76 FR 79192 - Patient Safety Organizations: Voluntary Relinquishment From HSMS Patient Safety Organization

Science.gov (United States)

2011-12-21

... Organizations: Voluntary Relinquishment From HSMS Patient Safety Organization AGENCY: Agency for Healthcare... voluntary relinquishment from the HSMS Patient Safety Organization of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109...

Security Expertise

DEFF Research Database (Denmark)

systematic study of security expertise and opens up a productive dialogue between science and technology studies and security studies to investigate the character and consequences of this expertise. In security theory, the study of expertise is crucial to understanding whose knowledge informs security making......This volume brings together scholars from different fields to explore the power, consequences and everyday practices of security expertise. Expertise mediates between different forms of knowledge: scientific and technological, legal, economic and political knowledge. This book offers the first...... and to reflect on the impact and responsibility of security analysis. In science and technology studies, the study of security politics adds a challenging new case to the agenda of research on expertise and policy. The contributors investigate cases such as academic security studies, security think tanks...

76 FR 60495 - Patient Safety Organizations: Voluntary Relinquishment From the Patient Safety Group

Science.gov (United States)

2011-09-29

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From the Patient Safety Group AGENCY: Agency for Healthcare Research and... voluntary relinquishment from The Patient Safety Group of its status as a Patient Safety Organization (PSO...

77 FR 11120 - Patient Safety Organizations: Voluntary Relinquishment From UAB Health System Patient Safety...

Science.gov (United States)

2012-02-24

... Organizations: Voluntary Relinquishment From UAB Health System Patient Safety Organization AGENCY: Agency for... notification of voluntary relinquishment from the UAB Health System Patient Safety Organization of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005...

Ethical and legal implications of the risks of medical tourism for patients: a qualitative study of Canadian health and safety representatives’ perspectives

Science.gov (United States)

Crooks, Valorie A; Turner, Leigh; Cohen, I Glenn; Bristeir, Janet; Snyder, Jeremy; Casey, Victoria; Whitmore, Rebecca

2013-01-01

Objectives Medical tourism involves patients’ intentional travel to privately obtain medical care in another country. Empirical evidence regarding health and safety risks facing medical tourists is limited. Consideration of this issue is dominated by speculation and lacks meaningful input from people with specific expertise in patient health and safety. We consulted with patient health and safety experts in the Canadian province of British Columbia to explore their views concerning risks that medical tourists may be exposed to. Herein, we report on the findings, linking them to existing ethical and legal issues associated with medical tourism. Design We held a focus group in September 2011 in Vancouver, British Columbia with professionals representing different domains of patient health and safety expertise. The focus group was transcribed verbatim and analysed thematically. Participants Seven professionals representing the domains of tissue banking, blood safety, health records, organ transplantation, dental care, clinical ethics and infection control participated. Results Five dominant health and safety risks for outbound medical tourists were identified by participants: (1) complications; (2) specific concerns regarding organ transplantation; (3) transmission of antibiotic-resistant organisms; (4) (dis)continuity of medical documentation and (5) (un)informed decision-making. Conclusions Concern was expressed that medical tourism might have unintended and undesired effects upon patients’ home healthcare systems. The individual choices of medical tourists could have significant public consequences if healthcare facilities in their home countries must expend resources treating postoperative complications. Participants also expressed concern that medical tourists returning home with infections, particularly antibiotic-resistant infections, could place others at risk of exposure to infections that are refractory to standard treatment regimens and thereby pose

Programs and Expertise

CERN Document Server

2001-01-01

Description of programs and expertise implemented by Radiation Protection Centre is presented. RPC implements study assessing the doses received by air crew members of Lithuanian Airlines. In 2001 RPC started measurements of indoor radon concentrations in the houses of regions with karst formations, commenced new program analyzing amounts of radionuclides in typical diet of hospital patients.

A Proposed Set of Metrics to Reduce Patient Safety Risk From Within the Anatomic Pathology Laboratory.

Science.gov (United States)

Banks, Peter; Brown, Richard; Laslowski, Alex; Daniels, Yvonne; Branton, Phil; Carpenter, John; Zarbo, Richard; Forsyth, Ramses; Liu, Yan-Hui; Kohl, Shane; Diebold, Joachim; Masuda, Shinobu; Plummer, Tim; Dennis, Eslie

2017-05-01

Anatomic pathology laboratory workflow consists of 3 major specimen handling processes. Among the workflow are preanalytic, analytic, and postanalytic phases that contain multistep subprocesses with great impact on patient care. A worldwide representation of experts came together to create a system of metrics, as a basis for laboratories worldwide, to help them evaluate and improve specimen handling to reduce patient safety risk. Members of the Initiative for Anatomic Pathology Laboratory Patient Safety (IAPLPS) pooled their extensive expertise to generate a list of metrics highlighting processes with high and low risk for adverse patient outcomes. : Our group developed a universal, comprehensive list of 47 metrics for patient specimen handling in the anatomic pathology laboratory. Steps within the specimen workflow sequence are categorized as high or low risk. In general, steps associated with the potential for specimen misidentification correspond to the high-risk grouping and merit greater focus within quality management systems. Primarily workflow measures related to operational efficiency can be considered low risk. Our group intends to advance the widespread use of these metrics in anatomic pathology laboratories to reduce patient safety risk and improve patient care with development of best practices and interlaboratory error reporting programs. © American Society for Clinical Pathology 2017.

Expertise, Ethics Expertise, and Clinical Ethics Consultation: Achieving Terminological Clarity

Science.gov (United States)

Iltis, Ana S.; Sheehan, Mark

2016-01-01

The language of ethics expertise has become particularly important in bioethics in light of efforts to establish the value of the clinical ethics consultation (CEC), to specify who is qualified to function as a clinical ethics consultant, and to characterize how one should evaluate whether or not a person is so qualified. Supporters and skeptics about the possibility of ethics expertise use the language of ethics expertise in ways that reflect competing views about what ethics expertise entails. We argue for clarity in understanding the nature of expertise and ethics expertise. To be an ethics expert, we argue, is to be an expert in knowing what ought to be done. Any attempt to articulate expertise with respect to knowing what ought to be done must include an account of ethics that specifies the nature of moral truth and the means by which we access this truth or a theoretical account of ethics such that expertise in another domain is linked to knowing or being better at judging what ought to be done and the standards by which this “knowing” or “being better at judging” is determined. We conclude with a discussion of the implications of our analysis for the literature on ethics expertise in CEC. We do think that there are clear domains in which a clinical ethics consultant might be expert but we are skeptical about the possibility that this includes ethics expertise. Clinical ethics consultants should not be referred to as ethics experts. PMID:27256848

Expertise and contra expertise independence and transparency

International Nuclear Information System (INIS)

Abarnou, G.; Ades, Y.; Ancelin, G.; Balle, St.; Bardy, J.Ch.; Beringer, F.; Blanc, M.; Bontoux, J.; Bovy, M.; Brunet, F.; Calafat, A.; Cartier, M.; Constant, H.; Delcourt, R.; Duvert, J.C.; Eichholtzer, F.; Fernandez, P.; Fernex, S.; Foechterle, A.; Gatesoupe, J.P.; Geneau, Ch.; Goerg, C.; Gourod, A.; Graschaire, G.; Hubscher Ibert, J.; Jaegert, M.; Lacoste, A.C.; Lacote, J.P.; Laroche, D.; Lazar, Ph.; Lelievre, D.; Levasseur, E.; Levent, L.; Louvat, D.; Manon, Ch.; Maugein, J.; Melguen, M.; Mouchet, Ch.; Mourat, J.P.; Naegelen, L.; Niquet, G.; Perves, J.P.; Potelet, P.; Regent, A.; Romann, J.M.; Rossa, N.; Saut, C.; Sazy, Ch.; Schmitt, P.; Sene, M.; Sene, Raymond; Sornein, J.F.; Sugier, A.; Tfibel, V.; Uhart, M.; Vidal, J.; Vieillard Baron, B.; Vigny, P.; Walgenwitz, G.; Wiest, A.; Wisselmann, R.; Zuberbuhler, A.

2006-01-01

About sixty participants: members of C.L.I., academics, elected representatives, manufacturers, representatives of association, institutional, crossed their experiences. The debate was mainly centred on the role of the expert, the limits of its intervention and its independence. The presented titles are following: experiences of two C.L.I. in expertise; the work of communication of the nuclear experts; interest and limits of the expertise; presentation of the I.R.S.N. and the D.G.S.N.R.; expertise: problems and experiences; presentation of the works realised in work group; the considerations of the C.S.S.I.N.. (N.C.)

The nature of expertise and human resource functions supporting expertise in nuclear industry organizations

International Nuclear Information System (INIS)

Rintala, N.; Katri, S.; Eila, J.; Pahkin, K.; Anneli, L.

2007-01-01

Full text: The nuclear industry worldwide faces the challenge of preserving the existing expertise, competence and knowledge despite of the ageing workforce and upcoming retirements. Challenges are also imposed by the reducing amount of new recruits and students entering the nuclear industry, which amounts to fewer young professionals that have the potential to become nuclear experts in the future. Although many other industries share similar challenges, the preservation of expertise in the nuclear industry is even more important due to the safety-critical nature of the nuclear operations and the special characteristics that high-reliability organizations such as nuclear power plants have. As a response to the risk of knowledge loss, nuclear organizations have engaged in knowledge capturing efforts. New information systems and organizational practices have been implemented to safeguard nuclear expertise. Recently, IAEA has proposed nuclear organizations to design and adopt people-centered programs that encompass themes such as workforce planning, recruitment, training, succession planning, leadership development and knowledge management. Thus, in order to address the current risks to nuclear expertise, attention should be focused on these different areas and corresponding human resources (HR) functions within the nuclear organizations. Our paper presents results from a project which examines the nature of expert work and human resources (HR) functions that support the development and preservation of expertise. The study adopts a qualitative cross-sectional case study design. Two organizational units from different nuclear industry organizations have been selected as cases. The research data will be gathered in April-May 2007 and preliminary results will be presented in the International Conference of Knowledge Management in Nuclear Facilities, in June 2007. The main data will comprise of thematic interviews to experts, their managers and HR representatives

76 FR 71345 - Patient Safety Organizations: Voluntary Relinquishment From Emergency Medicine Patient Safety...

Science.gov (United States)

2011-11-17

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From Emergency Medicine Patient Safety Foundation AGENCY: Agency for... notification of voluntary relinquishment from Emergency Medicine Patient Safety Foundation of its status as a...

78 FR 40146 - Patient Safety Organizations: Voluntary Relinquishment From Northern Metropolitan Patient Safety...

Science.gov (United States)

2013-07-03

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From Northern Metropolitan Patient Safety Institute AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of Delisting. SUMMARY: The Patient Safety and...

