Reducing wrong intraocular lens implants in cataract surgery

2017 ◽  
Vol 30 (6) ◽  
pp. 492-505 ◽  
Author(s):  
Huey Peng Loh ◽  
Dirk Frans de Korne ◽  
Soon Phaik Chee ◽  
Ranjana Mathur
Keyword(s):  
Patient Safety ◽  
Cataract Surgery ◽  
Intraocular Lens ◽  
Systems Engineering ◽  
Patient Safety Culture ◽  
Absolute Number ◽  
Near Miss ◽  
Content Type ◽  
Near Misses ◽  
Safety Interventions

Purpose Wrong lens implants have been associated with the highest frequency of medical errors in cataract surgery. The purpose of this paper is to explore the use of the Systems Engineering Initiative for Patient Safety (SEIPS) framework to sustainably reduce wrong intraocular lens (IOL) implants in cataract surgery. Design/methodology/approach In this mixed-methods study, the SEIPS framework was used to analyse a series of (near) misses of IOL implants in a national tertiary specialty hospital in Singapore. A series of interventions was developed and applied in the case hospital. Risk assessment audits were done before the interventions (2012; n=6,111 surgeries), during its implementation (n=7,475) and in the two years post-interventions (2013-2015; n=39,390) to compare the wrong IOL-rates. Findings Although the absolute number of incidents was low, the incident rate decreased from 4.91 before to 2.54 per 10,000 cases after. Near miss IOL error decreased from 5.89 before to 3.55 per 1,000 cases after. The number of days between two IOL incidents increased from 35 to an initial peak of 385 before stabilizing on 56. The large variety of available IOL types and vendors was found as the main root cause of wrong implants that required reoperation. Practical implications The SEIPS framework seems to be helpful to assess components involved and develop sustainable quality and safety interventions that intervene at different levels of the system. Originality/value The SEIPS model is supportive to address differences between person and system root causes comprehensively and thereby foster quality and patient safety culture.

scholarly journals The effect of patient safety culture on nurses’ near-miss reporting intention: the moderating role of perceived severity of near misses

2021 ◽  
Vol 26 (1-2) ◽  
pp. 6-16
Author(s):  
Yi Yang ◽  
Huaping Liu
Keyword(s):  
Patient Safety ◽  
Safety Culture ◽  
Improve Patient Safety ◽  
Patient Safety Culture ◽  
Working Environment ◽  
Near Miss ◽  
Cross Sectional Survey ◽  
Near Misses ◽  
Perceived Severity ◽  
The Relationship

Background Reporting near misses is a practical approach to improve the confounding challenge of patient safety. Evidence suggests that patient safety culture and the characteristics of errors might have important impacts on reporting. No studies, however, have examined the relationships among patient safety culture, perceived severity of near misses and near-miss reporting. Aims To explore the relationship between patient safety culture and nurses’ near-miss reporting intention, and examine the potential moderating effect the perceived severity of near misses might have on this relationship. Methods Using a cross-sectional survey, data were collected with three validated survey instruments completed by 920 Registered Nurses in eight tertiary hospitals in China. Multiple regression analysis tested relationships among the variables. Results Nurses reported a moderate–high level of near-miss reporting intention. Patient safety culture was positively associated with nurses’ near-miss reporting intention. Perceived severity of near misses did not significantly moderate the relationship between patient safety culture and reporting intention. Conclusions Nurses generally showed a positive willingness to report near misses. A specific near-miss management and education system within a learning, supportive working environment are key components to improve reporting intention among nurses which could significantly improve patient safety.

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.

