Patient safety incident framework will ensure affected staff are not overlooked

2021 ◽  
Vol 30 (21) ◽  
pp. 1263-1263
Author(s):  
Sam Foster

Sam Foster, Chief Nurse, Oxford University Hospitals, considers the term ‘second victim’, which is used to describe staff who are affected psychologically and emotionally in the aftermath of an incident

2021 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Nicole Serre ◽  
Sherry Espin ◽  
Alyssa Indar ◽  
Sue Bookey-Bassett ◽  
Karen LeGrow

PLoS ONE ◽  
2015 ◽  
Vol 10 (12) ◽  
pp. e0144107 ◽  
Author(s):  
Ann-Marie Howell ◽  
Elaine M. Burns ◽  
George Bouras ◽  
Liam J. Donaldson ◽  
Thanos Athanasiou ◽  
...  

2021 ◽  
Vol 10 (2) ◽  
pp. 90-102
Author(s):  
Vivi Silvia ◽  
Rokiah Kusumapradja ◽  
Idrus Jus'at

Patient safety has become a global issue in the field of health service including hospital. Implementation of patient safety in the hospital requires the involvement of leadership, effective communication and patient’s trust. At X Hospital Jakarta, the root case that frequently occurs on patient safety incident is communication matter. This has an impact on the reoccurrence of patient safety incident. This research aims to analyze the influence of transformational leadership and effective communication towards the implementation of patient safety by trust as mediation. The method of this research is causal associative with quantitative approach. There are 37 nurses as  samples counted with G-Power Statistics application. The technique of collecting data uses primary data questionnaires and is processed by path analysis. The result shows that there is a great influence on transformational leadership towards trust.  Therefore, in implementing patient safety in hospital, it needs program development on transformational leadership; controlling, and evaluating the implementation of effective communication; and improving nursing care as a form of professional nursing practice to create and to maintain patient’s trust towards nurse.


2019 ◽  
pp. bmjspcare-2019-001824
Author(s):  
Toby Dinnen ◽  
Huw Williams ◽  
Sarah Yardley ◽  
Simon Noble ◽  
Adrian Edwards ◽  
...  

ObjectivesAdvance care planning (ACP) is essential for patient-centred care in the last phase of life. There is little evidence available on the safety of ACP. This study characterises and explores patient safety incidents arising from ACP processes in the last phase of life.MethodsThe National Reporting and Learning System collates patient safety incident reports across England and Wales. We performed a keyword search and manual review to identify relevant reports, April 2005–December 2015. Mixed-methods, combining structured data coding, exploratory and thematic analyses were undertaken to describe incidents, underlying causes and outcomes, and identify areas for improvement.ResultsWe identified 70 reports in which ACP caused a patient safety incident across three error categories: (1) ACP not completed despite being appropriate (23%, n=16). (2) ACP completed but not accessible or miscommunicated between professionals (40%, n=28). (3) ACP completed and accessible but not followed (37%, n=26). Themes included staff lacking the knowledge, confidence, competence or belief in trustworthiness of prior documentation to create or enact ACP. Adverse outcomes included cardiopulmonary resuscitation attempts contrary to ACP, other inappropriate treatment and/or transfer or admission.ConclusionThis national analysis identifies priority concerns and questions whether it is possible to develop strong system interventions to ensure safety and quality in ACP without significant improvement in human-dependent issues in social programmes such as ACP. Human-dependent issues (ie, varying patient, carer and professional understanding, and confidence in enacting prior ACP when required) should be explored in local contexts alongside systems development for ACP documentation.


2019 ◽  
Vol 30 (4) ◽  
pp. 777-779
Author(s):  
Gerda Zeeman ◽  
Loes Schouten ◽  
Deborah Seys ◽  
Ellen Coeckelberghs ◽  
Philomeen Weijenborg ◽  
...  

Abstract We evaluated the presence of prolonged mental health sequelae in the aftermath of a patient safety incident and the impact of a formal complaint or lawsuit on these mental health sequelae in 19 hospitals and 2635 nurses and doctors. Of 2635 respondents, 983 (37.3%) reported a complaint and 190 (7.2%) reported a lawsuit. In both doctors and nurses prolonged mental health sequelae reflecting a stressor-related disorder were highly prevalent, each well over 20% overall. They were consistently more prevalent in case of a formal complaint or lawsuit. Lawsuits showed 2-, 3- and 4-fold increases in prevalence of mental health sequelae.


2017 ◽  
Vol 08 (02) ◽  
pp. 593-602 ◽  
Author(s):  
Katharine Adams ◽  
Jessica Howe ◽  
Allan Fong ◽  
Joseph Puthumana ◽  
Kathryn Kellogg ◽  
...  

SummaryBackground: With the widespread use of electronic health records (EHRs) for many clinical tasks, interoperability with other health information technology (health IT) is critical for the effective delivery of care. While it is generally recognized that poor interoperability negatively impacts patient care, little is known about the specific patient safety implications. Understanding the patient safety implications will help prioritize interoperability efforts around architectures and standards.Objectives: Our objectives were to (1) identify patient safety incident reports that reflect EHR interoperability challenges with other health IT, and (2) perform a detailed analysis of these reports to understand the health IT systems involved, the clinical care processes impacted, whether the incident occurred within or between provider organizations, and the reported severity of the patient safety events.Methods: From a database of 1.735 million patient safety event (PSE) reports spanning multiple provider organizations, 2625 reports that were indicated as being health IT related by the event reporter were reviewed to identify EHR interoperability related reports. Through a rigorous coding process 209 EHR interoperability related events were identified and coded.Results: The majority of EHR interoperability PSE reports involved interfacing with pharmacy systems (i.e. medication related), followed by laboratory, and radiology. Most of the interoperability challenges in these clinical areas were associated with the EHR receiving information from other health IT systems as opposed to the EHR sending information to other systems. The majority of EHR interoperability challenges were within a provider organization and while many of the safety events reached the patient, only a few resulted in patient harm.Conclusions: Interoperability efforts should prioritize systems in pharmacy, laboratory, and radiology. Providers should recognize the need to improve EHRs interfacing with other health IT systems within their own organization.Citation: Adams KT, Howe JL, Fong A, Puthumana JS, Kellogg KM, Gaunt M, Ratwani RM. An analysis of patient safety incident reports associated with electronic health record interoperability. Appl Clin Inform 2017; 8: 593–602 https://doi.org/10.4338/ACI-2017-01-RA-0014


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