scholarly journals Surgical learning and guidance on operative risks and potential errors

2017 ◽  
Vol 29 (5) ◽  
pp. 326-342 ◽  
Author(s):  
Minna Ruoranen ◽  
Teuvo Antikainen ◽  
Anneli Eteläpelto
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Hospital Environment ◽  
Surgical Operation ◽  
Learning From Errors ◽  
Content Type ◽  
Surgical Residents ◽  
Context Of Learning ◽  
Surgical Learning ◽  
Surgical Operations

Purpose Within the framework of learning from errors, this study focused on how operative risks and potential errors are addressed in guidance to surgical residents during authentic surgical operations. The purpose of this paper is to improve patient safety and to diminish medical complications resulting from possible operating errors. Further in the process of the optimal contexts for instruction aimed at preventing risks and errors in the practical hospital environment was evaluated. Design/methodology/approach The five authentic surgical operations were analyzed, all of which were organized as training sessions for surgical residents. The data (collected via video-recoding) were analyzed by a consultant surgeon and an education expert working together. Findings The results showed that the risks and potential errors in the surgical operations were rarely addressed in guidance during operations. The guidance provided mostly concerned technical issues, such as instrument handling, and exploration of critical anatomical structures. There was little guidance focusing on situation-based risks and potential errors, such as unexpected procedural challenges, teamwork and practical decision-making. The findings showed that optimal context of learning about risks and potential errors of surgical operation are not always the authentic operation context. Originality/value The study was conducted in an authentic surgical operation-cum-training context. The originality of the study derives from its focus on guidance related to risk and error prevention in surgical workplace learning. The findings can be used to create a meaningful learning environment – including powerful guidance – for practice-based surgical learning, maximally addressing patient safety, but giving possibilities also for other training options.

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 Assessment of patient safety culture in intensive care units and factors affecting it

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
M A Tlili ◽  
W Aouicha ◽  
H Lamine ◽  
E Taghouti ◽  
M B e n Dhiab ◽  
...  
Keyword(s):  
Patient Safety ◽  
Intensive Care ◽  
Adverse Events ◽  
Intensive Care Units ◽  
Safety Culture ◽  
Improve Patient Safety ◽  
Healthcare Quality ◽  
Patient Safety Culture ◽  
Cross Sectional ◽  
Learning From Errors

Abstract Background The intensive care units are a high-risk environments for the occurrence of adverse events with serious consequences. The development of patient safety culture is a strategic focus to prevent these adverse events and improve patient safety and healthcare quality. This study aimed to assess patient safety culture in Tunisian intensive care units and to determine its associated factors. Methods It is a multicenter, descriptive cross-sectional study, among healthcare professionals of the intensive care units in the Tunisian center. The data collection was spread over a period of 2 months (October-November 2017). The measuring instrument used is the validated French version of the Hospital Survey On Patient Safety Culture questionnaire. Data entry and analysis was carried out by the Statistical Package for Social Sciences (SPSS 20.0) and Epi Info 6.04. Chi-square test was used to explore factors associated with patient safety culture. Results A total of 404 professionals participated in the study with a participation rate of 81.94%, spread over 10 hospitals and 18 units. All dimensions were to be improved. The overall perception of safety was 32.35%. The most developed dimension was teamwork within units with a score of 47.87% and the least developed dimension was the non-punitive response to error (18.6%). The patient safety culture was significantly more developed in private hospitals in seven of the 10 dimensions. Participants working in small units had a significantly higher patient safety culture. It has been shown that when workload is reduced the patient safety culture was significantly increased. Conclusions This study has shown that the patient safety culture still needs to be improved and allowed a clearer view of the safety aspects requiring special attention. Thus, improving patient safety culture. by implementing the quality management and error reporting systems could contribute to enhance the quality of healthcare provided to patients. Key messages The culture of culpability is the main weakness in the study. Encouraging event reporting and learning from errors s should be priorities in hospitals to enhance patient safety and healthcare quality.