Assessment of patient safety culture during COVID-19: a cross-sectional study in a tertiary a-level hospital in China

2021 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Chih-Hsuan Huang ◽  
Ying Wang ◽  
Hsin-Hung Wu ◽  
Lee Yii-Ching
Keyword(s):  
Patient Safety ◽  
Working Conditions ◽  
Emotional Exhaustion ◽  
Safety Culture ◽  
Team Building ◽  
Reliability And Validity ◽  
Patient Safety Culture ◽  
Cross Sectional ◽  
Content Type ◽  
Safety Attitudes

PurposeThe aims of this study are to (1) evaluate physicians and nurses' perspectives on patient safety culture amid the COVID-19 pandemic and (2) integrate the emotional exhaustion of physicians and nurses into an evaluation of patient safety culture to provide insights into appropriate implications for medical care.Design/methodology/approachPatient safety culture was assessed with the Chinese version of the Safety Attitudes Questionnaire. Confirmatory factor analysis was conducted to validate the structure of the data (i.e. reliability and validity), and Pearson's correlation analysis was performed to identify relationships between safety-related dimensions.FindingsSafety climate was strongly associated with working conditions and teamwork climate. In addition, working conditions was highly correlated with perceptions of management and job satisfaction, respectively. It is worth noting that the stress and emotional exhaustion of the physicians and nurses during this epidemic were high and needed attention.Practical implicationsFor healthcare managers and practitioners, team-building activities, power of public opinions, IoT-focused service, and Employee Assistance Programs are important implications for inspiring the patient safety-oriented culture during the period of the COVID-19 pandemic.Originality/valueThis paper considers the role of emotional state into patient safety instrument, a much less understood but equally important dimension in the field of patient safety.

Broadening the concept of patient safety culture through value-based healthcare

2021 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Viktor Dombrádi ◽  
Klára Bíró ◽  
Guenther Jonitz ◽  
Muir Gray ◽  
Anant Jani
Keyword(s):  
Patient Safety ◽  
Patient Experience ◽  
Safety Culture ◽  
Improve Patient Safety ◽  
Cost Benefit ◽  
Population Level ◽  
Patient Safety Culture ◽  
Content Type ◽  
Experience Of Care ◽  
Improve Patient

PurposeDecision-makers are looking for innovative approaches to improve patient experience and outcomes with the finite resources available in healthcare. The concept of value-based healthcare has been proposed as one such approach. Since unsafe care hinders patient experience and contributes to waste, the purpose of this paper is to investigate how the value-based approach can help broaden the existing concept of patient safety culture and thus, improve patient safety and healthcare value.Design/methodology/approachIn the arguments, the authors use the triple value model which consists of personal, technical and allocative value. These three aspects together promote healthcare in which the experience of care is improved through the involvement of patients, while also considering the optimal utilisation and allocation of finite healthcare resources.FindingsWhile the idea that patient involvement should be integrated into patient safety culture has already been suggested, there is a lack of emphasis that economic considerations can play an important role as well. Patient safety should be perceived as an investment, thus, relevant questions need to be addressed such as how much resources should be invested into patient safety, how the finite resources should be allocated to maximise health benefits at a population level and how resources should be utilised to get the best cost-benefit ratio.Originality/valueThus far, both the importance of patient safety culture and value-based healthcare have been advocated; this paper emphasizes the need to consider these two approaches together.

Evaluation of patient safety culture in a private general hospital: a case study in Brazil

2021 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Cassiana Gil Prates ◽  
Rita Catalina Aquino Caregnato ◽  
Ana Maria Müller de Magalhães ◽  
Daiane Dal Pai ◽  
Janete de Souza Urbanetto ◽  
...  
Keyword(s):  
Patient Safety ◽  
Safety Culture ◽  
Patient Safety Culture ◽  
Administrative Staff ◽  
Management Support ◽  
Content Type ◽  
Administrative Services ◽  
Graduate Degrees ◽  
Brazilian Version

PurposeThe purpose is to assess the patient safety culture perceived by healthcare and administrative staff in a Brazilian hospital and examine whether education and experience are related to positive perceptions.Design/methodology/approachA descriptive–analytical case study was carried out at Ernesto Dornelles Hospital, a private Brazilian institution. The Brazilian version of the Hospital Survey on Patient Safety Culture was used to assess the perceptions of 618 participants, of whom 315 worked in healthcare assistance and 303 in administrative services. The main outcome was the percentage of positive responses, and the independent variables included the type of work, schooling and length of experience.FindingsNone of the twelve dimensions was strengthened. The percentage of positive responses was the highest for “Hospital management support for patient safety” (67.5%), and the lowest was for “Nonpunitive response to error” (29%). The healthcare staff had a slightly higher average than the administrative staff. The percentage of positive responses from professionals with undergraduate or graduate degrees was higher for the eight dimensions of safety culture. The length of hospital experience was not associated with any dimensions.Originality/valueThis study explored the influence of education and professional experience on the perception of patient safety in healthcare and administrative staff from a private institution. These approaches allow to know with greater depth and clarity factors that are related to the patient safety culture and, thus, have more consistent evidence to support interventions in specific needs.

