Process Risks in Perioperative Medication Delivery

2020 ◽  
Vol 64 (1) ◽  
pp. 1100-1100
Author(s):  
Sarah M. Coppola ◽  
Patience Osei ◽  
Ayse P. Gurses ◽  
Myrtede Alfred ◽  
David M. Neyans ◽  
...  
Keyword(s):  
Patient Safety ◽  
Systems Engineering ◽  
Maintenance Phase ◽  
Hospital Units ◽  
Medication Delivery ◽  
Anesthesia Providers ◽  
Safety Interventions ◽  
Consensus Procedure ◽  
Process Risk ◽  
Perioperative Medication

One anesthesia provider is often responsible for prescribing, formulating, dispensing, administering, and documenting medications in the operating room. Unlike other hospital units, there are few safety interventions. Systems engineering approaches can provide important insights into improving patient safety during medication delivery processes (Kaplan et al., 2013; Reid et al., 2005). This study observed anesthesia medication delivery during 20 anesthetic cases in the OR and interviewed 10 anesthesia providers in a large midatlantic academic hospital using a Systems Engineering Initiative for Patient Safety (SEIPS) framework to identify process risk in perioperative medication delivery (Holden et al., 2013). Anesthesia attendings, fellows, residents, and certified resident nurse anesthetists (CRNAs) were sampled based on who was in the OR during observations and who volunteered for interviews. Interviews were transcribed and coded through a consensus procedure. The medication delivery process was described using a SEIPS-based process map. Tasks were separated based on the anesthesia phase, though the tasks and phases are not linear; e.g: a provider may prepare for the next case during the maintenance phase.

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.

Patient Safety Climate (Psc) in Outpatient Surgery Centers — Part Two

2005 ◽  
Vol 49 (16) ◽  
pp. 1464-1468
Author(s):  
Carla J. Alvarado ◽  
Pascale Carayon ◽  
Ann Schoofs Hundt
Keyword(s):  
Patient Safety ◽  
Systems Engineering ◽  
Health Care Professionals ◽  
Safety Climate ◽  
Outpatient Surgery ◽  
Post Intervention ◽  
Quality Of Working Life ◽  
Specific Patient ◽  
Patient Safety Climate ◽  
Safety Interventions

We report results of safety climate questions from health care professionals involved in the “Systems Engineering Intervention in Outpatient Surgery - a Collaborative Community Perspective” study undertaken at the University of Wisconsin-Madison. Surveys were conducted in five outpatient surgery centers pre- and post-intervention. The objectives of this study were to examine patient safety climate across various outpatient surgery centers pre- and post-specific patient safety interventions and to examine the relationship between patient safety climate and job categories, individual outpatient centers and the respondents' Quality of Working Life (QWL). Our results indicate that four patient safety climate scales can be created from the pre- and post-intervention 12-item questionnaire: (1) Top management commitment to patient safety, (2) General patent safety climate, (3) Employee commitment to patient safety and (4) Patient safety change. In one of the survey centers, patient safety climate became more negative over time.

Illuminating the decision-making strategies of anesthesia providers in challenging cases

2020 ◽  
Vol 64 (1) ◽  
pp. 653-657
Author(s):  
Joshua Biro ◽  
David M. Neyens ◽  
Candace Jaruzel ◽  
Catherine D. Tobin ◽  
Myrtede Alfred ◽  
...  
Keyword(s):  
Decision Making ◽  
Work Environment ◽  
Medication Errors ◽  
Information Seeking ◽  
Best Practice ◽  
Practice Recommendations ◽  
Medication Delivery ◽  
Anesthesia Providers ◽  
Healthcare Work ◽  
Realistic View

Medication errors and error-related scenarios in anesthesia remain an important area of research. Interventions and best practice recommendations in anesthesia are often based in the work-as-imagined healthcare system, remaining under-used due to a range of unforeseen complexities in healthcare work-as- done. In order to design adaptable anesthesia medication delivery systems, a better understanding of clinical cognition within the context of anesthesia work is needed. Fourteen interviews probing anesthesia providers’ decision making were performed. The results revealed three overarching themes: (1) anesthesia providers find cases challenging when they have incomplete information, (2) decision-making begins with information seeking, and (3) attributes such as expertise, experience, and work environment influence anesthesia providers’ information seeking and synthesis of tasks. These themes and the context within this data help create a more realistic view of work-as-done and generate insights into what potential medication error reducing interventions should look to avoid and what they could help facilitate.

