scholarly journals NHS Hospital ‘Learning from Deaths’ reports: A qualitative and quantitative analysis of the first year of a countrywide patient safety programme

2020 ◽  
Author(s):  
Zoe Brummell ◽  
Cecilia Vindrola-Padros ◽  
Dorit Braun ◽  
S. Ramani Moonesinghe
Keyword(s):  
Patient Safety ◽  
Secondary Care ◽  
Secondary Data ◽  
Patient Safety Culture ◽  
Organisational Learning ◽  
First Year ◽  
Qualitative And Quantitative ◽  
Safety Programme ◽  
National Guidance ◽  
Common Learning

ABSTRACTIntroductionPotentially preventable deaths occur worldwide within healthcare organisations. Organisational learning from incidents is essential to improve quality of care. In England, inconsistencies in how NHS secondary care trusts reviewed, investigated and shared learning from deaths, resulted in the introduction of national guidance on ‘Learning from Deaths’ (LfDs) in 2017. This guidance provides a ‘framework for identifying, reporting, investigating and learning from deaths’. Amendments to NHS Quality Account regulations, legally require NHS trusts in England to report quantitative and qualitative information relating to patient deaths annually. The programme intended trusts would share this learning and take measurable action to prevent future deaths.MethodWe undertook qualitative and quantitative secondary data analysis of all NHS secondary care trust LfDs reports within their 2017/18 Quality Accounts, to review how organisations are using the LfDs programme to learn from and prevent, potentially preventable deaths.ResultsAll statutory elements of LfDs reporting were reported by 98 out of 222 (44%) trusts. The percentage of deaths judged more likely than not due to problems in healthcare was between 0% and 13%. The majority of trusts (89%) reported lessons learnt; the most common learning theme was poor communication. 106 out of 222 trusts (48%) have shared or plan to share the learning within their own organisation. The majority of trusts (86%) reported actions taken and 47% discussed or had a plan for assessment of impact. 37 out of 222 trusts (17%) mentioned involvement of bereaved families.ConclusionsThe wide variation in reporting demonstrates that some trusts have engaged fully with LfDs, while other trusts appear to have disengaged with the programme. This may reveal a disparity in organisational learning and patient safety culture which could result in inequity for bereaved families. Many themes identified from the LfD reports have previously been identified in national and international reports and inquiries. Further work is needed to strengthen the LfDs programme.

scholarly journals NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme

BMJ Open ◽  
2021 ◽  
Vol 11 (7) ◽  
pp. e046619
Author(s):  
Zoe Brummell ◽  
Cecilia Vindrola-Padros ◽  
Dorit Braun ◽  
S Ramani Moonesinghe
Keyword(s):  
Patient Safety ◽  
Secondary Data ◽  
Document Analysis ◽  
Patient Safety Culture ◽  
First Year ◽  
Qualitative Information ◽  
Qualitative And Quantitative ◽  
Safety Programme ◽  
National Guidance ◽  
Common Learning

ObjectivesTo review how National Health Service (NHS) Secondary Care Trusts (NSCTs) are using the Learning from Deaths (LfDs) programme to learn from and prevent, potentially preventable deaths.IntroductionPotentially preventable deaths occur worldwide within healthcare organisations. In England, inconsistencies in how NSCTs reviewed, investigated and shared LfDs, resulted in the introduction of national guidance on ‘LfDs’ in 2017. This guidance provides a ‘framework for identifying, reporting, investigating and LfDs’. Amendments to NHS Quality Account regulations, legally require NSCTs in England to report quantitative and qualitative information relating to patient deaths annually. The programme intended NSCTs would share this learning and take measurable action to prevent future deaths.MethodWe undertook qualitative and quantitative secondary data, document analysis of all NSCTs LfDs reports within their 2017/2018 Quality Accounts (n=222).ResultsAll statutory elements of LfDs reporting were reported by 98 out of 222 (44%) NSCTs. The percentage of deaths judged more likely than not due to problems in healthcare was between 0% and 13%. The majority of NSCTs (89%) reported lessons learnt; the most common learning theme was poor communication. 106 out of 222 NSCTs (48%) have shared or plan to share the learning within their own organisation. The majority of NSCTs (86%) reported actions taken and 47% discussed or had a plan for assessment of impact. 37 out of 222 NSCTs (17%) mentioned involvement of bereaved families.ConclusionsThe wide variation in reporting demonstrates that some NSCTs have engaged fully with LfDs, while other NSCTs appear to have disengaged with the programme. This may reveal a disparity in organisational learning and patient safety culture which could result in inequity for bereaved families. Many themes identified from the LfDs reports have previously been identified by national and international reports and inquiries.