76 FR 7853 - Patient Safety Organizations: Voluntary Delisting From Oregon Patient Safety Commission

Science.gov (United States)

2011-02-11

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Delisting From Oregon Patient Safety Commission AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of delisting. SUMMARY: Oregon Patient Safety Commission: AHRQ...

Unitizing worker expertise and maximizing the brain reward centers

Energy Technology Data Exchange (ETDEWEB)

Martinez, Anthony Bert [Los Alamos National Laboratory

2010-01-01

People are experts when it comes to the work they do; unfortunately their expertise is not utilized as frequently as it could be. More opportunities need to be provided that allow people to participate in the design of their work including: accident investigations, job planning, and process improvements. Many employers use some form of job hazard analysis process to identify and document hazards and controls, but the front line worker is rarely involved. This presentation will show the core principles supporting employee involvement, provide examples where workers had brilliant ideas but no one listened, and provide examples where workers were given the opportunity to use their expertise to improve occupational safety. According to Abraham Maslow's Hierarch of Needs model, one essential human need is to be innovative and solve problems. Advances in brain science have proven, through functional magnetic resonance imaging (fMRI) studies, the brain reward pathway is activated when people are recognized for their intellectual contributions. As people contribute their expertise to improve occupational safety more frequently they will feel a sense of gratification. In addition, safety professionals will have more time to spend on strategic planning of emerging occupational safety issues. One effect of the current global recession is that SH&E professionals are asked to do more with less. Therefore, to be successful it is essential that SH&E professionals incorporate worker expertise in job planning. This will be illustrated in the presentation through an example where a worker had the answer to a difficult decision on appropriate personal protective equipment for a job but no one asked the worker for his idea during the job planning phase. Fortunately the worker was eventually consulted and his recommendation for the appropriate personal protective equipment for the job was implemented before work began. The goal of this presentation is to expand the awareness and

76 FR 58812 - Patient Safety Organizations: Delisting for Cause of Patient Safety Organization One, Inc.

Science.gov (United States)

2011-09-22

... Organizations: Delisting for Cause of Patient Safety Organization One, Inc. AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION: Notice of Delisting. SUMMARY: Patient Safety Organization One, Inc.: AHRQ has delisted Patient Safety Organization One, Inc. as a Patient Safety Organization (PSO...

The state of quality improvement and patient safety teaching in health professional education in New Zealand.

Science.gov (United States)

Robb, Gillian; Stolarek, Iwona; Wells, Susan; Bohm, Gillian

2017-10-27

To investigate how quality and patient safety domains are being taught in the pre-registration curricula of health profession education programmes in New Zealand. All tertiary institutions providing training for medicine, nursing, midwifery, dentistry, pharmacy, physiotherapy, dietetics and 11 other allied health professions in New Zealand were contacted and a person with relevant curriculum knowledge was invited to participate. Interviews were conducted using a semi-structured interview guide to explore nine quality and safety domains; improvement science, patient safety, quality and safety culture, evidence-based practice, patient-centred care, teamwork and communication, leadership for change, systems thinking and use of information technology (IT). Transcribed data were extracted and categorised by discipline and domain. Two researchers independently identified and categorised themes within each domain, using a general inductive approach. Forty-nine institutions were contacted and 43 (88%) people were interviewed. The inclusion and extent of quality and safety teaching was variable. Evidence-based practice, patient-centred care and teamwork and communication were the strongest domains and well embedded in programmes, while leadership, systems thinking and the role of IT were less explicitly included. Except for two institutions, improvement science was absent from pre-registration curricula. Patient safety teaching was focused mainly around incident reporting, and to a lesser extent learning from adverse events. Although a 'no blame' culture was articulated as important, the theme of individual accountability was still apparent. While participants agreed that all domains were important, the main barriers to incorporating improvement science and patient safety concepts into existing programmes included an 'already stretched curriculum' and having faculty with limited expertise in these areas. Although the building blocks for improving the quality and safety of

HRET patient safety leadership fellowship: the role of "community" in patient safety.

Science.gov (United States)

Leonhardt, Kathryn Kraft

2010-01-01

Community engagement is widely endorsed but poorly defined as a strategy to improve patient safety. With strong evidence that engaging patients can positively influence health outcomes, it is presumed that community engagement could improve patient safety. Leaning on the models from other disciplines such as public health, the adequate knowledge and application of the principles of community engagement are critical for this approach to be effective. This article provides a description of the theories supporting patient partnership and community engagement, reviews critical elements of successful community-based programs, and identifies the potential for empowering communities to improve patient safety.

E-Commerce Audit Judgment Expertise: Does Expertise in System Change Management and Information Technology Auditing Mediate E-Commerce Audit Judgment Expertise?

Directory of Open Access Journals (Sweden)

Jagdish PATHAK

2010-01-01

Full Text Available A global survey of 203 E-commerce auditors was conducted to investigate the perceptions about the potential determinants of expertise in E-commerce audits. We hypothesize and find evidence indicating that information technology and communication expertise are positively related to expertise in E-commerce audit judgment. We also find that system change management expertise and information technology audit expertise mediate this relationship.

Patient safety culture among nurses.

Science.gov (United States)

Ammouri, A A; Tailakh, A K; Muliira, J K; Geethakrishnan, R; Al Kindi, S N

2015-03-01

Patient safety is considered to be crucial to healthcare quality and is one of the major parameters monitored by all healthcare organizations around the world. Nurses play a vital role in maintaining and promoting patient safety due to the nature of their work. The purpose of this study was to investigate nurses' perceptions about patient safety culture and to identify the factors that need to be emphasized in order to develop and maintain the culture of safety among nurses in Oman. A descriptive and cross-sectional design was used. Patient safety culture was assessed by using the Hospital Survey on Patient Safety Culture among 414 registered nurses working in four major governmental hospitals in Oman. Descriptive statistics and general linear regression were employed to assess the association between patient safety culture and demographic variables. Nurses who perceived more supervisor or manager expectations, feedback and communications about errors, teamwork across hospital units, and hospital handoffs and transitions had more overall perception of patient safety. Nurses who perceived more teamwork within units and more feedback and communications about errors had more frequency of events reported. Furthermore, nurses who had more years of experience and were working in teaching hospitals had more perception of patient safety culture. Learning and continuous improvement, hospital management support, supervisor/manager expectations, feedback and communications about error, teamwork, hospital handoffs and transitions were found to be major patient safety culture predictors. Investing in practices and systems that focus on improving these aspects is likely to enhance the culture of patient safety in Omani hospitals and others like them. Strategies to nurture patient safety culture in Omani hospitals should focus upon building leadership capacity that support open communication, blame free, team work and continuous organizational learning. © 2014 International

Sustainable network of independent technical expertise for radioactive waste disposal (SITEX)

Energy Technology Data Exchange (ETDEWEB)

Serres, Christophe; Rocher, Muriel [Institut de Radioprotection et de Surete Nucleaire (IRSN), Fontenay-aux-Roses (France); Bernier, Frederic [FANC, Brussels (Belgium); Havlova, Vaclava [UJV Rez, a.s., Rez (Czech Republic); Mrskova, Adela [DECOM A.S., Trnava (Slovakia); Dubreuil, Gilles Heriard [MUTADIS, Paris (France)

2013-07-01

SITEX is a 24 months FP7 Euratom project (from January 2012 to December 2013) led by IRSN and bringing together organisations representing technical safety organisations and nuclear safety authorities performing technical and scientific assessment of geological disposals for radioactive waste in the framework of their respective national regulatory review process of the safety case. Civil society outreach specialists of interaction with civil society are also involved in the project. SITEX aims at establishing the conditions required for developing sustainable interactions among experts from various horizons (nuclear safety authorities, technical safety organisations, civil society organisations..) capable of developing and coordinating joint and harmonized activities in relation with the safety assessment of the safety case. Among foreseen activities, partnership with the civil society experts is considered as a key function of the future network in order to contribute in enhancing trust in the decision making process. The SITEX program of work is split into a set of six workpackages that address technical and organizational issues allowing in fine to propose a structure of the activities and operating modes of the future network. These issues relate on the one hand to the study of the potential for sharing and developing technical expertise practices independently from the expertise developed by waste management organisations, on the other hand on the ability to implement coordinated R and D programs run by technical safety organisations in order to develop the scientific knowledge necessary to perform technical assessments. (orig.)

78 FR 59036 - Patient Safety Organizations: Voluntary Relinquishment From Cogent Patient Safety Organization, Inc.

Science.gov (United States)

2013-09-25

... Organizations: Voluntary Relinquishment From Cogent Patient Safety Organization, Inc. AGENCY: Agency for... for the formation of Patient Safety Organizations (PSOs), which collect, aggregate, and analyze... Cogent Patient Safety Organization, Inc. of its status as a PSO, and has delisted the PSO accordingly...

76 FR 9350 - Patient Safety Organizations: Voluntary Delisting From Rocky Mountain Patient Safety Organization

Science.gov (United States)

2011-02-17

... Organizations: Voluntary Delisting From Rocky Mountain Patient Safety Organization AGENCY: Agency for Healthcare... Organization: AHRQ has accepted a notification of voluntary relinquishment from Rocky Mountain Patient Safety Organization, a component entity of Colorado Hospital Association, of its status as a Patient Safety...

Patient safety--worker safety: building a culture of safety to improve healthcare worker and patient well-being.

Science.gov (United States)

Yassi, Annalee; Hancock, Tina

2005-01-01

Patient safety within the Canadian healthcare system is currently a high national priority, which merits a comprehensive understanding of the underlying causes of adverse events. Not least among these is worker health and safety, which is linked to patient outcomes. Healthcare workers have a high risk of workplace injuries and more mental health problems than most other occupational groups. Many healthcare professionals feel fatigued, stressed, in pain, or at risk of illness or injury-factors they feel impede their ability to provide consistent quality care. With this background, the Occupational Health and Safety Agency for Healthcare (OHSAH) in British Columbia, jointly governed by healthcare unions and healthcare employers, launched several major initiatives to improve the healthcare workplace. These included the promotion of safe patient handling, adaptive clothing, scheduled toileting, stroke management training, measures to improve management of aggressive behaviour and, of course, infection control-all intended to improve the safety of workers, but also to improve patient safety and quality of care. Other projects also explicitly promoting physical and mental health at work, as well as patient safety are also underway. Results of the projects are at various stages of completion, but ample evidence has already been obtained to indicate that looking after the well-being of healthcare workers results in safer and better quality patient care. While more research is needed, our work to date suggests that a comprehensive systems approach to promoting a climate of safety, which includes taking into account workplace organizational factors and physical and psychological hazards for workers, is the best way to improve the healthcare workplace and thereby patient safety.

