Patient Safety and Quality Improvement: Medical Errors and Adverse Events

2010 ◽  
Vol 31 (4) ◽  
pp. 151-158 ◽  
Author(s):  
Michael S. Leonard
Keyword(s):  
Patient Safety ◽  
Quality Improvement ◽  
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 Quality and Safety in Healthcare for Medical Students: Challenges and the Road Ahead

Healthcare ◽  
2020 ◽  
Vol 8 (4) ◽  
pp. 540
Author(s):  
Luz Berenice López-Hernández ◽  
Benjamín Gómez Díaz ◽  
Edgar Oswaldo Zamora González ◽  
Karen Itzel Montes-Hernández ◽  
Stephanie Simone Tlali Díaz ◽  
...  
Keyword(s):  
Patient Safety ◽  
Quality Improvement ◽  
Medical Students ◽  
Medical Errors ◽  
Just Culture ◽  
The Road ◽  
Reporting Systems ◽  
Safety Interventions ◽  
Fourth Year Medical Students ◽  
Essential Knowledge

Background: The development of skills, behaviors and attitudes regarding patient safety is of utmost importance for promoting safety culture for the next generation of health professionals. This study describes our experience of implementing a course on patient safety and quality improvement for fourth year medical students in Mexico during the COVID-19 outbreak. The course comprised essential knowledge based on the patient safety curriculum provided by the WHO. We also explored perceptions and attitudes of students regarding patient safety. Methods: Fourth year medical students completed a questionnaire regarding knowledge, skills, and attitudes on patient safety and quality improvement in medical care. The questionnaire was voluntarily answered online prior to and after the course. Results: In total, 213 students completed the questionnaires. Most students were able to understand medical error, recognize failure and the nature of causation, perform root-cause analysis, and appreciate the role of patient safety interventions. Conversely, a disapproving perspective prevailed among students concerning the preventability of medical errors, utility of reporting systems, just culture and infrastructure (p < 0.05). Conclusion: We found students had a positive perspective concerning learning quality in healthcare and patient safety during our course; nevertheless, their perception of the usefulness of reporting systems to prevent future adverse events and prevent medical errors is uncomplimentary. Medical education should promote error reporting and just culture to change the current perception of medical students.

Adverse Events Associated with Bone Marrow Biopsy In A Resident Training Program; First Do No Harm

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 4775-4775
Author(s):  
James T. Paul ◽  
Emily K. Rimmer ◽  
Carmen Morales ◽  
Graham Bay ◽  
Kiraninder Lamba ◽  
...  
Keyword(s):  
Internal Medicine ◽  
Bone Marrow ◽  
Patient Safety ◽  
Quality Improvement ◽  
Adverse Events ◽  
Case Series ◽  
Resident Training ◽  
Health Science ◽  
Sample Quality ◽  
Ensure Patient Safety

Abstract Abstract 4775 BACKGROUND: Bone marrow aspirates and biopsies are commonly performed to evaluate a variety of hematological abnormalities. Generally, it is regarded as a safe procedure; however, the complication rate is uncertain. Much of the data surrounding bone marrow complications derives from retrospective, voluntary reported data from the UK and is estimated to occur in 0.08 – 0.12% of procedures. Data also suggests that the quality of bone marrow specimens may vary with operator expertise. OBJECTIVES: In this report we present a case series of adverse events following bone marrow examinations performed by internal medical residents. In response to these procedural outcomes, we will outline a comprehensive quality improvement and quality assurance initiative designed to improve resident training, ensure patient safety, and enhance sample quality. CASE SERIES: Four cases of attempted bone marrow aspirate and biopsy on the Clinical Teaching Units (CTU) at the Health Science Centre from June 2010 to April 2011 were identified. All four procedures were performed by internal medicine residents at varying levels of training and were unsuccessful despite multiple attempts. In two of the cases the GIM attending was also unsuccessful in obtaining sample. Two cases of major bleeding occurred necessitating multiple units of red blood cells to be transfused and one patient required admission to the intensive care unit. In another case the patient was unable to ambulate for 3 days due to severe leg pain at the site of attempted biopsy. Improper landmarking for the procedure was common in all cases and confirmed with 3D computed axial tomographic rendering in 2 patients. INTERVENTION: In response to these patient adverse patient outcomes and with patient safety in mind, we decided that, until a more detailed plan could be developed, all bone marrow biopsies performed on the CTU will be supervised by an attending hematologist. With involvement from stakeholders in internal medicine, hematology and hematopathology, we developed a multifaceted quality improvement and assurance initiative. We designed an educational curriculum starting with an academic half day that would consist of an instructional video followed by a practical session in the Clinical Learning and Simulation Facility. This will allow residents to strengthen communication skills by obtaining informed consent and build important procedural skills through the use of simulators. Learning will be reinforced through resident rotations on the Hematology service that will include participation in a weekly bone marrow clinic. This clinic would allow residents an opportunity to perform a number of successive bone marrows in a controlled environment under the supervision of an attending hematologist. To evaluate resident performance and adverse events, a data collection instrument will be developed to monitor the success of these interventions for bone marrows completed on the CTUs. A credentialing process to ensure competency of resident training is being considered. ANCTICIPATED RESULTS: With the implementation of a multifaceted and comprehensive strategy we expect to improve resident training, ensure patient safety, and enhance sample quality resulting in less need for repeat procedures. Disclosures: No relevant conflicts of interest to declare.

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