Top four types of sentinel events in Saudi Arabia during the period 2016–19

2021 ◽  
Vol 33 (1) ◽  
Author(s):  
Nasser Altalhi ◽  
Haifa Alnaimi ◽  
Mafaten Chaouali ◽  
Falaa Alahmari ◽  
Noor Alabdulkareem ◽  
...  
Keyword(s):  
Health Care ◽  
Saudi Arabia ◽  
Patient Safety ◽  
Reporting System ◽  
Improve Patient Safety ◽  
Health Care Facilities ◽  
Common Root ◽  
Private Hospitals ◽  
Care Facilities ◽  
Sentinel Events

Abstract Background This study discusses the summary, investigation and root causes of the top four sentinel events (SEs) in Saudi Arabia (SA) that occurred between January 2016 and December 2019, as reported by the Ministry of Health (MOH) and private hospitals through the MOH SE reporting system (SERS). It is intended for use by legislators, health-care facilities and the public to shed light on areas that still need improvement to preserve patient safety. Objectives The purpose of this study is to review the most common SEs reported by the MOH and private hospitals between the years 2016 and 2019 to assess the patterns and identify risk areas and the common root causes of these events in order to promote country-wide learning and support services that can improve patient safety. Methods In this retrospective descriptive study, the data were retrieved from the SERS, which routinely collects records from both MOH and private hospitals in SA. SEs were analyzed by type of event, location, time, patient demographics, outcome and root causes. Results There were 727 SEs during this period, 38.4% of which were under the category of unexpected patient death, 19.4% under maternal death, 11.7% under unexpected loss of limb or function and 9.9% under retained instruments or sponge. Common root causes were related to policies and procedures, guidelines, miscommunication between health-care facilities, shortage of staff and lack of competencies. Conclusion Given these results, efforts should focus on improving the care of deteriorating patients in general wards, ICU (Intensive Care Units) admission/discharge criteria and maternal, child and surgical safety. The results also highlighted the problem of underreporting of SEs, which needs to be addressed and improved. Linking data sources such as claims and patient complaints databases and electronic medical records to the national reporting system must also be considered to ensure an optimal estimation of the number of events.

scholarly journals Nursing Leadership Models in Promoting and Improving Patient’s Safety Culture in Healthcare Facilities; A Systematic Review

2020 ◽  
Author(s):  
Yodang Yodang ◽  
Nuridah Nuridah
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Safety Culture ◽  
Improve Patient Safety ◽  
Patient Safety Culture ◽  
Nursing Leadership ◽  
Health Care Facilities ◽  
Leadership Models ◽  
Care Facilities ◽  
Improve Patient

Background: Nurse leader has an important role in encouraging patient’s safety culture among nurses in the healthcare system. This literature review aims to identify the nursing leadership model and to promote and improve patient safety culture to improve patient outcomes in health care facilities including hospitals, primary health care, and nursing home settings. Methods: Searching appropriate journals through some journal databases were applied including DOAJ, GARUDA, Google Scholar, MDPI, Proquest, Pubmed, Sage Journals, ScienceDirect, and Wiley Online Library, which were published from 2015 to 2020. Results: Fourteen articles meet the criteria and are included in this review. The majority of these articles were retrieved from western countries, the US, Canada, and Finland. This review identifies three nursing leadership models that seem useful to promote and improve patient safety culture in health care facilities which are transformational, authentic, and ethical leadership models. Conclusion: The patient safety influences health care outcomes. The evidence shows the leadership has positive relation to patient satisfaction and patient safety outcomes improvement. The transformational, authentic, and ethical leadership models seem to be more useful in promoting, maintaining, and improving patient safety culture in health care facilities.  

Involving Nonclinical Departments in Patient Safety Discussions can Reduce the Risk of Serious Errors; “40 of K” is Not OK; NDC Number ID of Compounded Prescription Ingredient Leads to Error; Topamax-Toprol XL Mix-Up

2002 ◽  
Vol 37 (11) ◽  
pp. 1140-1146
Author(s):  
Michael R. Cohen
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Medication Errors ◽  
Training Programs ◽  
Health Care Facilities ◽  
Inservice Training ◽  
Safe Medication ◽  
Care Facilities ◽  
Procedural Safeguards

These medication errors have occurred in health care facilities at least once. They will happen again–perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

scholarly journals Patient safety culture in health care facilities in Ukraine (message 1)

2021 ◽  
Vol 26 (3) ◽  
pp. 179-187
Author(s):  
A.P. Yavorovsky ◽  
M.M. Rygan ◽  
A.N Naumenko ◽  
Yu.N. Skaletsky ◽  
S.G. Gichka ◽  
...  
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Opportunity To Learn ◽  
Patient Safety Culture ◽  
The United States ◽  
Health Care Facilities ◽  
Alpha Coefficient ◽  
Length Of Service ◽  
Care Facilities ◽  
Comparison Groups

Using a questionnaire from the United States Agency for Research and Quality in Health Care (AHRQ), the characteristics of patient safety (PS) culture in the staff of various health care facilities (HCF) in Ukraine were analyzed. In addition, the characteristics of PS culture were analyzed depending on the length of service and affiliation of the respondents to the medical or nursing staff, as well as the profile of therapeutic or surgical activities. It is established that the weakness of the PS culture of the staff of domestic HCF is "Reaction to mistakes" (less than 30% of positive responses), which indicates the predominance of culture of accusation (unfair culture) in Ukrainian HCF and as a consequence fears of the staff to disclose mistakes and accordingly, the lack of opportunity to learn from these mistakes.“Staffing” is identified as a weakness of the PS culture (less than 50% of positive responses) in most comparison groups. It is worth noting such a characteristic of the culture of BP, as the "Frequency of error messages" (less than 70% of positive responses). The Cronbach's alpha coefficient in all groups of respondents ranged from 0.62 to 0.78, which indicates the truth of the results of the study.

