A Three-Decade Perspective on Anesthesia Safety

2006 ◽  
Vol 72 (11) ◽  
pp. 985-989 ◽  
Author(s):  
William L. Lanier
Keyword(s):  
Improve Patient Safety ◽  
Mortality Rates ◽  
Hospital Environment ◽  
Quality And Safety ◽  
Road Map ◽  
Anesthesia Safety ◽  
Safety Improvement ◽  
Modern Medical Practice ◽  
Improve Patient ◽  
Current Report

Modern medical practice, and particularly that within the hospital environment, has been under intense scrutiny in an attempt to improve patient safety and optimize outcomes. Anesthesiology has been cited as among the most successful specialties effecting improvements. According to the Institute of Medicine's 1999 report, To Err is Human, “… anesthesiology has successfully reduced anesthesia mortality rates from two deaths per 10,000 anesthetics administered, to one death per 200,000 to 300,000 anesthetics administered.” The current report reviews representative highlights from 30 years of progress in improving anesthesiology safety and offers a speculative synthesis of the factors critical to past and future successes. The seven identified points include 1) the emergence of a champion and his allies, 2) initial efforts to identify and quantify broad-reaching problems, 3) research addressing intellectually “amusing” problems of relevance to practitioners, 4) reaching out to others with focused expertise in problem prevention and problem solving, 5) sharing the responsibility for quality and safety improvement with other specialties, 6) expanding buy-in and participation within the anesthesia community, and 7) preparing for the future. The factors provide not only an accounting of anesthesiologists’ successes, but also a road map for other groups and specialties desiring to emulate the anesthesiologists’ experience.

scholarly journals Quality and Safety in eHealth: The Need to Build the Evidence Base (Preprint)

2019 ◽  
Author(s):  
Elizabeth Borycki
Keyword(s):  
Health Informatics ◽  
Improve Patient Safety ◽  
Health Technology ◽  
Evidence Base ◽  
Evidence Based ◽  
Quality And Safety ◽  
Design Development ◽  
Health Technologies ◽  
Safety Science ◽  
Improve Patient

UNSTRUCTURED Research in the area of health technology safety has demonstrated that technology may both improve patient safety and introduce new types of technology-induced errors. Thus, there is a need to publish safety science literature to develop an evidence-based research base, on which we can continually develop new, safe technologies and improve patient safety. The aim of this viewpoint is to argue for the need to advance evidence-based research in health informatics, so that new technologies can be designed, developed, and implemented for their safety prior to their use in health care. This viewpoint offers a historical perspective on the development of health informatics and safety literature in the area of health technology. I argue for the need to conduct safety studies of technologies used by health professionals and consumers to develop an evidence base in this area. Ongoing research is necessary to improve the quality and safety of health technologies. Over the past several decades, we have seen health informatics emerge as a discipline, with growing research in the field examining the design, development, and implementation of different health technologies and new challenges such as those associated with the quality and safety of technology use. Future research will need to focus on how we can continually extend safety science in this area. There is a need to integrate evidence-based research into the design, development, and implementation of health technologies to improve their safety and reduce technology-induced errors.

Root Causes of Falls in Veterans With Dementia: Opportunity for Intervention in Patient Safety Improvement—A Retrospective Review

2021 ◽  
Vol 75 (Supplement_2) ◽  
pp. 7512510267p1-7512510267p1
Author(s):  
Elizabeth Rhodus ◽  
Elizabeth Lancaster ◽  
Mary Duke ◽  
Andrew Harris
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Health Care Systems ◽  
Veterans Health ◽  
Health Administration ◽  
Root Cause ◽  
Safety Improvement ◽  
Care Systems ◽  
Improve Patient ◽  
Patient Safety Improvement