TSO support to safety authorities in new reactor licensing

Energy Technology Data Exchange (ETDEWEB)

Numark, N.J.; Bowling, M.L. [Numark Associates, Inc., Washington, DC (United States)

2013-07-01

Technical Support Organizations (TSOs) can provide review assistance to a safety authority in a cost-effective and timely manner. TSO scope tailored to safety authority needs. TSOs must understand and adhere to safety authority priorities and culture. TSOs must be flexible in regulatory approaches, work locations, time zones, and languages. Safety authorities have varying technical support needs. For instance, authorities may have substantial staff and expertise on various types of commercial Nuclear Power Plants (NPP), substantial staff and expertise on a single type of commercial NPP, limited staff but with expertise on commercial NPPs or limited staff and no expertise on commercial NPPs.

Sustainable network of independent technical expertise for radioactive waste disposal

International Nuclear Information System (INIS)

Serres, Christophe; Rocher, Muriel; Lemy, Frank; Havlova, Vaclava; Mrskova, Adela; Heriard Dubreuil, Gilles

2014-01-01

Full text of publication follows: SITEX is a 24-month FP7 project led by IRSN and bringing together 15 organisations representing technical safety organisations (TSO) and safety authorities, as well as civil society outreach specialists involved in the 'regulatory' review process of geological disposal of radioactive waste. SITEX aims at establishing the conditions required for developing a sustainable network of experts from various horizons (authorities, TSO, academic organisations, civil society,...) capable of developing and coordinating the technical expertise that is required from the stakeholders in charge of delivering opinion, independently from the waste management organisations (WMO), on the safety of geological disposals. The SITEX programme of work is split into a set of six work packages that address technical and organisational issues allowing to propose a structure of the missions and operating mode of the future network. These issues relate on the one hand to the study of the potential for sharing and developing technical expertise practices amongst stakeholders, on the other hand on the ability to implement co-ordinated R and D programmes run by TSO in order to develop the scientific knowledge necessary to perform independent technical assessments. Two major perspectives are identified for the future of the SITEX network: its ability to foster co-operation between regulatory bodies, TSO, implementers and civil society with a view to enhancing common understanding of key safety issues and challenges and to identifying possible harmonisation of practices; the constitution of a scientific task force (mainly driven by TSO) for research definition and implementation at the European level allowing to improve the co-ordination of scientific programmes between TSO and developing its own skills and analytical tools, independently of the WMO. A comprehensive list of safety issues relevant to the development and implementation of a geological repository has

Patient involvement in patient safety: Protocol for developing an intervention using patient reports of organisational safety and patient incident reporting

Directory of Open Access Journals (Sweden)

Armitage Gerry

2011-05-01

Full Text Available Abstract Background Patients have the potential to provide a rich source of information on both organisational aspects of safety and patient safety incidents. This project aims to develop two patient safety interventions to promote organisational learning about safety - a patient measure of organisational safety (PMOS, and a patient incident reporting tool (PIRT - to help the NHS prevent patient safety incidents by learning more about when and why they occur. Methods To develop the PMOS 1 literature will be reviewed to identify similar measures and key contributory factors to error; 2 four patient focus groups will ascertain practicality and feasibility; 3 25 patient interviews will elicit approximately 60 items across 10 domains; 4 10 patient and clinician interviews will test acceptability and understanding. Qualitative data will be analysed using thematic content analysis. To develop the PIRT 1 individual and then combined patient and clinician focus groups will provide guidance for the development of three potential reporting tools; 2 nine wards across three hospital directorates will pilot each of the tools for three months. The best performing tool will be identified from the frequency, volume and quality of reports. The validity of both measures will be tested. 300 patients will be asked to complete the PMOS and PIRT during their stay in hospital. A sub-sample (N = 50 will complete the PMOS again one week later. Health professionals in participating wards will also be asked to complete the AHRQ safety culture questionnaire. Case notes for all patients will be reviewed. The psychometric properties of the PMOS will be assessed and a final valid and reliable version developed. Concurrent validity for the PIRT will be assessed by comparing reported incidents with those identified from case note review and the existing staff reporting scheme. In a subsequent study these tools will be used to provide information to wards/units about their

Relationship between patient safety and accountability of nurses in Al-Zahra Gilangharb Hospital in 2015.

Science.gov (United States)

Esfandnia, F; Mohammadi, E; Mohammadi, M; Cheraghi, R; Esfandnia, N; Esfandnia, A

2015-01-01

Introduction. The purpose of this research was to investigate the connection between the patient safety and the accountability of nurses in Gilangharb Hospital in 2015. Methods. This research was a cross-sectional study conducted in Al-Gilangharb, in 2015. The data needed for research was taken from the library and an internet search and was gathered by using standard questionnaireThe professional and caring nurses' questionnaire was based on the extension evaluation office Nursing Care, Ministry of Health and Medical Education and demographic information and questions about 4 different roles of nurses were prepared and included. Moreover, patient safety was highlighted in a validation questionnaire, validated by experts judging group of teachers and academics, which was established. Cronbach's alpha test was used to assess the reliability. Finally, the reliability and professional standards of nursing care, patient safety questionnaire 093. 86/ 0 percent calculated the population of Gilangharb Hospital nurses (n = 70) and, in the strata selected, a statistical analysis using data from the questionnaires included in the SPSS statistical software, version 21, took place. Results. The patients' safety and accountability was observed at the level of 95 percent by using the Spearman correlation (SIG = .000). The correlation coefficient was (R=.768). Also, the dimensions of responsibility between the patient's safety (regarding the role of the nurse teacher, manager, researcher, and clinician) at 95 percent and the positive use of Spearman correlation was found (SIG = .000). Conclusions. Given the correlation among the patient protection and accountability, it can be said that the nurses in all roles (educator, researcher, administrator, and clinical specialist) have been successful, so, we suggested that given the experience, expertise and abilities, they have made an efficient use of their lifting power.

Recommendations for centres of expertise in rare anaemias. The ENERCA White Book

OpenAIRE

Joan-Lluis Vives Corrons; María del Mar Mañú Pereira; Carlos Romeo-Casabona; Pilar Nicolás; Béatrice Gulbis; Androulla Eleftheriou; Michael Angastiniotis; Patricia Aguilar Martínez; Paola Bianchi; Richard Van Wijk; Hermann Heimpel; Barbara De la Salle; Andrea Mosca

2014-01-01

The Community added value of Centres of Expertise (CoE) and European Reference Networks (ERN) is particularly high for rare diseases (RD) due to the rarity of these conditions, which implies both a small number of patients and scarcity of expertise within a single country. Gathering expertise at the European level is therefore, paramount in order to ensure equal access to accurate information, appropriate and timely diagnosis and high quality clinical care and follow up for patients with rare...

Effects of an educational patient safety campaign on patients' safety behaviours and adverse events.

Science.gov (United States)

Schwappach, David L B; Frank, Olga; Buschmann, Ute; Babst, Reto

2013-04-01

Rationale, aims and objectives  The study aims to investigate the effects of a patient safety advisory on patients' risk perceptions, perceived behavioural control, performance of safety behaviours and experience of adverse incidents. Method  Quasi-experimental intervention study with non-equivalent group comparison was used. Patients admitted to the surgical department of a Swiss large non-university hospital were included. Patients in the intervention group received a safety advisory at their first clinical encounter. Outcomes were assessed using a questionnaire at discharge. Odds ratios for control versus intervention group were calculated. Regression analysis was used to model the effects of the intervention and safety behaviours on the experience of safety incidents. Results  Two hundred eighteen patients in the control and 202 in the intervention group completed the survey (75 and 77% response rates, respectively). Patients in the intervention group were less likely to feel poorly informed about medical errors (OR = 0.55, P = 0.043). There were 73.1% in the intervention and 84.3% in the control group who underestimated the risk for infection (OR = 0.51, CI 0.31-0.84, P = 0.009). Perceived behavioural control was lower in the control group (meanCon  = 3.2, meanInt  = 3.5, P = 0.010). Performance of safety-related behaviours was unaffected by the intervention. Patients in the intervention group were less likely to experience any safety-related incident or unsafe situation (OR for intervention group = 0.57, CI 0.38-0.87, P = 0.009). There were no differences in concerns for errors during hospitalization. There were 96% of patients (intervention) who would recommend other patients to read the advisory. Conclusions  The results suggest that the safety advisory decreases experiences of adverse events and unsafe situations. It renders awareness and perceived behavioural control without increasing concerns for safety and

Priming patient safety: A middle-range theory of safety goal priming via safety culture communication.

Science.gov (United States)

Groves, Patricia S; Bunch, Jacinda L

2018-05-18

The aim of this paper is discussion of a new middle-range theory of patient safety goal priming via safety culture communication. Bedside nurses are key to safe care, but there is little theory about how organizations can influence nursing behavior through safety culture to improve patient safety outcomes. We theorize patient safety goal priming via safety culture communication may support organizations in this endeavor. According to this theory, hospital safety culture communication activates a previously held patient safety goal and increases the perceived value of actions nurses can take to achieve that goal. Nurses subsequently prioritize and are motivated to perform tasks and risk assessment related to achieving patient safety. These efforts continue until nurses mitigate or ameliorate identified risks and hazards during the patient care encounter. Critically, this process requires nurses to have a previously held safety goal associated with a repertoire of appropriate actions. This theory suggests undergraduate educators should foster an outcomes focus emphasizing the connections between nursing interventions and safety outcomes, hospitals should strategically structure patient safety primes into communicative activities, and organizations should support professional development including new skills and the latest evidence supporting nursing practice for patient safety. © 2018 John Wiley & Sons Ltd.

Developing patient safety in dentistry.

Science.gov (United States)

Pemberton, M N

2014-10-01

Patient safety has always been important and is a source of public concern. Recent high profile scandals and subsequent reports, such as the Francis report into the failings at Mid Staffordshire, have raised those concerns even higher. Mortality and significant morbidity associated with the practice of medicine has led to many strategies to help improve patient safety, however, with its lack of associated mortality and lower associated morbidity, dentistry has been slower at systematically considering how patient safety can be improved. Recently, several organisations, researchers and clinicians have discussed the need for a patient safety culture in dentistry. Strategies are available to help improve patient safety in healthcare and deserve further consideration in dentistry.

Patient safety climate and worker safety behaviours in acute hospitals in Scotland.

Science.gov (United States)

Agnew, Cakil; Flin, Rhona; Mearns, Kathryn

2013-06-01

To obtain a measure of hospital safety climate from a sample of National Health Service (NHS) acute hospitals in Scotland and to test whether these scores were associated with worker safety behaviors, and patient and worker injuries. Data were from 1,866 NHS clinical staff in six Scottish acute hospitals. A Scottish Hospital Safety Questionnaire measured hospital safety climate (Hospital Survey on Patient Safety Culture), worker safety behaviors, and worker and patient injuries. The associations between the hospital safety climate scores and the outcome measures (safety behaviors, worker and patient injury rates) were examined. Hospital safety climate scores were significantly correlated with clinical workers' safety behavior and patient and worker injury measures, although the effect sizes were smaller for the latter. Regression analyses revealed that perceptions of staffing levels and managerial commitment were significant predictors for all the safety outcome measures. Both patient-specific and more generic safety climate items were found to have significant impacts on safety outcome measures. This study demonstrated the influences of different aspects of hospital safety climate on both patient and worker safety outcomes. Moreover, it has been shown that in a hospital setting, a safety climate supporting safer patient care would also help to ensure worker safety. The Scottish Hospital Safety Questionnaire has proved to be a usable method of measuring both hospital safety climate as well as patient and worker safety outcomes. Copyright © 2013 National Safety Council and Elsevier Ltd. Published by Elsevier Ltd. All rights reserved.

