scholarly journals Learning from errors for continuously improving patient safety

2018 ◽  
Vol 30 (6) ◽  
pp. 493-493
Author(s):  
CHIH-WEI HUANG ◽  
USMAN IQBAL ◽  
YU-CHUAN (JACK) LI
Keyword(s):  
Patient Safety ◽  
Learning From Errors

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 Surgical learning and guidance on operative risks and potential errors

2017 ◽  
Vol 29 (5) ◽  
pp. 326-342 ◽  
Author(s):  
Minna Ruoranen ◽  
Teuvo Antikainen ◽  
Anneli Eteläpelto
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Hospital Environment ◽  
Surgical Operation ◽  
Learning From Errors ◽  
Content Type ◽  
Surgical Residents ◽  
Context Of Learning ◽  
Surgical Learning ◽  
Surgical Operations

Purpose Within the framework of learning from errors, this study focused on how operative risks and potential errors are addressed in guidance to surgical residents during authentic surgical operations. The purpose of this paper is to improve patient safety and to diminish medical complications resulting from possible operating errors. Further in the process of the optimal contexts for instruction aimed at preventing risks and errors in the practical hospital environment was evaluated. Design/methodology/approach The five authentic surgical operations were analyzed, all of which were organized as training sessions for surgical residents. The data (collected via video-recoding) were analyzed by a consultant surgeon and an education expert working together. Findings The results showed that the risks and potential errors in the surgical operations were rarely addressed in guidance during operations. The guidance provided mostly concerned technical issues, such as instrument handling, and exploration of critical anatomical structures. There was little guidance focusing on situation-based risks and potential errors, such as unexpected procedural challenges, teamwork and practical decision-making. The findings showed that optimal context of learning about risks and potential errors of surgical operation are not always the authentic operation context. Originality/value The study was conducted in an authentic surgical operation-cum-training context. The originality of the study derives from its focus on guidance related to risk and error prevention in surgical workplace learning. The findings can be used to create a meaningful learning environment – including powerful guidance – for practice-based surgical learning, maximally addressing patient safety, but giving possibilities also for other training options.

scholarly journals Healthcare Professional’s Perception of Patient Safety Measured by the Hospital Survey on Patient Safety Culture: A Systematic Review and Meta-Analysis

2018 ◽  
Vol 2018 ◽  
pp. 1-11 ◽  
Author(s):  
Julia Hiromi Hori Okuyama ◽  
Tais Freire Galvao ◽  
Marcus Tolentino Silva
Keyword(s):  
Patient Safety ◽  
Safety Culture ◽  
Meta Analysis ◽  
Patient Safety Culture ◽  
The United States ◽  
Three Dimensions ◽  
Asian Continent ◽  
Learning From Errors ◽  
Event Reporting ◽  
Arcsine Transformation

Objective.To assess the culture of patient safety in studies that employed the hospital survey on patient safety culture (HSOPS) in hospitals around the world.Method.We searched MEDLINE, EMBASE, SCOPUS, CINAHL, and SciELO. Two researchers selected studies and extracted the following data: year of publication, country, percentage of physicians and nurses, sample size, and results for the 12 HSOPS dimensions. For each dimension, a random effects meta-analysis with double-arcsine transformation was performed, as well as meta-regressions to investigate heterogeneity, and tests for publication bias.Results.59 studies with 755,415 practitioners surveyed were included in the review. 29 studies were conducted in the Asian continent and 11 in the United States. On average studies scored 9 out of 10 methodological quality score. Of the 12 HSOPS dimensions, six scored under 50% of positivity, with “nonpunitive response to errors” the lowest one. In the meta-regression, three dimensions were shown to be influenced by the proportion of physicians and five by the continent where survey was held.Conclusions.The HSOPS is widely used in several countries to assess the culture of patient safety in hospital settings. The culture of culpability is the main weakness across studies. Encouraging event reporting and learning from errors should be priorities in hospitals worldwide.

scholarly journals Factors contributing to the patient safety culture in Saudi Arabia: a systematic review

BMJ Open ◽  
2020 ◽  
Vol 10 (10) ◽  
pp. e037875
Author(s):  
Abdulmajeed Albalawi ◽  
Lisa Kidd ◽  
Eileen Cowey
Keyword(s):  
Systematic Review ◽  
Saudi Arabia ◽  
Patient Safety ◽  
Healthcare System ◽  
Safety Culture ◽  
Patient Safety Culture ◽  
Arab Countries ◽  
Patient Perspectives ◽  
Positive Patient ◽  
Learning From Errors

BackgroundPatient safety, concerned with the prevention of harm to patients, has become a fundamental component of the global healthcare system. The evidence regarding the status of the patient safety culture in Arab countries in general shows that it is at a suboptimal level due to a punitive approach to errors and deficits in the openness of communications.ObjectivesTo identify factors contributing to the patient safety culture in Saudi Arabia.DesignSystematic review.MethodsA systematic search was carried out in May 2018 in five electronic databases and updated in July 2020—MEDLINE, CINAHL, Embase, PsycINFO and the Cochrane Database of Systematic Reviews. Relevant journals and reference lists of included studies were also hand-searched. Two independent reviewers verified that the studies met the inclusion criteria, assessed the quality of studies and extracted their relevant characteristics. The Yorkshire Contributory Factors Framework (YCFF) was used to categorise factors affecting safety culture in the included papers.Results14 papers were included and the majority of studies were appraised as being of good quality. Strength and weakness factors that contribute to patient safety culture were identified. Ineffective leadership, a blame culture, workload/inadequate staffing and poor communication are reported as the main factors hindering a positive patient safety culture in Saudi Arabia. Conversely, ‘strength’ factors contributing to a positive patient safety culture included supportive organisational attitudes to learning/continuous improvement, good teamwork within units and support from hospital management for patient safety. There is an absence of patient perspectives regarding patient safety culture in Saudi Arabia.ConclusionPolicymakers in the Saudi healthcare system should pay attention to the factors that may contribute to a positive patient safety culture, especially establishing a blame-free culture, improving communications and leadership capacity, learning from errors and involving patient perspectives in safety initiatives. Further research is required to understand in depth the barriers and facilitators to the implementation of a positive patient safety culture in Saudi Arabia.