Abstract Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. The presented research offers an introduction to the use of root-cause analyses in the Veterans Health Administration for identification of falls in veterans with dementia who were referred to or receiving OT. Results identify specific areas for improvement that may be immediately implemented by OTin all health care systems. Such improvements to care may drastically improve patient safety and decrease fall risk in older adults with dementia. Primary Author and Speaker: Elizabeth Rhodus Contributing Authors: Elizabeth Lancaster, Mary Duke, and Andrew Harris

scholarly journals Development of a Taxonomy for Medication-Related Patient Safety Events Related to Health Information Technology in Pediatrics

2020 ◽  
Vol 11 (05) ◽  
pp. 714-724
Author(s):  
Kirk D. Wyatt ◽  
Tyler J. Benning ◽  
Timothy I. Morgenthaler ◽  
Grace M. Arteaga
Keyword(s):  
Information Technology ◽  
Patient Safety ◽  
Health Information Technology ◽  
Health Information ◽  
Improve Patient Safety ◽  
Help Desk ◽  
Safety Improvement ◽  
Safety Event ◽  
Improve Patient ◽  
Medication Related Events

Abstract Background Although electronic health records (EHRs) are designed to improve patient safety, they have been associated with serious patient harm. An agreed-upon and standard taxonomy for classifying health information technology (HIT) related patient safety events does not exist. Objectives We aimed to develop and evaluate a taxonomy for medication-related patient safety events associated with HIT and validate it using a set of events involving pediatric patients. Methods We performed a literature search to identify existing classifications for HIT-related safety events, which were assessed using real-world pediatric medication-related patient safety events extracted from two sources: patient safety event reporting system (ERS) reports and information technology help desk (HD) tickets. A team of clinical and patient safety experts used iterative tests of change and consensus building to converge on a single taxonomy. The final devised taxonomy was applied to pediatric medication-related events assess its characteristics, including interrater reliability and agreement. Results Literature review identified four existing classifications for HIT-related patient safety events, and one was iteratively adapted to converge on a singular taxonomy. Safety events relating to usability accounted for a greater proportion of ERS reports, compared with HD tickets (37 vs. 20%, p = 0.022). Conversely, events pertaining to incorrect configuration accounted for a greater proportion of HD tickets, compared with ERS reports (63 vs. 8%, p < 0.01). Interrater agreement (%) and reliability (kappa) were 87.8% and 0.688 for ERS reports and 73.6% and 0.556 for HD tickets, respectively. Discussion A standardized taxonomy for medication-related patient safety events related to HIT is presented. The taxonomy was validated using pediatric events. Further evaluation can assess whether the taxonomy is suitable for nonmedication-related events and those occurring in other patient populations. Conclusion Wider application of standardized taxonomies will allow for peer benchmarking and facilitate collaborative interinstitutional patient safety improvement efforts.

scholarly journals Sharing the pain: lessons from missed opportunities for healthcare improvement from patient complaints and litigation in the Australian health system

2019 ◽  
Vol 43 (4) ◽  
pp. 382 ◽  
Author(s):  
Benjamin M. Nowotny ◽  
Erwin Loh ◽  
Katherine Lorenz ◽  
Euan M. Wallace
Keyword(s):  
Improve Patient Safety ◽  
Opportunity To Learn ◽  
Improve Patient Care ◽  
Quality And Safety ◽  
System Quality ◽  
Missed Opportunities ◽  
Hospital System ◽  
Australian Health ◽  
Patient Complaints ◽  
Improve Patient

Learning from medical errors to prevent their recurrence is an important component of any healthcare system’s quality and safety improvement functions. Traditionally, this been achieved principally from review of adverse clinical outcomes. The opportunity to learn systematically and in a system manner from patient complaints and litigation has been less well harnessed. Herein we describe the pathways and processes for both patient complaints and medicolegal claims in Victoria, and Australia more broadly, and assess the potential for these to be used for system improvement. We conclude that both patient complaints and medicolegal claims could afford the potential to additionally inform and direct safety and quality improvement. At present neither patient complaints nor medicolegal claims are used systematically to improve patient safety. We identify how this may be done, particularly through sharing findings across agencies. What is known about the topic? Patient complaints and medicolegal claims are accepted parts of the healthcare industry. However, using these in a shared and collated manner as part of an improvement agenda has not been widely considered or proposed. What does the paper add? This paper provides a summary of the patient complaint and medicolegal landscape in public hospital system in Australia broadly, and Victoria more specifically, identifying the agencies involved and the opportunities for sharing learnings. The paper draws on existing literature and experiences from both Australia and elsewhere to propose a framework whereby complaints and claims data could be shared systematically and strategically to reduce future harm and improve patient care. What are the implications for practitioners? We offer an approach for practitioners, healthcare managers and policy makers in all Australian jurisdictions to design and implement a statewide capacity to share patient complaints and medicolegal claims as an additional component of system quality and safety.