Institutionalized Ignorance as a Precondition for Rational Risk Expertise

DEFF Research Database (Denmark)

Merkelsen, Henrik

2011-01-01

the lowest organizational level, where concrete risks occur, to the highest organizational level, where the body of professional risk expertise is situated. The article emphasizes the role of knowledge, responsibility, loyalty, and trust as risk-attenuation factors and concludes by suggesting......The present case study seeks to explain the conditions for experts’ rational risk perception by analyzing the institutional contexts that constitute a field of food safety expertise in Denmark. The study highlights the role of risk reporting and how contextual factors affect risk reporting from...... that the preconditions for the expert's rationality may rather be a lack of risk-specific knowledge due to poor risk reporting than a superior level of risk knowledge....

76 FR 9351 - Patient Safety Organizations: Voluntary Delisting From West Virginia Center for Patient Safety

Science.gov (United States)

2011-02-17

... Patient Safety, a component entity of West Virginia Hospital Association, West Virginia Medical Institute (WVMI), and West Virginia State Medical. Association (WVSMA), of its status as a Patient Safety... Patient Safety, a component entity of West Virginia Hospital Association, West Virginia Medical Institute...

77 FR 25179 - Patient Safety Organizations: Voluntary Relinquishment From Surgical Safety Institute

Science.gov (United States)

2012-04-27

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety... voluntary relinquishment from the Surgical Safety Institute of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorizes the...

National Patient Safety Foundation

Science.gov (United States)

... News Member Testimonials Lifetime Members Stand Up for Patient Safety Welcome Stand Up Members Stand Up e-News ... PLS Webcast Archives Stand Up Templates and Logos Patient Safety Coalition Coalition Overview Coalition Member Roster Members-Only ...

Safety for all: bringing together patient and employee safety.

Science.gov (United States)

Stevenson, R Lynn; Moss, Lesley; Newlands, Tracey; Archer, Jana

2013-01-01

The safety of patients and of employees in healthcare have historically been separately managed and regulated. Despite efforts to reduce injury rates for employees and adverse events for patients, healthcare organizations continue to see less-than-optimal outcomes in both domains. This article challenges readers to consider how the traditional siloed approach to patient and employee safety can lead to duplication of effort, confusion, missed opportunities and unintended consequences. The authors propose that only through integrating patient and employee safety activities and challenging the paradigms that juxtapose the two will healthcare organizations experience sustained and improved safety practice and outcomes. Copyright © 2013 Longwoods Publishing.

IMPROVING PATIENT SAFETY:

DEFF Research Database (Denmark)

Bagger, Bettan; Taylor Kelly, Hélène; Hørdam, Britta

Improving patient safety is both a national and international priority as millions of patients Worldwide suffer injury or death every year due to unsafe care. University College Zealand employs innovative pedagogical approaches in educational design. Regional challenges related to geographic......, social and cultural factors have resulted in a greater emphasis upon digital technology. Attempts to improve patient safety by optimizing students’ competencies in relation to the reporting of clinical errors, has resulted in the development of an interdisciplinary e-learning concept. The program makes...

Challenging patient safety culture: survey results

NARCIS (Netherlands)

Hellings, Johan; Schrooten, Ward; Klazinga, Niek; Vleugels, Arthur

2007-01-01

PURPOSE: The purpose of this paper is to measure patient safety culture in five Belgian general hospitals. Safety culture plays an important role in the approach towards greater patient safety in hospitals. DESIGN/METHODOLOGY/APPROACH: The Patient Safety Culture Hospital questionnaire was

IRSN's expertise about nuclear medicine hospital effluents

International Nuclear Information System (INIS)

2009-01-01

This brief note aims at presenting the radioactivity follow up of hospital effluents performed by the French Institute of Radiation Protection and Nuclear Safety (IRSN). This follow up concerns the radioactive compounds and radiopharmaceuticals used in nuclear medicine, and principally technetium 99 and iodine 131. The IRSN has developed a network of remote measurement systems for the monitoring of sewers and waste water cleaning facilities. Data are compiled in a data base for analysis and subsequent expertise. (J.S.)

Researchers' Roles in Patient Safety Improvement.

Science.gov (United States)

Pietikäinen, Elina; Reiman, Teemu; Heikkilä, Jouko; Macchi, Luigi

2016-03-01

In this article, we explore how researchers can contribute to patient safety improvement. We aim to expand the instrumental role researchers have often occupied in relation to patient safety improvement. We reflect on our own improvement model and experiences as patient safety researchers in an ongoing Finnish multi-actor innovation project through self-reflective narration. Our own patient safety improvement model can be described as systemic. Based on the purpose of the innovation project, our improvement model, and the improvement models of the other actors in the project, we have carried out a wide range of activities. Our activities can be summarized in 8 overlapping patient safety improvement roles: modeler, influencer, supplier, producer, ideator, reflector, facilitator, and negotiator. When working side by side with "practice," researchers are offered and engage in several different activities. The way researchers contribute to patient safety improvement and balance between different roles depends on the purpose of the study, as well as on the underlying patient safety improvement models. Different patient safety research paradigms seem to emphasize different improvement roles, and thus, they also face different challenges. Open reflection on the underlying improvement models and roles can help researchers with different backgrounds-as well as other actors involved in patient safety improvement-in structuring their work and collaborating productively.

Predicting complex acute wound healing in patients from a wound expertise centre registry: a prognostic study

OpenAIRE

Ubbink, Dirk T; Lindeboom, Robert; Eskes, Anne M; Brull, Huub; Legemate, Dink A; Vermeulen, Hester

2015-01-01

It is important for caregivers and patients to know which wounds are at risk of prolonged wound healing to enable timely communication and treatment. Available prognostic models predict wound healing in chronic ulcers, but not in acute wounds, that is, originating after trauma or surgery. We developed a model to detect which factors can predict (prolonged) healing of complex acute wounds in patients treated in a large wound expertise centre (WEC). Using Cox and linear regression analyses, we ...

E-expertise modern collective intelligence

CERN Document Server

Gubanov, Dmitry; Novikov, Dmitry; Raikov, Alexander

2014-01-01

  This book focuses on organization and mechanisms of expert decision-making support using modern information and communication technologies, as well as information analysis and collective intelligence technologies (electronic expertise or simply e-expertise). Chapter 1 (E-Expertise) discusses the role of e-expertise in decision-making processes. The procedures of e-expertise are classified, their benefits and shortcomings are identified, and the efficiency conditions are considered. Chapter 2 (Expert Technologies and Principles) provides a comprehensive overview of modern expert technologies. A special emphasis is placed on the specifics of e-expertise. Moreover, the authors study the feasibility and reasonability of employing well-known methods and approaches in e-expertise. Chapter 3 (E-Expertise: Organization and Technologies) describes some examples of up-to-date technologies to perform e-expertise. Chapter 4 (Trust Networks and Competence Networks) deals with the problems of expert finding and grouping...

Innovative Patient Safety Curriculum Using iPAD Game (PASSED) Improved Patient Safety Concepts in Undergraduate Medical Students.

Science.gov (United States)

Kow, A W C; Ang, B L S; Chong, C S; Tan, W B; Menon, K R

2016-11-01

While healthcare outcomes have improved significantly, the complex management of diseases in the hospitals has also escalated the risks in patient safety. Therefore, in the process of training medical students to be proficient in medical knowledge and skills, the importance of patient safety cannot be neglected. A new innovation using mobile apps gaming system (PAtient Safety in Surgical EDucation-PASSED) to teach medical students on patient safety was created. Students were taught concepts of patient safety followed by a gaming session using iPad games created by us. This study aims to evaluate the outcome of patient safety perception using the PASSED games created. An interactive iPad game focusing on patient safety issues was created by the undergraduate education team in the Department of Surgery, Yong Loo Lin School of Medicine at the National University of Singapore. The game employed the unique touched-screen feature with clinical scenarios extracted from the hospital sentinel events. Some of the questions were time sensitive, with extra bonus marks awarded if the student provided the correct answer within 10 s. Students could reattempt the questions if the initial answer was wrong. However, this entailed demerit points. Third-year medical students posted to the Department of Surgery experienced this gaming system in a cohort of 55-60 students. Baseline understanding of the students on patient safety was evaluated using Attitudes to Patient Safety Questionnaire III (APSQ-III) prior to the game. A 20 min talk on concept of patient safety using the WHO Patient Safety Guidelines was conducted. Following this, students downloaded the apps from ITune store and played with the game for 20-30 min. The session ended with the students completing the postintervention questionnaire. A total of 221 3rd year medical students responded to the survey during the PASSED session. Majority of the students felt that the PASSED game had trained them to understand the

Measuring patient safety culture in Taiwan using the Hospital Survey on Patient Safety Culture (HSOPSC).

Science.gov (United States)

Chen, I-Chi; Li, Hung-Hui

2010-06-07

Patient safety is a critical component to the quality of health care. As health care organizations endeavour to improve their quality of care, there is a growing recognition of the importance of establishing a culture of patient safety. In this research, the authors use the Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire to assess the culture of patient safety in Taiwan and attempt to provide an explanation for some of the phenomena that are unique in Taiwan. The authors used HSOPSC to measure the 12 dimensions of the patient safety culture from 42 hospitals in Taiwan. The survey received 788 respondents including physicians, nurses, and non-clinical staff. This study used SPSS 15.0 for Windows and Amos 7 software tools to perform the statistical analysis on the survey data, including descriptive statistics and confirmatory factor analysis of the structural equation model. The overall average positive response rate for the 12 patient safety culture dimensions of the HSOPSC survey was 64%, slightly higher than the average positive response rate for the AHRQ data (61%). The results showed that hospital staff in Taiwan feel positively toward patient safety culture in their organization. The dimension that received the highest positive response rate was "Teamwork within units", similar to the results reported in the US. The dimension with the lowest percentage of positive responses was "Staffing". Statistical analysis showed discrepancies between Taiwan and the US in three dimensions, including "Feedback and communication about error", "Communication openness", and "Frequency of event reporting". The HSOPSC measurement provides evidence for assessing patient safety culture in Taiwan. The results show that in general, hospital staffs in Taiwan feel positively toward patient safety culture within their organization. The existence of discrepancies between the US data and the Taiwanese data suggest that cultural uniqueness should be taken into

