scholarly journals Improving patient safety culture through low cost innovation

2018 ◽  
Vol 5 ◽  
pp. A5-A5
Author(s):  
Kelsey Flott ◽  
Will Gage ◽  
Marie Batey ◽  
Julian Redhead ◽  
Ara Darzi
2019 ◽  
Vol 19 (76) ◽  
Author(s):  
Andre Barros Ferreira ◽  
Ricardo Rodrigues de Castro Teixeira

RESUMOEm uma época em que o tema segurança do paciente vem sendo desenvolvido sistematicamente por órgãos de fiscalização e qualidade, os hospitais e clínicas devem cada dia mais ampliar a cultura de segurança do paciente. Para fazer isso, é necessário adotar medidas estratégicas e ferramentas de gestão LEAN, inspiradas em práticas de gestão e resultados do sistema Toyota. Este artigo relata a implantação de ferramentas LEAN no Núcleo de Segurança do Paciente (NSP) em um hospital de olhos de médio porte. Os objetivos da implantação eram: elevar a cultura de segurança do paciente na instituição e aumentar as notificações de possíveis eventos (near miss) a fim de garantir ação prévia e evitar danos; em paralelo, diminuir subnotificações e o tempo de ação dos membros do NSP frente às notificações, facilitando o acesso das notificação aos colaboradores e, desta forma, permitir a prevenção de eventos adversos com dano. A implantação foi desenvolvida em cinco fases, que vão da concepção do projeto até a análise dos resultados. Foram evidenciadas melhorias na compreensão da finalidade do NSP, ampliando de 82% para 100% o conhecimento sobre o Núcleo por parte dos colaboradores. Os resultados mostraram a importância na utilização das ferramentas Jidoka e Kaizen, fomentando a criação do website do NSP que permitiu ampliar os conhecimentos dos colaboradores e diminuir de 77% para 3% a dificuldade em notificar. O sistema de envio de e-mail imediato aos membros melhorou o tempo de ação do NSP, reduzindo a média de 27 dias para apenas 1 dia. Observamos que, mesmo em época de crise, com pequeno custo, houve um aumento da cultura de segurança do paciente no hospital em 357,14% em comparação com o ano anterior, com aumento de notificações de near miss (eventos que podem ser controlados para não causarem dano). Hoje em dia, a aplicação de ferramentas e conceitos LEAN nas estratégias gerenciais é garantia fundamental da sustentabilidade, cumprimento de normas e leis, sem que haja impacto financeiro que impeça a garantia da segurança do paciente.Palavras-chave: Segurança do paciente. Administração hospitalar. Gestão de riscos. Eficiência organizacional. Indicadores de qualidade em assistência à saúde. ABSTRACTAt a time when the subject of patient safety has been systematically developed by oversight and quality agencies, hospitals and clinics must increasingly broaden the patient safety culture. To do this, strategic measures and LEAN management tools, based on Toyota system management practices and results, must be adopted. This article reports the implementation of LEAN tools at the Patient Safety Center (NSP) in a medium-sized eye hospital. The objectives of the implantation were: to elevate the patient safety culture in the institution and increase the notifications of possible events (near miss) in order to guarantee previous action and avoid damages; in parallel, reduce underreporting and action time of NSP members in the face of notifications, facilitating the access of notifications to employees and, thus, allowing the prevention of adverse events with damage. The deployment was developed in five phases, ranging from project design to results analysis. Improvements in the understanding of the purpose of the NSP were evidenced, increasing from 82% to 100% the knowledge about the Center by the employees. The results showed the importance of using the Jidoka and Kaizen tools, promoting the creation of the NSP website that allowed the employees to increase their knowledge and reduce from 77% the difficulty to notify. Members' immediate email system has improved NSP action time, reducing the average from 27 days to just 1 day. Even at a time of crisis, at a low cost, there was an increase in the patient safety culture in the hospital by 357.14% compared to the previous year, with an increase in near miss reports (events that can be controlled for do no harm). Nowadays, the application of LEAN tools and concepts in management strategies is a fundamental guarantee of sustainability, compliance with rules and laws, without having a financial impact that does not guarantee patient safety.Keywords: Patient Safety. Hospital administration. Risk management. Efficiency, organizational. Quality indicators, Health Care.


1970 ◽  
Vol 4 (2) ◽  
Author(s):  
Lia Mulyati ◽  
Dedy Rachman ◽  
Yana Herdiana

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.


