Setting the Stage

2019 ◽  
pp. 3-14
Author(s):  
Robert L. Wears ◽  
Kathleen M. Sutcliffe
Keyword(s):  
Patient Safety ◽  
Medical Errors ◽  
Institute Of Medicine ◽  
Reform Effort ◽  
The Public ◽  
Public Agenda ◽  
Celebrity Status ◽  
A Charge

The Institute of Medicine report, To Err Is Human, which led the news in late 1999 with a charge that “medical errors” were killing 44,000 to 120,000 Americans each year, gave patient safety “celebrity status.” But the emergence of patient safety as a major concern on the public agenda was not a given. In this chapter, the authors raise questions about why it developed at this time even though the problem of medical harm had long been known, why it was understood as “error” as opposed to “risk” or “hazard,” and, finally, who gained control of the reform effort and to what end.

Reducing Medical Errors and Increasing Patient Safety

2017 ◽  
pp. 87-115
Keyword(s):  
Patient Safety ◽  
Medical Errors ◽  
Motor Vehicle ◽  
Motor Vehicle Accidents ◽  
Healthcare Sector ◽  
Institute Of Medicine ◽  
Vehicle Accidents ◽  
Functional Quality ◽  
Atmosphere Interaction ◽  
Quality Dimensions

This chapter will describe the interrelationship between ICT, total relationship medicine approach, 5 Q and reducing medical errors and increasing patient safety. Medical errors are one of the Nation's leading causes of death and injury. A report published in 2000 by the Institute of Medicine (IOM) estimates that as many as 44,000 to 98,000 people die in U.S. hospitals each year as the result of medical errors. By 2004 the result was 195000 die and 1 000 000 excess injures by the medical errors. This means that more people die from medical errors than from motor vehicle accidents, breast cancer, or AIDS. Few studies have been conducted to investigate the link between technological, technical and functional quality dimensions and the level of patient's safety, medical errors and patient satisfaction in the healthcare sector. None of the identified studies have empirically examined how the atmosphere, interaction and infrastructure which focuses on availability of technology might prevent the medical errors and impact overall patient's quality perception and satisfaction.

scholarly journals Leveraging IT to Improve Patient Safety

2003 ◽  
Vol 12 (01) ◽  
pp. 153-158
Author(s):  
D.E. Garets ◽  
T.J. Handler ◽  
M.J. Ball
Keyword(s):  
Patient Safety ◽  
Medical Errors ◽  
Improve Patient Safety ◽  
Quality Care ◽  
Quality Of Healthcare ◽  
The United States ◽  
Institute Of Medicine ◽  
The Media ◽  
The Military ◽  
Improve Patient

Abstract:Medical errors and issues of patient safety are hardly new phenomena. Even during the dawn of medicine, Hippocrates counselled new physicians “to above all else do no harm.” In the United States, efforts to improve the quality of healthcare can be seen in almost every decade of the last century. In the early 1900s, Dr. Ernest Codman failed in his efforts to get fellow surgeons to look at the outcomes of their cases. In the 1970s, there was an outcry that the military allowed an almost blind surgeon to continue to practice and even transferred him to the prestigious Walter Reed Hospital. More recently, two reports by the Institute of Medicine caught the attention of the media, the American public, and the healthcare industry. To Err Is Human highlights the need to reduce medical errors and improve patient safety, and Crossing The Quality Chasm calls for a new health system to provide quality care for the 21st century.

Medication Errors in Family Practice, in Hospitals and after Discharge from the Hospital: An Ethical Analysis

2004 ◽  
Vol 32 (2) ◽  
pp. 349-357 ◽  
Author(s):  
Peter A. Clark
Keyword(s):  
Patient Safety ◽  
Health System ◽  
Vietnam War ◽  
Medication Errors ◽  
Family Practice ◽  
Medical Errors ◽  
Ethical Analysis ◽  
Institute Of Medicine ◽  
Surgery Patient

The issue of death due to medical errors is not new. We have all heard horror stories about patients dying in the hospital because of a drug mix-up or a surgery patient having the wrong limb amputated. Most people believed these stories were the exception to the rule until November 1999, when the Institute of Medicine (IOM) issued a report entitled To Err Is Human: Building A Safer Health System. This report focused on medical errors and patient safety in U.S. hospitals. The report indicated that as many as 44,000 to 98,000 people die each year in hospitals as a result of medical errors. These numbers suggest that more Americans are killed in U.S.hospitals every 6 months than died in the entire Vietnam War, and some have compared the alleged rate to fully loaded jumbo jets crashing every other day. This report was not without its critics.