PATIENT SAFETY IN SURGERY: THE QUALITY OF IMPLEMENTATION OF PATIENT SAFETY CHECKLISTS IN A REGIONAL HOSPITAL

Directory of Open Access Journals (Sweden)

V. Karyadinata

2012-09-01

Full Text Available Introduction. Patient safety and the avoidance of inhospital adverse events is a key focus of clinical practice and medical audit. A large of proportion of medical errors affect surgical patients in the peri-operative setting. Safety checklists have been adopted by the medical profession from the aviation industry as a cheap and reliable method of avoiding errors which arise from complex or stressful situations. Current evidence suggests that the use of periooperative checklists has led to a decrease in surgical morbidity and hospital costs. Aim. To assess the quality of implementation of a modified patient safety checklist in a UK district general hospital. Methods. An observational tool was designed to assess in real time the peri-operative performance of the surgical safety checklist in patients undergoing general surgical, urological or orthopaedic procedures. Initiation of the checklist, duration of performance and staff participation were audited in real time. Results. 338 cases were monitored. Nurses were most active in initiating the safety checklist. The checklist was performed successfully in less than a minute in most cases. 11-24% of staff (according to professional group present in the operating room did not participate in the checklist. Critical safety checks (patient identity and procedure name were performed in all cases across all specialties. Variations were noted in checking other categories, such as deep vein thrombosis (DVT prophylaxis or patient warming. Conclusions. There is still a potential for improving the practice and culture of surgical patient safety activities. Staff training and designation of patient safety leadership roles is needed in increasing compliance and implementation of patient safety mechanism, such as peri-operative checklists. There is significant data to advocate the need to implement patient safety surgical checklists internationally

Driven by Expertise and Insulation? The Autonomy of European Regulatory Agencies

Directory of Open Access Journals (Sweden)

Christoph Ossege

2015-03-01

Full Text Available Expertise and autonomy are cornerstones to the effective operation and legitimacy of European Regulatory Agencies (ERAs. Yet, we know little about ERAs’ actual autonomy, nor about factors shaping it. This article studies ERAs’ actual autonomy from public and private actors, emphasising two crucial explanatory factors: expertise and rulemaking competences. The lack of insights on expertise is particularly striking, as expertise—the “raison d’être” and main resource of expert bodies—provides ERAs with a potentially powerful means to increase autonomy. Relying on a rational institutionalist framework within which ERAs enjoy substantive discretion to pursue their goals, the study empirically compares three powerful ERAs—the European Medicines Agency, the European Chemicals Agency, and the European Food Safety Authority. Based on the analysis of 39 semi-structured expert interviews, findings show that expertise is a crucial explanation for ERAs’ substantive autonomy from the Commission. Towards research intensive private stakeholders, the role of expertise becomes less pronounced. Instead, ERAs are more successful in protecting their autonomy by engaging in the risk-averse interpretation of the regulatory framework and by adapting rules over time to adapt their needs: they engage in “procedural insulation”. Political salience provides a scope condition for ERAs to use expert knowledge and rulemaking competences more strategically—potentially undermining scientific quality.

Laboratory safety and the WHO World Alliance for Patient Safety.

Science.gov (United States)

McCay, Layla; Lemer, Claire; Wu, Albert W

2009-06-01

Laboratory medicine has been a pioneer in the field of patient safety; indeed, the College of American Pathology first called attention to the issue in 1946. Delivering reliable laboratory results has long been considered a priority, as the data produced in laboratory medicine have the potential to critically influence individual patients' diagnosis and management. Until recently, most attention on laboratory safety has focused on the analytic stage of laboratory medicine. Addressing this stage has led to significant and impressive improvements in the areas over which laboratories have direct control. However, recent data demonstrate that pre- and post-analytical phases are at least as vulnerable to errors; to further improve patient safety in laboratory medicine, attention must now be focused on the pre- and post-analytic phases, and the concept of patient safety as a multi-disciplinary, multi-stage and multi-system concept better understood. The World Alliance for Patient Safety (WAPS) supports improvement of patient safety globally and provides a potential framework for considering the total testing process.

Patient participation in patient safety and nursing input - a systematic review.

Science.gov (United States)

Vaismoradi, Mojtaba; Jordan, Sue; Kangasniemi, Mari

2015-03-01

This systematic review aims to synthesise the existing research on how patients participate in patient safety initiatives. Ambiguities remain about how patients participate in routine measures designed to promote patient safety. Systematic review using integrative methods. Electronic databases were searched using keywords describing patient involvement, nursing input and patient safety initiatives to retrieve empirical research published between 2007 and 2013. Findings were synthesized using the theoretical domains of Vincent's framework for analysing risk and safety in clinical practice: "patient", "healthcare provider", "task", "work environment", "organisation & management". We identified 17 empirical research papers: four qualitative, one mixed-method and 12 quantitative designs. All 17 papers indicated that patients can participate in safety initiatives. Improving patient participation in patient safety necessitates considering the patient as a person, the nurse as healthcare provider, the task of participation and the clinical environment. Patients' knowledge, health conditions, beliefs and experiences influence their decisions to engage in patient safety initiatives. An important component of the management of long-term conditions is to ensure that patients have sufficient knowledge to participate. Healthcare providers may need further professional development in patient education and patient care management to promote patient involvement in patient safety, and ensure that patients understand that they are 'allowed' to inform nurses of adverse events or errors. A healthcare system characterised by patient-centredness and mutual acknowledgement will support patient participation in safety practices. Further research is required to improve international knowledge of patient participation in patient safety in different disciplines, contexts and cultures. Patients have a significant role to play in enhancing their own safety while receiving hospital care. This

Patient Safety and Healthcare Quality

Directory of Open Access Journals (Sweden)

Aikaterini Toska

2012-01-01

Full Text Available Introduction: Due to a variety of circumstances and world-wide research findings, patient safety andquality care during hospitalization have emerged as major issues. Patient safety deficits may burdenhealth systems as well as allocated resources. The international community has examined severalproposals covering general and systemic aspects in order to improve patient safety; several long-termprograms and strategies have also been implemented promoting the participation of health-relatedagents, and also government agencies and non-governmental organizations.Aim: Those factors that have negative correlations with patient safety and quality healthcare weredetermined; WHO and EU programs as well as the Greek health policy were also reviewed.Method: Local and international literature was reviewed, including EU and WHO official publications,by using the appropriate keywords.Conclusions: International cooperation on patient safety is necessary in order to improvehospitalization and healthcare quality standards. Such incentives depend heavily on establishing worldwideviable and effective health programs and planning. These improvements also require further stepson safe work procedures, environment safety, hazard management, infection control, safe use ofequipment and medication, and sufficient healthcare staff.

Exploring relationships between hospital patient safety culture and Consumer Reports safety scores.

Science.gov (United States)

Smith, Scott Alan; Yount, Naomi; Sorra, Joann

2017-02-16

A number of private and public companies calculate and publish proprietary hospital patient safety scores based on publicly available quality measures initially reported by the U.S. federal government. This study examines whether patient safety culture perceptions of U.S. hospital staff in a large national survey are related to publicly reported patient safety ratings of hospitals. The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture (Hospital SOPS) assesses provider and staff perceptions of hospital patient safety culture. Consumer Reports (CR), a U.S. based non-profit organization, calculates and shares with its subscribers a Hospital Safety Score calculated annually from patient experience survey data and outcomes data gathered from federal databases. Linking data collected during similar time periods, we analyzed relationships between staff perceptions of patient safety culture composites and the CR Hospital Safety Score and its five components using multiple multivariate linear regressions. We analyzed data from 164 hospitals, with patient safety culture survey responses from 140,316 providers and staff, with an average of 856 completed surveys per hospital and an average response rate per hospital of 56%. Higher overall Hospital SOPS composite average scores were significantly associated with higher overall CR Hospital Safety Scores (β = 0.24, p Consumer Reports Hospital Safety Score, which is a composite of patient experience and outcomes data from federal databases. As hospital managers allocate resources to improve patient safety culture within their organizations, their efforts may also indirectly improve consumer-focused, publicly reported hospital rating scores like the Consumer Reports Hospital Safety Score.

Patient Safety and Healthcare Quality

OpenAIRE

Aikaterini Toska; Panagiotis Kyloudis; Maria Rekleiti; Maria Saridi

2012-01-01

Introduction: Due to a variety of circumstances and world-wide research findings, patient safety andquality care during hospitalization have emerged as major issues. Patient safety deficits may burdenhealth systems as well as allocated resources. The international community has examined severalproposals covering general and systemic aspects in order to improve patient safety; several long-termprograms and strategies have also been implemented promoting the participation of health-relatedagent...

Acute care patients discuss the patient role in patient safety.

Science.gov (United States)

Rathert, Cheryl; Huddleston, Nicole; Pak, Youngju

2011-01-01

Patient safety has been a highly researched topic in health care since the year 2000. One strategy for improving patient safety has been to encourage patients to take an active role in their safety during their health care experiences. However, little research has shed light on how patients view their roles. This study attempted to address this deficit by inductively exploring the results of a qualitative study in which patients reported their ideas about what they believe their roles should be. Patients with an overnight stay in the previous 90 days at one of three hospitals were surveyed using a mailing methodology. Of 1,040 respondents, 491 provided an open-ended response regarding what they believe the patient role should be. Qualitative analysis found several prominent themes. The largest proportion of responses (23%) suggested that patients should follow instructions given by care providers. Other prominent themes were that patients should ask questions and become informed about their conditions and treatments, and many implied that they should expect competent care. Our results suggest that patients believe they should be able to trust that they are being provided competent care, as opposed to assuming a leadership role in their safety. Our results suggest that engaging patients in safety efforts may be complex, requiring a variety of strategies. Managers must provide environments conducive to staff and patient interactions to support patients in this effort. Different types of patients may require different engagement strategies.

Patient safety is not elective: a debate at the NPSF Patient Safety Congress.

Science.gov (United States)

McTiernan, Patricia; Wachter, Robert M; Meyer, Gregg S; Gandhi, Tejal K

2015-02-01

The opening keynote session of the 16th Annual National Patient Safety Foundation Patient Safety Congress, held 14-16 May 2014, featured a debate addressing the merits and challenges of accountability with respect to key issues in patient safety. The specific resolution debated was: Certain safety practices should be inviolable, and transgressions should result in penalties, potentially including fines, suspensions, and firing. The themes discussed in the debate are issues that healthcare professionals and leaders commonly struggle with in their day-to-day work. How do we draw a line between systems problems and personal failings? When should clinicians and staff be penalised for failing to follow a known safety protocol? The majority of those who listened to the live debate agreed that it is time to begin holding health professionals accountable when they wilfully or repeatedly violate policies or protocols put in place by their institutions to protect the safety of patients. This article summarises the debate as well as the questions and discussion generated by each side. A video of the original debate can be found at http://bit.ly/Npsf_debate. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Patients' and healthcare workers' perceptions of a patient safety advisory.