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.

Patient safety culture in Hungarian hospitals

2019 ◽  
Vol 32 (2) ◽  
pp. 412-424 ◽  
Author(s):  
Nina Granel ◽  
Josep Maria Manresa-Domínguez ◽  
Anita Barth ◽  
Katalin Papp ◽  
Maria Dolors Bernabeu-Tamayo
Keyword(s):  
Patient Safety ◽  
Safety Culture ◽  
Improve Patient Safety ◽  
Patient Safety Culture ◽  
Healthcare Staff ◽  
Content Type ◽  
Work Area ◽  
Exploratory Factor Analyses ◽  
The Usa ◽  
Blame Culture

Purpose The Hospital Survey on Patient Safety Culture (HSOPSC) is a rigorously designed tool for measuring inpatient safety culture. The purpose of this paper is to develop a cross-cultural HSOPSC for Hungary and determine its strengths and weaknesses. Design/methodology/approach The original US version was translated and adapted using existing guidelines. Healthcare workers (n=371) including nurses, physicians and other healthcare staff from six Hungarian hospitals participated. Answers were analyzed using exploratory factor analyses and reliability tests. Findings Positive responses in all dimensions were lower in Hungary than in the USA. Half the participants considered their work area “acceptable” regarding patient safety. Healthcare staff worked in “crisis mode,” trying to accomplish too much and too quickly. The authors note that a “blame culture” does not facilitate patient safety improvements in Hungary. Practical implications The results provide valuable information for promoting a more positive patient safety culture in Hungary and for evaluating future strategies to improve patient safety. Originality/value Introducing a validated scale to measure patient safety culture in Hungary improves healthcare quality.

scholarly journals Evaluating inputs of failure modes and effects analysis in identifying patient safety risks

2019 ◽  
Vol 32 (1) ◽  
pp. 191-207 ◽  
Author(s):  
Mecit Can Emre Simsekler ◽  
Gulsum Kubra Kaya ◽  
James R. Ward ◽  
P. John Clarkson
Keyword(s):  
Patient Safety ◽  
Failure Modes ◽  
Systems Approach ◽  
Improve Patient Safety ◽  
Risk Identification ◽  
Formal Structure ◽  
Potential Contribution ◽  
Content Type ◽  
Identification Process ◽  
Safety Risks

Purpose There is a growing awareness on the use of systems approaches to improve patient safety and quality. While earlier studies evaluated the validity of such approaches to identify and mitigate patient safety risks, so far only little attention has been given to their inputs, such as structured brainstorming and use of system mapping approaches (SMAs), to understand their impact in the risk identification process. To address this gap, the purpose of this paper is to evaluate the inputs of a well-known systems approach, failure modes and effects analysis (FMEA), in identifying patient safety risks in a real healthcare setting. Design/methodology/approach This study was conducted in a newly established adult attention deficit hyperactivity disorder service at Cambridge and Peterborough Foundation Trust in the UK. Three stakeholders of the chosen service together with the facilitators conducted an FMEA exercise along with a particular system diagram that was initially found as the most useful SMA by eight stakeholders of the service. Findings In this study, it was found that the formal structure of FMEA adds value to the risk identification process through comprehensive system coverage with the help of the system diagram. However, results also indicates that the structured brainstorming refrains FMEA participants from identifying and imagining new risks since they follow the process predefined in the given system diagram. Originality/value While this study shows the potential contribution of FMEA inputs, it also suggests that healthcare organisations should not depend solely on FMEA results when identifying patient safety risks; and therefore prioritising their safety concerns.

scholarly journals Does electronic medication reconciliation at hospital discharge decrease prescription medication errors?

