scholarly journals Clinical Governance in Action

2013 ◽  
Vol 95 (1) ◽  
pp. 1-4 ◽  
Author(s):  
AH Mirza ◽  
L McClelland ◽  
M Bentley ◽  
S Mazengarb ◽  
NS Jones
Keyword(s):  
Quality Assurance ◽  
Adverse Events ◽  
Clinical Governance ◽  
Learning From Errors ◽  
Safe Environment ◽  
Significant Challenge ◽  
Self Development ◽  
Management Of Risk

Clinical governance encompasses quality assurance, measures to ensure self-development, comparing standards and learning from errors and suboptimal results. The management of risk poses a significant challenge in itself, as to reduce it to zero would require practice coming to a standstill. The implementation of structures to provide a safe environment for the patients we treat remains one of the greatest challenges faced by healthcare organisations today. Additionally, the potential litigious outcome provides an added conspicuous incentive to not only continuously review and address adverse events but to ensure that our patients remain free from harm.

scholarly journals Assessment of patient safety culture in intensive care units and factors affecting it

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
M A Tlili ◽  
W Aouicha ◽  
H Lamine ◽  
E Taghouti ◽  
M B e n Dhiab ◽  
...  
Keyword(s):  
Patient Safety ◽  
Intensive Care ◽  
Adverse Events ◽  
Intensive Care Units ◽  
Safety Culture ◽  
Improve Patient Safety ◽  
Healthcare Quality ◽  
Patient Safety Culture ◽  
Cross Sectional ◽  
Learning From Errors

Abstract Background The intensive care units are a high-risk environments for the occurrence of adverse events with serious consequences. The development of patient safety culture is a strategic focus to prevent these adverse events and improve patient safety and healthcare quality. This study aimed to assess patient safety culture in Tunisian intensive care units and to determine its associated factors. Methods It is a multicenter, descriptive cross-sectional study, among healthcare professionals of the intensive care units in the Tunisian center. The data collection was spread over a period of 2 months (October-November 2017). The measuring instrument used is the validated French version of the Hospital Survey On Patient Safety Culture questionnaire. Data entry and analysis was carried out by the Statistical Package for Social Sciences (SPSS 20.0) and Epi Info 6.04. Chi-square test was used to explore factors associated with patient safety culture. Results A total of 404 professionals participated in the study with a participation rate of 81.94%, spread over 10 hospitals and 18 units. All dimensions were to be improved. The overall perception of safety was 32.35%. The most developed dimension was teamwork within units with a score of 47.87% and the least developed dimension was the non-punitive response to error (18.6%). The patient safety culture was significantly more developed in private hospitals in seven of the 10 dimensions. Participants working in small units had a significantly higher patient safety culture. It has been shown that when workload is reduced the patient safety culture was significantly increased. Conclusions This study has shown that the patient safety culture still needs to be improved and allowed a clearer view of the safety aspects requiring special attention. Thus, improving patient safety culture. by implementing the quality management and error reporting systems could contribute to enhance the quality of healthcare provided to patients. Key messages The culture of culpability is the main weakness in the study. Encouraging event reporting and learning from errors s should be priorities in hospitals to enhance patient safety and healthcare quality.

Quality assurance and audit

2016 ◽  
Author(s):  
Amal Rushdy ◽  
Sam Ghebrehewet
Keyword(s):  
Quality Assurance ◽  
Data Collection ◽  
Research Evaluation ◽  
Clinical Audit ◽  
Clinical Governance ◽  
Health Protection ◽  
Specific Practice ◽  
The Subject ◽  
The Relationship

This chapter describes the relationship between quality assurance, clinical governance, and clinical audit. These subjects are clearly defined and their application explored in the context of health protection practice. The chapter clearly outlines the differences between audit, research, evaluation, and surveillance, with health protection examples. Audit in health protection is described in detail, including areas of practice in which clinical audit is relevant, prioritization of audit topics, planning an audit, criteria and standards, data collection, analysis and interpretation, and implementation of change. Furthermore, quality assurance and improvement in health protection are described in detail. Relevant references and sources of audit tools are provided so that the discerning reader may explore the subject in more depth in relation to their specific practice and setting.

