Understanding Patient Safety in Surgical Care

2018 ◽  
Author(s):  
Amir Ghaferi
Keyword(s):  
Patient Safety ◽  
Systems Engineering ◽  
Human Performance ◽  
High Reliability ◽  
Surgical Care ◽  
Organizational Factors ◽  
Systems Science ◽  
System Failures ◽  
Hand Off ◽  
Safety Systems

This chapter describes the growing knowledge of factors that affect human performance and how these factors contribute to adverse surgical outcomes. Highlights include factors that affect performance, including teamwork, communication, and environmental and organizational factors. Tables and figures include a schematic depiction of the process by which system failures may lead to injury, accepted definitions of patient safety related terms, hand off coordination and communication objectives, and the Systems Engineering Initiative for Patient Safety model of work system and patient safety. This review contains 3 figures, 3 tables, and 78 references Key Words: Patient safety, systems science, medical error, adverse events, systems engineering, teamwork, communication, organizational resilience, high reliability organizations

Understanding Patient Safety in Surgical Care

2018 ◽  
Author(s):  
Amir Ghaferi
Keyword(s):  
Patient Safety ◽  
Systems Engineering ◽  
Human Performance ◽  
High Reliability ◽  
Surgical Care ◽  
Organizational Factors ◽  
Systems Science ◽  
System Failures ◽  
Hand Off ◽  
Safety Systems

This chapter describes the growing knowledge of factors that affect human performance and how these factors contribute to adverse surgical outcomes. Highlights include factors that affect performance, including teamwork, communication, and environmental and organizational factors. Tables and figures include a schematic depiction of the process by which system failures may lead to injury, accepted definitions of patient safety related terms, hand off coordination and communication objectives, and the Systems Engineering Initiative for Patient Safety model of work system and patient safety. This review contains 3 figures, 3 tables, and 78 references Key Words: Patient safety, systems science, medical error, adverse events, systems engineering, teamwork, communication, organizational resilience, high reliability organizations

Understanding Patient Safety in Surgical Care

2018 ◽  
Author(s):  
Amir Ghaferi
Keyword(s):  
Patient Safety ◽  
Systems Engineering ◽  
Human Performance ◽  
High Reliability ◽  
Surgical Care ◽  
Organizational Factors ◽  
Systems Science ◽  
System Failures ◽  
Hand Off ◽  
Safety Systems

This chapter describes the growing knowledge of factors that affect human performance and how these factors contribute to adverse surgical outcomes. Highlights include factors that affect performance, including teamwork, communication, and environmental and organizational factors. Tables and figures include a schematic depiction of the process by which system failures may lead to injury, accepted definitions of patient safety related terms, hand off coordination and communication objectives, and the Systems Engineering Initiative for Patient Safety model of work system and patient safety. This review contains 3 figures, 3 tables, and 78 references Key Words: Patient safety, systems science, medical error, adverse events, systems engineering, teamwork, communication, organizational resilience, high reliability organizations

Understanding Patient Safety in Surgical Care

2018 ◽  
Author(s):  
Amir Ghaferi
Keyword(s):  
Patient Safety ◽  
Systems Engineering ◽  
Human Performance ◽  
High Reliability ◽  
Surgical Care ◽  
Organizational Factors ◽  
Systems Science ◽  
System Failures ◽  
Hand Off ◽  
Safety Systems

This chapter describes the growing knowledge of factors that affect human performance and how these factors contribute to adverse surgical outcomes. Highlights include factors that affect performance, including teamwork, communication, and environmental and organizational factors. Tables and figures include a schematic depiction of the process by which system failures may lead to injury, accepted definitions of patient safety related terms, hand off coordination and communication objectives, and the Systems Engineering Initiative for Patient Safety model of work system and patient safety. This review contains 3 figures, 3 tables, and 78 references Key Words: Patient safety, systems science, medical error, adverse events, systems engineering, teamwork, communication, organizational resilience, high reliability organizations