2015 ◽  
Vol 28 (6) ◽  
pp. 564-573 ◽  
Author(s):  
Geneve M. Allison ◽  
Bernard Weigel ◽  
Christina Holcroft
Keyword(s):  
Patient Safety ◽  
Hospital Discharge ◽  
Medication Errors ◽  
Medication Reconciliation ◽  
Improve Patient Safety ◽  
Safety Issue ◽  
Inpatient Service ◽  
Intravenous Antibiotic ◽  
Content Type ◽  
The Impact

Purpose – Medication errors are an important patient safety issue. Electronic medication reconciliation is a system designed to correct medication discrepancies at transitions in healthcare. The purpose of this paper is to measure types and prevalence of intravenous antibiotic errors at hospital discharge before and after the addition of an electronic discharge medication reconciliation tool (EDMRT). Design/methodology/approach – A retrospective study was conducted at a tertiary hospital where house officers order discharge medications. In total, 100 pre-EDMRT and 100 post-EDMRT subjects were randomly recruited from the study center’s clinical Outpatient Parenteral Antimicrobial Therapy (OPAT) program. Using infectious disease consultant recommendations as gold standard, each antibiotic listed in these consultant notes was compared to the hospital discharge orders to ascertain the primary outcome: presence of an intravenous antibiotic error in the discharge orders. The primary covariate of interest was pre- vs post-EDMRT group. After generating the crude prevalence of antibiotic errors, logistic regression accounted for potential confounding: discharge day (weekend vs weekday), average years of practice by prescribing physician, inpatient service (medicine vs surgery) and number of discharge mediations per patient. Findings – Prevalence of medication errors decreased from 30 percent (30/100) among pre-EDMRT subjects to 15 percent (15/100) errors among post-EDMRT subjects. Dosage errors were the most common type of medication error. The adjusted odds ratio of discharge with intravenous antibiotic error in the post-EDMRT era was 0.39 (0.18, 0.87) compared to the pre-EDMRT era. In the adjusted model, the total number of discharge medications was associated with increased OR of discharge error. Originality/value – To the authors’ knowledge, no other study has examined the impact of reconciliation on types and prevalence of medication errors at hospital discharge. The focus on intravenous antibiotics as a class of high-stakes medications with serious risks to patient safety during error events highlights the clinical importance of the findings. Electronic medication reconciliation may be an important tool in efforts to improve patient safety.

Use of ethical predictability in respect for human rights in Iranian hospitals with a 360-degree approach

2020 ◽  
Vol 13 (5) ◽  
pp. 445-455
Author(s):  
Roya Malekzadeh ◽  
Ghasem Abedi ◽  
Ehsan Abedini ◽  
Elaheh Haghgoshayie ◽  
Edris Hasanpoor ◽  
...  
Keyword(s):  
Human Rights ◽  
Patient Safety ◽  
Patient Satisfaction ◽  
Human Resources ◽  
Public Hospitals ◽  
Hospital Environment ◽  
Cross Sectional Survey ◽  
Mazandaran Province ◽  
Cross Sectional ◽  
Content Type

Purpose Respect for human rights is one of the most important criteria for the delivery of medical care in hospitals. Ethical predictability is useful to identify human rights concerns in health-care organizations. The hospital environment and the flow of its processes make the topic of predictability much more sensitive and, at the same time, more difficult than other organizations. The purpose of this paper is to determine and compare the ethical predictive factors in selected hospitals in Mazandaran province. Design/methodology/approach This cross-sectional survey using multilevel sampling (four hospitals, 938 patients, 186 staff) was conducted in the first half of 2017. The measurement instrument was a researcher-made questionnaire consisting of seven areas of service recipients’ rights, patient safety, patient satisfaction, human resources, governance, organizational and financial commitments. The analysis of the collected data was performed through SPSS V. 22 and one-way ANOVA and post hoc Tukey’s tests. Findings Ethical predictability was higher in social security hospitals compared to private and public hospitals, and patient safety and patient rights showed higher magnitudes compared to other dimensions. Financial domain, patient satisfaction, governance and organizational commitment formed the middle priorities in ethical predictability, and human resources had the least average in ethical predictability in the selected hospitals in the province. Originality/value Identifying the factors which influence ethical predictability, in addition to promoting service recipients’ rights and patient satisfaction, is of great help to the managers and health service authorities, so that they can have a better understanding of these factors and, consequently, make appropriate micro and macro-decisions to provide better services.

