Application of Bow-tie methodology to improve patient safety

2016 ◽  
Vol 29 (4) ◽  
pp. 425-440 ◽  
Author(s):  
Zhaleh Abdi ◽  
Hamid Ravaghi ◽  
Mohsen Abbasi ◽  
Bahram Delgoshaei ◽  
Somayeh Esfandiari
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Blood Stream Infection ◽  
Improve Patient Safety ◽  
Blood Stream ◽  
Clinical Settings ◽  
Content Type ◽  
Clinical Risks ◽  
Improve Patient ◽  
Bow Tie

Purpose – The purpose of this paper is to apply Bow-tie methodology, a proactive risk assessment technique based on systemic approach, for prospective analysis of the risks threatening patient safety in intensive care unit (ICU). Design/methodology/approach – Bow-tie methodology was used to manage clinical risks threatening patient safety by a multidisciplinary team in the ICU. The Bow-tie analysis was conducted on incidents related to high-alert medications, ventilator associated pneumonia, catheter-related blood stream infection, urinary tract infection, and unwanted extubation. Findings – In total, 48 potential adverse events were analysed. The causal factors were identified and classified into relevant categories. The number and effectiveness of existing preventive and protective barriers were examined for each potential adverse event. The adverse events were evaluated according to the risk criteria and a set of interventions were proposed with the aim of improving the existing barriers or implementing new barriers. A number of recommendations were implemented in the ICU, while considering their feasibility. Originality/value – The application of Bow-tie methodology led to practical recommendations to eliminate or control the hazards identified. It also contributed to better understanding of hazard prevention and protection required for safe operations in clinical settings.

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.

scholarly journals Adverse events analysis as an educational tool to improve patient safety culture in primary care: A randomized trial

2011 ◽  
Vol 12 (1) ◽  
Author(s):  
Clara González-Formoso ◽  
María Victoria Martín-Miguel ◽  
Ma José Fernández-Domínguez ◽  
Antonio Rial ◽  
Fernando Isidro Lago-Deibe ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Adverse Events ◽  
Randomized Trial ◽  
Safety Culture ◽  
Improve Patient Safety ◽  
Patient Safety Culture ◽  
Educational Tool ◽  
Improve Patient

Effectiveness of systems changes suggested by simulation of adverse surgical outcomes

2015 ◽  
Vol 1 (3) ◽  
pp. 83-86 ◽  
Author(s):  
Meghan E Garstka ◽  
Douglas P Slakey ◽  
Christopher A Martin ◽  
Eric R Simms ◽  
James R Korndorffer
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Adverse Events ◽  
Surgical Outcomes ◽  
Improve Patient Safety ◽  
Healthcare Systems ◽  
Adverse Outcomes ◽  
Cause Analysis ◽  
Root Cause ◽  
Improve Patient

BackgroundSimulation of adverse outcomes (SAO) has been described as a technique to improve effectiveness of root cause analysis (RCA) in healthcare. We hypothesise that SAO can effectively identify unsuspected root causes amenable to systems changes.MethodsSystems changes were developed and tested for effectiveness in a modified simulation, which was performed eight times, recorded and analysed.ResultsIn seven of eight simulations, systems changes were effectively utilised by participants, who contacted anaesthesia using the number list and telephone provided to express concern. In six of seven simulations where anaesthesia was contacted, they provided care that avoided the adverse event. In two simulations, the adverse event transpired despite implemented systems changes, but for different reasons than originally identified. In one case, appropriate personnel were contacted but did not provide the direction necessary to avoid the adverse event, and in one case, the telephone malfunctioned.ConclusionsSystems changes suggested by SAO can effectively correct deficiencies and help improve outcomes, although adverse events can occur despite implementation. Further study of systems concepts may provide suggestions for changes that function more reliably in complex healthcare systems. The information gathered from these simulations can be used to identify potential deficiencies, prevent future errors and improve patient safety.

scholarly journals The potential of artificial intelligence to improve patient safety: a scoping review

2021 ◽  
Vol 4 (1) ◽  
Author(s):  
David W. Bates ◽  
David Levine ◽  
Ania Syrowatka ◽  
Masha Kuznetsova ◽  
Kelly Jean Thomas Craig ◽  
...  
Keyword(s):  
Artificial Intelligence ◽  
Patient Safety ◽  
Adverse Events ◽  
Scoping Review ◽  
Adverse Drug Events ◽  
Improve Patient Safety ◽  
Relevant Literature ◽  
Pressure Sensors ◽  
Diagnostic Errors ◽  
Improve Patient