scholarly journals Attitudes Toward Patient Safety among Medical Students in Malaysia

2020 ◽  
Vol 17 (21) ◽  
pp. 7721
Author(s):  
Sathia Prakash Nadarajan ◽  
Sumitra Ropini Karuthan ◽  
Jeevitha Rajasingam ◽  
Karuthan Chinna
Keyword(s):  
Patient Safety ◽  
Medical Students ◽  
Patient Involvement ◽  
Working Hours ◽  
Patient Safety Culture ◽  
First Year ◽  
First Year Students ◽  
Safety Attitudes ◽  
Average Percentage ◽  
Team Functioning

The biggest challenge in moving toward a safer healthcare system is patient safety culture—that is, the prevention of harm to patients. Safe medical practices can prevent doing harm to the patients. For this, healthcare professionals must have good attitudes toward patient safety. Medical education plays an important role in promoting patient safety and patient safety attitudes. A study was conducted among medical students in Malaysia to assess their perceptions toward patient safety, using the 26-items Attitudes Toward Patient Safety Questionnaire (APSQ-III). In the analysis, the average percentage of positive responses (APPR) were computed for each domain, and APPR values of ≥75 were used as an indicator of positive perception. Out of the nine domains of APSQ, the students’ attitude was positive in six—Safety Training (85.2%), Error Reporting (76.3%), Working Hours (89.5%), Error Inevitability (86.1%), Team Functioning (94.6%), and Patient Involvement (80.1%). The desired level of positive attitude was not met in Disclosure Responsibility (68.5%), Professional Incompetence (70.0%), and Safety Curriculum (71.1%). APRR for disclosure responsibility was high among the first-year students, but, generally, the effect wore off over the years of study. The results support the need to enhance perception on Disclosure Responsibility, Professional Incompetence, and Safety Curriculum among the medical students in Malaysia.

Employee Engagement Dan Stress Kerja Pengaruhnya Terhadap Kepuasan Kerja Dan Turnover Intention di Aman Villas Nusa Dua – Bali

2020 ◽  
Vol 2 (1) ◽  
pp. 60-79
Author(s):  
Wayan Arya Paramarta ◽  
Ni Putu Kurnia Darmayanti
Keyword(s):  
Job Satisfaction ◽  
Employee Engagement ◽  
Work Stress ◽  
Turnover Intention ◽  
Secondary Data ◽  
Qualitative And Quantitative ◽  
Library Research ◽  
Analysis Technique ◽  
Negative Effect ◽  
Positive Effect

The aims of this study was to explain the effect of employee engagement and work stress on job satisfaction and turnover intention at Aman Villas Nusa Dua-Bali. The type of data used in this study is qualitative and quantitative data, with data sources namely primary and secondary data. Data collection method is interview, distributing questionnaires to respondents and library research, while the data analysis technique used Smart PLS 3.2.8. The results of this study showed that employee engagement had a positive effect and significant on job satisfaction, work stress had a negative effect but not significant on job satisfaction, employee engagement had a negative effect and significant on turnover intention, work stress had a positive effect and significant on turnover intention, job satisfaction had a negative effect but not significant on turnover intention, employee engagement had a positive effect but not significant on turnover intention trough job satisfaction, work stress had a positive effect but not significant on turnover intention trough job satisfaction at Aman Villas Nusa Dua-Bali.

