Consolidation and Stagnation

2019 ◽  
pp. 161-190
Author(s):  
Robert L. Wears ◽  
Kathleen M. Sutcliffe
Keyword(s):  
Patient Safety ◽  
Hindsight Bias ◽  
Diagnostic Error ◽  
The State ◽  
Institute Of Medicine ◽  
Safety Science ◽  
Interactive Models

Safety activity is prevalent, but little of value is produced. Several scandals tainted the patient safety movement. Diagnostic “error” became popular but in a highly medicalized way vulnerable to hindsight bias. Safety science moved on from linear, complicated models to emergent, interactive models based on complexity. In 2015, 15 years after the IOM report, four separate reports on the state of patient safety concluded that it had accomplished little and that the approach to safety must be changed dramatically. But the change they recommended was no different from that recommended in the Institute of Medicine report 15 years earlier.

Lessons in clinical reasoning – pitfalls, myths, and pearls: the contribution of faulty data gathering and synthesis to diagnostic error

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Martin A. Schaller-Paule ◽  
Helmuth Steinmetz ◽  
Friederike S. Vollmer ◽  
Melissa Plesac ◽  
Felix Wicke ◽  
...  
Keyword(s):  
Patient Safety ◽  
Clinical Reasoning ◽  
Data Gathering ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Care Physician ◽  
Diagnostic Process ◽  
Myasthenic Crisis ◽  
Hospital Organization ◽  
Substantial Impact

Abstract Objectives Errors in clinical reasoning are a major factor for delayed or flawed diagnoses and put patient safety at risk. The diagnostic process is highly dependent on dynamic team factors, local hospital organization structure and culture, and cognitive factors. In everyday decision-making, physicians engage that challenge partly by relying on heuristics – subconscious mental short-cuts that are based on intuition and experience. Without structural corrective mechanisms, clinical judgement under time pressure creates space for harms resulting from systems and cognitive errors. Based on a case-example, we outline different pitfalls and provide strategies aimed at reducing diagnostic errors in health care. Case presentation A 67-year-old male patient was referred to the neurology department by his primary-care physician with the diagnosis of exacerbation of known myasthenia gravis. He reported shortness of breath and generalized weakness, but no other symptoms. Diagnosis of respiratory distress due to a myasthenic crisis was made and immunosuppressive therapy and pyridostigmine were given and plasmapheresis was performed without clinical improvement. Two weeks into the hospital stay, the patient’s dyspnea worsened. A CT scan revealed extensive segmental and subsegmental pulmonary emboli. Conclusions Faulty data gathering and flawed data synthesis are major drivers of diagnostic errors. While there is limited evidence for individual debiasing strategies, improving team factors and structural conditions can have substantial impact on the extent of diagnostic errors. Healthcare organizations should provide the structural supports to address errors and promote a constructive culture of patient safety.

scholarly journals Prevalence and factors associated with nutritional deviations in women in the pre-pregnancy phase in two municipalities of the State of Rio de Janeiro, Brazil

2014 ◽  
Vol 17 (1) ◽  
pp. 45-58 ◽  
Author(s):  
Daniele Marano ◽  
Silvana Granado Nogueira da Gama ◽  
Rosa Maria Soares Madeira Domingues ◽  
Paulo Roberto Borges de Souza Junior
Keyword(s):  
Rio De Janeiro ◽  
Multinomial Logistic Regression ◽  
First Trimester ◽  
Overweight And Obesity ◽  
The State ◽  
The Body ◽  
Nutritional Risk ◽  
Institute Of Medicine ◽  
Cross Sectional ◽  
Factors Associated

OBJECTIVE: To assess the prevalence and potential factors associated with pre-pregnancy nutritional status of women. METHODS: This is a cross-sectional study carried out between December 2007 and November 2008 with 1,535 women in the first trimester of pregnancy and randomly selected in health units of the Brazilian public health system (SUS) in the municipalities of Queimados and Petrópolis in the State of Rio de Janeiro. The diagnosis of nutritional deviations was based on the Body Mass Index, according to the classification of the Institute of Medicine, and the following categories were obtained: underweight, normal weight, overweight and obesity. In the statistical analysis, the multinomial logistic regression model was used and an odds ratio and confidence interval of 95% were estimated. RESULTS: The sample included women between 13 and 45 years. The prevalence of underweight, overweight and obesity were 10, 18 and 11%, respectively. Women living in Queimados, adolescents, women who did not live with a partner and smokers had a higher proportion of low pre-pregnancy weight. There was an association between hypertension, overweight and obesity. Adolescents presented lower chance to overweight and obesity. Living in Queimados reduced the odds of overweight. CONCLUSION: The proportion of pre-pregnancy nutritional deviations was high, and recognizing factors that lead to them is very important for an early identification of women at nutritional risk, with view to interventions to reduce the adverse effects of malnutrition on maternal and child health.

