Root Cause Analysis in Perinatal Care: Health Care Professionals Creating Safer Health Care Systems

2001 ◽  
Vol 15 (1) ◽  
pp. 40-54 ◽  
Author(s):  
Margaret Mueller Boyer
2019 ◽  
Vol 161 (6) ◽  
pp. 911-921 ◽  
Author(s):  
Karthik Balakrishnan ◽  
Michael J. Brenner ◽  
John W. Gosbee ◽  
Cecelia E. Schmalbach

With increasing emphasis on patient safety/quality improvement, health care systems are mirroring industry in the implementation of root cause analysis (RCA) for the identification and mitigation of errors. RCA uses a team approach with emphasis on the system, as opposed to the individual, to accrue empirical data on what happened and why. While many otolaryngologists have a broad understanding of RCA, practical experience is often lacking. Part II of this patient safety/quality improvement primer investigates the manner in which RCA is utilized in the prevention of medical errors. Attention is given to identifying system errors, recording adverse events, and determining which events warrant RCA. The primer outlines steps necessary to conduct an effective RCA, with emphasis placed on actions that arise from the RCA process through the root cause analysis and action (or RCA2) rubric. In addition, the article provides strategies for the implementation of RCA into clinical practice and medical education.


2018 ◽  
Author(s):  
Christina Østervang ◽  
Lene Vedel Vestergaard ◽  
Karin Brochstedt Dieperink ◽  
Dorthe Boe Danbjørg

BACKGROUND In cancer settings, relatives are often seen as a resource as they are able to support the patient and remember information during hospitalization. However, geographic distance to hospitals, work, and family obligations are reasons that may cause difficulties for relatives’ physical participation during hospitalization. This provided inspiration to uncover the possibility of telehealth care in connection with enabling participation by relatives during patient rounds. Telehealth is used advantageously in health care systems but is also at risk of failing during the implementation process because of, for instance, health care professionals’ resistance to change. Research on the implications for health care professionals in involving relatives’ participation through virtual presence during patient rounds is limited. OBJECTIVE This study aimed to investigate health care professionals’ experiences in using and implementing technology to involve relatives during video-consulted patient rounds. METHODS The design was a qualitative approach. Methods used were focus group interviews, short open interviews, and field observations of health care professionals working at a cancer department. The text material was analyzed using interpretative phenomenological analysis. RESULTS Field observational studies were conducted for 15 days, yielding 75 hours of observation. A total of 14 sessions of video-consulted patient rounds were observed and 15 pages of field notes written, along with 8 short open interviews with physicians, nurses, and staff from management. Moreover, 2 focus group interviews with 9 health care professionals were conducted. Health care professionals experienced the use of technology as a way to facilitate involvement of the patient’s relatives, without them being physically present. Moreover, it raised questions about whether this way of conducting patient rounds could address the needs of both the patients and the relatives. Time, culture, and change of work routines were found to be the major barriers when implementing new technology involving relatives. CONCLUSIONS This study identified a double change by introducing both new technology and virtual participation by relatives at the same time. The change had consequences on health care professionals’ work routines with regard to work load, culture, and organization because of the complexity in health care systems.


2008 ◽  
Vol 24 (5) ◽  
pp. 1159-1161 ◽  
Author(s):  
Claudia Travassos

The Introduction outlines this issue's special Forum on equity in access to health care, including three Articles and a Postscript. The Forum represents a continuation of the debates raised during a seminar organized by the Oswaldo Cruz Foundation in the city of Rio de Janeiro, Brazil, in 2006, in collaboration with UNICEF, UNDP, World Bank, the WHO Special Program for Research and Training in Tropical Diseases, and the United Nations Research Institute for Social Development. The authors approach health care access and equity from a comprehensive and contemporaneous perspective, introducing a new conceptual framework for access, in which information plays a central role. Trust is proposed as an important value for an equitable health care system. Unethical practices by health administrators and health care professionals are highlighted as hidden critical aspects of inequities in health care. As a whole, the articles represent a renewed contribution for understating inequalities in access, and for building socially just health care systems.


