scholarly journals Responding to adverse patient safety events in Viet Nam

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Reema Harrison ◽  
Anurag Sharma ◽  
Merrilyn Walton ◽  
Esmond Esguerra ◽  
Seinyenede Onobrakpor ◽  
...  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Physical Health ◽  
Psychological Health ◽  
Health Professionals ◽  
Incident Reporting ◽  
Near Miss ◽  
Viet Nam ◽  
Organisational Support ◽  
Doctors And Nurses

Abstract Background The psychological and professional impact of adverse events on doctors and nurses is well-established, but limited data has emerged from low- and middle-income. This article reports the experiences of being involved in a patient safety event, incident reporting and organisational support available to assist health professionals in Viet Nam to learn and recover. Method Doctors and nurses (1000) from all departments of a 1500-bed surgical and trauma hospital in Viet Nam were invited to take part in a cross-sectional survey. The survey explored respondents’ involvement in adverse events and/or near miss, their emotional, behavioural and coping responses, experiences of organisational incident reporting, and the learning and/or other consequences of the event. Survey items also assessed the availability of organisational support including peer support and mentorship. Results Of the 497 respondents, 295 (59%) experienced an adverse event in which a patient was harmed, of which 86 (17%) resulted in serious patient harm. 397 (80%) of respondents experienced a near miss, with 140 of these (28%) having potential for serious harm. 386 (77%) reporting they had been affected professionally or personally in some way, with impacts to psychological health (416; 84%), physical health (388; 78%), job satisfaction (378; 76%) and confidence in their ability (276; 56%) commonly reported. Many respondents were unable to identify local improvements (373; 75%) or organisation-wide improvements following safety events (359; 72%) and 171 (34%) admitted that they had not reported an event to their organisation or manager that they should have. Conclusions Health professionals in Viet Nam report impacts to psychological and physical health as a result of involvement in safety events that reflect those of health professionals internationally. Reports of limited organisational learning and improvement following safety events suggest that patient safety culture is underdeveloped in Viet Nam currently. In order to progress work on patient safety cultures and incident reporting in Viet Nam, health professionals will need to be convinced not only that they will not be exposed to punitive action, but that learning and positive changes will occur as a result of reporting safety events.

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 FACILITIES AND DIFFICULTIES OF HEALTH PROFESSIONALS REGARDING THE ADVERSE EVENT REPORTING PROCESS

2019 ◽  
Vol 28 ◽  
Author(s):  
Franciane Aceli de Souza Mascarenhas ◽  
Jane Cristina Anders ◽  
Francine Lima Gelbcke ◽  
Gabriela Marcellino de Melo Lanzoni ◽  
Patricia Ilha
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Health Professionals ◽  
Educational Practice ◽  
Knowledge Work ◽  
Adverse Event Reporting ◽  
Structured Interviews ◽  
Health Events ◽  
Lack Of Commitment ◽  
Adverse Health Events

ABSTRACT Objective: To describe the facilities and difficulties that health professionals have in relation to reporting adverse events in the hospital context. Method: a descriptive, exploratory study with a qualitative approach, conducted in a high complexity public cardiovascular hospital in southern Brazil, between april and may 2017 with 39 health professionals. Semi-structured interviews and thematic analysis were used. Results: Two categories emerged: Facilities for reporting adverse events and obstacles that hinder this process. The practice illustrates the fear of punishment, fragility in knowledge, work overload and lack of commitment of professionals, leading to underreporting. Difficulties occur with regard to non-compliance with routines and unpreparedness to use the reporting form of the institution. Some positive aspects are related to the support of the Patient Safety Center, the feedback of notifications and the recognition of the importance of reporting adverse health events. Conclusion: The notification process is permeated by positive aspects and some obstacles that need to be overcome. Strategies with a focus on communication and educational practice are needed to disseminate information about the notification process, as well as to promote a culture without culpability and accountability for achieving patient safety.

scholarly journals Descriptive Epidemiology of Safety Events at an Academic Medical Center

