scholarly journals Criminalisation of human error in health care: How and why legal accountability can crowd out professional accountability and undermine patient safety

2020 ◽  
Vol 16 (2) ◽  
pp. 83-104
Author(s):  
Sigurbjörg Sigurgeirsdóttir
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Health Professionals ◽  
Improve Patient Safety ◽  
Internet Survey ◽  
Court Case ◽  
Professional Accountability ◽  
Legal Accountability ◽  
Crowd Out ◽  
The Impact

This research is about accountability in health care. Theoretically it aims to shed light on two types of public accountability, how these types interact and relate to the aim of learning to improve patient safety. The study addresses the theoretical questions how and why legal accountability can crowd out professional accountability. It seeks to answer the empirical question what is the impact of criminal charges against health professionals by presenting two sets of data: First, a case study of an event, first of its kind in Iceland, in which a nurse in an intensive care unit was charged for manslaughter by negligence in May 2014. The court case material is examined and specialised in-depth and semistructured interviews conducted to describe the experience at the level of the individual and to account for organisational responses. Second, explorative focus groups were carried out in preparation of an internet survey conducted among all practising nurses in Iceland measuring the impact of the prosecution. The narrative highlights the complexities and risks of error involved in health care. Survey results show that the prosecution has increased the level of insecurity among nurses and raised awareness of the risk involved to themselves in their job. This court case established a precedent and constitutes a defining moment in the health care system. While accountability mechanisms were in their infancies in the system, health professionals in Iceland lost their immunity with a possible setback for the fostering of effective professional accountability mechanisms and devastating consequences for patient safety.

scholarly journals Patient safety challenges in primary health care: a scoping review

2020 ◽  
Vol 73 (5) ◽  
Author(s):  
Carlise Rigon Dalla Nora ◽  
Mariur Gomes Beghetto
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Primary Health Care ◽  
Scoping Review ◽  
Health Professionals ◽  
Health Care Professionals ◽  
Improve Patient Safety ◽  
Policy Makers ◽  
Primary Health ◽  
Enhancing Resources

ABSTRACT Objectives: to identify the patient safety challenges described by health professionals in Primary Health Care. Methods: a scoping review was conducted on the LILACS, MEDLINE, IBECS, BDENF, and CINAHL databases, and on the Cochrane, SciELO, Pubmed, and Web of Science libraries in January 2019. Original articles on patient safety in the context of Primary Health Care by health professionals were included. Results: the review included 26 studies published between 2002 and 2019. Four categories resulted from the analysis: challenges of health professionals, administration challenges of health services, challenges with the patient and family, and the potential enhancing resources for patient safety. Conclusions: patient safety challenges for Primary Care professionals are multiple and complex. This study provides insight into resources to improve patient safety for health care professionals, patients, administrators, policy makers, educators, and researchers.

Top four types of sentinel events in Saudi Arabia during the period 2016–19

2021 ◽  
Vol 33 (1) ◽  
Author(s):  
Nasser Altalhi ◽  
Haifa Alnaimi ◽  
Mafaten Chaouali ◽  
Falaa Alahmari ◽  
Noor Alabdulkareem ◽  
...  
Keyword(s):  
Health Care ◽  
Saudi Arabia ◽  
Patient Safety ◽  
Reporting System ◽  
Improve Patient Safety ◽  
Health Care Facilities ◽  
Common Root ◽  
Private Hospitals ◽  
Care Facilities ◽  
Sentinel Events

Abstract Background This study discusses the summary, investigation and root causes of the top four sentinel events (SEs) in Saudi Arabia (SA) that occurred between January 2016 and December 2019, as reported by the Ministry of Health (MOH) and private hospitals through the MOH SE reporting system (SERS). It is intended for use by legislators, health-care facilities and the public to shed light on areas that still need improvement to preserve patient safety. Objectives The purpose of this study is to review the most common SEs reported by the MOH and private hospitals between the years 2016 and 2019 to assess the patterns and identify risk areas and the common root causes of these events in order to promote country-wide learning and support services that can improve patient safety. Methods In this retrospective descriptive study, the data were retrieved from the SERS, which routinely collects records from both MOH and private hospitals in SA. SEs were analyzed by type of event, location, time, patient demographics, outcome and root causes. Results There were 727 SEs during this period, 38.4% of which were under the category of unexpected patient death, 19.4% under maternal death, 11.7% under unexpected loss of limb or function and 9.9% under retained instruments or sponge. Common root causes were related to policies and procedures, guidelines, miscommunication between health-care facilities, shortage of staff and lack of competencies. Conclusion Given these results, efforts should focus on improving the care of deteriorating patients in general wards, ICU (Intensive Care Units) admission/discharge criteria and maternal, child and surgical safety. The results also highlighted the problem of underreporting of SEs, which needs to be addressed and improved. Linking data sources such as claims and patient complaints databases and electronic medical records to the national reporting system must also be considered to ensure an optimal estimation of the number of events.

