The Lilypond: An integrated model of Safety II principles in the workplace. A quantum shift in patient safety thinking

2020 ◽  
Vol 25 (2) ◽  
pp. 85-90 ◽  
Author(s):  
Paul Stretton
Keyword(s):  
Patient Safety ◽  
Conceptual Model ◽  
Safety Performance ◽  
Cross Sectional ◽  
Linear Approach ◽  
Swiss Cheese Model ◽  
Safety Models ◽  
The Impact ◽  
Cheese Model ◽  
Insight Into

The Lilypond is a new conceptual model to describe patient safety performance. It radically diverges from established patient safety models to develop the reality of complexity within the healthcare systems as well as incorporating Safety II principles. There are two viewpoints of the Lilypond that provide insight into patient safety performance. From above, we are able to observe the organisational outcomes. This supersedes the widely used Safety Triangle and provides a more accurate conceptual model for understanding what outcomes are generated within healthcare. From a cross-sectional view, we are able to gain insights into how these outcomes come to manifest. This includes recognition of the complexity of our workplace, the impact of micro-interactions, effective leadership behaviours as well as patterns of behaviour that all provide learning. This replaces the simple, linear approach of The Swiss Cheese Model when analysing outcome causation. By applying the principles of Safety II and replacing outdated models for understanding patient safety performance, a more accurate, beneficial and respectful understanding of safety outcomes is possible.

scholarly journals Assessing the Impact of Multi-Morbidity and Related Constructs on Patient Reported Safety in Primary Care: Generalized Structural Equation Modelling of Observational Data

2021 ◽  
Vol 10 (8) ◽  
pp. 1782
Author(s):  
Ignacio Ricci-Cabello ◽  
Aina María Yañez-Juan ◽  
Maria A. Fiol-deRoque ◽  
Alfonso Leiva ◽  
Joan Llobera Canaves ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Structural Equation ◽  
Structural Equation Models ◽  
Cross Sectional ◽  
Morbidity Burden ◽  
Patient Reported ◽  
Patient Complexity ◽  
Complex Relationships ◽  
The Impact

We aimed to examine the complex relationships between patient safety processes and outcomes and multimorbidity using a comprehensive set of constructs: multimorbidity, polypharmacy, discordant comorbidity (diseases not sharing either pathogenesis nor management), morbidity burden and patient complexity. We used cross-sectional data from 4782 patients in 69 primary care centres in Spain. We constructed generalized structural equation models to examine the associations between multimorbidity constructs and patient-reported patient safety (PREOS-PC questionnaire). These associations were modelled through direct and indirect (mediated by increased interactions with healthcare) pathways. For women, a consistent association between higher levels of the multimorbidity constructs and lower levels of patient safety was observed via either pathway. The findings for men replicated these observations for polypharmacy, morbidity burden and patient complexity via indirect pathways. However, direct pathways showed unexpected associations between higher levels of multimorbidity and better safety. The consistent association between multimorbidity constructs and worse patient safety among women makes it advisable to target this group for the development of interventions, with particular attention to the role of comorbidity discordance. Further research, particularly qualitative research, is needed for clarifying the complex associations among men.

scholarly journals Culture of Blame—An Ongoing Burden for Doctors and Patient Safety

2019 ◽  
Vol 16 (23) ◽  
pp. 4826 ◽  
Author(s):  
Ognjen Brborović ◽  
Hana Brborović ◽  
Iskra Alexandra Nola ◽  
Milan Milošević
Keyword(s):  
Patient Safety ◽  
Healthcare Workers ◽  
Health Workers ◽  
Patient Safety Culture ◽  
Cross Sectional Study ◽  
Sectional Study ◽  
Cross Sectional ◽  
Single Item ◽  
Shortage Of Doctors ◽  
The Impact