2019 ◽  
Vol 38 (1) ◽  
pp. 147-155 ◽  
Author(s):  
Dawn M. Hawthorne ◽  
Shirley C. Gordon

Background and Purpose: Spirituality has been identified as the essence of being human and is recognized, by many health care professionals, as a central component in health and healing. Scholars have identified spiritual nursing care as essential to nursing practice and include caring for the human spirit through the development of relationships and interconnectedness between the nurse and the patient. However, despite the recognition of spiritual practices as important to health, little attention has been given to spirituality in nursing practice and education in the literature. The purpose of this article is to explore factors contributing to the invisibility of spiritual nursing care practices (SNCP), recognition and offer strategies to enhance the visibility of SNCP. Two major factors that reduce visibility of SNCP are conceptual confusion differentiating between spirituality and religion and limited education in the area of spirituality including nursing curricula and organizations. Strategies to enhance visibility of SNCP include educational approaches in nursing curricula and health care organizations. to influence nurses’ perceptions about spirituality and creation of a culture of spiritual care. Conclusion: Holistic nursing includes assessing and responding to the spiritual needs of patients. Changes in nursing education and health care systems are needed to increase the visibility of SNCP.


2003 ◽  
Vol 33 (1) ◽  
pp. 173-192
Author(s):  
Ida Hellander

This report presents information on the state of U.S. health care in mid-2002. It provides data on the uninsured and underinsured and their difficulties in finding health care; the increasing costs of care; health, social, and economic inequalities; and the role of corporate money in health care. Information is also presented on mental health care, the hospital and pharmaceutical industries, Medicare HMOs, and the state of nursing. The author then provides updates on Congressional activity and the results of polls on matters of health, and some data on health care systems elsewhere in the world.


2018 ◽  
Vol 5 (1) ◽  
Author(s):  
Patricia Lynn Dobkin

Amidst the commotion of constant changes in health care systems, budget cuts, burnout and compassion fatigue there are resilient clinicians who relieve suffering and promote healing in those who seek their care. This workshop will focus on how doctors, nurses, and allied health care professionals serve in this way while maintaining equanimity and sense of meaning in their work and personal lives.This 90-minute experiential-based workshop will be divided into three parts.First, Mindful Clinical Practice will be described using narratives from different health care professionals in various settings. Mindful Congruence will be defined, along with Satir’s four other communication stances.Second, how the Four Noble Truths stemming from Buddhist philosophy inform clinical practice will be discussed with an emphasis on the Eightfold Path to end suffering. Third, a model of Healing Relationships (Scott et al, 2008; 2009) will be used to help participants identify underlying processes contributing to the relational outcomes: hope, trust, and being known. An Appreciative Inquiry exercise will be used to enrich participants’ understanding of their own experiences of being healers in clinical encounters.If and how medicine may be a spiritual practice will be examined.At the end of the workshop participants will be able to: 1. Define Mindful Congruence.2. Understand how the Four Noble Truths from Buddhist philosophy inform clinical practice.3. See how meditation practice contributes to clinicians’ mindfulness and emotional regulation.4. Discern the competencies and processes underlying healing.


Author(s):  
Elham Navab ◽  
Mehraneh Shali

Background: The practical difficulties for patients with stroke include lack of information about their condition, poor knowledge of the services and benefits available. Specialist Stroke nurses provide education and support services for people with Stroke  in many health care systems. A key goal is helping and empowering unable people to self-manage their stroke and supporting caregivers of these valnurable population, too.Objective: The objective of this review was to assess the role of specialist nurse in care for patients following a stroke and their caregivers support.Search methods: The databases CINAHL, PubMed, Science Direct and Synergy were searched from 1988 to 2017 using the keywords Stroke, Specialist Nurse, Care, Caregivers and support. Bibliographies of relevant papers were searched, and hand searching of relevant publications was undertaken to identify additional Studies.Selection criteria: All studies of the effects of a specialist nurse practitioner on short and long term stroke outcomes were included in the review.Data collection and analysis: Three investigators performed data extraction and quality scoring independently; any discrepancies were resolved by consensus.Findings:  Stroke, Specialist Nurse, Care, Caregivers concepts and labels are defined and measured in different and often contradictory ways by using 31 founded study.Conclusions: The findings indicate a dissonance in the views of different stakeholders within the care system. The division of labour associated with nursing care and specialist nurse requires further exploration. The contrasting paradigms of health care professionals and people with stroke regarding models of disability were highlighted.  Stroke, like other chronic illnesses, requires substantial nursing care. There is a growing number of specialist nurses in the workforce, however, little is known how their role interfaces with other nurses.  


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