scholarly journals Importance of safety climate, teamwork climate and demographics: understanding nurses, allied health professionals and clerical staff perceptions of patient safety

2018 ◽  
Vol 7 (4) ◽  
pp. e000433
Author(s):  
Shahram Zaheer ◽  
Liane R Ginsburg ◽  
Hannah J Wong ◽  
Kelly Thomson ◽  
Lorna Bain
Keyword(s):  
Patient Safety ◽  
Health Professionals ◽  
Allied Health ◽  
Safety Climate ◽  
Outcome Variable ◽  
Senior Leadership ◽  
Staff Perceptions ◽  
Allied Health Professionals ◽  
Leadership Support ◽  
The Impact

BackgroundThere is growing evidence regarding the importance of contextual factors for patient/staff outcomes and the likelihood of successfully implementing safety improvement interventions such as checklists; however, certain literature gaps still remain—for example, lack of research examining the interactive effects of safety constructs on outcomes. This study has addressed some of these gaps, together with adding to our understanding of how context influences safety.PurposeThe impact of staff perceptions of safety climate (ie, senior and supervisory leadership support for safety) and teamwork climate on a self-reported safety outcome (ie, overall perceptions of patient safety (PS)) were examined at a hospital in Southern Ontario.MethodsCross-sectional survey data were collected from nurses, allied health professionals and unit clerks working on intensive care, general medicine, mental health or emergency department.ResultsHierarchical regression analyses showed that perceptions of senior leadership (p<0.001) and teamwork (p<0.001) were significantly associated with overall perceptions of PS. A non-significant association was found between perceptions of supervisory leadership and the outcome variable. However, when staff perceived poorer senior leadership support for safety, the positive effect of supervisory leadership on overall perceptions of PS became significantly stronger (p<0.05).Practice implicationsOur results suggest that leadership support at one level (ie, supervisory) can substitute for the absence of leadership support for safety at another level (ie, senior level). While healthcare organisations should recruit into leadership roles and retain individuals who prioritise safety and possess adequate relational competencies, the field would now benefit from evidence regarding how to build leadership support for PS. Also, it is important to provide on-site workshops on topics (eg, conflict management) that can strengthen working relationships across professional and unit boundaries.

scholarly journals Efficacy of a brief online mindfulness-based intervention on the psychological well-being of health care professionals and trainees during the COVID-19 pandemic: A mixed method design

2021 ◽  
Vol 26 ◽  
Author(s):  
Iram Osman ◽  
Shaista Hamid ◽  
Veena S. Singaram
Keyword(s):  
South Africa ◽  
Health Care ◽  
Mixed Method ◽  
Health Professionals ◽  
Health Care Professionals ◽  
Well Being ◽  
Personal Accomplishment ◽  
Intervention Analysis ◽  
Health Crisis ◽  
The Impact

Background: During the coronavirus disease 2019 (COVID-19) pandemic, health professionals were pushed to the front line of a global health crisis unprepared and resource constrained, which affected their mental well-being.Aim: This study aimed to investigate the effectiveness of a brief online mindfulness-based intervention (MBI) on stress and burnout for health professionals training and working in South Africa during the COVID-19 crisis.Setting: The context of the study is the overburdened, under-resourced health care system in South Africa during a global pandemic.Methods: A mixed method framework was adopted for this study. The quantitative data was analysed using descriptive analysis and the participants’ qualitative experiences were interpreted using interpretative phenomenological analysis.Results: Forty-seven participants took part in this study. The study found a statistically significant (p 0.05) reduction in stress levels and emotional exhaustion as well as an increase in mindful awareness and feelings of personal accomplishment after the intervention. The participants’ shared experiences were analysed in two parts. The pre-intervention analysis presented with central themes of loss of control and a sense of powerlessness because of COVID-19. The post-intervention analysis comprised themes of a sense of acquired control and empowerment through increased mindfulness.Conclusions: The study found that a brief online MBI can be associated with reduced levels of stress and burnout as well as an increased sense of control and empowerment, felt both personally and professionally, during a global crisis.Contribution: The impact of an online MBI for health care professionals amidst a pandemic has not been previously documented.

scholarly journals The Impact of Patient Safety Climate on Medical Errors in a Sample of Nurses: Creating Safer Health Care.

Health Scope ◽  
2013 ◽  
Vol 1 (4) ◽  
Author(s):  
Seyed Bagher Mortazavi ◽  
Morteza Oostakhan ◽  
Amirabbas Mofidi ◽  
Aliakbar Babaei
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Medical Errors ◽  
Safety Climate ◽  
Patient Safety Climate ◽  
The Impact

scholarly journals Quality Indicators of the Pre-Analytical Phase

2012 ◽  
Vol 31 (3) ◽  
pp. 174-183 ◽  
Author(s):  
Nada Majkić-Singh ◽  
Zorica Šumarac
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Quality Indicators ◽  
Task Force ◽  
Improve Patient Safety ◽  
Laboratory Data ◽  
Sample Collection ◽  
Laboratory Errors ◽  
Analytical Phase ◽  
Total Testing Process