Introduction: Every procedure in healthcare carries a certain degree of inherent unsafety resulting from problems in practice, which might lead to a healthcare adverse event (HAE). It is very important, and even mandatory, to report HAE. The point of HAE reporting is not to blame the person, but to learn from the HAE in order to prevent future HAEs. Study question: Our aim was to examine the prevalence and the impact of culture of blame on health workers’ health. Methods: A cross-sectional study on healthcare workers at two Croatian hospitals was conducted using the Hospital Survey on Patient Safety Culture (PSC). Results: The majority of PSC dimensions in both hospitals were high. Among the dimensions, Hospital Handoffs and Transitions and Overall Perceptions of Safety had the highest values. The Nonpunitive Response to Error dimension had low values, indicating the ongoing culture of blame. The Staffing dimension had low values, indicating the ongoing shortage of doctors and nurses. Discussion: We found inconsistencies between a single-item measure and PSC dimensions. It was expected that Frequency of Events Reported (PSC dimension) relates to Number of Events Reported (single-item measure). However, in our study, the relations between these pairs of measures were different between hospitals. Our results indicate the ongoing culture of blame. Healthcare workers do not report HAE because they fear they will be punished by management or by law.

Recognizing the Ordinary as Extraordinary: Insight Into the “Way We Work” to Improve Patient Safety Outcomes

2017 ◽  
Vol 26 (4) ◽  
pp. 272-277 ◽  
Author(s):  
Elizabeth A. Henneman
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Eye Tracking ◽  
Medical Errors ◽  
Improve Patient Safety ◽  
Safety Net ◽  
Near Miss ◽  
The Impact ◽  
Risk Processes ◽  
Insight Into

The Institute of Medicine (now National Academy of Medicine) reports “To Err is Human” and “Crossing the Chasm” made explicit 3 previously unappreciated realities: (1) Medical errors are common and result in serious, preventable adverse events; (2) The majority of medical errors are the result of system versus human failures; and (3) It would be impossible for any system to prevent all errors. With these realities, the role of the nurse in the “near miss” process and as the final safety net for the patient is of paramount importance. The nurse’s role in patient safety is described from both a systems perspective and a human factors perspective. Critical care nurses use specific strategies to identify, interrupt, and correct medical errors. Strategies to identify errors include knowing the patient, knowing the plan of care, double-checking, and surveillance. Nursing strategies to interrupt errors include offering assistance, clarifying, and verbally interrupting. Nurses correct errors by persevering, being physically present, reviewing/confirming the plan of care, or involving another nurse or physician. Each of these strategies has implications for education, practice, and research. Surveillance is a key nursing strategy for identifying medical errors and reducing adverse events. Eye-tracking technology is a novel approach for evaluating the surveillance process during common, high-risk processes such as blood transfusion and medication administration. Eye tracking has also been used to examine the impact of interruptions to care caused by bedside alarms as well as by other health care personnel. Findings from this safety-related eye-tracking research provide new insight into effective bedside surveillance and interruption management strategies.

scholarly journals Duration of second victim symptoms in the aftermath of a patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands

BMJ Open ◽  
2019 ◽  
Vol 9 (7) ◽  
pp. e029923 ◽  
Author(s):  
Kris Vanhaecht ◽  
Deborah Seys ◽  
Loes Schouten ◽  
Luk Bruyneel ◽  
Ellen Coeckelberghs ◽  
...  
Keyword(s):  
Patient Safety ◽  
Healthcare Providers ◽  
Direct Patient Care ◽  
Secondary Outcome ◽  
Symptom Duration ◽  
Common Symptom ◽  
Patient Harm ◽  
Cross Sectional ◽  
Safety Incident ◽  
The Impact

ObjectivesTo describe healthcare providers’ symptoms evoked by patient safety incidents (PSIs), the duration of these symptoms and the association with the degree of patient harm caused by the incident.DesignCross-sectional survey.Setting32 Dutch hospitals that participate in the ‘Peer Support Collaborative’.Participants4369 healthcare providers (1619 doctors and 2750 nurses) involved in a PSI at any time during their career.InterventionsAll doctors and nurses working in direct patient care in the 32 participating hospitals were invited via email to participate in an online survey.Primary and secondary outcome measuresPrevalence of symptoms, symptom duration and its relationship with the degree of patient harm.ResultsIn total 4369 respondents were involved in a PSI and completely filled in the questionnaire. Of these, 462 reported having been involved in a PSI with permanent harm or death during the last 6 months. This had a personal, professional impact as well as impact on effective teamwork requirements. The impact of a PSI increased when the degree of patient harm was more severe. The most common symptom was hypervigilance (53.0%). The three most common symptoms related to teamwork were having doubts about knowledge and skill (27.0%), feeling unable to provide quality care (15.6%) and feeling uncomfortable within the team (15.5%). PSI with permanent harm or death was related to eightfold higher likelihood of provider-related symptoms lasting for more than 1 month and ninefold lasting longer than 6 months compared with symptoms reported when the PSI caused no harm.ConclusionThe impact of PSI remains an underestimated problem. The higher the degree of harm, the longer the symptoms last. Future studies should evaluate how these data can be integrated in evidence-based support systems.