Improving service operations: linking safety culture to hospital performance

2017 ◽  
Vol 28 (1) ◽  
pp. 57-84 ◽  
Author(s):  
Gregory N. Stock ◽  
Kathleen L. McFadden
Keyword(s):  
Patient Safety ◽  
Performance Measures ◽  
Safety Culture ◽  
Linear Regression Analysis ◽  
Patient Safety Culture ◽  
Hospital Performance ◽  
Data Set ◽  
Content Type ◽  
Objective Performance ◽  
Objective Performance Measures

Purpose The purpose of this paper is to examine the relationship between patient safety culture and hospital performance using objective performance measures and secondary data on patient safety culture. Design/methodology/approach Patient safety culture is measured using data from the Agency for Healthcare Research and Quality’s Hospital Survey on Patient Safety Culture. Hospital performance is measured using objective patient safety and operational performance metrics collected by the Centers for Medicare and Medicaid Services (CMS). Control variables were obtained from the CMS Provider of Service database. The merged data included 154 US hospitals, with an average of 848 respondents per hospital providing culture data. Hierarchical linear regression analysis is used to test the proposed relationships. Findings The findings indicate that patient safety culture is positively associated with patient safety, process quality and patient satisfaction. Practical implications Hospital managers should focus on building a stronger patient safety culture due to its positive relationship with hospital performance. Originality/value This is the first study to test these relationships using several objective performance measures and a comprehensive patient safety culture data set that includes a substantial number of respondents per hospital. The study contributes to the literature by explicitly mapping high-reliability organization (HRO) theory to patient safety culture, thereby illustrating how HRO theory can be applied to safety culture in the hospital operations context.

Organizational learning and patient safety: hospital pharmacy settings

2019 ◽  
Vol 33 (6) ◽  
pp. 695-713
Author(s):  
Wael Abdallah ◽  
Craig Johnson ◽  
Cristian Nitzl ◽  
Mohammed A. Mohammed
Keyword(s):  
Patient Safety ◽  
Organizational Learning ◽  
Safety Culture ◽  
Hospital Pharmacy ◽  
Patient Safety Culture ◽  
Partial Least Square ◽  
Equation Modeling ◽  
Content Type ◽  
Hospital Pharmacies ◽  
The Relationship

Purpose The purpose of this paper is to explore the relationship between organizational learning and patient safety culture in hospital pharmacy settings as determined by the learning organization survey short-form (LOS-27) and pharmacy survey on patient safety culture instruments, and to further explore how dimensions of organizational learning relate to dimensions of pharmacy patient safety culture. Design/methodology/approach This study is a cross-sectional study. Data were obtained from three public hospital pharmacies and three private hospital pharmacies in Kuwait. Partial least square structural equation modeling was used to analyze the data. Findings A total of 272 surveys (59.1 percent response rate) were completed and returned. The results indicated a significant positive relationship between organizational learning and patient safety culture in hospital pharmacy settings (path coefficient of 0.826, p-value <0.05 and R2 of 0.683). Several dimensions of the organizational learning showed significant links to the various dimensions of the pharmacy patient safety culture. Specifically, training (TRN), management that reinforces learning (MRL) and supportive learning environment (SLE) had the strongest effects on the pharmacy patient safety culture dimensions. Moreover, these effects indicated that MRL, SLE and TRN were associated with improvements in most dimensions of pharmacy patient safety culture. Originality/value To the best of the authors’ knowledge, this is the first attempt to assess the relationship between organizational learning, patient safety culture and their dimensions in hospital pharmacy settings.

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