Science.gov (United States)

Schwappach, David L B; Frank, Olga; Koppenberg, Joachim; Müller, Beat; Wasserfallen, Jean-Blaise

2011-12-01

To assess patients' and healthcare workers' (hcw) attitudes and experiences with a patient safety advisory, to investigate predictors for patients' safety-related behaviors and determinants for staff support for the advisory. Cross-sectional surveys of patients (n= 1053) and hcw (n= 275). Three Swiss hospitals. Patients who received the safety advisory and hcw caring for these patients. Patient safety advisory disseminated to patients at the study hospitals. Attitudes towards and experiences with the advisory. Hcw support for the intervention and patients' intentions to apply the recommendations were modelled using regression analyses. Patients (95%) and hcw (78%) agreed that hospitals should educate patients how to prevent errors. Hcw and patients' evaluations of the safety advisory were positive and followed a similar pattern. Patients' intentions to engage in safety were significantly predicted by behavioral control, subjective norms, attitudes, safety behaviors during hospitalization and experiences with taking action. Hcw support for the campaign was predicted by rating of the advisory (Odds ratio (OR) 3.4, confidence interval (CI) 1.8-6.1, Ppatients (OR 1.9, CI 1.1-3.3, P= 0.034) and experience of unpleasant situations (OR 0.6, CI 0.4-1.0, P= 0.035). The safety advisory was well accepted by patients and hcw. To be successful, the advisory should be accompanied by measures that target norms and barriers in patients, and support staff in dealing with difficult situations.

A sanctuary of safety: A study of how patients with dual diagnosis experience caring conversations.

Science.gov (United States)

Priebe, Åsa; Wiklund Gustin, Lena; Fredriksson, Lennart

2018-04-01

The prevalence of dual diagnosis, that is, the combination of psychiatric illnesses and substance use disorders, is high. As a vast majority of previous research in this context focusses on the effects of different treatment methods, rather than interpersonal issues, the purpose of the present study was to explore and illuminate in what way patients with a dual diagnosis experience conversations with nurses in an outpatient clinic to be caring. Five patients were interviewed regarding their experiences of caring conversations. The analysis and interpretation were inspired by a previously-used hermeneutical process. These yielded three themes: (i) reciprocity creates safety and communion; (ii) suffering is made visible and understandable; and (iii) self-esteem is restored. When synthesized, these themes gave rise to a main theme - a sanctuary of safety - where suffering is alleviated and dignity and self-esteem are restored. It is concluded that the caring conversation contributes to experiences of safeness. In this specific context, safety appears to be more fundamental than trust for patients' recoveries. The caring conversation also contributes to recovery, as it supports the individual's learning and understanding as a way to cope with problems, which also enables patients to make informed decisions about their own care. The caring conversation contributes to the alleviation of suffering and restoration of dignity and self-esteem for patients with a dual diagnosis. However, there is a need for further research focussing on how the caring conversation can contribute to psychiatric nurses' caring expertise. © 2017 Australian College of Mental Health Nurses Inc.

Powering Ideas through Expertise

DEFF Research Database (Denmark)

Seabrooke, Leonard; Wigan, Duncan

2016-01-01

This contribution discusses how ideas are powered through expertise and moral authority. Professionals compete with each other to power ideas by linking claims to expertise, how things best work, to moral claims about how things should be. To show how, we draw on a case of battles over global tax...... reporting multinational corporations should provide to ensure they pay their fair share of tax. Ideas powered by expertise contain shared causal beliefs, as well as principled beliefs about value systems. We demonstrate that professionals can contest the established order when demonstrations of expertise...

A multilevel model of patient safety culture: cross-level relationship between organizational culture and patient safety behavior in Taiwan's hospitals.

Science.gov (United States)

Chen, I-Chi; Ng, Hui-Fuang; Li, Hung-Hui

2012-01-01

As health-care organizations endeavor to improve their quality of care, there is a growing recognition of the importance of establishing a culture of patient safety. The main objective of this study was to investigate the cross-level influences of organizational culture on patient safety behavior in Taiwan's hospitals. The authors measured organizational culture (bureaucratic, supportive and innovative culture), patient safety culture and behavior from 788 hospital workers among 42 hospitals in Taiwan. Multilevel analysis was applied to explore the relationship between organizational culture (group level) and patient safety behavior (individual level). Patient safety culture had positive impact on patient safety behavior in Taiwan's hospitals. The results also indicated that bureaucratic, innovative and supportive organizational cultures all had direct influence on patient safety behavior. However, only supportive culture demonstrated significant moderation effect on the relationship between patient safety culture and patient safety behavior. Furthermore, organizational culture strength was shown correlated negatively with patient safety culture variability. Overall, organizational culture plays an important role in patient safety activities. Safety behaviors of hospital staff are partly influenced by the prevailing cultural norms in their organizations and work groups. For management implications, constructed patient priority from management commitment to leadership is necessary. For academic implications, research on patient safety should consider leadership, group dynamics and organizational learning. These factors are important for understanding the barriers and the possibilities embedded in patient safety. Copyright © 2011 John Wiley & Sons, Ltd.

Educating future leaders in patient safety

Science.gov (United States)

Leotsakos, Agnès; Ardolino, Antonella; Cheung, Ronny; Zheng, Hao; Barraclough, Bruce; Walton, Merrilyn

2014-01-01

Education of health care professionals has given little attention to patient safety, resulting in limited understanding of the nature of risk in health care and the importance of strengthening systems. The World Health Organization developed the Patient Safety Curriculum Guide: Multiprofessional Edition to accelerate the incorporation of patient safety teaching into higher educational curricula. The World Health Organization Curriculum Guide uses a health system-focused, team-dependent approach, which impacts all health care professionals and students learning in an integrated way about how to operate within a culture of safety. The guide is pertinent in the context of global educational reforms and growing recognition of the need to introduce patient safety into health care professionals’ curricula. The guide helps to advance patient safety education worldwide in five ways. First, it addresses the variety of opportunities and contexts in which health care educators teach, and provides practical recommendations to learning. Second, it recommends shared learning by students of different professions, thus enhancing student capacity to work together effectively in multidisciplinary teams. Third, it provides guidance on a range of teaching methods and pedagogical activities to ensure that students understand that patient safety is a practical science teaching them to act in evidence-based ways to reduce patient risk. Fourth, it encourages supportive teaching and learning, emphasizing the need to establishing teaching environments in which students feel comfortable to learn and practice patient safety. Finally, it helps educators incorporate patient safety topics across all areas of clinical practice. PMID:25285012

Organizational change and human expertise in nuclear power plants

International Nuclear Information System (INIS)

Masson, M.; Malaisc, N.

1992-01-01

Reliability and safety are two very important goals, which depend on technical and organizational factors, but also on human expertise. How to ensure a safe functioning of a nuclear power plant in a changing context, and what might be the role and aspects of training and transfer of knowledge? These are the questions we shall deal with in this paper, on the basis of two field studies. The two field studies stress the needs for setting up case based training, which best ensure the acquisition of know-how. Furthermore, as shown by the second one, gaining expertise involves developing large repertoires of highly skilled, semi-routinized activities. Supporting expert operators not only should tackle problem solving activities but should thus also include the prevention of routine errors, which go along with skill acquisition. (author)

Patient safety culture in primary care

NARCIS (Netherlands)

Verbakel, N.J.

2015-01-01

Background A constructive patient safety culture is a main prerequisite for patient safety and improvement initiatives. Until now, patient safety culture (PSC) research was mainly focused on hospital care, however, it is of equal importance in primary care. Measuring PSC informs practices on their

Patient Involvement in Patient Safety: A Qualitative Study of Nursing Staff and Patient Perceptions.

Science.gov (United States)

Bishop, Andrea C; Macdonald, Marilyn

2017-06-01

The risk associated with receiving health care has called for an increased focus on the role of patients in helping to improve safety. Recent research has highlighted that patient involvement in patient safety practices may be influenced by patient perceptions of patient safety practices and the perceptions of their health care providers. The objective of this research was to describe patient involvement in patient safety practices by exploring patient and nursing staff perceptions of safety. Qualitative focus groups were conducted with a convenience sample of nursing staff and patients who had previously completed a patient safety survey in 2 tertiary hospital sites in Eastern Canada. Six focus groups (June 2011 to January 2012) were conducted and analyzed using inductive thematic analysis. Four themes were identified: (1) wanting control, (2) feeling connected, (3) encountering roadblocks, and (4) sharing responsibility for safety. Both patient and nursing staff participants highlighted the importance of building a personal connection as a precursor to ensuring that patients are involved in their care and safety. However, perceptions of provider stress and nursing staff workload often reduced the ability of the nursing staff and patient participants to connect with one another and promote involvement. Current strategies aimed at increasing patient awareness of patient safety may not be enough. The findings suggest that providing the context for interaction to occur between nursing staff and patients as well as targeted interventions aimed at increasing patient control may be needed to ensure patient involvement in patient safety.

Involving patients in patient safety programmes: A scoping review and consensus procedure by the LINNEAUS collaboration on patient safety in primary care.

Science.gov (United States)

Trier, Hans; Valderas, Jose M; Wensing, Michel; Martin, Helle Max; Egebart, Jonas

2015-09-01

Patient involvement has only recently received attention as a potentially useful approach to patient safety in primary care. To summarize work conducted on a scoping review of interventions focussing on patient involvement for patient safety; to develop consensus-based recommendations in this area. Scoping review of the literature 2006-2011 about methods and effects of involving patients in patient safety in primary care identified evidence for previous experiences of patient involvement in patient safety. This information was fed back to an expert panel for the development of recommendations for healthcare professionals and policy makers. The scoping review identified only weak evidence in support of the effectiveness of patient involvement. Identified barriers included a number of patient factors but also the healthcare workers' attitudes, abilities and lack of training. The expert panel recommended the integration of patient safety in the educational curricula for healthcare professionals, and expected a commitment from professionals to act as first movers by inviting and encouraging the patients to take an active role. The panel proposed a checklist to be used by primary care clinicians at the point of care for promoting patient involvement. There is only weak evidence on the effectiveness of patient involvement in patient safety. The recommendations of the panel can inform future policy and practice on patient involvement in safety in primary care.

Role of effective nurse-patient relationships in enhancing patient safety.

Science.gov (United States)

Conroy, Tiffany; Feo, Rebecca; Boucaut, Rose; Alderman, Jan; Kitson, Alison

2017-08-02

Ensuring and maintaining patient safety is an essential aspect of care provision. Safety is a multidimensional concept, which incorporates interrelated elements such as physical and psychosocial safety. An effective nurse-patient relationship should ensure that these elements are considered when planning and providing care. This article discusses the importance of an effective nurse-patient relationship, as well as healthcare environments and working practices that promote safety, thus ensuring optimal patient care.