AbstractArtificial intelligence (AI) represents a valuable tool that could be used to improve the safety of care. Major adverse events in healthcare include: healthcare-associated infections, adverse drug events, venous thromboembolism, surgical complications, pressure ulcers, falls, decompensation, and diagnostic errors. The objective of this scoping review was to summarize the relevant literature and evaluate the potential of AI to improve patient safety in these eight harm domains. A structured search was used to query MEDLINE for relevant articles. The scoping review identified studies that described the application of AI for prediction, prevention, or early detection of adverse events in each of the harm domains. The AI literature was narratively synthesized for each domain, and findings were considered in the context of incidence, cost, and preventability to make projections about the likelihood of AI improving safety. Three-hundred and ninety-two studies were included in the scoping review. The literature provided numerous examples of how AI has been applied within each of the eight harm domains using various techniques. The most common novel data were collected using different types of sensing technologies: vital sign monitoring, wearables, pressure sensors, and computer vision. There are significant opportunities to leverage AI and novel data sources to reduce the frequency of harm across all domains. We expect AI to have the greatest impact in areas where current strategies are not effective, and integration and complex analysis of novel, unstructured data are necessary to make accurate predictions; this applies specifically to adverse drug events, decompensation, and diagnostic errors.

scholarly journals A strategic framework for selecting adverse events in healthcare for investigation to improve patient safety

2021 ◽  
Author(s):  
Athar Ali Tajik
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Improve Patient Safety ◽  
Research Question ◽  
Theoretical Framework ◽  
Vulnerable Groups ◽  
Selection Mechanism ◽  
Serious Adverse Events ◽  
Case Selection ◽  
Improve Patient

AimsThis paper aims to address the research question: What is an effective framework to strategically select nationally reported serious adverse events in healthcare for investigation to improve patient safety? BackgroundThe healthcare system is globally under strain due to an aging population with increasing co-morbidities. Serious adverse events remain a consistent challenge. Patient safety can be improved by investigating cases and addressing underlying systemic risks. However, due to resource limitations, only a limited number of cases can be investigated. This necessitates a strategic selection of cases with the greatest potential for improving patient safety. This paper aims to develop a theoretical framework that identifies the key strategic issues that should be addressed when setting up a new national healthcare safety investigative body to select adverse events for investigation.MethodsThis study will primarily draw on semi-structured interviews with senior stakeholders in key healthcare regulatory agencies in Norway. For comparative purposes, a stakeholder from a key United Kingdom healthcare agency was also interviewed. The interview template is developed based on insights from a literature review and develop existing safety frameworks such as the Framework for Managing Risk. The paper also draws on selected tools from Strategy Management.ResultsA novel theoretical framework was developed to help set up case selection mechanism in a new national investigative body. The framework consists of four strategic themes that should be considered both sequentially and cyclically. Within each theme several key policy questions were identified.(1)Governance: role and powers, independence, and stakeholder engagement (2)Monitoring risk: adverse events, quality indicators, and unexplained variation(3)Strategic portfolio: broad coverage, vulnerable groups, and underreporting (4)Individual case selection: outcome, systemic risk, and learning potentialConclusionsPolicy makers should carefully consider the themes and questions in the proposed theoretical framework when setting up a new national safety investigative agency. In turn, this can ensure that the implemented selection mechanism identifies cases with the greatest potential to improve patient safety.

scholarly journals Comprehensive interventions of safety culture to improve patient safety: A longitudinal follow-up in northeast China

2019 ◽  
Author(s):  
Chuang Zhao ◽  
Qing Chang ◽  
Xi Zhang ◽  
Qijun Wu ◽  
Nan Wu ◽  
...  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Safety Culture ◽  
Improve Patient Safety ◽  
Skills Training ◽  
Patient Safety Culture ◽  
Tertiary Hospital ◽  
Emergency Plans ◽  
Safety Attitudes ◽  
Improve Patient

Abstract Background: Safety culture in hospitals can affect patient disease processes and health status. However, comprehensive measures to improve patient safety and effective methods to precisely assess the outcomes are limited in China. Methods: A cohort study was carried out in a tertiary hospital in China. Medical caregivers received comprehensive interventions such as a study on emergency plans and professional skills training to improve safety culture at the beginning of January 2017. A total of 553 caregivers in March, 299 caregivers in June and 284 caregivers in December in the same year participated in the three evaluation surveys. The safety attitude questionnaire (SAQ), the dimension frequency and number of events reported in the hospital survey of patient safety culture (HSOPSC) and a questionnaire on barriers to reporting adverse events were used to examine the safety culture changes before, during and at the end of intervention implementation. Results: The scores for dimension teamwork climate, job satisfaction and perception of management in the SAQ were significantly increased (p < 0.05). The scores for the 17 items in the barriers to reporting adverse events questionnaire were significantly increased (p < 0.05). No significant changes were observed in the scores for the dimension frequency and number of events reported in the HSOPSC after the interventions. Conclusion: Our findings showed that the interventions improved safety attitudes, and the barriers to reporting adverse events decreased, suggesting that the comprehensive interventions used were helpful for improving the safety culture.