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.

scholarly journals Quality and Safety in eHealth: The Need to Build the Evidence Base

10.2196/16689 ◽  
2019 ◽  
Vol 21 (12) ◽  
pp. e16689 ◽  
Author(s):  
Elizabeth Borycki
Keyword(s):  
Health Informatics ◽  
Improve Patient Safety ◽  
Health Technology ◽  
Evidence Base ◽  
Evidence Based ◽  
Quality And Safety ◽  
Design Development ◽  
Health Technologies ◽  
Safety Science ◽  
Improve Patient

Research in the area of health technology safety has demonstrated that technology may both improve patient safety and introduce new types of technology-induced errors. Thus, there is a need to publish safety science literature to develop an evidence-based research base, on which we can continually develop new, safe technologies and improve patient safety. The aim of this viewpoint is to argue for the need to advance evidence-based research in health informatics, so that new technologies can be designed, developed, and implemented for their safety prior to their use in health care. This viewpoint offers a historical perspective on the development of health informatics and safety literature in the area of health technology. I argue for the need to conduct safety studies of technologies used by health professionals and consumers to develop an evidence base in this area. Ongoing research is necessary to improve the quality and safety of health technologies. Over the past several decades, we have seen health informatics emerge as a discipline, with growing research in the field examining the design, development, and implementation of different health technologies and new challenges such as those associated with the quality and safety of technology use. Future research will need to focus on how we can continually extend safety science in this area. There is a need to integrate evidence-based research into the design, development, and implementation of health technologies to improve their safety and reduce technology-induced errors.

scholarly journals Editorial: Advances in healthcare provider and patient training to improve the quality and safety of patient care

2015 ◽  
pp. 348-352
Keyword(s):  
Patient Safety ◽  
Patient Care ◽  
Healthcare Provider ◽  
New Technologies ◽  
Improve Patient Safety ◽  
Quality And Safety ◽  
Special Issue ◽  
Computer Based Training ◽  
Computer Based ◽  
Improve Patient

This special issue of the Knowledge Management & E-Learning: An International Journal is dedicated to describing “Advances in Healthcare Provider and Patient Training to Improve the Quality and Safety of Patient Care.” Patient safety is an important and fundamental requirement of ensuring the quality of patient care. Training and education has been identified as a key to improving healthcare provider patient safety competencies especially when working with new technologies such as electronic health records and mobile health applications. Such technologies can be harnessed to improve patient safety; however, if not used properly they can negatively impact on patient safety. In this issue we focus on advances in training that can improve patient safety and the optimal use of new technologies in healthcare. For example, use of clinical simulations and online computer based training can be employed both to facilitate learning about new clinical discoveries as well as to integrate technology into day to day healthcare practices. In this issue we are publishing papers that describe advances in healthcare provider and patient training to improve patient safety as it relates to the use of educational technologies, health information technology and on-line health resources. In addition, in the special issue we describe new approaches to training and patient safety including, online communities, clinical simulations, on-the-job training, computer based training and health information systems that educate about and support safer patient care in real-time (i.e. when health professionals are providing care to patients). These educational and technological initiatives can be aimed at health professionals (i.e. students and those who are currently working in the field). The outcomes of this work are significant as they lead to safer care for patients and their family members. The issue has both theoretical and applied papers that describe advances in patient safety and training.

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