scholarly journals 245. The impact of patient safety report and sentinel events on the prescribing and practice habits of infectious disease physicians

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S122-S122
Author(s):  
Vidya S Kollu ◽  
Zareen Zaidi ◽  
Jonathan J Cho ◽  
Andrew Abbott ◽  
Lennox Archibald ◽  
...  
Keyword(s):  
Infectious Disease ◽  
Patient Safety ◽  
Adverse Events ◽  
Laboratory Tests ◽  
Prescribing Practices ◽  
Prescribing Habits ◽  
Safety Report ◽  
Sentinel Event ◽  
Sentinel Events ◽  
The Impact

Abstract Background Adverse events associated with antimicrobials range from mild to severe and may cause distress or harm to patients, and anxiety for prescribers. The basic tenets of prescribing antimicrobials are based on knowledge of the disease, pharmacokinetics, and pharmacodynamics of the prescribed agent, and effectiveness of the therapy. Inappropriate prescribing can increase costs and may cause reactions or the emergence of resistance. There is a paucity of published data on the prescribing habits of physicians after a sentinel event or patient safety report. Thus, we carried out this study to ascertain whether patient safety reports and sentinel events influence physician antimicrobial prescribing practices Methods We invited Infectious Disease physicians at the University of Florida to participate in a survey of their perception of risks and prescribing habits after a sentinel event. Participants were interviewed using a standardized questionnaire. Data were analyzed using Epi Info statistical software. Thematic analyses were performed on the open-ended interview questions. Results Of 17 faculty and fellows who participated in the survey, 5 (29.4%) had been practicing infectious disease for 1–3 years, 3 (17.6%) for 4–6 years, 2 (11.7%) for 7–9 years, and 7 (41.1 %) for >nine years. Two (11.7%) had a patient safety report filed against them. All participants had experienced at least one sentinel event involving an antimicrobial agent. Sixteen (94%) changed their practice after sentinel events; 8 (47%) increased the frequency of ordering laboratory tests, and 7 (41%) indicated they might change to more expensive antimicrobials with better safety profiles. Eight (47%) participants endorsed hypervigilance when using antibiotics Conclusion We found that sentinel events affect physicians’ prescribing practices and monitoring of antimicrobial therapy. The most frequent changes included closer follow-up and obtaining more laboratory tests. However, some participants avoided certain antimicrobial agents or used more expensive therapies with better safety profiles. Although physicians use evidence-based medicine to alter their prescribing habits, serious adverse events can have an impact on the way we practice Disclosures Jonathan J. Cho, MD, Novartis (Shareholder)

Eliminating Critical Incident Tracking Network Patient Safety Events at a Veterans Affairs Institution Through Crew Resource Management Training

2016 ◽  
Vol 32 (5) ◽  
pp. 480-484 ◽  
Author(s):  
SreyRam Kuy ◽  
Ramon A. L. Romero
Keyword(s):  
Patient Safety ◽  
Resource Management ◽  
Adverse Events ◽  
Critical Incident ◽  
Medical Center ◽  
Crew Resource Management ◽  
Management Training ◽  
Veterans Affairs ◽  
Crew Resource Management Training ◽  
The Impact

The objective of this study was to determine whether rates of Critical Incident Tracking Network (CITN) patient safety adverse events change after implementation of crew resource management (CRM) training at a Veterans Affairs (VA) hospital. CRM training was conducted for all surgical staff at a VA hospital. Compliance with briefing and debriefing checklists was assessed for all operating room procedures. Tracking of adverse patient safety events utilizing the VA CITN events was performed. There was 100% adherence to performance of briefings and debriefings after initiation of CRM training. There were 3 CITN events in the year prior to implementation of CRM training; following CRM training, there have been zero CITN events. Following CRM training, CITN events were eliminated, and this has been sustained for 2.5 years. This is the first study to demonstrate the impact of CRM training on CITN events, specifically, in a VA medical center.

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.

