scholarly journals Safety Culture: Identifying a Healthcare Organization’s Approach to Safety Event Review and Response Through the Analysis of Event Recommendations

2021 ◽  
pp. 92-102
Author(s):  
Ella Franklin ◽  
Jessica Howe ◽  
Ram Dixit ◽  
Tracy Kim ◽  
Allan Fong ◽  
...  
Keyword(s):  
Safety Culture ◽  
Review Process ◽  
Healthcare Organization ◽  
Event Report ◽  
Event Type ◽  
Clinical Safety ◽  
Event Reporting ◽  
Review Analysis ◽  
Safety Event ◽  
Category Labels

A nonpunitive approach to safety event reporting and analysis is an important dimension of healthcare organization safety culture. A system-based safety event review process, one focused on understanding and improving the conditions in which individuals do their work, generally leads to more effective and sustainable safety solutions. On the contrary, the more typical person-based approach, that blames individuals for errors, often results in unsustainable and ineffective safety solutions, but these solutions can be faster and less resource intensive to implement. We sought to determine the frequency of system-based and person-based approaches to adverse event reviews through analysis of the recommendation text provided by a healthcare organization in response to an event report. Human factors and clinical safety science experts developed a taxonomy to describe the content of the recommendation text, reviewed 8,546 event report recommendations, and assigned one or more taxonomy category labels to each recommendation. The taxonomy categories aligned with a system-based approach, aligned with a person-based approach, did not provide an indicator of the approach, or indicated the review/analysis was pending. A total of 9,848 category labels were assigned to the 8,546 event report recommendations. The most frequently used category labels did not provide an indicator of the approach to event review (4,145 of 9,848 category labels, 42.1%), followed by a person-based approach (2,327, 23.6%), review/analysis pending (1,862 ,18.9%), and a system-based approach (1,514, 15.4%). Analyzing the data at the level of each recommendation, 23.2% (1,979 of 8,546) had at least one person-based and no system-based category, 13.3% (1,133) had at least one system-based and no person-based category, and 3% (254) had at least one person-based and one system-based category. There was variability in the event review approach based on the general event type assigned to the safety event (e.g., medication, transfusion, etc.) as well as harm severity. Results suggest improvements in applying system-based approaches are needed, especially for certain general event type categories. Recommendations for improving safety event reviews are provided.

An Evaluation of Patient Safety Event Report Categories Using Unsupervised Topic Modeling

2015 ◽  
Vol 54 (04) ◽  
pp. 338-345 ◽  
Author(s):  
A. Fong ◽  
R. Ratwani
Keyword(s):  
Patient Safety ◽  
Natural Language Processing ◽  
Natural Language ◽  
Language Processing ◽  
Topic Modeling ◽  
Free Text ◽  
Event Data ◽  
Event Type ◽  
Modeling Approach ◽  
Safety Event

SummaryObjective: Patient safety event data repositories have the potential to dramatically improve safety if analyzed and leveraged appropriately. These safety event reports often consist of both structured data, such as general event type categories, and unstructured data, such as free text descriptions of the event. Analyzing these data, particularly the rich free text narratives, can be challenging, especially with tens of thousands of reports. To overcome the resource intensive manual review process of the free text descriptions, we demonstrate the effectiveness of using an unsupervised natural language processing approach.Methods: An unsupervised natural language processing technique, called topic modeling, was applied to a large repository of patient safety event data to identify topics, or themes, from the free text descriptions of the data. Entropy measures were used to evaluate and compare these topics to the general event type categories that were originally assigned by the event reporter.Results: Measures of entropy demonstrated that some topics generated from the un-supervised modeling approach aligned with the clinical general event type categories that were originally selected by the individual entering the report. Importantly, several new latent topics emerged that were not originally identified. The new topics provide additional insights into the patient safety event data that would not otherwise easily be detected.Conclusion: The topic modeling approach provides a method to identify topics or themes that may not be immediately apparent and has the potential to allow for automatic reclassification of events that are ambiguously classified by the event reporter.

scholarly journals pelaksanaan proses pengkajian keperawatan di ruang rawat inap

2019 ◽  
Author(s):  
khairunnisa ayu ramadhan
Keyword(s):  
Literature Review ◽  
Review Process ◽  
Assessment Process ◽  
Nursing Process ◽  
Nursing Assessment ◽  
Review Analysis

Latar belakang : pelaksanaan proses pengkajian keperawatan merupakan suatu tahapan yang pertama pada proses keperawatan yang dapat dilakukan perawat secara sistematis. Tujuan : tujuan pembuatan pengkajian ini untuk membuat perawat mampu melakukan proses pengkajian di ruang rawat inap secara benar dan komperhensif. Metode : metode yang digunakan berdasarkan buku referensi, Literature review analisis, e-book, e-journal, dan juga referensi jurnal minimal 5 tahun terakhir. Hasil : dengan melakukan pengkajian ini perawat dapat melakukan proses pengkajian keperawatan di ruang rawat inap dengan benar. Kesimpulan : dari beberapa referensi buku dan juga beberapa jurnal yang telah dibaca, bahwa kita sebagai perawat harus mampu melaksanakan proses pengkajian keperawatan pada pasien di rumah sakit khususnya di ruang rawat inap.AbstrackBackground : The implementation of the nursing review process is the first stage in the nursing process that nurses can do systematically. Purpose: the purpose of making this assessment is to make nurses able to carry out the assessment process in the inpatient room correctly and comprehensively. Method: the method used is based on reference books, literature review analysis, e-books, e-journals, and also journal references at least the last 5 years. Results: by doing this study nurses can do the nursing assessment process in the inpatient room correctly. Conclusion : from several reference books and also several journals that have been read, that we as nurses must be able to carry out the process of nursing assessment in patients in hospitals, especially in the inpatient room.