Systems Engineering Initiative for Patient Safety-Informed Interview Guide

2018 ◽  
Author(s):  
Jinjiao Wang ◽  
Sandra F. Simmons ◽  
Cathy A. Maxwell ◽  
David G. Schlundt ◽  
Lorraine C. Mion
Keyword(s):  
Patient Safety ◽  
Systems Engineering ◽  
Interview Guide

Investigating Intraoperative and Intraprofessional Handoffs in Anesthesia

2018 ◽  
Vol 62 (1) ◽  
pp. 469-473
Author(s):  
Katherina Jurewicz ◽  
Myrtede Alfred ◽  
David M. Neyens ◽  
Ken Catchpole ◽  
Anjali Joseph ◽  
...  
Keyword(s):  
International Organizations ◽  
Medical Errors ◽  
Maintenance Phase ◽  
Healthcare Systems ◽  
Surgical Team ◽  
High Quality ◽  
Effective Strategies ◽  
Surgical Case ◽  
Anesthesia Providers ◽  
Contextual Elements

Handoffs occur frequently in healthcare systems, and miscommunications and critical omissions within handoffs have been linked to serious medical errors. Handoff quality is a priority of patient safety initiatives across several international organizations. The majority of previous research in handoffs have focused on postoperative handoffs; yet, there is a need to specifically investigate intraoperative handoffs, especially within individual professions or subspecialties. Each subspecialty within a surgical team may approach handoffs differently. The anesthesia team is especially unique as they take a team-based approach to patient care where multiple anesthesia providers may be involved in one surgical case. We describe an observational study of intraoperative and intraprofessional handoffs in anesthesia. Temporary and permanent handoffs were investigated as well as the contextual elements that influenced handoff procedures. In a sample of 35 video recorded surgeries, a total of 16 handoffs were identified for the maintenance phase of surgery. These handoffs ranged between 33 seconds and 7.42 minutes in duration. Our study revealed variability in intraoperative handoffs during the maintenance phase of anesthesia and emphasizes that intraoperative and intraprofessional handoffs warrant more in-depth examination in order to develop effective strategies or tools for high quality handoffs in anesthesia.

scholarly journals Team Cognition as a Barrier and Facilitator in Care Transitions: Implications for Work System Design

2019 ◽  
Vol 63 (1) ◽  
pp. 648-652
Author(s):  
Abigail R. Wooldridge ◽  
Pascale Carayon ◽  
Peter Hoonakker ◽  
Bat-Zion Hose ◽  
Thomas B. Brazelton ◽  
...  
Keyword(s):  
Patient Safety ◽  
System Design ◽  
Systems Engineering ◽  
Care Transitions ◽  
Pediatric Trauma ◽  
Barriers And Facilitators ◽  
Distributed Teams ◽  
Future Research ◽  
Team Cognition ◽  
Work System

Inpatient care of pediatric trauma patients includes care transitions, including from emergency department (ED) to operating room (OR), OR to pediatric intensive care unit (PICU) and ED to PICU, which are important to patient safety and quality of care. Previous research identified work system barriers and facilitators in these transitions; the most common related to team cognition. We conducted interviews with 18 healthcare professionals to better understand how work system design influences team cognition barriers and facilitators. Using Systems Engineering Initiative for Patient Safety (SEIPS)-based process modeling, we identified when each barrier/facilitator occurred. The ED to OR transition had more barriers in transition preparation, while OR to PICU had more facilitators in the transition. Future research should explore solutions to support team cognition early in the ED to OR transition, such as designing a technology to be used by distributed teams.

scholarly journals Time series evaluation of improvement interventions to reduce alarm notifications in a paediatric hospital