Using Patient Safety Indicators to Estimate the Impact of Potential Adverse Events on Outcomes

2007 ◽  
Vol 65 (1) ◽  
pp. 67-87 ◽  
Author(s):  
Peter E. Rivard ◽  
Stephen L. Luther ◽  
Cindy L. Christiansen ◽  
Shibei Zhao ◽  
Susan Loveland ◽  
...  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Patient Safety Indicators ◽  
The Impact

scholarly journals Formulation, implementation and evaluation of a distance course for accreditation in patient safety

2018 ◽  
Vol 16 (2) ◽  
Author(s):  
Poliana Nunes Wanderlei ◽  
Erik Montagna
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Learning Environment ◽  
Virtual Learning ◽  
Patient Safety Culture ◽  
Hospital Staff ◽  
Course Evaluation ◽  
Reporting Rate ◽  
Virtual Learning Environment ◽  
The Impact

ABSTRACT Objective To formulate and to implement a virtual learning environment course in patient safety, and to propose ways to estimate the impact of the course in patient safety outcomes. Methods The course was part of an accreditation process and involved all employees of a public hospital in Brazil. The whole hospital staff was enrolled in the course. The accreditation team defined the syllabus. The education guidelines were divided into 12 modules related to quality, patient safety and required organizational practices. The assessment was performed at the end of each module through multiple-choice tests. The results were estimated according to occurrence of adverse events. Data were collected after the course, and employees’ attitude was surveyed. Results More than 80% of participants reached up to 70% success on tests after the course; the event-reporting rate increased from 714 (16,264 patients) to 1,401 (10,180 patients). Conclusion Virtual learning environment was a successful tool data. Data on course evaluation is consistent with increase in identification and reporting of adverse events. Although the report increment is not positive per si, it indicates changes in patient safety culture.

scholarly journals Trend Analysis of Patient Safety Incidents and Their Associated Factors in Korea Using National Patient Safety Report Data (2017~2019)

2021 ◽  
Vol 18 (16) ◽  
pp. 8482
Author(s):  
Sunhwa Shin ◽  
Mihwa Won
Keyword(s):  
Patient Safety ◽  
Trend Analysis ◽  
Medical Department ◽  
Patient Age ◽  
Near Misses ◽  
Safety Report ◽  
Patient Âgé ◽  
Report Data ◽  
Sentinel Events ◽  
Patient Safety Incidents

This study analyzed trends in patient safety incidents (PSIs) and the factors associated with the PSIs by analyzing 2017–2019 Patient Safety Report data in Korea. We extracted 2940 records in 2017, 5889 in 2018, and 7386 in 2019, from hospitals with more than 200 beds, and used all 16,215 cases for analysis. SPSS 25.0 was used for a multi-nominal logistic regression analysis. The PSI trend analysis, the standardized Jonckheere–Terpstra test was significant. On analyzing the probability of adverse events based on near misses, the significant variables were patient age, the season when PSIs occurred, incident reporter, hospital size, the location of PSIs, the type of PSIs, and medical department. Additionally, the factors that were likely to precipitate sentinel events based on near misses were patient sex, patient age, incident reporter, the type of PSIs, and medical department. To prevent sentinel events in PSIs, female and older patients are required to pay close attention. Moreover, it is necessary to establish a patient safety reporting system in which not only all medical personnel, but also patients, generally, can actively participate in patient safety activities and report voluntarily.

From Fable to Reality at Parkland Hospital: The Impact of Evidence-Based Design Strategies on Patient Safety, Healing, and Satisfaction in an Adult Inpatient Environment

2020 ◽  
pp. 193758672097019
Author(s):  
Renae K. Rich ◽  
Francesqca E. Jimenez ◽  
Susan E. Puumala ◽  
Sheila DePaola ◽  
Kathy Harper ◽  
...  
Keyword(s):  
Patient Safety ◽  
Patient Satisfaction ◽  
Adverse Events ◽  
Noise Temperature ◽  
Evidence Based ◽  
Patient Acuity ◽  
Hospital Design ◽  
Inpatient Outcomes ◽  
Adult Inpatient ◽  
The Impact