Resident duty hour regulation and patient safety: establishing a balance between concerns about resident fatigue and adequate training in neurosurgery

2009 ◽  
Vol 110 (5) ◽  
pp. 828-836 ◽  
Author(s):  
M. Sean Grady ◽  
H. Hunt Batjer ◽  
Ralph G. Dacey
Keyword(s):  
Patient Safety ◽  
Work Force ◽  
External Pressure ◽  
Work Hours ◽  
Institute Of Medicine ◽  
The Public ◽  
The Past ◽  
Resident Work ◽  
Neurological Surgery ◽  
Resident Work Hours

Postgraduate training in medicine has been under scrutiny over the past 10 years with a major focus on physician personal health and patient safety. The culmination of a series of events led to the 80-hour work week instituted by the Accreditation Council on Graduate Medical Education in 2003. The effect this mandate has had on surgical education, and specifically training in neurological surgery, has been incompletely evaluated. Nevertheless, external pressure has prompted the Institute of Medicine to issue a new report on resident work hours and patient safety. In this report, the authors focus on the unique aspects of neurosurgical training in which physicians are trained to safely and effectively carry out complex high-risk tasks, the experience from abroad where work hours are reduced to well below 80 hours/week, and the risk that further reduction in work hours poses to the public. The authors conclude that there must be an adequate balance between the risks associated with resident fatigue and those associated with an inexperienced neurosurgical work force for public health.

Irruption onto the World Stage

2019 ◽  
pp. 119-140
Author(s):  
Robert L. Wears ◽  
Kathleen M. Sutcliffe
Keyword(s):  
Patient Safety ◽  
United Kingdom ◽  
Small Group ◽  
Federal Government ◽  
Medical Errors ◽  
Healthcare Research ◽  
Institute Of Medicine ◽  
Safety Program ◽  
The United Kingdom ◽  
The World

The Institute of Medicine (IOM) report To Err Is Human created a media firestorm. Prior to this, interest in patient safety might be described as a cult—a small group of passionate believers—but the IOM report and its aftermath moved patient safety to a prominent place on the broad public agenda, creating pressure for quick action. The federal government announced a safety program at the Agency for Healthcare Research and Quality; President Clinton committed to a “50% reduction in medical errors in five years”; similar events occurred in the United Kingdom. Programmatic efforts in patient safety began to crowd out safety scientists. The litany of fear-provoking incidents of patient harm continued.

Hospital Nurses’ Intention to Report Near Misses, Patient Safety Culture and Professional Seniority

2021 ◽  
Author(s):  
Orly Toren ◽  
Dokhi Mohanad ◽  
Freda DeKeyser Ganz
Keyword(s):  
Patient Safety ◽  
Safety Culture ◽  
Medical Errors ◽  
Improve Patient Safety ◽  
Patient Safety Culture ◽  
Team Work ◽  
Near Miss ◽  
Institute Of Medicine ◽  
Near Misses ◽  
The Relationship

Abstract Background Preventable medical errors are the third cause of death after cancer and heart disease. The first step in coping with medical errors in the healthcare system is to develop a culture of patient safety. Reporting medical errors, especially near misses, is one of the chosen methods of dealing with patient safety issues, recommended by the Institute of Medicine. Despite this recommendation, few studies examined the relationship between reporting near misses and improvements in patient safety culture. Intention to report a near miss event is another means to understand the phenomena of reporting, but no studies were found that included this variable and its relationship to safety culture. The aims of this study were to determine the extent nurses reported near miss events; to describe the relationship between patient safety culture, professional seniority and intention to report near misses; and to determine predictors of intention to report near miss events. Methods This was a descriptive cross-sectional study, based on the Hospital Survey on Patient Safety (HSOPS). The target population was ICU and inpatient ward nurses working in general hospitals. The sampling method was cluster convenience sampling. Statistical analysis included descriptive and predictive analyses. Results The sample included 227 nurses. Most nurses rated the patient safety culture components as moderately positive. Approximately 80% stated their intention to report a near miss, however 52.4% indicated that they did not report a near miss event in the past year. A positive correlation was found between all components of the patient safety culture and the intention to report a near miss event. Professional seniority was not related to any safety culture components or intention to report a near-miss event. Three variables predicted intention to report: team work, feedback and communication about errors, and the amount of near misses reported in the last year. Conclusions There is a discrepancy between what nurses describe as their intent to report a near miss event and their actual reporting of an event. Components of safety culture, especially communication openness, teamwork and reported near misses in the last year are significant predictors of the intent to report. Therefore, reinforcement of these components should be encouraged at the policy level to enable nurses to report near misses and thus improve patient safety.

scholarly journals Medication-related harm and the newspapers - what has been communicated to the public in Ireland: A systematic content analysis

2021 ◽  
Vol 29 (Supplement_1) ◽  
pp. i28-i29
Author(s):  
R Munshi ◽  
T Grimes
Keyword(s):  
Patient Safety ◽  
Content Analysis ◽  
Quantitative Data ◽  
Data Extraction ◽  
Life Stage ◽  
Opioid Analgesics ◽  
Daily Mail ◽  
The Public ◽  
Related Harm ◽  
Newspaper Articles