Patient Safety in Surgical Care

2014 ◽  
Author(s):  
Caprice C. Greenberg ◽  
Amir Ghaferi
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Systems Engineering ◽  
Health Care Professionals ◽  
Care Facility ◽  
Surgical Care ◽  
The United States ◽  
Adverse Outcomes ◽  
Patient Safety Indicators ◽  
National Quality

The 1999 report of the Institute of Medicine, To Err Is Human: Building a Safer Health System, made national headlines with its estimates of the frequency and severity of adverse events in health care, including that as many as 98,000 medical error–related deaths occur each year in the United States. The observation that the basic principles of human error are highly applicable to clinical practice has markedly advanced our understanding and willingness to address error in this setting. This review seeks to address the characteristics of systems in general and the system of surgical care in particular. It describes the growing knowledge of factors that affect human performance and how these factors contribute to adverse surgical outcomes. The review also outlines current obstacles to improving safety,  identifies  systems approaches to making improvements, and discusses ways in which surgeons can take the lead in overcoming these obstacles. An overall goal is that acceptance of error and a willingness to investigate its underlying causes will allow health care professionals to make use of the lessons learned from study of nonmedical systems. Tables include definitions of terms related to patient safety, the operation profile, handoff coordination and communication objectives and relevant strategies, nonmedical system techniques applicable to medical systems, Agency for Healthcare Quality and Research patient safety indicators, National Quality Forum list of health care facility–related serious reportable events, and examples of surgically relevant quality improvement practices appropriate for widespread implementation. Figures include the Swiss Cheese Model representing the relationship between latent and active errors and adverse outcomes, a schematic depiction of the process by which system failures may lead to injury, the Systems Engineering in Patient Safety Model of work system and patient safety, and a depiction of contrasting characteristics of medical practice in the 20th and 21st centuries. This review contains 4 figures, 7 tables, and 165 references.

Patient Safety in Surgical Care

2016 ◽  
Author(s):  
Caprice C. Greenberg ◽  
Amir Ghaferi
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Systems Engineering ◽  
Health Care Professionals ◽  
Care Facility ◽  
Surgical Care ◽  
The United States ◽  
Adverse Outcomes ◽  
Patient Safety Indicators ◽  
National Quality

The 1999 report of the Institute of Medicine, To Err Is Human: Building a Safer Health System, made national headlines with its estimates of the frequency and severity of adverse events in health care, including that as many as 98,000 medical error–related deaths occur each year in the United States. The observation that the basic principles of human error are highly applicable to clinical practice has markedly advanced our understanding and willingness to address error in this setting. This review seeks to address the characteristics of systems in general and the system of surgical care in particular. It describes the growing knowledge of factors that affect human performance and how these factors contribute to adverse surgical outcomes. The review also outlines current obstacles to improving safety,  identifies  systems approaches to making improvements, and discusses ways in which surgeons can take the lead in overcoming these obstacles. An overall goal is that acceptance of error and a willingness to investigate its underlying causes will allow health care professionals to make use of the lessons learned from study of nonmedical systems. Tables include definitions of terms related to patient safety, the operation profile, handoff coordination and communication objectives and relevant strategies, nonmedical system techniques applicable to medical systems, Agency for Healthcare Quality and Research patient safety indicators, National Quality Forum list of health care facility–related serious reportable events, and examples of surgically relevant quality improvement practices appropriate for widespread implementation. Figures include the Swiss Cheese Model representing the relationship between latent and active errors and adverse outcomes, a schematic depiction of the process by which system failures may lead to injury, the Systems Engineering in Patient Safety Model of work system and patient safety, and a depiction of contrasting characteristics of medical practice in the 20th and 21st centuries.This review contains 4 figures, 7 tables, and 165 references.