Objective: This research aimed to evaluate the quantitative effects of new hospital design on adult inpatient outcomes. Background: Tenets of evidence-based healthcare design, notably single-patient acuity-adaptable and same-handed rooms, decentralized nursing stations, onstage offstage layout, and access to nature were expected to promote patient healing and increase patient satisfaction, while decreasing adverse events. Methods: Patient healing was operationalized through length of stay (LOS) and patient safety through three adverse events: falls, hospital-acquired infections (HAI), and medication-related events. Standard patient surveys captured patient satisfaction. Patient records from 2013 through 2017 allowed for equivalent time periods surrounding the move to the new hospital in August 2015. Stratified by hospital division where significant, pre/post comparisons utilized proportional hazards or logistic regression models as appropriate; interrupted time series analyses afforded longitudinal interpretations. Results: Observed higher postmove LOS was due to previously increasing trends, not increases after the move. In surgical and trauma units, a constant increase in falls was unaffected by the move. Medication events decreased consistently over time; medication events with harm dropped significantly after the move. No change in HAI was found. Significant improvement on most relevant patient satisfaction items occurred after the move. Call button response decreased immediately after the move but subsequently improved. Conclusion: Results did not clearly indicate a net change in adult inpatient outcomes of healing and safety due to the hospital design. There was evidence that the new hospital improved patient satisfaction outcomes related to the environment, including comfort, noise, temperature, and aesthetics.

scholarly journals Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review

BMJ Open ◽  
2018 ◽  
Vol 8 (8) ◽  
pp. e022202 ◽  
Author(s):  
Martin Müller ◽  
Jonas Jürgens ◽  
Marcus Redaèlli ◽  
Karsten Klingberg ◽  
Wolf E Hautz ◽  
...  
Keyword(s):  
Systematic Review ◽  
Patient Safety ◽  
Adverse Events ◽  
Patient Outcomes ◽  
Cochrane Library ◽  
Secondary Outcome ◽  
Communication Tool ◽  
Clinical Routine ◽  
Wide Range ◽  
The Impact

ObjectivesCommunication breakdown is one of the main causes of adverse events in clinical routine, particularly in handover situations. The communication tool SBAR (situation, background, assessment and recommendation) was developed to increase handover quality and is widely assumed to increase patient safety. The objective of this review is to summarise the impact of the implementation of SBAR on patient safety.DesignA systematic review of articles published on SBAR was performed in PUBMED, EMBASE, CINAHL, Cochrane Library and PsycINFO in January 2017. All original research articles on SBAR fulfilling the following eligibility criteria were included: (1) SBAR was implemented into clinical routine, (2) the investigation of SBAR was the primary objective and (3) at least one patient outcome was reported.SettingA wide range of settings within primary and secondary care and nursing homes.ParticipantsA variety of heath professionals including nurses and physicians.Primary and secondary outcome measuresAspects of patient safety (patient outcomes) defined as the occurrence or incidence of adverse events.ResultsEight studies with a before–after design and three controlled clinical trials performed in different clinical settings met the inclusion criteria. The objectives of the studies were to improve team communication, patient hand-offs and communication in telephone calls from nurses to physicians. The studies were heterogeneous with regard to study characteristics, especially patient outcomes. In total, 26 different patient outcomes were measured, of which eight were reported to be significantly improved. Eleven were described as improved but no further statistical tests were reported, and six outcomes did not change significantly. Only one study reported a descriptive reduction in patient outcomes.ConclusionsThis review found moderate evidence for improved patient safety through SBAR implementation, especially when used to structure communication over the phone. However, there is a lack of high-quality research on this widely used communication tool.Trial registrationnone

scholarly journals An integrated literature review on cultural management systems and patient safety

2021 ◽  
Vol 2 (2) ◽  
pp. 30-54
Author(s):  
Oladunni Abiodun ◽  
◽  
Oluyemi Toyinbo ◽  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Safety Culture ◽  
Health Professionals ◽  
Patient Safety Culture ◽  
Management Systems ◽  
Healthcare Organizations ◽  
Cultural Management ◽  
The Right ◽  
The Impact