Teaching the Culture of Safety

2011 ◽  
Vol 16 (3) ◽  
Author(s):  
Jane Barnsteiner
Keyword(s):  
Patient Safety ◽  
Nursing Education ◽  
Healthcare Professionals ◽  
High Reliability ◽  
Essential Elements ◽  
High Reliability Organizations ◽  
Culture Of Safety ◽  
Safety Science ◽  
Licensure Programs

Although a healthcare culture of safety has been a practice priority for many years, there has been less attention to incorporating culture of safety content into the education of healthcare professionals. Students need to become knowledgeable about system vulnerabilities and understand how knowledge, skills, and attitudes promoting utilization of safety science will lead to safer care for patients and families. Learning about both patient safety and system vulnerabilities needs to begin in pre-licensure programs and become an integral part of learning in all phases of nursing education and practice. In this article the author will begin by reviewing the essential elements of a culture of safety and considering what students need to know about a culture of safety. She will describe activities that promote safety, high reliability organizations, and external drivers of safety, and conclude by offering strategies for integrating a culture of safety into the curriculum.

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.

Shedding the Light on the Off-Hours Problem in Radiology

2020 ◽  
Vol 35 (5) ◽  
pp. 419-426
Author(s):  
Christopher G. Roth ◽  
Gilda Boroumand ◽  
Jaydev K. Dave
Keyword(s):  
Patient Safety ◽  
Diagnostic Error ◽  
Time Frame ◽  
Operational Efficiency ◽  
X Rays ◽  
Safety Education ◽  
Survey Results ◽  
Diagnostic Delays ◽  
Patient Safety Education ◽  
Improvement Effort

Diagnostic error and diagnostic delays in health care are widespread. This article outlines an improvement effort targeting weekday evening inpatient radiology delays through staffing changes replacing trainees with faculty-trainee team coverage, pushing faculty coverage from 4 pm to 8 pm. Order-report turnaround times (TATs), critical findings TATs for pneumothorax and intracranial hemorrhage (ICH), and percentage meeting target were compared pre and post implementation for the 4 to 8 pm time frame using the Mann-Whitney U and χ2 tests, respectively. Stakeholder surveys assessed patient safety, morale, education, and operational efficiency. Median TATs (minutes) improved: X-rays 906 to 112, computed tomography 994 to 84, magnetic resonance imaging 1172 to 233, and ultrasound 88 to 58. Median critical findings TATs (minutes) improved from 853 to 30 and 112 to 22 for pneumothorax and ICH, respectively, and the percentage meeting target improved from 45% to 65%. Survey results reported perceived improvement in patient safety, education, and operational efficiency and no impact on morale.

Safety and quality assurance in anaesthesia

2017 ◽  
Author(s):  
Sven Staender ◽  
Andrew Smith
Keyword(s):  
Quality Assurance ◽  
Patient Safety ◽  
Clinical Medicine ◽  
High Reliability ◽  
Research Literature ◽  
International Standard Organization ◽  
Institute Of Medicine ◽  
Standard Organization ◽  
Definition Of ◽  
Based Medicine

Quality assurance has its roots in industry and therefore is strongly influenced by concepts from business, hence the reference to the definition of the term ‘quality’ according to the International Standard Organization (ISO), for example. In order to better understand the various concepts of quality assurance, this chapter clarifies concepts such as ‘effectiveness’, ‘efficiency’, ‘patient-centredness’, and ‘equity’. Of major importance in clinical medicine are guidelines, standards, recommendations, and their grade of evidence. Guidelines in particular have the advantage of facilitation of the practice of evidence-based medicine in that they can provide a practically orientated summary of the relevant research literature. Other important tools for quality assurance include ‘plan–do–study–act’ (PDSA) cycles, process mapping, monitoring of outcome indicators, auditing, and peer review. Patient safety is another rather young discipline in academic medicine. Triggered by the landmark publication of To Err is Human by the US Institute of Medicine (IOM) in 1999, patient safety gained widespread attention in healthcare. Anaesthesiology as a typical safety discipline was among the first to adopt safety measures such as ‘incident reporting’ or ‘human factors training’ years before the IOM report. Safety is closely related to outcome and therefore mortality, morbidity, as well as adverse events in general have to be considered. In order to improve, safety lessons can be learned from the so-called high-reliability organizations and transferred into clinical practice.