Abstract Introduction Reducing the global prevalence of severe, avoidable medication-related harm (MRH) by 50% by the end of 2022 is the WHO’s third global patient safety challenge [1]. MRH is reported frequently in the academic literature, with increasing age being a key risk factor. The WHO have highlighted the need to improve public health literacy and knowledge about medications. Little is known about the frequency and nature of Irish newspaper reports about MRH. This study sought to address this gap and to examine reporting during the calendar years 2019 and 2009. Methods In this mixed-methods study, LexisNexis® [2], an online newspaper archive database, was searched for newspaper articles reporting on MRH, published in the Republic of Ireland during the calendar years 2019 and 2009. The search strategy focussed on “medication” AND “harm” AND “patient”. Quantitative data extraction aimed to describe the frequency (by count of articles) of reporting of MRH and the nature by describing the publishing newspaper titles and the reported details of: drug class(es), demographics (age or life stage, gender) of those experiencing harm and the severity of harm. Qualitatively, a systematic content analysis, using inductive coding is ongoing and will be reported separately. Research ethics committee approval for this study is not required because this is an analysis of material in the public domain. Results In total, 7098 newspaper articles were identified through database searching for 2019 (n=3217) and 2009 (n=3881). To date, 54% (3867: n=3217, 45% 2019, n=650, 9% 2009) of these were screened, of which 63 newspaper articles (n=44 2019, n=19 2009) were included and quantitative data were extracted. Within these 63 articles, 71 cases of individual people experiencing MRH were reported (52 in 2019 and 19 in 2009). The newspapers most commonly reporting MRH were Irish Daily Mail (31/63: 27 in 2019 and 4 in 2009) and Irish Times (17/63:9 in 2019 and 8 in 2009). Drug classes most frequently reported as causing MRH were central nervous system drugs (antiepileptics n=10, opioid analgesics n=5, antidepressants n=9, and anxiolytics n=1), cancer chemotherapy (23 cases) and non-steroidal anti-inflammatories (n=3). MRH was reported as being fatal (13 /71:8 in 2019 and 5 in 2009) and non-fatal (58/71), with seven cases (5 in 2019 and 2 in 2009) of permanent harm. Among the 71 individual cases of MRH, the majority were adults aged 18–64 years (n=36), children (n=7), older adults (n=8), foetus (n=3) and newborn (n=1), while the remainder did not report the person’s age. Conclusion MRH is frequently reported to the public through Irish newspapers. The study is limited by focus on newsprint media with the exclusion of other forms of digital or social media and restriction to two calendar years in a single country, which likely stifles the generalisability of findings to other contexts. Future work could explore this issue across a wider range of media platforms and examine changes in reporting over time. The study findings may support an agenda to improve the general public's exposure to information and knowledge of MRH and medication safety. References 1. Donaldson, L.J., et al., Medication without harm: WHO's third global patient safety challenge. 2017. 389(10080): p. 1680–1681. 2. https://advance-lexis-com.elib.tcd.ie/firsttime?crid=d5f713e8-8107-4efd-91cc-1e99c82cdb58&pdmfid=1519360.

An exposition of trade policy formulation through the issuing of "Trade Policy Directives" by the Minister of Trade, Industry and Competition under the International Trade Administration Act 71 of 2002

2021 ◽  
Vol 25 ◽  
Author(s):  
Clive Vinti
Keyword(s):  
International Trade ◽  
Trade Policy ◽  
Rule Of Law ◽  
Policy Formulation ◽  
Procedural Rationality ◽  
Abstract Section ◽  
The Rule Of Law ◽  
The Public ◽  
The Republic ◽  
A Charge

ABSTRACT Section 5 of the International Trade Administration Act 71 of 2002 (ITAA) provides that the Minister of Trade, Industry and Competition has the power to issue "Trade Policy Directives" subject to the procedures and requirements of the Constitution of the Republic of South Africa, 1996 (Constitution) and other laws. However, there is uncertainty as to how trade policy is formulated under section 5 of the ITAA and the rights of affected parties in this regard. Thus, this article offers an exposition of the process of trade policy formulation under section 5 of the ITAA. To this end, it is my view that trade policy formulation under section 5 must be guided by section 195 of the Constitution, which requires that the public must be "encouraged" to participate in policy formulation and that this must occur in a climate of openness, transparency and accountability. In the narrower sense, it is also my view that interested parties must be given an opportunity to participate in trade policy formulation on the ground of procedural rationality and to avoid a charge of arbitrariness as twin components of the rule of law. Keywords: Trade policy; International Trade Administration Act; rule of law; legality; rationality; arbitrariness; transparency; accountability; governance.

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