THE APPLICATION OF PREVIEW, READ, WRITE, AND RECITE (PRWR) METHOD TO IMPROVE STUDENT’S ACHIEVEMENT IN READING RECOUNT TEXT

2014 ◽  
Vol 3 (2) ◽  
Author(s):  
Rahmat Nasution And Rahmah
Keyword(s):  
Secondary Data ◽  
Analysis Data ◽  
Primary Data ◽  
Average Score ◽  
First Year ◽  
Generic Structure ◽  
The Subject ◽  
Minimum Criteria ◽  
Main Ideas ◽  
Orientation Test

The objective of this research is to find out whether the application Preview, Read,Write, and Recite (PRWR) method improve student’s achievement in readingrecount text. This research applied classroom action research model. This studywas done in six meetings. The subject of this study was first year of SMAN 1Delitua. Primary data were collected by giving 20 questions of multiple-choicetest, the aspects contained in the tests focused on generic structure, main ideas,factual information, and Secondary data were collected by (interview, observationsheet, and questionnaire sheet. Based on analysis data, it was found that thestudent’s achievement improved. It could be seen from the comparison of result inthe orientation test and the cycle test I and II. There were only 9 students who hadpassed minimum criteria KKM in orientation test (75). The improvement showedthat in cycle I and II, based on the total average score it was 16 (42,4%) up to 26(78,7%) in cycle II, The secondary data gathered from interview, observationsheet, and questionnaire sheet, showed that students’ expression and enthusiasticalso improved. Thus, it was found that the applications of Preview, Read, Write,and Recite (PRWR) method in process of teaching improved students’achievement in reading recount text. It is suggested that English teachers applyPRWR method in teaching reading recount text.

Fakor Determinan yang Memengaruhi Budaya Keselamatan Pasien di RS Pemerintah Kabupaten Kuningan

1970 ◽  
Vol 4 (2) ◽  
Author(s):  
Lia Mulyati ◽  
Dedy Rachman ◽  
Yana Herdiana
Keyword(s):  
Patient Safety ◽  
Safety Culture ◽  
Work Satisfaction ◽  
Patient Safety Culture ◽  
Team Work ◽  
Chi Square ◽  
Cross Sectional ◽  
Work Related Stress ◽  
Work Related ◽  
Related Stress

Budaya keselamatan merupakan kunci untuk mendukung tercapainya peningkatan keselamatan dan kesehatan kerja dalam organisasi. Upaya membangun budaya keselamatan merupakan langkah pertama dalam mencapai keselamatan pasien. Terdapat beberapa faktor yang berkontribusi dalam perkembangan budaya keselamatan yaitu; sikap baik individu maupun organisasi, kepemimpinan, kerja tim, komunikasi dan beban kerja. Penelitian ini bertujuan mengetahui faktor determinan yang berhubungan dengan terciptanya budaya keselamatan pasien di RS Pemerintah Kabupaten Kuningan. Teknik pengambilan sampel yang digunakan incidental sampling 88 orang perawat pelaksana. Rancangan penelitian menggunakan survey analitik dengan pendekatan cross sectional, uji hipotesis digunakan Chi Square dan regresi logistik ganda. Hasil penelitian menunjukan terdapat pengaruh yang signifikan antara persepsi terhadap manajemen (p 0.0005, odd rasio 21.3), dukungan tim kerja (p 0.0005, odd rasio 13.34), stress kerja (p 0.006, odd rasio 3.94), kepuasan kerja (nilai p 0. 002) dengan budaya keselamatan pasien. Tidak terdapat pengaruh yang signifikan kondisi kerja dengan budaya keselamatan pasien dengan nilai p 0.507. Berdasarkan analisis multuvariat diperoleh persepsi terhadap manajemen menjadi factor determinan dengan nilai p 0.000 < α 0.05. Simpulan; unsur pimpinan memiliki pengaruh yang signifikan dalam menciptakan budaya keselamatan pasien. Pimpinan memiliki kewenangan dalam menerapkan system yang berlaku dalam organisasi, oleh karena itu gaya kepemimpinan, teknik komunikasi serta kemampuan manajerial merupakan suatu hal yang sangat perlu diperhatikan dalam menciptakan atmosfer kerja yang kondusif sebagai upaya terciptanya budaya keselamatan pasien. Berdasarkan hasil penelitian bahwa model kepemimpinan transformasional merupakan model yang sesuai diterapkan untuk meningkatkan budaya keselamatan pasien, pelatihan keterampilan komunikasi efektif serta pengembangan model pendidikan antar profesi sebagai upaya peningkatan kemampuan kolaborasi.Kata kunci:Budaya keselamatan pasien, stress kerja, kepuasan kerja.Determinant factors that are Influencing Patient Safety Culture in a Government-owned Hospitals in Kuningan Regency AbstractSafety culture is a key to support the achievement of occupational health and safety in an organization. An effort to build safety culture is the first step in ensuring patient safety. There are some factors that contribute in the development of safety culture, namely, individual and organizational attitude, leadership, team work, communication, and work load. This study aimed to identify the determinant factors that are related to achievement of patient safety culture in a government-owned hospital in Kuningan Regency. Eighty eight samples of nurses were recruited using incidental sampling technique. The research design was using cross sectional study, the hypothesis testing were using Chi Square and multiple logistic regression. The results showed that there were significant influenced between perception towards management (p= 0.0005, odd rasio 21.3), team work support (p= 0.0005, odd rasio 13.34), work-related stress (p= 0.006, odd rasio 3.94), work satisfaction (p= 0. 002) with patient safety culture. There was not significant influenced between work condition and patient safety (p= 0.507). The multivariate analysis showed that perception towards management was the determinant factor for patient safety culture (p 0.000 < α 0.05). In conclusion, leaders have significant influence in creating patient safety culture. Leaders have authority to implement systems in the organization. Therefore, leadership style, communication technique, and managerial ability are important in order to create a conducive atmosphere for developing patient safety culture. As recommendation, transformational leadership is a model that is appropriate to be applied in order to increase patient safety culture, trainings of effective communication and inter-professional education model are also needed to increase the collaboration skills among health professionals.Keywords:Patient safety culture, work-related stress, work satisfaction.