2020 ◽  
Vol 29 (9) ◽  
pp. 717-726 ◽  
Author(s):  
Colleen M Pater ◽  
Tina K Sosa ◽  
Jacquelyn Boyer ◽  
Rhonda Cable ◽  
Melinda Egan ◽  
...  
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Tertiary Care ◽  
Secondary Outcome ◽  
Secondary Outcome Measure ◽  
Tertiary Care Centre ◽  
Patient Acuity ◽  
Nursing Satisfaction ◽  
Paediatric Hospital ◽  
Hospital Units

Background10The Joint Commission identified inpatient alarm reduction as an opportunity to improve patient safety; enhance patient, family and nursing satisfaction; and optimise workflow. We used quality improvement (QI) methods to safely decrease non-actionable alarm notifications to bedside providers.MethodsIn a paediatric tertiary care centre, we convened a multidisciplinary team to address alarm notifications in our acute care cardiology unit. Alarm notification was defined as any alert to bedside providers for each patient-triggered monitor alarm. Our aim was to decrease alarm notifications per monitored bed per day by 60%. Plan-Do-Study-Act testing cycles included updating notification technology, establishing alarm logic and modifying bedside workflow processes, including silencing the volume on all bedside monitors. Our secondary outcome measure was nursing satisfaction. Balancing safety measures included floor to intensive care unit transfers and patient acuity level.ResultsAt baseline, there was an average of 71 initial alarm notifications per monitored bed per day. Over a 3.5-year improvement period (2014–2017), the rate decreased by 68% to 22 initial alarm notifications per monitored bed per day. The proportion of initial to total alarm notifications remained stable, decreasing slightly from 51% to 40%. There was a significant improvement in subjective nursing satisfaction. At baseline, 32% of nurses agreed they were able to respond to alarms appropriately and quickly. Following interventions, agreement increased to 76% (p<0.001). We sustained these improvements over a year without a change in monitored balancing measures.ConclusionWe successfully reduced alarm notifications while preserving patient safety over a 4-year period in a complex paediatric patient population using technological advances and QI methodology. Continued efforts are needed to further optimise monitor use across paediatric hospital units.

scholarly journals Assessing information sources to elucidate diagnostic process errors in radiologic imaging — a human factors framework

2018 ◽  
Vol 25 (11) ◽  
pp. 1507-1515 ◽  
Author(s):  
Laila Cochon ◽  
Ronilda Lacson ◽  
Aijia Wang ◽  
Neena Kapoor ◽  
Ivan K Ip ◽  
...  
Keyword(s):  
Patient Safety ◽  
Diagnostic Imaging ◽  
Peer Review ◽  
Systems Engineering ◽  
Information Sources ◽  
Diagnostic Process ◽  
Peer Review System ◽  
Review System ◽  
Potential Safety ◽  
Technical Factors

Abstract Objective To assess information sources that may elucidate errors related to radiologic diagnostic imaging, quantify the incidence of potential safety events from each source, and quantify the number of steps involved from diagnostic imaging chain and socio-technical factors. Materials and Methods This retrospective, Institutional Review Board-approved study was conducted at the ambulatory healthcare facilities associated with a large academic hospital. Five information sources were evaluated: an electronic safety reporting system (ESRS), alert notification for critical result (ANCR) system, picture archive and communication system (PACS)-based quality assurance (QA) tool, imaging peer-review system, and an imaging computerized physician order entry (CPOE) and scheduling system. Data from these sources (January-December 2015 for ESRS, ANCR, QA tool, and the peer-review system; January-October 2016 for the imaging ordering system) were collected to quantify the incidence of potential safety events. Reviewers classified events by the step(s) in the diagnostic process they could elucidate, and their socio-technical factors contributors per the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Results Potential safety events ranged from 0.5% to 62.1% of events collected from each source. Each of the information sources contributed to elucidating diagnostic process errors in various steps of the diagnostic imaging chain and contributing socio-technical factors, primarily Person, Tasks, and Tools and Technology. Discussion Various information sources can differentially inform understanding diagnostic process errors related to radiologic diagnostic imaging. Conclusion Information sources elucidate errors in various steps within the diagnostic imaging workflow and can provide insight into socio-technical factors that impact patient safety in the diagnostic process.

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