2020 ◽  
Vol 17 (1) ◽  
pp. 353
Author(s):  
Alexandre R. Marra ◽  
Abdullah Algwizani ◽  
Mohammed Alzunitan ◽  
Theresa M. H. Brennan ◽  
Michael B. Edmond
Keyword(s):  
Patient Safety ◽  
Patient Care ◽  
Surveillance System ◽  
Medical Center ◽  
Academic Medical Center ◽  
Incident Reporting ◽  
Near Miss ◽  
Descriptive Epidemiology ◽  
Near Misses ◽  
Academic Medical

Background: Adverse safety events in healthcare are of great concern, and despite an increasing focus on the prevention of error and harm mitigation, the epidemiology of safety events remains incomplete. Methods: We performed an analysis of all reported safety events in an academic medical center using a voluntary incident reporting surveillance system for patient safety. Safety events were classified as: serious (reached the patient and resulted in moderate to severe harm or death); precursor (reached the patient and resulted in minimal or no detectable harm); and near miss (did not reach the patient). Results: During a three-year period, there were 31,817 events reported. Most of the safety events were precursor safety events (reached the patient and resulted in minimal harm or no detectable harm), corresponding to 77.3%. Near misses accounted for 10.8%, and unsafe conditions for 11.8%. The number of reported serious safety events was low, accounting for only 0.1% of all safety events. Conclusions: The reports analysis of these events should lead to a better understanding of risks in patient care and ways to mitigate it.

scholarly journals "PENTINGNYA PENCEGAHAN BAHAYA DAN ADVERSE EVENT SEBAGAI UPAYA MENJAGA KESELAMATAN PASIEN DI RUMAH SAKIT"

2020 ◽  
Author(s):  
Awina Milla Shilmy Sitorus
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Adverse Events ◽  
Near Miss

Rumah sakit adalah sarana pelayanan kesehatan yang dibutuhkan ketika seseorang sakit dan membutuhkan bantuan dengan tujuan untuk menyelamatkan kondisi pasien. Keselamatan Pasien (patient safety) merupakan sesuatu yang jauh lebih penting dari pada sekedar efisiensi pelayanan. Perilaku perawat dengan kemampuan perawat sangat berperan penting dalam pelaksanaan keselamatan pasien. Perilaku yang tidak aman, lupa, kurangnyaperhatian/motivasi, kecerobohan, tidak teliti dan kemampuan yang tidak memedulikan dan menjaga keselamatan pasien berisiko untuk terjadinya kesalahan dan akan mengakibatkan cedera pada pasien, berupa Near Miss (Kejadian Nyaris Cedera/KNC) atau Adverse Event (Kejadian Tidak Diharapkan/KTD) selanjutnya pengurangan kesalahan dapat dicapai dengan memodifikasi perilaku. Perawat harus melibatkan kognitif, afektif dan tindakan yang mengutamakan keselamatan pasien (Julia, 2016).Cahyono (2008) menyatakan setiap asuhan klinis baik terkait dengan proses diagnosis, terapi, tindakan pembedahan, pemberian obat, pemeriksaan laboratorium, dsb dapat menimbulkan kerugian yang tidak diharapkan pasien baik secara fisik (cedera iatrogenik), finansial, maupun sosial. Secara lebih populer, asuhan klinis yang kemudian menimbulkan dampak yang merugikan bagi pasien akibat manajemen medis dan bukan akibat penyakit yang diderita pasien dikenal sebagai adverse events atau KTD (baik oleh dokter maupun pasien).

scholarly journals Mencegah terjadinya adverse events dengan memberikan pendidikan kesehatan tentang peran pasien dan keluarga untuk mencegah terjadinya bahaya

2020 ◽  
Author(s):  
Indri Novita Magdalena Aruan
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Adverse Events ◽  
World Health Organization ◽  
Near Miss ◽  
World Health ◽  
Health Organization

