  
Staff Perceptions ◽  
Leadership Support ◽  
The Impact

Abstract Background This study contributes to a small but growing body of literature on how context influences perceptions of patient safety in healthcare settings. We examine the impact of senior leadership support for safety, supervisory leadership support for safety, teamwork, and turnover intention on overall patient safety grade. Interaction effects of predictors on perceptions of patient safety are also examined. Methods In this mixed methods study, cross-sectional survey data (N = 185) were collected from nurses and non-physician healthcare professionals. Semi-structured interview data (N = 15) were collected from nurses. The study participants worked in intensive care, general medicine, mental health, or the emergency department of a large community hospital in Southern Ontario. Results Hierarchical regression analyses showed that staff perceptions of senior leadership (p < 0.001), teamwork (p < 0.01), and turnover intention (p < 0.01) were significantly associated with overall patient safety grade. The interactive effect of teamwork and turnover intention on overall patient safety grade was also found to be significant (p < 0.05). The qualitative findings corroborated the survey results but also helped expand the characteristics of the study’s key concepts (e.g., teamwork within and across professional boundaries) and why certain statistical relationships were found to be non-significant (e.g., nurse interviewees perceived the safety specific responsibilities of frontline supervisors much more broadly compared to the narrower conceptualization of the construct in the survey). Conclusions The results of the current study suggest that senior leadership, teamwork, and turnover intention significantly impact nursing staff perceptions of patient safety. Leadership is a modifiable contextual factor and resources should be dedicated to strengthen relational competencies of healthcare leaders. Healthcare organizations must also proactively foster inter and intra-professional collaboration by providing teamwork educational workshops or other on-site learning opportunities (e.g., simulation training). Healthcare organizations would benefit by considering the interactive effect of contextual factors as another lever for patient safety improvement, e.g., lowering staff turnover intentions would maximize the positive impact of teamwork improvement initiatives on patient safety.

Critical Values in Anatomic Pathology

2006 ◽  
Vol 130 (5) ◽  
pp. 638-640 ◽  
Author(s):  
Jan F. Silverman ◽  
Telma C. Pereira
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Clinical Pathology ◽  
Critical Values ◽  
Surgical Pathology ◽  
Anatomic Pathology ◽  
Wide Range ◽  
Enhance Patient Safety ◽  
Pathology Reports ◽  
Improve Patient

Abstract Similar to critical values (CVs) in clinical pathology, occasional diagnoses in surgical pathology and cytology could require immediate notification of the physician to rapidly initiate treatment. However, there are no established CV guidelines in anatomic pathology. A retrospective review of surgical pathology reports was recently conducted to study the incidence of CVs in surgical pathology and to survey the perceptions of pathologists and clinicians about CVs in surgical pathology, with a similar analysis of CVs performed in cytology. The results indicated that CVs in surgical pathology and cytology are uncommon but not rare and that there is a wide range of opinion among pathologists and between pathologists and clinicians about the need for an immediate telephone call and about the degree of urgency. It was obvious from the study that there is a lack of consensus in identifying what constitutes surgical pathology and cytology CV cases. Since the Institute of Medicine's report on medical errors, there has been an increasing number of initiatives to improve patient safety. Having guidelines for anatomic pathology CVs could enhance patient safety, in contrast to the current practice in which CV cases are managed based on common sense and on personal experience. Therefore, a discussion involving the pathology community might prove useful in an attempt to establish anatomic pathology CV guidelines that could represent a practice improvement.

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