scholarly journals Learning from errors for continuously improving patient safety

2018 ◽  
Vol 30 (2) ◽  
pp. 81-81
Author(s):  
Chih-Wei Huang ◽  
Usman Iqbal ◽  
Yu-Chuan (Jack) Li
Keyword(s):  
Patient Safety ◽  
Learning From Errors

scholarly journals Characterization of patient safety incidents reported by patients or families to the brazilian health regulatory system – 2014 – 2019

2021 ◽  
pp. 45655-45661
Keyword(s):  
Patient Safety ◽  
Regulatory System ◽  
Public Health Issue ◽  
P Value ◽  
Age Group ◽  
Global Public Health ◽  
Learning From Errors ◽  
Safety Incident ◽  
Significant Difference ◽  
Patient Safety Incidents

Patient safety incidents, especially adverse events (AEs), are a global public health issue. The objective of the study was to characterize patient safety incidents reported by patients or families to the Brazilian Health Regulatory System (SNVS). This is a descriptive, retrospective study with a quantitative approach, using a database from the Brazilian Health Regulatory Agency (ANVISA), NOTIVISA - Citizen module, 2014 to 2019. A total of 1355 safety incident were reported, a majority from the Southeast region (45.3%), occurred more frequently among women (58.0%) aged between 26 and 35 (16.7%) and 56 and 65 years (16.5%). Healthcare-associated infections (HAIs) (36.3%) were the most frequently notified event, followed by medication/intravenous fluid (IV) incident (36.2%). Injury was mostly classified as mild (32.0%) and moderate (23.7%). From a total of 33 deaths, the majority (51.5%) were due to HAI. There was a significant association between the proportion of deaths and age group (p-value = 0.032). Most notifications were related to HAIs, followed by drugs or IV fluids and most reported incidents resulting in death were due to HAIs, with a significant difference observed in the proportion of deaths in relation to age group. The study demonstrates the need for greater encouragement and participation of patients and family members in reporting incidents, valuing their experiences for continuous learning from errors in health services.

scholarly journals PATIENT EDUCATION AND ITS IMPORTANCE IN TERMS OF PATIENT SAFETY

2018 ◽  
Vol 6 (12) ◽  
pp. 109-120
Author(s):  
Nurdan Kirimlioğlu
Keyword(s):  
Patient Safety ◽  
Patient Education ◽  
Health Services ◽  
Medical Errors ◽  
Health Care Quality ◽  
Safety Information ◽  
Care Quality ◽  
Learning From Errors ◽  
Patient Health ◽  
And Behavior

Patient safety and prevention of medical errors in every stage of health services is among the priorities of health system. Measures taken for prevention of medical errors in patient safety, one of the most important in care quality for health services, are the basis of patient safety. Information, skill and behavior increasing the degree of patient safety and making learning from errors easier can be gained through both training of health professionals and patient. Today, patient education focused on accurate application of treatment aims firstly for providing patient and patient family with accurate decision ability on care and taking responsibilities. Patient education helps patient with learning and understanding of his/her diagnosis and treatment, gaining active self-care attitude, and getting rid of feeling “weakness” due to illness. This process, in which effective and observable changes in patient behaviors are aimed, is not limited to inpatient treatment, but continuous. Patient education is not limited to patient health, but also includes increasing health care quality. Patient’s healthcare expense get less and less proportionally as hospitalization time gets closer to end. Importance of patient education, financing of which is so profitable, increases more and more today.

scholarly journals Teaching patient safety in the medical undergraduate program at the Universidade Federal de São Paulo

2015 ◽  
Vol 13 (1) ◽  
pp. 7-13 ◽  
Author(s):  
Elena Bohomol ◽  
Isabel Cristina Kowal Olm Cunha
Keyword(s):  
Patient Safety ◽  
Clinical Skills ◽  
Educational Practice ◽  
Sao Paulo ◽  
World Health ◽  
Infection Prevention And Control ◽  
São Paulo ◽  
Learning From Errors ◽  
Educational Project ◽  
Medical Undergraduate

Objective To analyze the Educational Project of the undergraduate medical course to verify what is taught regarding Patient Safety and to enable reflections on the educational practice. Methods A descriptive study, using document research as strategy. The document of investigation was the Educational Project of the medical course, in 2006, at the Escola Paulista de Medicina of the Universidade Federal de São Paulo. The theoretical framework adopted was the Multi-Professional Patient Safety Curriculum Guide of the World Health Organization, which led to the preparation of a list with 153 tracking terms. Results We identified 65 syllabus units in the Educational Project of the course, in which 40 (61.5%) addressed topics related to Patient Safety. Themes on the topic “Infection prevention and control” were found in 19 (47.5%) units and teaching of “Interaction with patients and caregivers” in 12 (32.5%); however content related to “Learning from errors to prevent harm” were not found. None of the framework topics had their proposed themes entirely taught during the period of education of the future physicians. Conclusion Patient safety is taught in a fragmented manner, which values clinical skills such as the diagnosis and treatment of diseases, post-treatment, surgical procedures, and follow-up. Since it is a recent movement, the teaching of patient safety confronts informative proposals based on traditional structures centered on subjects and on specific education, and it is still poorly valued.

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