Traditional Lectures Actually Improve the Body of Knowledge, Skills, and Attitudes of Health Care Professional for Health Incident Reporting System

2020 ◽  
pp. 001857872091855
Author(s):  
Marcus Vinicius de Souza Joao Luiz ◽  
Fabiana Rossi Varallo ◽  
Celsa Raquel Villaverde Melgarejo ◽  
Tales Rubens de Nadai ◽  
Patricia de Carvalho Mastroianni
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Health Care Professional ◽  
Safety Culture ◽  
Reporting System ◽  
Patient Safety Culture ◽  
Incident Reporting ◽  
Event Reporting ◽  
Incident Reporting System ◽  
Traditional Lectures

Introduction: A solid patient safety culture lies at the core of an effective event reporting system in a health care setting requiring a professional commitment for event reporting identification. Therefore, health care settings should provide strategies in which continuous health care education comes up as a good alternative. Traditional lectures are usually more convenient in terms of costs, and they allow us to disseminate data, information, and knowledge through a large number of people in the same room. Taking in consideration the tight money budgets in Brazil and other countries, it is relevant to investigate the impact of traditional lectures on the knowledge, skills, and attitudes to incident reporting system and patient safety culture. Objective: The study aim was to assess the traditional lecture impact on the improvement of health care professional competency dimensions (knowledge, skills, and attitudes) and on the number of health care incident reports for better patient safety culture. Participants and Methods: An open-label, nonrandomized trial was conducted in ninety-nine health care professionals who were assessed in terms of their competencies (knowledge, skills, and attitudes) related to the health incident reporting system, before and after education intervention (traditional lectures given over 3 months). Results: All dimensions of professional competencies were improved after traditional lectures ( P < .05, 95% confidence interval). Conclusions: traditional lectures are helpful strategy for the improvement of the competencies for health care incident reporting system and patient safety.

scholarly journals Healthcare Professional’s Perception of Patient Safety Measured by the Hospital Survey on Patient Safety Culture: A Systematic Review and Meta-Analysis

2018 ◽  
Vol 2018 ◽  
pp. 1-11 ◽  
Author(s):  
Julia Hiromi Hori Okuyama ◽  
Tais Freire Galvao ◽  
Marcus Tolentino Silva
Keyword(s):  
Patient Safety ◽  
Safety Culture ◽  
Meta Analysis ◽  
Patient Safety Culture ◽  
The United States ◽  
Three Dimensions ◽  
Asian Continent ◽  
Learning From Errors ◽  
Event Reporting ◽  
Arcsine Transformation

Objective.To assess the culture of patient safety in studies that employed the hospital survey on patient safety culture (HSOPS) in hospitals around the world.Method.We searched MEDLINE, EMBASE, SCOPUS, CINAHL, and SciELO. Two researchers selected studies and extracted the following data: year of publication, country, percentage of physicians and nurses, sample size, and results for the 12 HSOPS dimensions. For each dimension, a random effects meta-analysis with double-arcsine transformation was performed, as well as meta-regressions to investigate heterogeneity, and tests for publication bias.Results.59 studies with 755,415 practitioners surveyed were included in the review. 29 studies were conducted in the Asian continent and 11 in the United States. On average studies scored 9 out of 10 methodological quality score. Of the 12 HSOPS dimensions, six scored under 50% of positivity, with “nonpunitive response to errors” the lowest one. In the meta-regression, three dimensions were shown to be influenced by the proportion of physicians and five by the continent where survey was held.Conclusions.The HSOPS is widely used in several countries to assess the culture of patient safety in hospital settings. The culture of culpability is the main weakness across studies. Encouraging event reporting and learning from errors should be priorities in hospitals worldwide.

scholarly journals Barriers to Safety Event Reporting in an Academic Radiology Department: Authority Gradients and Other Human Factors

Radiology ◽  
2018 ◽  
Vol 288 (3) ◽  
pp. 693-698 ◽  
Author(s):  
Bettina Siewert ◽  
Suzanne Swedeen ◽  
Olga R. Brook ◽  
Ronald L. Eisenberg ◽  
Mary Hochman
Keyword(s):  
Human Factors ◽  
Radiology Department ◽  
Event Reporting ◽  
Safety Event ◽  
Academic Radiology

scholarly journals Using patient safety-event report data to assess health-IT safety: benefits and challenges

2019 ◽  
Vol 1 (3) ◽  
pp. e104-e105
Author(s):  
Jessica L Howe ◽  
A Zachary Hettinger ◽  
Raj M Ratwani
Keyword(s):  
Patient Safety ◽  
Health It ◽  
Event Report ◽  
Safety Event ◽  
Report Data
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