Keselamatan Pasien (Patient Safety) merupakan sesuatu yang jauh lebih penting dari pada sekedar efisiensi pelayanan. Perilaku perawat dengan kemampuan perawat sangat berperan penting dalam pelaksanaan keselamatan pasien. Perilaku yang tidak aman, lupa, kurangnya perhatian/motivasi, kecerobohan, tidak teliti dan kemampuan yang tidak memperdulikan dan menjaga keselamatan pasien berisiko untuk terjadinya kesalahan dan akan mengakibatkan cedera pada pasien, berupa Near Miss (Kejadian Nyaris Cedera/KNC) atau Adverse Event (Kejadian Tidak Diharapkan/KTD) selanjutnya pengurangan kesalahan dapat dicapai dengan memodifikasi perilaku. Perawat harus melibatkan kognitif, afektif dan tindakan yang mengutamakan keselamatan pasien. World Health Organization (WHO), 2014 Keselamatan pasien merupakan masalah keseahatan masyarakat global yang serius.

scholarly journals An integrated literature review on cultural management systems and patient safety

2021 ◽  
Vol 2 (2) ◽  
pp. 30-54
Author(s):  
Oladunni Abiodun ◽  
◽  
Oluyemi Toyinbo ◽  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Safety Culture ◽  
Health Professionals ◽  
Patient Safety Culture ◽  
Management Systems ◽  
Healthcare Organizations ◽  
Cultural Management ◽  
The Right ◽  
The Impact

The incidence of adverse events in healthcare is a global problem with negative consequences for all stakeholders including patients, their family members, health professionals and the government. Patient safety and patient safety culture lie at the heart of all adverse events within healthcare settings. The culture of an organization determines its approach to problem solving and determines how individuals within that setting work; this is also true for patient safety culture and the reduction of adverse events within healthcare organizations. The aim of this study was to assess, identify and have a better understanding of the importance of patient safety culture within the healthcare organization and to create insights on the impact of cultural management systems regarding patient safety. The research method of this study is an integrated literature of the patient safety culture and perspectives of healthcare workers, assessed using the Modified Stanford Instrument (MSI) and Manchester Patient Safety Framework (MaPSaF). Analysis of the data revealed that health professionals working in the same organizations have differing opinions on the same topic; therefore, there is need for open communication and a systematic approach to establishing the right safety culture within healthcare organizations. In conclusion, establishing the right culture and having systematic ways of measurement enable improvements and the ability of organizations to learn from their mistakes. There is paucity of data with respect to the use of these tools in the respective countries (Canada and United Kingdom) even though the tools are the national tools established through rigorous research. Therefore, a study of MaPSaF in New Zealand was also analyzed. There is need for further research and publications to enable learning on patient safety, which will reduce the incidence of adverse events and associated consequences in healthcare organizations.

scholarly journals The practice of reporting adverse events in a teaching hospital

2017 ◽  
Vol 51 (0) ◽  
Author(s):  
Andréia Guerra Siman ◽  
Simone Graziele Silva Cunha ◽  
Maria José Menezes Brito
Keyword(s):  
Patient Safety ◽  
Content Analysis ◽  
Adverse Events ◽  
Teaching Hospital ◽  
Health Professionals ◽  
Qualitative Case Study ◽  
Educational Practice ◽  
Nursing Team ◽  
Objective Understanding

Abstract OBJECTIVE Understanding the practice of reporting adverse events by health professionals. METHOD A qualitative case study carried out in a teaching hospital with participants of the Patient Safety Center and the nursing team. The collection took place from May to December 2015, and was conducted through interviews, observation and documentary research to treat the data using Content Analysis. RESULTS 31 professionals participated in the study. Three categories were elaborated: The practice of reporting adverse events; Barriers in the effective practice of notifications; The importance of reporting adverse events. CONCLUSION Notification was permeated by gaps in knowledge, fear of punishment and informal communication, generating underreporting. It is necessary to improve the interaction between leaders and professionals, with an emphasis on communication and educational practice.

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