Patient Safety Improvement Related to Repeat Irradiation Identified With Near-Miss Incident Reporting

Purpose Patient safety remains a top priority in healthcare. Many organizations have developed systems to monitor and prevent harm, and have invested in different approaches to quality improvement. Despite these organizational efforts to better detect adverse events, efficient resolution of safety problems remains a significant challenge. The authors developed and implemented a comprehensive multimodal patient safety improvement program called SafetyLEAP. The term “LEAP” is an acronym that highlights the three facets of the program including: a Leadership and Engagement approach; Audit and feedback; and a Planned improvement intervention. The purpose of this paper is to evaluate the implementation of the SafetyLEAP program in the intensive care units (ICUs) of three large hospitals. Design/methodology/approach A comparative case study approach was used to compare and contrast the adherence to each component of the SafetyLEAP program. The study was conducted using a convenience sample of three (n=3) ICUs from two provinces. Two reviewers independently evaluated major adherence metrics of the SafetyLEAP program for their completeness. Analysis was performed for each individual case, and across cases. Findings A total of 257 patients were included in the study. Overall, the proportion of the SafetyLEAP tasks completed was 64.47, 100, and 26.32 percent, respectively. ICU nos 1 and 2 were able to identify opportunities for improvement, follow a quality improvement process and demonstrate positive changes in patient safety. The main factors influencing adherence were the engagement of a local champion, competing priorities, and the identification of appropriate resources. Practical implications The SafetyLEAP program allowed for the identification of processes that could result in patient harm in the ICUs. However, the success in improving patient safety was dependent on the engagement of the care teams. Originality/value The authors developed an evidence-based approach to systematically and prospectively detect, improve, and evaluate actions related to patient safety.

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Multidisciplinary guidance for safe tracheostomy care during the COVID‐19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP)

Anaesthesia ◽

10.1111/anae.15120 ◽

2020 ◽

Vol 75 (12) ◽

pp. 1659-1670 ◽

Cited By ~ 12

Author(s):

B. A. McGrath ◽

N. Ashby ◽

M. Birchall ◽

P. Dean ◽

C. Doherty ◽

...

Keyword(s):

Patient Safety ◽

Safety Improvement ◽

National Patient ◽

Improvement Programme ◽

Patient Safety Improvement

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Responding to adverse patient safety events in Viet Nam

BMC Health Services Research ◽

10.1186/s12913-019-4518-y ◽

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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