Studying Real-World Perceptual Expertise

Directory of Open Access Journals (Sweden)

Jianhong eShen

2014-08-01

Full Text Available Significant insights into visual cognition have come from studying real-world perceptual expertise. Many have previously reviewed empirical findings and theoretical developments from this work. Here we instead provide a brief perspective on approaches, considerations, and challenges to studying real-world perceptual expertise. We discuss factors like choosing to use real-world versus artificial object domains of expertise, selecting a target domain of real-world perceptual expertise, recruiting experts, evaluating their level of expertise, and experimentally testing experts in the lab and online. Throughout our perspective, we highlight expert birding (also called birdwatching as an example, as it has been used as a target domain for over two decades in the perceptual expertise literature.

Accurate diagnosis of CHD by Paediatricians with Expertise in Cardiology.

Science.gov (United States)

Jacob, Hannah C; Massey, Hannah; Yates, Robert W M; Kelsall, A Wilfred

2017-08-01

Introduction Paediatricians with Expertise in Cardiology assess children with a full history, examination, and often perform an echocardiogram. A minority are then referred to an outreach clinic run jointly with a visiting paediatric cardiologist. The accuracy of the echocardiography diagnosis made by the Paediatrician with Expertise in Cardiology is unknown. Materials and methods We conducted a retrospective review of clinic letters for children seen in the outreach clinic for the first time between March, 2004 and March, 2011. Children with CHD diagnosed antenatally or elsewhere were excluded. We recorded the echocardiography diagnosis made by the paediatric cardiologist and previously by the Paediatrician with Expertise in Cardiology. The Paediatrician with Expertise in Cardiology referred 317/3145 (10%) children seen in the local cardiac clinics to the outreach clinic over this period, and among them 296 were eligible for inclusion. Their median age was 1.5 years (range 1 month-15.1 years). For 244 (82%) children, there was complete diagnostic agreement between the Paediatrician with Expertise in Cardiology and the paediatric cardiologist. For 29 (10%) children, the main diagnosis was identical with additional findings made by the paediatric cardiologist. The abnormality had resolved in 17 (6%) cases by the time of clinic attendance. In six (2%) patients, the paediatric cardiologist made a different diagnosis. In total, 138 (47%) patients underwent a surgical or catheter intervention. Discussion Paediatricians with Expertise in Cardiology can make accurate diagnoses of CHD in children referred to their clinics. This can allow effective triage of children attending the outreach clinic, making best use of limited specialist resources.

Assessment of Contributions to Patient Safety Knowledge by the Agency for Healthcare Research and Quality-Funded Patient Safety Projects

Science.gov (United States)

Sorbero, Melony E S; Ricci, Karen A; Lovejoy, Susan; Haviland, Amelia M; Smith, Linda; Bradley, Lily A; Hiatt, Liisa; Farley, Donna O

2009-01-01

Objective To characterize the activities of projects funded in Agency for Healthcare Research and Quality (AHRQ)' patient safety portfolio and assess their aggregate potential to contribute to knowledge development. Data Sources Information abstracted from proposals for projects funded in AHRQ' patient safety portfolio, information on safety practices from the AHRQ Evidence Report on Patient Safety Practices, and products produced by the projects. Study Design This represented one part of the process evaluation conducted as part of a longitudinal evaluation based on the Context–Input–Process–Product model. Principal Findings The 234 projects funded through AHRQ' patient safety portfolio examined a wide variety of patient safety issues and extended their work beyond the hospital setting to less studied parts of the health care system. Many of the projects implemented and tested practices for which the patient safety evidence report identified a need for additional evidence. The funded projects also generated a substantial body of new patient safety knowledge through a growing number of journal articles and other products. Conclusions The projects funded in AHRQ' patient safety portfolio have the potential to make substantial contributions to the knowledge base on patient safety. The full value of this new knowledge remains to be confirmed through the synthesis of results. PMID:21456108

Selection of indicators for continuous monitoring of patient safety: recommendations of the project 'safety improvement for patients in Europe'

DEFF Research Database (Denmark)

Kristensen, Solvejg; Mainz, Jan; Bartels, Paul

2009-01-01

such as culture, infections, surgical complications, medication errors, obstetrics, falls and specific diagnostic areas. CONCLUSION: The patient safety indicators recommended present a set of possible measures of patient safety. One of the future perspectives of implementing patient safety indicators...... for systematic monitoring is that it will be possible to continuously estimate the prevalence and incidence of patient safety quality problems. The lesson learnt from quality improvement is that it will pay off in terms of improving patient safety....

Patients for patient safety in China: a cross sectional study.

Science.gov (United States)

Zhang, Qiongwen; Li, Yulin; Li, Jing; Mao, Xuanyue; Zhang, Lijuan; Ying, Qinghua; Wei, Xin; Shang, Lili; Zhang, Mingming

2012-02-01

To investigate the baseline status of patients' awareness, knowledge, and attitudes to patient safety in China, and to determine the factors that influence patients' involvement in patient safety. We conducted a cross sectional survey using questionnaires adapted from recent studies on patient safety from outside China. The items included medical errors, infection, medication safety, and other aspects of patient safety. The questionnaire included 17 items and 5 domains. The survey was conducted between Jan. 2009 and Dec. 2010 involving 1000 patients from ten grade-A hospitals in seven provinces or cities in China. Most patients from the surgery departments completed the questionnaires voluntarily and anonymously. Five reviewers independently input the data into Microsoft Excel 2003, and the data were double-checked. Data were analyzed using SPSS 15.0 software for differences in the perceptions and attitudes of patients toward patient safety among different genders, ages, and regions. We distributed 1000 questionnaires and collected 959 completed questionnaires (response rate: 96%). Among the respondents, 58% of patients did not know what medical error is. Sixty-five percent of patients wanted disclosure of all medical errors. After errors occurred, 58% of patients wanted explanations of all possible harms that had resulted. Among 187 patients who had experienced medical errors, 83% of patients had sought appropriate legal action. About 52% of patients understood hospital infection, but 28% patients did not know that infections could occur in hospital. Seventy-eight percent of patients thought that medical staff should wash their hands before examining patients. More than half of the patients (68%) were willing to remind the staff of hygiene if they saw unsanitary conditions in a health clinic. Only 14% of patients knew the side effects of medications that they took. The majority of patients surveyed expressed willingness to contribute to patient safety, but their

CENS as a network for knowledge dissemination and for expertise on energy, nuclear safety and security

International Nuclear Information System (INIS)

Chakraborty, S.; Stoian, A.

2005-01-01

This is a time when the whole of Europe faces energy and environmental transitions. CEE countries face in addition the challenge of implementing medium- to long-term energy reforms in order to comply with EU legislation and practices. Crucial to the proper managing of these common and fundamental concerns is the cooperation between developed and transforming countries. At a lower level this implies that problems specific to CEE countries, such as fragmentation and lack of performing resources, can be overcome through collaboration and knowledge transfer within a network of concerned and competent entities. As an organization aiming to support environmental protection by enhancing the safety and security of nuclear facilities in CEE countries, CENS is focused on being an independent forum and platform organization for the dissemination of scientific and technical knowledge and of expertise in the nuclear and energy-related communities. In seeking to achieve this objective, CENS has over the past two years provided a system of networking and international membership for nuclear regulators in CEE countries and for technical support organizations from around Europe. (orig.)

Expertise on the project for the decommissioning of the pilot incineration plant at the Paul Scherrer Institute

International Nuclear Information System (INIS)

2012-12-01

This expertise report published by the Swiss Federal Nuclear Safety Inspectorate ENSI takes a look at the proposed decommissioning of the pilot incineration plant at the Paul Scherrer Institute PSI in Switzerland. Details concerning the operator PSI, the installation, the documentation and criteria used in the expertise are presented. Experience in the decommissioning of nuclear installations is reviewed. Decommissioning variants and the concept proposed are described and details concerning radiation sources and problematical materials such as asbestos are reviewed. The views of the Swiss Federal Nuclear Safety Inspectorate ENSI are presented and proposals for the disposal of radioactive wastes are examined. Finally, the costs incurred are reviewed

Early Engagement of Safety and Mission Assurance Expertise Using Systems Engineering Tools: A Risk-Based Approach to Early Identification of Safety and Assurance Requirements

Science.gov (United States)

Darpel, Scott; Beckman, Sean

2016-01-01

Decades of systems engineering practice have demonstrated that the earlier the identification of requirements occurs, the lower the chance that costly redesigns will needed later in the project life cycle. A better understanding of all requirements can also improve the likelihood of a design's success. Significant effort has been put into developing tools and practices that facilitate requirements determination, including those that are part of the model-based systems engineering (MBSE) paradigm. These efforts have yielded improvements in requirements definition, but have thus far focused on a design's performance needs. The identification of safety & mission assurance (S&MA) related requirements, in comparison, can occur after preliminary designs are already established, yielding forced redesigns. Engaging S&MA expertise at an earlier stage, facilitated by the use of MBSE tools, and focused on actual project risk, can yield the same type of design life cycle improvements that have been realized in technical and performance requirements.

Patient safety culture in Norwegian nursing homes.

Science.gov (United States)

Bondevik, Gunnar Tschudi; Hofoss, Dag; Husebø, Bettina Sandgathe; Deilkås, Ellen Catharina Tveter

2017-06-20

Patient safety culture concerns leader and staff interaction, attitudes, routines, awareness and practices that impinge on the risk of patient-adverse events. Due to their complex multiple diseases, nursing home patients are at particularly high risk of adverse events. Studies have found an association between patient safety culture and the risk of adverse events. This study aimed to investigate safety attitudes among healthcare providers in Norwegian nursing homes, using the Safety Attitudes Questionnaire - Ambulatory Version (SAQ-AV). We studied whether variations in safety attitudes were related to professional background, age, work experience and mother tongue. In February 2016, 463 healthcare providers working in five nursing homes in Tønsberg, Norway, were invited to answer the SAQ-AV, translated and adapted to the Norwegian nursing home setting. Previous validation of the Norwegian SAQ-AV for nursing homes identified five patient safety factors: teamwork climate, safety climate, job satisfaction, working conditions and stress recognition. SPSS v.22 was used for statistical analysis, which included estimations of mean values, standard deviations and multiple linear regressions. P-values safety factors teamwork climate, safety climate, job satisfaction and working conditions. Not being a Norwegian native speaker was associated with a significantly higher mean score for job satisfaction and a significantly lower mean score for stress recognition. Neither professional background nor work experience were significantly associated with mean scores for any patient safety factor. Patient safety factor scores in nursing homes were poorer than previously found in Norwegian general practices, but similar to findings in out-of-hours primary care clinics. Patient safety culture assessment may help nursing home leaders to initiate targeted quality improvement interventions. Further research should investigate associations between patient safety culture and the occurrence

Simulation research to enhance patient safety and outcomes: recommendations of the Simnovate Patient Safety Domain Group

OpenAIRE

Pucher, PH; Tamblyn, R; Boorman, D; Dixon-Woods, Mary Margaret; Donaldson, L; Draycott, T; Forster, A; Nadkarni, V; Power, C; Sevdalis, N; Aggarwal, R

2017-01-01

The use of simulation-based training has established itself in healthcare but its implementation has been varied and mostly limited to technical and non-technical skills training. This article discusses the possibilities of the use of simulation as part of an overarching approach to improving patient safety, and represents the views of the Simnovate Patient Safety Domain Group, an international multidisciplinary expert group dedicated to the improvement of patient safety. The application and ...