Improving Patient Safety in Surgical Care

2018 ◽  
Author(s):  
Amir Ghaferi
Keyword(s):  
Patient Safety ◽  
Systems Engineering ◽  
Surgical Care ◽  
Medical Systems ◽  
Key Words Human ◽  
Safety Measures ◽  
Cause Analysis ◽  
Root Cause ◽  
Improvement Strategies ◽  
National Patient

This chapter outlines current obstacles to improving safety, identifies systems approaches to making improvements, and discusses ways in which surgeons can take the lead in overcoming these obstacles. Lessons from other high-risk domains are described as are techniques for identifying system flaws. Tables and figures include nonmedical system techniques applicable to medical systems, national patient safety measures, examples of improvement strategies across surgical practice, and contrasting characteristics of medical practice in the twentieth and twenty-first centuries. This review contains 1 figures, 4 tables, and 84 references Key Words: human factors, medical error, peer review, patient safety, root cause analysis, systems engineering, teamwork

Patient Safety in Surgical Care

2017 ◽  
Author(s):  
Caprice C. Greenberg ◽  
Amir Ghaferi
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Systems Engineering ◽  
Health Care Professionals ◽  
Care Facility ◽  
Surgical Care ◽  
The United States ◽  
Adverse Outcomes ◽  
Patient Safety Indicators ◽  
National Quality

The 1999 report of the Institute of Medicine, To Err Is Human: Building a Safer Health System, made national headlines with its estimates of the frequency and severity of adverse events in health care, including that as many as 98,000 medical error–related deaths occur each year in the United States. The observation that the basic principles of human error are highly applicable to clinical practice has markedly advanced our understanding and willingness to address error in this setting. This review seeks to address the characteristics of systems in general and the system of surgical care in particular. It describes the growing knowledge of factors that affect human performance and how these factors contribute to adverse surgical outcomes. The review also outlines current obstacles to improving safety,  identifies  systems approaches to making improvements, and discusses ways in which surgeons can take the lead in overcoming these obstacles. An overall goal is that acceptance of error and a willingness to investigate its underlying causes will allow health care professionals to make use of the lessons learned from study of nonmedical systems. Tables include definitions of terms related to patient safety, the operation profile, handoff coordination and communication objectives and relevant strategies, nonmedical system techniques applicable to medical systems, Agency for Healthcare Quality and Research patient safety indicators, National Quality Forum list of health care facility–related serious reportable events, and examples of surgically relevant quality improvement practices appropriate for widespread implementation. Figures include the Swiss Cheese Model representing the relationship between latent and active errors and adverse outcomes, a schematic depiction of the process by which system failures may lead to injury, the Systems Engineering in Patient Safety Model of work system and patient safety, and a depiction of contrasting characteristics of medical practice in the 20th and 21st centuries. This review contains 4 figures, 7 tables, and 165 references.

Improving Patient Safety in Surgical Care

2018 ◽  
Author(s):  
Amir Ghaferi
Keyword(s):  
Patient Safety ◽  
Systems Engineering ◽  
Surgical Care ◽  
Medical Systems ◽  
Key Words Human ◽  
Safety Measures ◽  
Cause Analysis ◽  
Root Cause ◽  
Improvement Strategies ◽  
National Patient

This chapter outlines current obstacles to improving safety, identifies systems approaches to making improvements, and discusses ways in which surgeons can take the lead in overcoming these obstacles. Lessons from other high-risk domains are described as are techniques for identifying system flaws. Tables and figures include nonmedical system techniques applicable to medical systems, national patient safety measures, examples of improvement strategies across surgical practice, and contrasting characteristics of medical practice in the twentieth and twenty-first centuries. This review contains 1 figures, 4 tables, and 84 references Key Words: human factors, medical error, peer review, patient safety, root cause analysis, systems engineering, teamwork

scholarly journals How healthcare professionals in acute care environments describe patient safety: A case study

2021 ◽  
Author(s):  
◽  
Joanna Wailling
Keyword(s):  
Patient Safety ◽  
Acute Care ◽  
Healthcare Professionals ◽  
High Reliability ◽  
Acute Care Hospital ◽  
Patient Safety Culture ◽  
Building Blocks ◽  
Care Hospital ◽  
Safety Systems