scholarly journals The environment of safe care: considering building design as one facet of safety

2014 ◽  
Vol 3 (1) ◽  
pp. 123-127 ◽  
Author(s):  
Ellen Taylor ◽  
Sue Hignett ◽  
Anjali Joseph
Keyword(s):  
Patient Safety ◽  
Built Environment ◽  
Building Design ◽  
Healthcare Research ◽  
Design Decision ◽  
Organizational Research ◽  
Additional Layer ◽  
Swiss Cheese Model ◽  
Reform Organizations ◽  
Cheese Model

Patient safety is often considered in a behavioral context – what can someone do differently to improve outcomes? However, as a complex system of interactions, patient safety is better advanced through a systems thinking lens of human factors and ergonomics (HFE). While HFE is sometimes considered in three domains: physical, cognitive, and organizational, research in the area of the design of the physical environment is often limited to products, equipment and furnishings to accommodate a diverse population of users. With an increased focus on reimbursement related to patient safety as part of healthcare reform, organizations are becoming more aware of their own shortcomings and grappling with solutions to improve performance – typically people and processes. Yet the influence of the built environment, the space in which people work and are cared for, can act as a barrier or enhancement to achieving the desired results – physically, cognitively, and organizationally. Latent conditions of the built environment can contribute to hazards and risk within the system and using Reason’s Swiss Cheese Model can also become an additional layer of defense. A consensus-based safety risk assessment (SRA) design decision tool is being developed to address these built environment latent conditions funded through a three-year grant from the Agency for Healthcare Research and Quality (AHRQ).

The Power of Stars: Do Star Actors Drive the Success of Movies?

2007 ◽  
Vol 71 (4) ◽  
pp. 102-120 ◽  
Author(s):  
Anita Elberse
Keyword(s):  
Group Dynamics ◽  
Motion Picture Industry ◽  
Trading Behavior ◽  
Cross Sectional ◽  
Track Record ◽  
Box Office ◽  
Film Studios ◽  
Sectional Analysis ◽  
The Impact ◽  
Insight Into

Is the involvement of stars critical to the success of motion pictures? Film studios, which regularly pay multimillion-dollar fees to stars, seem to be driven by that belief. This article sheds light on the returns on this investment using an event study that considers the impact of more than 1200 casting announcements on trading behavior in a simulated and real stock market setting. The author finds evidence that the involvement of stars affects movies' expected theatrical revenues and provides insight into the magnitude of this effect. For example, the estimates suggest that, on average, stars are worth approximately $3 million in theatrical revenues. In a cross-sectional analysis grounded in the literature on group dynamics, the author also examines the determinants of the magnitude of stars' impact on expected revenues. Among other things, the author shows that the stronger a cast already is, the greater is the impact of a newly recruited star with a track record of box office successes or with a strong artistic reputation. Finally, in an extension to the study, the author does not find that the involvement of stars in movies increases the valuation of film companies that release the movies, thus providing insufficient grounds to conclude that stars add more value than they capture. The author discusses implications for managers in the motion picture industry.

Nursing Perception of the Impact of Medication Carts on Patient Safety and Ergonomics in a Teaching Health Care Center

2012 ◽  
Vol 26 (2) ◽  
pp. 131-137 ◽  
Author(s):  
Élise Rochais ◽  
Suzanne Atkinson ◽  
Jean-François Bussières
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Focus Group ◽  
Point Of Care ◽  
Care Center ◽  
Drug Distribution ◽  
University Hospital ◽  
Cross Sectional ◽  
Health Care Center ◽  
The Impact