National Analysis of Adverse Patient Safety Events in Bariatric Surgery

2005 ◽  
Vol 71 (5) ◽  
pp. 406-413 ◽  
Author(s):  
Benjamin K. Poulose ◽  
Marie R. Griffin ◽  
Yuwei Zhu ◽  
Walter Smalley ◽  
William O. Richards ◽  
...  
Keyword(s):  
Risk Factors ◽  
Bariatric Surgery ◽  
Patient Safety ◽  
Adverse Events ◽  
Cumulative Incidence ◽  
Improve Patient Safety ◽  
Male Gender ◽  
Patient Safety Indicators ◽  
National Analysis ◽  
Improve Patient

Identifying risk factors for adverse events after bariatric surgery (BaS) can help define high-risk groups to improve patient safety. We calculated cumulative incidence of adverse events and identified risk factors for these events using validated surgical patient safety indicators (PSIs) developed by the Agency for Healthcare Research and Quality. BaS patients ≥18 years old were identified using the 2002 Nationwide Inpatient Sample. Cumulative incidence at discharge was calculated for accidental puncture or laceration (APL), pulmonary embolus or deep venous thrombosis (PE/DVT), and postoperative respiratory failure (RF). Factors predictive of these PSIs were identified. From 7,853,982 discharges, a national cohort of 69,490 BaS patients was identified. During BaS hospitalization, the cumulative incidences per 1000 discharges of APL, PE/DVT, and RF were 12.6, 3.4, and 7.3, respectively. Risk factors for APL included male gender (odds ratio [OR] 1.6, 95% confidence interval 1.1–2.3, P < 0.05) and age of 40–49 years (OR 1.6 [1.1–2.3], P < 0.05) compared to ages 18–39 years. Patients aged 50–59 years (OR 3.5 [1.6–7.7], P < 0.05) had a higher chance of PE/DVT compared to those 18–39 years. Male gender (OR 1.8 [1.1–2.9], P < 0.05), ages 40–49 (OR 2.1 [1.1–4.2], P < 0.05) and 50–59 (OR 3.8 [2.1–6.9], P < 0.05), a history of chronic lung disease (OR 1.7 [1.1–2.7], P < 0.05), and Medicare coverage compared to private insurance (OR 2.2 [1.2–3.8], P < 0.05) were predictive of RF. This study established national measures for BaS adverse events. Further, risk factors associated with adverse events varied by gender, age, insurance status, and comorbidity. Evaluation of these higher risk BaS groups is needed to improve patient safety.

scholarly journals Flexible Endoscopes: Terminal Sterilization and Impact to Patient Safety

2020 ◽  
Vol 54 (s1) ◽  
pp. 80-83
Author(s):  
Alpa Patel ◽  
Nupur Jain
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Healthcare Facility ◽  
Blood Stream ◽  
Healthcare Associated Infections ◽  
Antibiotic Resistant ◽  
Healthcare Facilities ◽  
High Level ◽  
Healthcare Associated ◽  
Improve Patient

Abstract Flexible endoscopes are implicated in deaths from healthcare-associated infections (HAIs), in particular antibiotic-resistant infections. This article analyzes whether terminal sterilization should be required as part of endoscope reprocessing to reduce or eliminate HAIs and thus improve patient safety. Reusable flexible endoscopes are processed to make them ready for clinical use by the processing department of the healthcare facility. Unlike most critical and semicritical medical devices, the final step of processing an endoscope is high-level disinfection and not terminal sterilization. This is because most flexible endoscopes come in contact with mucosal membranes (versus contact with direct blood stream) and cannot withstand sterilization. However, sterilization currently is performed by a small number of U.S. healthcare facilities on reusable flexible endoscopes with the belief that they are safer for use compared to flexible endoscopes that are high-level disinfected. Based on the analysis in this article, terminal sterilization is not a required or necessary step to eliminate HAIs.

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