GESTÃO HOSPITALAR E CULTURA DE SEGURANÇA DO PACIENTE NA PERCEPÇÃO DA EQUIPE DE ENFERMAGEM

2017 ◽  
Vol 40 ◽  
Author(s):  
Edenise Maria Santos da Silva-Batalha ◽  
Marta Maria Melleiro
Keyword(s):  
Patient Safety ◽  
Safety Culture ◽  
Patient Safety Culture ◽  
Healthcare Research

O objetivo deste estudo foi avaliar a percepção de trabalhadores de enfermagem de um hospital de ensino acerca da cultura de segurança do paciente frente à gestão hospitalar. Trata-se de uma pesquisa quantitativa desenvolvida em um hospital de 900 leitos. A amostra foi composta por 301 profissionais de enfermagem. O instrumento de coleta foi o questionário da Agency for Healthcare Research and Quality, intitulado Hospital Survey on Patient Safety Culture, traduzido para o Português e adaptado da versão original em inglês. A análise deu-se por meio de estatísticas descritivas e testes específicos. Os resultados referentes à dimensão “Apoio da gestão hospitalar para segurança do paciente” evidenciaram que 53,6% dos participantes discordavam que a administração propiciava um clima de trabalho favorável à segurança do paciente, 46% discordavam que a segurança do paciente fosse uma prioridade da administração e 58,3% concordavam que a administração apenas se interessava pela segurança após a ocorrência de eventos adversos. Tais resultados demonstram a necessidade de envolvimento maior da gestão hospitalar para com a segurança dos pacientes, favorecendo o amadurecimento da cultura de segurança. Ainda, a relação entre a enfermagem e a gestão hospitalar deve ser fortalecida, baseando-se em relações mais próximas e lineares. Conclui-se que não é apenas uma parte da organização que é responsável pela cultura de segurança, há, portanto, a necessidade de envolver a gestão e todos os trabalhadores na criação, implementação e fortalecimento dos sentimentos, valores, comportamentos, atitudes e ações que irão fomentar essa cultura. Palavras-chave: Administração hospitalar. Segurança do paciente. Enfermagem.

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