Objectives: In our Quebec (Canada) University Hospital Center, 68 medication carts have been implemented as part of a nationally funded project on drug distribution technologies. There are limited data published about the impact of medication carts in point-of-care units. Our main objective was to assess nursing staff’s perception and satisfaction of medication carts on patient safety and ergonomics. Method: Quantitative and qualitative cross-sectional study. Data were gathered from a printed questionnaire administered to nurses and an organized focus group composed of nurses and pharmacists. Results: A total of 195 nurses completed the questionnaire. Eighty percent of the nurses agreed that medication carts made health care staff’s work easier and 64% agreed that it helped to reduce medication incidents/accidents. Only 27% and 43% agreed that carts’ location reduces the risk of patients’ interruptions and colleagues’ interruptions, respectively. A total of 17 suggestions were extracted from the focus group (n = 7 nurses; n = 3 pharmacist) and will be implemented in the next year. Conclusions: This descriptive study confirms the positive perception and satisfaction of nurses exposed to medication carts. However, interruptions are a major concern and source of dissatisfaction. The focus group has revealed many issues which will be improved.

scholarly journals THE IMPACT ANALYSIS OF MOTIVATION, TRAINING, AND WORK ENVIRONMENT TO NURSES PERFORMANCE IN PATIENT SAFETY

2019 ◽  
Vol 2 (1) ◽  
pp. 54
Author(s):  
Fushen Fushen ◽  
Meylona Verawaty Zendrato
Keyword(s):  
Patient Safety ◽  
Work Environment ◽  
Public Hospital ◽  
Impact Analysis ◽  
Working Environment ◽  
Cross Sectional ◽  
The Public ◽  
Increasing Demand ◽  
And Performance ◽  
The Impact

The development of hospitals in health industry as economic institutions and the establishment of many new hospitals increase the number of nurses needed while the number of nurses produced cannot keep pace with the increasing demand. In hospital services, nurse is the most frequently interacted person with patients and are fully responsible for patient care, including in terms of patient safety. This study aims to obtain empirical evidence about the effect of motivation, training and work environment on the performance of nurses in patient safety in the Public Hospital. Expected output from this study can be used as a reference to determine the policy for nurse management at the hospital. This is a correlational analytic study with a cross-sectional approach and descriptive method of verification. The research was conducted in a Public Hospital in Jakarta. The research sample are 90 nurses working in inpatient wards. The hypothesis of this study were analyzed with path analysis methods. The results of this study showed a significant positive effect between motivation and performance (20.7%), training and performance (21.8%), working environment and performance (20.7%), and the simultaneous influence from motivation, training, and working environment on the performance (63.2% ).

scholarly journals The impact of patient safety culture and the leader coaching behaviour of nurses on the intention to report errors: A cross-sectional survey

2020 ◽  
Author(s):  
Zahra Chegini ◽  
Edris Kakemam ◽  
Mohammad Asghari Jafarabadi ◽  
Ali Janati
Keyword(s):  
Patient Safety ◽  
Regression Analysis ◽  
Safety Culture ◽  
Linear Regression Analysis ◽  
Educational Status ◽  
Patient Safety Culture ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Coaching Behavior ◽  
The Impact

Abstract Background: There is growing interest in examining the factors affecting the reporting of errors by nurses. However, little research has been conducted into the effects of perceived patient safety culture and leader coaching of nurses on the intention to report errors. Methods: This cross-sectional study was conducted amongst 256 nurses in the emergency departments of 18 public and private hospitals in Tabriz, northwest Iran. Participants completed the Hospital Survey on Patient Safety Culture (HSOPSC), Coaching Behavior Scale and Intention to Report Errors questionnaires and the data was analyzed using multiple linear regression analysis. Results: Overall, 43% of nurses had an intention to report errors; 50% of respondents reported that their nursing managers demonstrated high levels of coaching. With regard to patient safety culture, areas of strength and weakness were “teamwork within units” (PRR = 66.80%) and “non-punitive response errors” (PRR = 19.66%). Regression analysis findings highlighted a significant association between an intention to report errors and patient safety culture (B=0.123, CI 95%: 0.005 to 0.328, P = 0.026), leader coaching behavior (B=0.172, CI 95%: 0.066 to 0.347, P = 0.004) and nurses’ educational status (B=0. 787, 95% CI: -.064 to 1.638, P = 0.048). Conclusions: Further research is needed to assess how interventions addressing patient safety culture and leader coaching behaviours might increase the intention to report errors.

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