Quality Indicators of the Pre-Analytical PhaseQuality indicatorsare tools that allow the quantification of quality in each of the segments of health care in comparison with selected criteria. They can be defined as an objective measure used to assess the critical health care segments such as, for instance, patient safety, effectiveness, impartiality, timeliness, efficiency, etc. In laboratory medicine it is possible to develop quality indicators or the measure of feasibility for any stage of the total testing process. The total process or cycle of investigation has traditionally been separated into three phases, the pre-analytical, analytical and post-analytical phase. Some authors also include a »pre-pre« and a »post-post« analytical phase, in a manner that allows to separate them from the activities of sample collection and transportation (pre-analytical phase) and reporting (post-analytical phase). In the year 2008 the IFCC formed within its Education and Management Division (EMD) a task force calledLaboratory Errors and Patient Safety (WG-LEPS)with the aim of promoting the investigation of errors in laboratory data, collecting data and developing a strategy to improve patient safety. This task force came up with the Model of Quality Indicators (MQI) for the total testing process (TTP) including the pre-, intra- and post-analytical phases of work. The pre-analytical phase includes a set of procedures that are difficult to define because they take place at different locations and at different times. Errors that occur at this stage often become obvious later in the analytical and post-analytical phases. For these reasons the identification of quality indicators is necessary in order to avoid potential errors in all the steps of the pre-analytical phase.

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.

Leveraging Information Technology Towards Enhancing Patient Care and a Culture of Safety in the U.S.

2003 ◽  
Vol 42 (05) ◽  
pp. 503-508 ◽  
Author(s):  
D. E. Garets ◽  
T. J. Handler ◽  
M. J. Ball
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Patient Care ◽  
Information Technologies ◽  
Improve Patient Safety ◽  
Medical Knowledge ◽  
Mortality And Morbidity ◽  
Culture Of Safety ◽  
Enabling Technologies ◽  
Enhance Patient Care

Summary Objectives: To heighten awareness about the critical issues currently affecting patient care and to propose solutions based on leveraging information technologies to enhance patient care and influence a culture of patient safety. Methods: Presentation and discussion of the issues affecting health care today, such as medical and medication-related errors and analysis of their root causes; proliferation of medical knowledge and medical technologies; initiatives to improve patient safety; steps necessary to develop a culture of safety; introduction of relevant enabling technologies; and evidence of results. Results and Conclusion: Medical errors affect not only mortality and morbidity, but they also create secondary costs leading to dissatisfaction by both provider and patient. Health care has been slow to acknowledge the benefits of enabling technologies to affect the quality of care. Evaluation of recent applications, such as the computerized patient record, physician order entry, and computerized alerting systems show tremendous potential to enhance patient care and influence the development of a culture focused on safety. They will also bring about changes in other areas, such as workflow and the creation of new partnerships among providers, patients, and payers.

scholarly journals The impact of computerized provider order entry on emergency department flow

CJEM ◽  
2016 ◽  
Vol 18 (4) ◽  
pp. 264-269 ◽  
Author(s):  
Andrew Gray ◽  
Christopher M.B. Fernandes ◽  
Kristine Van Aarsen ◽  
Melanie Columbus
Keyword(s):  
Emergency Department ◽  
Patient Safety ◽  
Improve Patient Safety ◽  
Patient Flow ◽  
Wait Time ◽  
Order Entry ◽  
Computerized Provider Order Entry ◽  
Left Without Being Seen ◽  
Before And After ◽  
The Impact

AbstractObjectivesComputerized provider order entry (CPOE) has been established as a method to improve patient safety by avoiding medication errors; however, its effect on emergency department (ED) flow remains undefined. We examined the impact of CPOE implementation on three measures of ED throughput: wait time (WT), length of stay (LOS), and the proportion of patients that left without being seen (LWBS).MethodsWe conducted a retrospective cohort study of all ED patients of 18 years and older presenting to London Health Sciences Centre during July and August 2013 and 2014, before and after implementation of a CPOE system. The three primary variables were compared between time periods. Subgroup analyses were also conducted within each Canadian Triage and Acuity Scale (CTAS) level (1–5) individually, as well as for admitted patients only.ResultsA significant increase in WT of 5 minutes (p=0.036) and LOS of 10 minutes (p=0.001), and an increase in LWBS from 7.2% to 8.1% (p=0.002) was seen after CPOE implementation. Admitted patients’ LOS increased by 63 minutes (p<0.001), the WT of CTAS 3 and 5 patients increased by 6 minutes (p=0.001) and 39 minutes (p=0.005), and LWBS proportion increased significantly for CTAS 3–5 patients, from 24.3% to 42.0% (p<0.001) for CTAS 5 patients specifically.ConclusionsCPOE implementation detrimentally impacted all patient flow throughput measures that we examined. The most striking clinically relevant result was the increase in LOS of 63 minutes for admitted patients. This raises the question as to whether the potential detrimental effects to patient safety of CPOE implementation outweigh its benefits.

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