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 Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?

2016 ◽  
pp. bmjqs-2016-005991 ◽  
Author(s):  
Kathryn M Kellogg ◽  
Zach Hettinger ◽  
Manish Shah ◽  
Robert L Wears ◽  
Craig R Sellers ◽  
...  
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Root Cause Analysis ◽  
Current Approach ◽  
Cause Analysis ◽  
Root Cause ◽  
Improve Patient

Using Aggregate Root Cause Analysis to Improve Patient Safety

2003 ◽  
Vol 29 (8) ◽  
pp. 434-439 ◽  
Author(s):  
Julia Neily ◽  
Greg Ogrinc ◽  
Peter Mills ◽  
Rodney Williams ◽  
Erik Stalhandske ◽  
...  
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause ◽  
Improve Patient

scholarly journals Adverse Event Reporting: Harnessing Residents to Improve Patient Safety

2017 ◽  
Vol 16 (4) ◽  
pp. 294-298 ◽  
Author(s):  
Sarah E. Tevis ◽  
Ryan K. Schmocker ◽  
Tosha B. Wetterneck
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Improve Patient Safety ◽  
Adverse Event Reporting ◽  
Event Reporting ◽  
Improve Patient

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.

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

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.

Sign in / Sign up

Export Citation Format

Share Document