The incidence of adverse events in healthcare is a global problem with negative consequences for all stakeholders including patients, their family members, health professionals and the government. Patient safety and patient safety culture lie at the heart of all adverse events within healthcare settings. The culture of an organization determines its approach to problem solving and determines how individuals within that setting work; this is also true for patient safety culture and the reduction of adverse events within healthcare organizations. The aim of this study was to assess, identify and have a better understanding of the importance of patient safety culture within the healthcare organization and to create insights on the impact of cultural management systems regarding patient safety. The research method of this study is an integrated literature of the patient safety culture and perspectives of healthcare workers, assessed using the Modified Stanford Instrument (MSI) and Manchester Patient Safety Framework (MaPSaF). Analysis of the data revealed that health professionals working in the same organizations have differing opinions on the same topic; therefore, there is need for open communication and a systematic approach to establishing the right safety culture within healthcare organizations. In conclusion, establishing the right culture and having systematic ways of measurement enable improvements and the ability of organizations to learn from their mistakes. There is paucity of data with respect to the use of these tools in the respective countries (Canada and United Kingdom) even though the tools are the national tools established through rigorous research. Therefore, a study of MaPSaF in New Zealand was also analyzed. There is need for further research and publications to enable learning on patient safety, which will reduce the incidence of adverse events and associated consequences in healthcare organizations.

Human Factoring Healthcare

2014 ◽  
Vol 3 (1) ◽  
pp. 191-195 ◽  
Author(s):  
Kristen Miller ◽  
Tandi Bagian ◽  
Linda Williams
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Human Factors ◽  
Human Error ◽  
System Level ◽  
Department Of Veterans Affairs ◽  
Just Culture ◽  
Safe Patient Care ◽  
The Individual ◽  
The Impact

Even in a just culture, preventable or avoidable adverse events can often be attributed to a failure to follow recognized, evidence-based best practices or guidelines at the individual and/or system level. Investigations of adverse events have heightened the awareness of the need to redesign systems and processes to prevent human error. Despite the existence of considerable information about how to improve care through the application of human factors, healthcare professionals are not provided a means to ensure sufficient education in healthcare human factors and the impact on patient safety. Additionally, even when existing knowledge is taught, providers are challenged to translate and apply knowledge to affect safe patient care. The Department of Veterans Affairs (VA) National Center for Patient Safety (NCPS) Healthcare Human Factors Modules were designed to address these challenges by combining dissemination of existing knowledge and recent research into accessible, hands-on activities that drive home human factors and patient safety competencies. These modules represent an innovative and engaging way to allow providers and administrators alike the ability to advance the shift to systems thinking through high-impact education.

scholarly journals World Patient Safety Day: the Tuscany region at the forefront of quality of care

2020 ◽  
Vol 32 (3) ◽  
pp. 221-222
Author(s):  
Sara Albolino ◽  
Giulia Dagliana
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Health Systems ◽  
Health Professionals ◽  
Care Delivery ◽  
Clinical Care ◽  
Patient Safety Culture ◽  
World Health ◽  
To Come ◽  
The Impact

Abstract Echoing the World Health Organization’s (WHO) request, the Patient Safety Declaration, launched by Health First Europe at the European Parliament, calls on policymakers, authorities and health professionals, patients and citizens to come together to build health systems that can help health professionals work better for patient-centred outcomes. The objective is to prevent the occurrence of adverse events arising from clinical care activities to focus resources on reducing the impact of the disease by promoting safer health systems and higher quality standards for patient safety in Europe. The Declaration intends to promote a European patient safety culture, starting with safety practices and exchanging effective practices to reduce adverse events arising from health activities. Tuscany, the fifth largest region of Italy, is strongly committed to make this happen. Its Regional Centre for Clinical Risk Management and Patient Safety and WHO Collaborating Centre (GRC Centre—Centro Gestione Rischio Clinico e Sicurezza del Paziente) aims at developing and promoting practices for safety, awareness raising and the analysis of adverse events for the constant improvement of care delivery.

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