Medical Errors, Adverse Events, and Patient Safety

2016 ◽  
pp. 2287-2295
Author(s):  
Daniel R. Neuspiel
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Medical Errors

Research Methods, Statistics, Patient Safety, and Quality Improvement

2020 ◽  
pp. 521-530
Author(s):  
Carlos Lerner
Keyword(s):  
Patient Safety ◽  
Quality Improvement ◽  
Adverse Events ◽  
Research Methods ◽  
Confidence Intervals ◽  
Medical Errors ◽  
Likelihood Ratios ◽  
Predictive Values ◽  
Analysis Of Variation ◽  
Answer Format

The chapter on research methods, statistics, patient safety, and quality improvement (QI) uses a question-and-answer format to make concepts in these areas relevant and accessible to general pediatricians. Research topics covered include study design and study types, validity, sources of bias, types of errors, sensitivity and specificity, positive and negative predictive values, likelihood ratios, incidence and prevalence, p values and confidence intervals. The patient safety questions focus on medical errors and adverse events, including their categorization, detection, prevention, and disclosure. Finally, the QI questions address key QI principles and methods, including tools to understand systems (e.g. fishbone diagrams and Pareto charts), analysis of variation, and the Langley Model for Improvement.

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 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.

Factors contributing to patient safety culture: the staff perspective

2021 ◽  
Vol 27 (12) ◽  
pp. 1-6
Author(s):  
Ahmed Yahya Ayoub ◽  
Nezar Ahmed Salim ◽  
Belal Mohammad Hdaib ◽  
Nidal F Eshah
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Safety Culture ◽  
Medical Errors ◽  
Relevant Literature ◽  
Healthcare Providers ◽  
Patient Safety Culture ◽  
Open Communication ◽  
Staffing Levels ◽  
Large Numbers

Background/Aims Unsafe medical practices lead to large numbers of injuries, disabilities and deaths each year worldwide. An understanding of safety culture in healthcare organisations is vital to improve practice and prevent adverse events from medical errors. This integrated literature review aimed to evaluate healthcare staff's perceptions of factors contributing to patient safety culture in their organisations. Methods A comprehensive in-depth review was conducted of studies associated with patient safety culture. Multiple electronic databases, such as PubMed, Wolters Kluwer Health, Karger, SAGE journal and Biomedical Central, were searched for relevant literature published between 2015 and 2020. The keywords ‘patient safety culture’, ‘patient safety’, ‘healthcare providers’, ‘adverse event’, ‘attitude’ and ‘perception’ were searched for. Results Overall, 18 articles met the inclusion criteria. Across all studies, staff highlighted several factors that need improvement to facilitate an effective patient safety culture, with most dimensions of patient safety culture lacking. In particular, staffing levels, open communication, feedback following an error and reporting of adverse events were perceived as lacking across the studies. Conclusion Many issues regarding patient safety culture were present across geographical locations and staff roles. It is crucial that healthcare managers and policymakers work towards an environment that focuses on organisational learning, rather than punishment, in regards to medical errors and adverse incidents. Teamwork between units, particularly during handovers, also requires improvement.

scholarly journals Desirable Features of an Interdisciplinary Handoff (Preprint)

2020 ◽  
Author(s):  
Anupam Ashutosh Sule ◽  
Dean Caputo ◽  
Jaskaren Gohal ◽  
Doug Dascenzo
Keyword(s):  
United States ◽  
Patient Safety ◽  
Adverse Events ◽  
Medical Errors ◽  
The United States ◽  
Critical Information ◽  
Patient Handoffs ◽  
Nursing Teams

UNSTRUCTURED Failure of communication of critical information during handoffs is one of the leading causes of medical errors, resulting in serious, yet preventable, adverse events in hospitals across the United States. Recent studies have shown that a majority of these errors occur during patient handoffs, with notable communication gaps in interdisciplinary handoffs. We suggest some features that would improve the handoff usability and effectiveness for interdisciplinary medical and nursing teams while potentially improving patient safety.

scholarly journals Desirable Features of an Interdisciplinary Handoff

JMIR Nursing ◽  
10.2196/18914 ◽  
2020 ◽  
Vol 3 (1) ◽  
pp. e18914
Author(s):  
Anupam Ashutosh Sule ◽  
Dean Caputo ◽  
Jaskaren Gohal ◽  
Doug Dascenzo
Keyword(s):  
United States ◽  
Patient Safety ◽  
Adverse Events ◽  
Medical Errors ◽  
The United States ◽  
Critical Information ◽  
Patient Handoffs ◽  
Nursing Teams

Failure of communication of critical information during handoffs is one of the leading causes of medical errors, resulting in serious, yet preventable, adverse events in hospitals across the United States. Recent studies have shown that a majority of these errors occur during patient handoffs, with notable communication gaps in interdisciplinary handoffs. We suggest some features that would improve the handoff usability and effectiveness for interdisciplinary medical and nursing teams while potentially improving patient safety.

scholarly journals Socio-economic aspects of medical errors and their consequences in medical organizations

2019 ◽  
Vol 10 (1) ◽  
pp. 99-113 ◽  
Author(s):  
O. L. Zadvornaya ◽  
Yu. E. Voskanyan ◽  
I. B. Shikina ◽  
K. N. Borisov
Keyword(s):  
Public Health ◽  
Patient Safety ◽  
Adverse Events ◽  
Medical Care ◽  
Medical Errors ◽  
Quality Management System ◽  
The State ◽  
Risk Indicators ◽  
Economic Costs ◽  
Published Evidence

Medical errors and adverse events are a global problem of strategic importance, accompanied by economic costs that impose a burden on the health care system, the country's economy and society as a whole. The article presents the results of a review of world experience in developing approaches to assessing the safety of medical care in medical organizations, systematization and analysis of factors affecting the patient safety.Purpose: the purpose of the article is to study and assess the risks associated with medical errors and adverse events in the activities of medical organizations that affect the patient safety in order to reduce the loss of public health, improve the system of identification and monitoring of risk indicators that affect the safety of medical care.Methods: the method of rapid assessment and content analysis of published evidence, including who experience in safety of medical care, was used to highlight the issue. The methodology of functional benchmarking, which included the collection and analysis of the necessary information, the choice of individual functions, processes, methods of work of medical organizations working in similar conditions, was used in the study.Results: the approaches allowing to predict occurrence and development of risks in ensuring safety of medical care, reduction of losses of public health and social and economic costs of the state are considered and offered.Conclusions and Relevance: the materials presented in the article show that safety is a fundamental principle of providing medical services to patients and a critical component of the quality management system of medical care. To reduce the loss of public health, direct and indirect socio-economic costs of the state, comprehensive efforts are needed to reduce the risks that threaten the patient safety and improve the activities of medical organizations. 

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