Clinical and information governance proposes; human fallibility disposes

2014 ◽  
Vol 19 (2) ◽  
pp. 94-109 ◽  
Author(s):  
Karen Renaud
Keyword(s):  
Adverse Event ◽  
Adverse Events ◽  
Education And Training ◽  
Clinical Governance ◽  
Complex Nature ◽  
Content Type ◽  
Information Governance ◽  
Governance Tools ◽  
The Impact ◽  
And Training

Purpose – There is a strong drive within the UK's National Health Service (NHS) towards ensuring quality and reducing adverse events. This incorporates clinical governance, which applies to clinical activities, and information governance, which applies to preserving the confidentiality, availability and integrity of patient information. The purpose of this paper is to consider why humans make errors, how the current governance tools can minimise the incidence of such errors and the causatives that can increase the likelihood of an error. Errors sometimes lead to adverse events, which have to be reported. The latest adverse event reports from NHS Scotland, recently published on the BBC website, were analysed to identify major themes that emerged from the recommendations made by the investigative teams. These themes are then discussed in terms of how the current clinical governance tools should be applied to further reduce the incidence of adverse events. A revised clinical governance diagram that more clearly depicts the cross-cutting nature of the themes that emerged from the analysis is proposed. Finally some opportunities for future research are identified. Design/methodology/approach – Qualitative analysis of adverse incidence reports in order to identify causatives. Used the insights delivered by this analysis in order to propose a change to Scally and Donaldson's clinical governance diagram. Findings – A clear reliance on education and training by adverse event review teams was found, which suggests that they do not really understand what causes error, and they do not acknowledge the impact of the situation on the actors. Also – a tendency to define processes to cover all eventualities, even though some situations cannot be encoded as processes. The main insight is that there are a number of cross-cutting concerns which means that the original clinical governance diagram would benefit from a level of integration which is not currently present. Research limitations/implications – The analysed reports were severely redacted which meant that nuances of the situation could have been missed by the researcher. However, the recommendations were never redacted so the researcher focused on these. Practical implications – The paper, in general, highlights the need for a more nuanced approach to clinical governance and less reliance on education and training as the universal panacea. Social implications – Over reliance on education and training puts the blame on the person, and does not acknowledge the causatives in the situation. Acknowledging the more complex nature of the problem makes adverse events less blame-worthy and more likely to lead to real learning and effective mitigation. Originality/value – The author is not aware of anyone else having analysed these reports.

scholarly journals Patient Safety in Cross-border Care

2015 ◽  
Vol 8 (1) ◽  
pp. 77-83
Author(s):  
Eva Turk ◽  
Stephen Leyshon ◽  
Morten Pytte
Keyword(s):  
European Union ◽  
Quality Assurance ◽  
Patient Safety ◽  
Adverse Events ◽  
Health Systems ◽  
Medical Errors ◽  
The State ◽  
The European Union ◽  
Cross Border

Patient safety is a right and it raises particular issues in the context of cross-border care. Patients should be able to have trust and confidence in the healthcare structure as a whole; they must be protected from the harm caused by poorly functioning health systems, medical errors and adverse events. This paper addresses the state of cross-border healthcare in the European Union, the state of patient safety, the question of quality assurance and the role of accreditation as a risk based approach.

scholarly journals Adverse events reporting by obstetric units in Norway as part of their quality assurance and patient safety work: an analysis of practice

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Lars T. Johansen ◽  
Geir Sverre Braut ◽  
Ganesh Acharya ◽  
Jan Fredrik Andresen ◽  
Pål Øian
Keyword(s):  
Quality Assurance ◽  
Patient Safety ◽  
Adverse Events ◽  
Birth Asphyxia ◽  
Internal Quality ◽  
Quality Assurance System ◽  
Serious Adverse Events ◽  
Assurance System ◽  
Safety Work ◽  
Quality And Patient Safety

Abstract Background The Norwegian Board of Health Supervision aims to contribute to the improvement of quality and patient safety in the healthcare services. Planned audits were performed to investigate how 12 selected Norwegian obstetric units reported and analyzed adverse events as the part of their quality assurance and patient safety work. Methods Serious adverse events coded as birth asphyxia, shoulder dystocia and severe postpartum hemorrhage that occurred during 2014 (the most recent year for which the quality assured data were available) were obtained from the Medical Birth Registry of Norway. The obstetric units were asked to submit medical records, internal adverse events reports, and their internal guidelines outlining which events should be reported to the quality assurance system. We identified the adverse events at each obstetric unit that were reported internally and/or to the central authorities. Two obstetricians carried out an evaluation of each event reported. Results Five hundred fifty-three serious adverse events were registered among 17,323 births that took place at the selected units. Twenty-one events were excluded because of incorrect coding or missing information. Eight events were registered in more than one category, and these were distributed to the category directly related to injury or adverse outcome. Nine of twelve (75 %) obstetric units had written guidelines describing which events should be reported. The obstetric units reported 49 of 524 (9.3 %) serious adverse events in their internal quality assurance system and 39 (7.4 %) to central authorities. Of the very serious adverse events, 29 of 149 (19.4 %) were reported. Twenty-three of 49 (47 %) reports did not contain relevant assessments or proposals for improving quality and patient safety. Conclusions This study showed that adverse event reporting and analyses by Norwegian obstetric units, as a part of quality assurance and patient safety work, are suboptimal. The reporting culture and compliance with guidelines need to be improved substantially for better safety in patient care, risk mitigation and clinical quality assurance.