scholarly journals Knowledge and Practices of Doctors About Patient Safety Working at Primary and Secondary Level Health Care Facilities in Bangladesh

2019 ◽  
Vol 38 (1) ◽  
pp. 5-11
Author(s):  
MHK Talukdera ◽  
Rumana Nazneen ◽  
S ABDULLA SA
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Medical Errors ◽  
Clinical Teaching ◽  
Secondary Level ◽  
Health Care Facilities ◽  
Cross Sectional ◽  
Primary Level ◽  
Ensure Patient Safety ◽  
Care Facilities

Aim: This descriptive type of cross sectional study was conducted with an objective to evaluate the views of doctors regarding knowledge and practices about patient safety working at primary and secondary level health care facilities in Bangladesh. Methods: Study period was from August 2016 to December 2016. Multistage, convenience sampling was done . Sample size was 550. Self administered semi structured questionnaire was used for data collection after pre testing. Data was collected by principle investigator , co-investigator & data collectors. Data was also collected by sending questionnaire by postage followed by a focal group discussion. Results: Result showed 70 % were male and 57% were primary level medical officers. 44.9% understands patients safety. 51.1% understands medical errors . 37.5% agreed that less duty hours will reduce medical errors . 62% strongly agreed that Learning about patient safety will enhance competency. 44.5% agreed that undergraduate course prepared them to ensure patient safety. 37.5 % agreed that they learned about medical errors during their undergraduate course. 40.6% stated that they were assigned to perform the tasks for which they were not trained competently, 34% said that they were assigned to perform the tasks which could have resulted easily in medical errors . Most of the respondents strongly agreed that teaching about patient safety should be an important priority. 46% stated that these should be in clinical teaching and 40% stated the same to be in bed side teaching . 24% stated that there were not enough topics in the existing curriculum regarding patient safety. 46% confessed that they made medical errors during their practices. 33% stated that they want patient safety education in their professional practice, 76.9% strongly agreed that patient safety is an important issue in their professional practices and 44% sensitizes their colleagues about patient safety to learn & practices. 54.7% stated that they did not have error reporting system/ death review/ medical audit in their hospital, 89.7% did not have attended any training on patient safety . 90% thought that training on patient safety is essential for doctors 67.2% respondents opined that there should be a competent organization / body who can take care of patient safety & medical errors in Bangladesh. Conclusion: The study reflects that many primary level medical officers do not understand patients safety and medical errors. The study also showed that most of them has a positive attitude torwards patient safety. Study recommended that doctors serving at primary and secondary level healthcare facilities to be oriented/ trained on different aspects of patient safety J Bangladesh Coll Phys Surg 2020; 38(1): 5-11

scholarly journals A comparative analysis on safety culture in domestic and foreign health care facilities and enterprises of other activities (message 2)

2021 ◽  
Vol 26 (4) ◽  
pp. 153-160
Author(s):  
A.P. Yavorovsky ◽  
M.M. Rygan ◽  
A.N. Naumenko ◽  
Yu.N. Skaletsky ◽  
S.G. Gichka ◽  
...  
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Safety Culture ◽  
Nuclear Power ◽  
Power Plants ◽  
Nuclear Power Plants ◽  
Real Data ◽  
Health Care Facilities ◽  
Hospital Environment ◽  
Care Facilities

The characteristics of the safety culture of patients and personnel in health care facilities in Ukraine as a whole and separately among doctors-pathologists are analyzed with correlation of the data obtained with similar indicators of the culture of patient safety in medical facilities of other countries and comparison with the safety culture of workers of domestic nuclear power plants. It was confirmed that the weaknesses of the safety culture of the personnel of domestic hospitals is characterized by "Reaction to mistakes", which indicates the prevalence of the culture of blame (unfair culture) in domestic hospitals and, as a result, the absence of real data on medical errors and other incidents of patient safety. The high percentage of positive responses to the safety culture characteristic “Response to mistakes” among the workers of Ukrainian nuclear power plants is an example of the possibility of forming an appropriate safety culture in a separate domestic industry, and the high percentage of positive answers by this characteristic in domestic pathologists is a significant potential for the development of a safe hospital environment for patients. in Ukraine.

Sometimes Things Get Lost in Translation New Color Code for 25 Gauge Safety Needles may Lead to Confusion and Errors New Tools that Address Pharmacy Issues Related to Patient Safety Intra-arterial Lines Can Unwittingly Furnish a Route for Medications Intended for IV Administration

2003 ◽  
Vol 38 (5) ◽  
pp. 412-415
Author(s):  
Michael R. Cohen
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Medication Errors ◽  
Training Programs ◽  
Health Care Facilities ◽  
Inservice Training ◽  
Color Code ◽  
Safe Medication ◽  
Care Facilities ◽  
Lost In Translation

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800–233–7767 (800–23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

scholarly journals Design and Testing of BACRA, a Web-Based Tool for Middle Managers at Health Care Facilities to Lead the Search for Solutions to Patient Safety Incidents

2016 ◽  
Vol 18 (9) ◽  
pp. e257 ◽  
Author(s):  
Irene Carrillo ◽  
José Joaquín Mira ◽  
Maria Asuncion Vicente ◽  
Cesar Fernandez ◽  
Mercedes Guilabert ◽  
...  
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Middle Managers ◽  
Health Care Facilities ◽  
Web Based ◽  
Care Facilities ◽  
Design And Testing ◽  
Patient Safety Incidents
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