<p>Patient safety has become an international healthcare priority over the past two decades. The prevailing approach to prevent harm in healthcare environments is the implementation of systems and structures that have made significant safety gains in high reliability organisations, such as aviation and nuclear power. However, similar safety improvements have not been realised in the healthcare environment. Studies suggest occupational culture is of importance, though our understanding of the relevance of safety subcultures is limited. This study explores how patient safety is described from the perspective of clinicians and organisational managers in an acute care hospital, using embedded case study design.  The case for this study was a New Zealand tertiary hospital. The emergency department and intensive care unit provided the settings for the embedded units. Three interviews with health care managers and six focus groups with nineteen doctors and nineteen nurses were undertaken. An interview guide, informed by the literature was used in data collection. Thematic data analysis was conducted within and across the case and embedded units. The theoretical concept of safety capability was developed from the data. Safety capability was defined as the ability to provide safe patient care and underpinned by the themes of resilient culture, and anticipation and vigilance.  A key finding of this research was that acute care environments have unique patient safety challenges, and these are influenced by complex factors. Patient safety was not assessed as being safe or unsafe, but rather perceived to exist across different levels of safety. Given this, healthcare professionals accept that some harm is inevitable in the healthcare setting. Doctors, nurses and managers understand and manage patient safety differently, and this affects how patient safety is addressed. This study identified anticipatory and vigilant systems are used to proactively manage risk by doctors and nurses, whereas incident reporting systems are used more by managers.    Given the need to keep patients safe and avoid harm, more proactive patient safety systems are needed to manage patient safety in hospitals; this will require a paradigm shift away from current reactive safety systems. Proactive systems must be underpinned by a resilient patient safety culture that focuses on the right building blocks to produce balance of resources and targets and develop collaboration in organisations. This will bring about flexibility and stability to meet the complex conditions presented by acute care environments.</p>

scholarly journals How healthcare professionals in acute care environments describe patient safety: A case study

2021 ◽  
Author(s):  
◽  
Joanna Wailling
Keyword(s):  
Patient Safety ◽  
Acute Care ◽  
Healthcare Professionals ◽  
High Reliability ◽  
Acute Care Hospital ◽  
Patient Safety Culture ◽  
Building Blocks ◽  
Care Hospital ◽  
Safety Systems

<p>Patient safety has become an international healthcare priority over the past two decades. The prevailing approach to prevent harm in healthcare environments is the implementation of systems and structures that have made significant safety gains in high reliability organisations, such as aviation and nuclear power. However, similar safety improvements have not been realised in the healthcare environment. Studies suggest occupational culture is of importance, though our understanding of the relevance of safety subcultures is limited. This study explores how patient safety is described from the perspective of clinicians and organisational managers in an acute care hospital, using embedded case study design.  The case for this study was a New Zealand tertiary hospital. The emergency department and intensive care unit provided the settings for the embedded units. Three interviews with health care managers and six focus groups with nineteen doctors and nineteen nurses were undertaken. An interview guide, informed by the literature was used in data collection. Thematic data analysis was conducted within and across the case and embedded units. The theoretical concept of safety capability was developed from the data. Safety capability was defined as the ability to provide safe patient care and underpinned by the themes of resilient culture, and anticipation and vigilance.  A key finding of this research was that acute care environments have unique patient safety challenges, and these are influenced by complex factors. Patient safety was not assessed as being safe or unsafe, but rather perceived to exist across different levels of safety. Given this, healthcare professionals accept that some harm is inevitable in the healthcare setting. Doctors, nurses and managers understand and manage patient safety differently, and this affects how patient safety is addressed. This study identified anticipatory and vigilant systems are used to proactively manage risk by doctors and nurses, whereas incident reporting systems are used more by managers.    Given the need to keep patients safe and avoid harm, more proactive patient safety systems are needed to manage patient safety in hospitals; this will require a paradigm shift away from current reactive safety systems. Proactive systems must be underpinned by a resilient patient safety culture that focuses on the right building blocks to produce balance of resources and targets and develop collaboration in organisations. This will bring about flexibility and stability to meet the complex conditions presented by acute care environments.</p>

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