Reducing medication errors using lean six sigma methodology in a Thai hospital: an action research study

2020 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Yaifa Trakulsunti ◽  
Jiju Antony ◽  
Mary Dempsey ◽  
Attracta Brennan
Keyword(s):  
Patient Safety ◽  
Action Research ◽  
Teaching Hospital ◽  
Six Sigma ◽  
Improve Patient Safety ◽  
Lean Six Sigma ◽  
Content Type ◽  
Six Sigma Methodology ◽  
Dispensing Errors

PurposeThe purpose of this paper is to illustrate the use of Lean Six Sigma (LSS) and its associated tools to reduce dispensing errors in an inpatient pharmacy of a teaching hospital in Thailand.Design/methodology/approachThe action research methodology was used to illustrate the implementation of Lean Six Sigma through the collaboration between the researcher and participants. The project team followed the Lean Six Sigma Define, Measure, Analyze, Improve, Control (DMAIC) methodology and applied its tools in various phases of the methodology.FindingsThe number of dispensing errors decreased from 6 to 2 incidents per 20,000 inpatient days per month between April 2018 and August 2019 representing a 66.66% reduction. The project has improved the dispensing process performance resulting in dispensing error reduction and improved patient safety. The communication channels between the hospital pharmacy and the pharmacy technicians have also been improved.Research limitations/implicationsThis study was conducted in an inpatient pharmacy of a teaching hospital in Thailand. Therefore, the findings from this study cannot be generalized beyond the specific setting. However, the findings are applicable in the case of similar contexts and/or situations.Originality/valueThis is the first study that employs a continuous improvement methodology for the purpose of improving the dispensing process and the quality of care in a hospital. This study contributes to an understanding of how the application of action research can save patients' lives, improve patient safety and increase work satisfaction in the pharmacy service.

Feasibility Evaluation of Smart Stretcher to Improve Patient Safety during Transfers

2011 ◽  
Vol 50 (03) ◽  
pp. 253-264 ◽  
Author(s):  
Y. Kurihara ◽  
K. Watanabe ◽  
L. Ohno-Machado ◽  
H. Tanaka ◽  
K. Ohashi
Keyword(s):  
Patient Safety ◽  
Wireless Network ◽  
Medical Staff ◽  
Improve Patient Safety ◽  
Hospital Environment ◽  
Small Scale ◽  
Identification System ◽  
Patient Identification ◽  
Technical Feasibility ◽  
Improve Patient

SummaryObjectives: The integration of noninvasive vital sign sensors and wireless sensor networks into intelligent alarm systems has the potential to improve patient safety. We developed a wireless network-based system (“Smart Stretcher”), which was designed to constantly monitor patient vital signs and detect apnea during transfers within a hospital. The system alerts medical staff in case of an emergency through a wireless network.Methods: A small-scale technical feasibility study was conducted to assess the performance of the system in a simulated hospital environment. Smart Stretcher consists of three components: a small air-mat type pressure sensor measuring respiratory rate and detecting apnea, a patient identification system using RFID technology, and an indoor positioning system using a ZigBee wireless network. In the feasibility experiment, two nurses transferred four subjects who stopped breathing for 10 seconds, after which we calculated the accuracy of apnea detections, repeating this at varying speeds and subject positions. We alsoperformed asubjective evaluation of perceptions and expectations of Smart Stretcher by nurses.Results: The system could detect apnea in all subjects at a rate of over 90%, patient IDs and locations were correctly detected in real time, and the system could alert medical staff. In addition, the results of nurse’s evaluations were mostly positive.Conclusions: The technical feasibility experiment and evaluation of Smart Stretcher suggest that the system could play a key role in monitoring patients during hospital transfers.

Sign in / Sign up

Export Citation Format

Share Document