Still Not Safe

2019 ◽  
Author(s):  
Robert Wears ◽  
Kathleen Sutcliffe
Keyword(s):  
Patient Safety ◽  
Medical Error ◽  
Health Professionals ◽  
Great Change ◽  
Crowding Out ◽  
Clinical Expertise ◽  
Radical Reform ◽  
Safety Science ◽  
The Future ◽  
Public Consciousness

Patient safety suddenly burst into public consciousness in the late 1990s and became a “celebrated” cause in the 2000s. It has since gradually faltered, and little improvement has been noted over almost 20 years. Both the rise and fall of patient safety demand explanation. Medical harm had been known long before the 1990s, so why did it suddenly become popular? And why were safety efforts ineffective? The authors propose that this rise was due to a discursive shift that reframed “medical harm” into “medical error” in the setting of anxiety about industrialization and great change in healthcare. The “error” framing, with its inherent notion of agency, was useful in advancing the agenda of a technocratic, managerial group of health professionals and diminishing the authority of the old guard based on clinical expertise. The fall was due to this “medicalization” of safety. Health professionals and managers with little knowledge of safety science came to dominate the patient safety field, crowding out expertise from the safety sciences (e.g., psychology, engineering) and thus keeping reform under the control of the healthcare establishment. Operating with a sort of delusional clarity, this scientific-bureaucratic cabal generated a great deal of activity but made little progress because they failed to engage with expertise in the safety sciences. Twenty years after sudden popularity, there is general agreement that little of value has been achieved. The future of patient safety is in doubt, and radical reform in approaches to safety will be required for progress to be made.

scholarly journals Crisis Standards of Care Implementation at the State Level in the United States

2020 ◽  
Vol 35 (6) ◽  
pp. 599-603 ◽  
Author(s):  
Colton Margus ◽  
Ritu R. Sarin ◽  
Michael Molloy ◽  
Gregory R. Ciottone
Keyword(s):  
United States ◽  
Large Scale ◽  
State Level ◽  
The United States ◽  
The State ◽  
Pediatric Care ◽  
Standards Of Care ◽  
Institute Of Medicine ◽  
Full Spectrum ◽  
The Us

AbstractIntroduction:In 2009, the Institute of Medicine published guidelines for implementation of Crisis Standards of Care (CSC) at the state level in the United States (US). Based in part on the then concern for H1N1 pandemic, there was a recognized need for additional planning at the state level to maintain health system preparedness and conventional care standards when available resources become scarce. Despite the availability of this framework, in the years since and despite repeated large-scale domestic events, implementation remains mixed.Problem:Coronavirus disease 2019 (COVID-19) rejuvenates concern for how health systems can maintain quality care when faced with unrelenting burden. This study seeks to outline which states in the US have developed CSC and which areas of care have thus far been addressed.Methods:An online search was conducted for all 50 states in 2015 and again in 2020. For states without CSC plans online, state officials were contacted by email and phone. Public protocols were reviewed to assess for operational implementation capabilities, specifically highlighting guidance on ventilator use, burn management, sequential organ failure assessment (SOFA) score, pediatric standards, and reliance on influenza planning.Results:Thirty-six states in the US were actively developing (17) or had already developed (19) official CSC guidance. Fourteen states had no publicly acknowledged effort. Eleven of the 17 public plans had updated within five years, with a majority addressing ventilator usage (16/17), influenza planning (14/17), and pediatric care (15/17), but substantially fewer addressing care for burn patients (9/17).Conclusion:Many states lacked publicly available guidance on maintaining standards of care during disasters, and many states with specific care guidelines had not sufficiently addressed the full spectrum of hazard to which their health care systems remain vulnerable.

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.

scholarly journals Controversies in diagnosis: contemporary debates in the diagnostic safety literature

Diagnosis ◽  
2020 ◽  
Vol 7 (1) ◽  
pp. 3-9 ◽  
Author(s):  
Paul A. Bergl ◽  
Thilan P. Wijesekera ◽  
Najlla Nassery ◽  
Karen S. Cosby
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Healthcare Research ◽  
Washington Dc ◽  
Approaches To Teaching ◽  
Key Topics ◽  
Medical Educators ◽  
Safety First

AbstractSince the 2015 publication of the National Academy of Medicine’s (NAM) Improving Diagnosis in Health Care (Improving Diagnosis in Health Care. In: Balogh EP, Miller BT, Ball JR, editors. Improving Diagnosis in Health Care. Washington (DC): National Academies Press, 2015.), literature in diagnostic safety has grown rapidly. This update was presented at the annual international meeting of the Society to Improve Diagnosis in Medicine (SIDM). We focused our literature search on articles published between 2016 and 2018 using keywords in Pubmed and the Agency for Healthcare Research and Quality (AHRQ)’s Patient Safety Network’s running bibliography of diagnostic error literature (Diagnostic Errors Patient Safety Network: Agency for Healthcare Research and Quality; Available from: https://psnet.ahrq.gov/search?topic=Diagnostic-Errors&f_topicIDs=407). Three key topics emerged from our review of recent abstracts in diagnostic safety. First, definitions of diagnostic error and related concepts are evolving since the NAM’s report. Second, medical educators are grappling with new approaches to teaching clinical reasoning and diagnosis. Finally, the potential of artificial intelligence (AI) to advance diagnostic excellence is coming to fruition. Here we present contemporary debates around these three topics in a pro/con format.

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