scholarly journals Techniques of hollow maxillary dentures: a literature review

2021 ◽  
Vol 8 (8) ◽  
pp. 4111
Author(s):  
Anas Omar Haroub ◽  
Alaa Mohammad Alaidarous ◽  
Mazen Thabet Alshahrani ◽  
Naif Mayouf Alrasheedi ◽  
Abdulhakeem Nasier Almodahi ◽  
...  
Keyword(s):  
Literature Review ◽  
Adverse Events ◽  
The Other ◽  
Efficacy And Safety ◽  
Denture Base ◽  
Future Studies ◽  
Significant Challenge ◽  
Atrophic Maxilla ◽  
Adequate Sample Size ◽  
Modeling Clay

Clinically, the management of severy atrophic maxilla might represent a significant challenge for the attending dentists and surgeons to successfully perform and achieve fabricated complete maxillary dentures. Making a hollow denture base for these defects has also been previously reported as a valid approach that can be used to decrease the weight of the maxillary prosthesis. Many modalities have been proposed for these procedures with favorable outcomes, and variable events of disadvantages and adverse events. This literature review aims to collect enough evidence regarding the different reported techniques of the hollow maxillary denture, according to the different studies. Many techniques have been previously reported as using magnets, using implants, intramucosal inserts, springs, suction disks, lightweight dentures, and modified impression techniques. Many materials have been previously used with the 3D spacers of the lightweight denture techniques as dental stone, silicon putty, cellophane-wrapped asbestos, light-body coated gauze, modeling clay, salt, thermocol, caramel, and glycerine soap. Favoring one of the modalities over the other requires the inauguration of future studies with an adequate sample size to validate the efficacy and safety of these modalities. All of this information is furtherly discussed within the manuscript based on the collected evidence from the different studies in the literature.

scholarly journals Complex neonatal airway surgery. Case report

2020 ◽  
Author(s):  
Daniel Martínez Catalá ◽  
Francisco Javier Escribá Alepuz ◽  
Pilar Argente Navarro
Keyword(s):  
Case Report ◽  
Adverse Events ◽  
Tracheal Stenosis ◽  
Extracorporeal Circulation ◽  
Anesthetic Management ◽  
Congenital Tracheal Stenosis ◽  
Significant Challenge ◽  
Pediatric Anesthesiologist ◽  
The Face ◽  
Challenging Situation

Airway-related pathology poses a significant challenge to the pediatric anesthesiologist. This case report involves a 28-day-old neonate diagnosed with congenital tracheal stenosis who underwent a slide tracheoplasty intervention with extracorporeal circulation. The anesthetic management is described, together with our experience in the face of a challenging situation, including adverse events during surgery.

Complications, Adverse Events and Clinical Governance

2015 ◽  
pp. 171-184
Author(s):  
Tim Lowes ◽  
Amy Gospel ◽  
Andrew Griffiths ◽  
Jeremy Henning
Keyword(s):  
Adverse Events ◽  
Clinical Governance

Adverse Events and Medical Errors in Greece

2012 ◽  
pp. 95-101 ◽  
Author(s):  
Athanassios Vozikis
Keyword(s):  
Quality Assurance ◽  
Knowledge Management ◽  
Adverse Events ◽  
Medical Errors ◽  
Healthcare Quality ◽  
Mandatory Reporting ◽  
Performance Data ◽  
Voluntary Reporting ◽  
Related Data ◽  
Over Time

For years, experts have recognized that medical errors exist and compromise healthcare quality. Much has been written worldwide about medical errors and improvements in their reporting and handling, with the proposals ranging from the implementation of nationwide mandatory reporting with public release of performance data to voluntary reporting and quality-assurance efforts that protect the confidentiality of error-related data. In the present chapter, the author first points out the lack of standardized nomenclature and a universal taxonomy-classification for adverse events and medical errors, which complicates the development of a response to these issues. The chapter also reviews a number of methods of and adverse events’ and medical errors’ knowledge management, each of which has evolved over time and been adapted to different contexts. Finally, the author assesses each of these methods, unveiling their particular strengths and advantages, and also weaknesses and limitations.

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