Author(s):  
Edenise Maria Santos da Silva-Batalha ◽  
Marta Maria Melleiro

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.


BMC Nursing ◽  
2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Na Young Kim ◽  
Kyoung Ja Moon

Abstract Background The present study aims to investigate the relationship between patient safety culture and the prevention of transmitting bloodborne pathogens among nurses at a general hospital. Methods The participants were 284 nurses working at a general hospital located in a city, and the data were collected between April 26 and May 15, 2019. Questionnaires on patient safety culture and the prevention of bloodborne pathogens were used, and SPSS version 22.0 was used for descriptive and hierarchical regression analysis. Results The results showed that the following factors affected the prevention of bloodborne pathogens: experience with needle stick and sharps injuries (β = − 0.94), teamwork (β = 0.41), knowledge and attitude toward patient safety (β = 0.34), leadership (β = 0.15), and priority of patient safety (β = 0.14). The model’s explanatory power was 53% (F = 32.26, p =< 0.001). Conclusions To increase the compliance of general hospital nurses with practices that promote the prevention of bloodborne pathogens, it is necessary to actively prevent needle sticks and sharps injuries. It is also necessary to prioritize patient safety and to develop and verify the effects of various programs that emphasize factors of patient safety culture, such as leadership, teamwork, knowledge, and attitude.


2021 ◽  
Vol 10 (1) ◽  
pp. e001001
Author(s):  
Safraz Hamid ◽  
Frederic Joyce ◽  
Aaliya Burza ◽  
Billy Yang ◽  
Alexander Le ◽  
...  

The transfer of a cardiac surgery patient from the operating room (OR) to the intensive care unit (ICU) is both a challenging process and a critical period for outcomes. Information transferred between these two teams—known as the ‘handoff’—has been a focus of efforts to improve patient safety. At our institution, staff have poor perceptions of handoff safety, as measured by low positive response rates to questions found in the Agency for Health Care Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS). In this quality improvement project, we developed a novel handoff protocol after cardiac surgery where we invited the ICU nurse and intensivist into the OR to receive a face-to-face handoff from the circulating nurse, observe the final 30 min of the case, and participate in the end-of-case debrief discussions. Our aim was to increase the positive response rates to handoff safety questions to meet or surpass the reported AHRQ national averages. We used plan, do, study, act cycles over the course of 123 surgical cases to test how our handoff protocol was leading to changes in perceptions of safety. After a 10-month period, we achieved our aim for four out of the five HSOPS questions assessing safety of handoff. Our results suggest that having an ICU team ‘run in parallel’ with the cardiac surgical team positively impacts safety culture.


2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Ian Litchfield ◽  
Kate Marsden ◽  
Lucy Doos ◽  
Katherine Perryman ◽  
Anthony Avery ◽  
...  

Abstract Background The NHS has recognised the importance of a high quality patient safety culture in the delivery of primary health care in the rapidly evolving environment of general practice. Two tools, PC-SafeQuest and MapSaf, were developed with the intention of assessing and improving patient safety culture in this setting. Both have been made widely available through their inclusion in the Royal College of General Practitioners’ Patient Safety Toolkit and our work offerss a timely exploration of the tools to inform practice staff as to how each might be usefully applied and in which circumstances. Here we present a comparative analysis of their content, and describe the perspectives of staff on their design, outputs and the feasibility of their sustained use. Methods We have used a content analysis to provide the context for the qualitative study of staff experiences of using the tools at a representative range of practices recruited from across the Midlands (UK). Data was collected through moderated focus groups using an identical topic guide. Results A total of nine practices used the PC-SafeQuest tool and four the MapSaf tool. A total of 159 staff completed the PC-SafeQuest tool 52 of whom took part in the subsequent focus group discussions, and 25 staff completed the MapSaf tool all of whom contributed to the focus group discussions. PC-SafeQuest was perceived as quick and easy to use with direct questions pertinent to the work of GP practices providing useful quantitative insight into important areas of safety culture. Though MaPSaF was more logistically challenging, it created a forum for synchronous cross- practice discussions raising awareness of perceptions of safety culture across the practice team. Conclusions Both tools were able to promote reflective and reflexive practice either in individual staff members or across the broader practice team and the oversight they granted provided useful direction for senior staff looking to improve patient safety. Because PC SafeQuest can be easily disseminated and independently completed it is logistically suited to larger practice organisations, whereas the MapSaf tool lends itself to smaller practices where assembling staff in a single workshop is more readily achieved.


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