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

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

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

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

Improving Root Cause Analysis of Patient Safety Events in Radiology

Radiographics ◽  
2020 ◽  
Vol 40 (5) ◽  
pp. 1434-1440
Author(s):  
Ashley S. Rosier ◽  
Laura C. Tibor ◽  
Mara A. Turner ◽  
Carrie J. Phillips ◽  
A. Nicholas Kurup
Keyword(s):  
Patient Safety ◽  
Root Cause Analysis ◽  
Cause Analysis ◽  
Root Cause

scholarly journals Assessment and improvement of junior doctor handover in the emergency department

2020 ◽  
Vol 9 (3) ◽  
pp. e001032
Author(s):  
Mark Sykes ◽  
Jack Garnham ◽  
Pablo Martin Kostelec ◽  
Hazel Hall ◽  
Anu Mitra
Keyword(s):  
Emergency Department ◽  
Patient Safety ◽  
Standard Operating Procedure ◽  
Baseline Survey ◽  
Junior Doctors ◽  
Improvement Strategy ◽  
Essential Components ◽  
Improvement Strategies ◽  
National Patient ◽  
Handover Process

IntroductionEffective handover between junior doctors is widely accepted as essential for patient safety. The British Medical Association in association with the National Health Service (NHS) National Patient Safety Agency and NHS Modernisation Agency have produced clear guidance regarding the contents and setting for a safe and efficient handover. We aimed to understand current junior doctor’s opinions on the handover process in a London emergency department (ED), with subsequent assessment, and any necessary improvement, of handover practices within the department.MethodsIn a London ED, a baseline survey was completed by the senior house officer (SHO) cohort to gauge current opinions of the existing handover process. Concurrently, a blinded prospective audit of handover practises was conducted. Multiple improvement strategies were subsequently implemented and assessed via Plan–Do–Study–Act (PDSA) cycles. A standard operating procedure was initially introduced and ‘rolled out’ throughout the department. This intervention was followed by development of an electronic handover note to ease completion of a satisfactory handover. Additional surveys were conducted to continually assess SHO opinion on how the handover process was developing. The final improvement strategy was formal handover teaching at the SHO induction.ResultsBaseline audit and SHO survey highlighted several opportunities for improvement. 5 handover components were deemed essential: (1) documented handover note; (2) doctor’s names; (3) history of presenting complaint; (4) ED actions; and (5) ongoing plan. The frequency of these components saw significant improvement by completion of the final PDSA. Following SHO rotation, all of the essential components fell, only to recover after the next improvement strategy.ConclusionsJunior doctors in a London ED were not satisfied with the current SHO handover process, and handover practices were not adequate. While the rotational nature of the SHO cohort makes sustained change challenging, implementation of thoughtful and realistic improvement strategies can significantly improve handover quality.

Transient Root Cause Analysis: A Model-Based Systems Engineering Methodology

2004 ◽  
Author(s):  
Trevor Bailey ◽  
Suzanne Woll ◽  
Rajul Misra ◽  
Kevin Otto
Keyword(s):  
Systems Engineering ◽  
Best Practice ◽  
Success Factors ◽  
System Modeling ◽  
Root Cause Analysis ◽  
System Level ◽  
Cause Analysis ◽  
Root Cause ◽  
Model Based ◽  
Model Based Systems Engineering

This paper presents a model-based systems engineering methodology that can be applied to perform a root cause analysis on transient systems. The methodology extends existing root cause analysis best practice by incorporating system modeling and analysis techniques. The methodology is deployed through a detailed 5-step process to understand, identify, assess, FMEA, and validate potential transient system-level root causes. A transient performance reliability analysis for a dual mode refrigeration system is used to demonstrate how the methodology can be applied. The paper also describes a set of success factors for applying the methodology using a phased approach with a large cross-functional team.

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