Patient safety culture assessment in oman.

Science.gov (United States)

Al-Mandhari, Ahmed; Al-Zakwani, Ibrahim; Al-Kindi, Moosa; Tawilah, Jihane; Dorvlo, Atsu S S; Al-Adawi, Samir

2014-07-01

To illustrate the patient safety culture in Oman as gleaned via 12 indices of patient safety culture derived from the Hospital Survey on Patient Safety Culture (HSPSC) and to compare the average positive response rates in patient safety culture between Oman and the USA, Taiwan, and Lebanon. This was a cross-sectional research study employed to gauge the performance of HSPSC safety indices among health workers representing five secondary and tertiary care hospitals in the northern region of Oman. The participants (n=398) represented different professional designations of hospital staff. Analyses were performed using univariate statistics. The overall average positive response rate for the 12 patient safety culture dimensions of the HSPSC survey in Oman was 58%. The indices from HSPSC that were endorsed the highest included 'organizational learning and continuous improvement' while conversely, 'non-punitive response to errors' was ranked the least. There were no significant differences in average positive response rates between Oman and the United States (58% vs. 61%; p=0.666), Taiwan (58% vs. 64%; p=0.386), and Lebanon (58% vs. 61%; p=0.666). This study provides the first empirical study on patient safety culture in Oman which is similar to those rates reported elsewhere. It highlights the specific strengths and weaknesses which may stem from the specific milieu prevailing in Oman.

Patient Safety Culture Assessment in Oman

Science.gov (United States)

Al-Mandhari, Ahmed; Al-Zakwani, Ibrahim; Al-Kindi, Moosa; Tawilah, Jihane; Dorvlo, Atsu S.S.; Al-Adawi, Samir

2014-01-01

Objective To illustrate the patient safety culture in Oman as gleaned via 12 indices of patient safety culture derived from the Hospital Survey on Patient Safety Culture (HSPSC) and to compare the average positive response rates in patient safety culture between Oman and the USA, Taiwan, and Lebanon. Methods This was a cross-sectional research study employed to gauge the performance of HSPSC safety indices among health workers representing five secondary and tertiary care hospitals in the northern region of Oman. The participants (n=398) represented different professional designations of hospital staff. Analyses were performed using univariate statistics. Results The overall average positive response rate for the 12 patient safety culture dimensions of the HSPSC survey in Oman was 58%. The indices from HSPSC that were endorsed the highest included ‘organizational learning and continuous improvement’ while conversely, ‘non-punitive response to errors’ was ranked the least. There were no significant differences in average positive response rates between Oman and the United States (58% vs. 61%; p=0.666), Taiwan (58% vs. 64%; p=0.386), and Lebanon (58% vs. 61%; p=0.666). Conclusion This study provides the first empirical study on patient safety culture in Oman which is similar to those rates reported elsewhere. It highlights the specific strengths and weaknesses which may stem from the specific milieu prevailing in Oman. PMID:25170407

Building patient safety in intensive care nursing : Patient safety culture, team performance and simulation-based training

OpenAIRE

Ballangrud, Randi

2013-01-01

Aim: The overall aim of the thesis was to investigate patient safety culture, team performance and the use of simulation-based team training for building patient safety in intensive care nursing. Methods: Quantitative and qualitative methods were used. In Study I, 220 RNs from ten ICUs responded to a patient safety culture questionnaire analysed with statistics. Studies II-IV were based on an evaluation of a simulation-based team training programme. Studies II-III included 53 RNs from seven I...

Whether Audit Committee Financial Expertise Is the Only Relevant Expertise: A Review of Audit Committee Expertise and Timeliness of Financial Reporting

Directory of Open Access Journals (Sweden)

Saeed Rabea Baatwah

2013-06-01

Full Text Available This study reviews the literature on audit committee expertise and financial reporting timeliness. Financial reporting timeliness and audit committee expertise are two areas of research gaining the attention of a large number of stakeholders because they contribute to the reliability and the  relevancy of financial reporting. Indeed, the focus of this review is primarily on the recent developments in the pertinent literature in order to show the limitations of such research and encourage future research to overcome these limitations. By also looking at the development of the audit committee expertise literature, this study concludes that (1 like most audit committee literature, financial reporting timeliness literature continues to assume the absence of the contribution of expertise other than financial expertise, and ignore the role of audit committee chair; (2 most of this literature fails to find a significant effect because it ignores the interaction among corporate governance mechanisms. Accordingly, this study posits that ignoring the issues raised in such research by future research would lead to major mistakes in reforms relating to how the quality of financial reporting can be enhanced.

The relationship between organizational leadership for safety and learning from patient safety events.

Science.gov (United States)

Ginsburg, Liane R; Chuang, You-Ta; Berta, Whitney Blair; Norton, Peter G; Ng, Peggy; Tregunno, Deborah; Richardson, Julia

2010-06-01

To examine the relationship between organizational leadership for patient safety and five types of learning from patient safety events (PSEs). Forty-nine general acute care hospitals in Ontario, Canada. A nonexperimental design using cross-sectional surveys of hospital patient safety officers (PSOs) and patient care managers (PCMs). PSOs provided data on organization-level learning from (a) minor events, (b) moderate events, (c) major near misses, (d) major event analysis, and (e) major event dissemination/communication. PCMs provided data on organizational leadership (formal and informal) for patient safety. Hospitals were the unit of analysis. Seemingly unrelated regression was used to examine the influence of formal and informal leadership for safety on the five types of learning from PSEs. The interaction between leadership and hospital size was also examined. Formal organizational leadership for patient safety is an important predictor of learning from minor, moderate, and major near-miss events, and major event dissemination. This relationship is significantly stronger for small hospitals (learning from safety events. Formal leadership support for safety is of particular importance in small organizations where the economic burden of safety programs is disproportionately large and formal leadership is closer to the front lines.

Developing the experts we need: Fostering adaptive expertise through education.

Science.gov (United States)

Mylopoulos, Maria; Kulasegaram, Kulamakan; Woods, Nicole N

2018-03-08

In this era of increasing complexity, there is a growing gap between what we need our medical experts to do and the training we provide them. While medical education has a long history of being guided by theories of expertise to inform curriculum design and implementation, the theories that currently underpin our educational programs do not account for the expertise necessary for excellence in the changing health care context. The more comprehensive view of expertise gained by research on both clinical reasoning and adaptive expertise provides a useful framing for re-shaping physician education, placing emphasis on the training of clinicians who will be adaptive experts. That is, have both the ability to apply their extensive knowledge base as well as create new knowledge as dictated by patient needs and context. Three key educational approaches have been shown to foster the development of adaptive expertise: learning that emphasizes understanding, providing students with opportunities to embrace struggle and discovery in their learning, and maximizing variation in the teaching of clinical concepts. There is solid evidence that a commitment to these educational approaches can help medical educators to set trainees on the path towards adaptive expertise. © 2018 John Wiley & Sons, Ltd.

Reflections on clinical expertise and silent know-how in voice therapy

DEFF Research Database (Denmark)

Iwarsson, Jenny

2014-01-01

The concept of ‘clinical expertise’ is described as a part of evidence-based practice (EBP) together with ‘external scientific evidence’ and ‘patient values and perspectives’. However, clinical expertise in the management of voice disorders has not been described or discussed in much detail....... The expertise seems to consist partly of silent know-how that, from the outside, may seem improperly related to the personality of the speech-language pathologist or exclusively dependent on the number of years in the field. In this paper, it is suggested that clinical expertise in voice therapy consists...

Rituals of environmental expertise

DEFF Research Database (Denmark)

Petersen, Lars Kjerulf

2008-01-01

Use of experts in media reports about the environment is not confined to its information function. Voices of expertise also serve a ritual function in societal communication by enacting collective sentiments and common world views cast around consensus as well as conflict. This article presents...... theoretical discussions and examples from a case study of Danish television news coverage of the environment supporting such an understanding of expertise in broadcast media. And adds to the discussion of expertise a discussion of the opposing category of lay knowledge....

John M. Eisenberg Patient Safety Awards. System innovation: Veterans Health Administration National Center for Patient Safety.

Science.gov (United States)

Heget, Jeffrey R; Bagian, James P; Lee, Caryl Z; Gosbee, John W

2002-12-01

In 1998 the Veterans Health Administration (VHA) created the National Center for Patient Safety (NCPS) to lead the effort to reduce adverse events and close calls systemwide. NCPS's aim is to foster a culture of safety in the Department of Veterans Affairs (VA) by developing and providing patient safety programs and delivering standardized tools, methods, and initiatives to the 163 VA facilities. To create a system-oriented approach to patient safety, NCPS looked for models in fields such as aviation, nuclear power, human factors, and safety engineering. Core concepts included a non-punitive approach to patient safety activities that emphasizes systems-based learning, the active seeking out of close calls, which are viewed as opportunities for learning and investigation, and the use of interdisciplinary teams to investigate close calls and adverse events through a root cause analysis (RCA) process. Participation by VA facilities and networks was voluntary. NCPS has always aimed to develop a program that would be applicable both within the VA and beyond. NCPS's full patient safety program was tested and implemented throughout the VA system from November 1999 to August 2000. Program components included an RCA system for use by caregivers at the front line, a system for the aggregate review of RCA results, information systems software, alerts and advisories, and cognitive acids. Following program implementation, NCPS saw a 900-fold increase in reporting of close calls of high-priority events, reflecting the level of commitment to the program by VHA leaders and staff.

Involving patients in patient safety programmes: A scoping review and consensus procedure by the LINNEAUS collaboration on patient safety in primary care

NARCIS (Netherlands)

Trier, H.; Valderas, J.M.; Wensing, M.; Martin, H.M.; Egebart, J.

2015-01-01

BACKGROUND: Patient involvement has only recently received attention as a potentially useful approach to patient safety in primary care. OBJECTIVE: To summarize work conducted on a scoping review of interventions focussing on patient involvement for patient safety; to develop consensus-based

Implementing Patient Safety Initiatives in Rural Hospitals

Science.gov (United States)

Klingner, Jill; Moscovice, Ira; Tupper, Judith; Coburn, Andrew; Wakefield, Mary

2009-01-01

Implementation of patient safety initiatives can be costly in time and energy. Because of small volumes and limited resources, rural hospitals often are not included in nationally driven patient safety initiatives. This article describes the Tennessee Rural Hospital Patient Safety Demonstration project, whose goal was to strengthen capacity for…

Understanding Expertise from Elite Badminton Coaches

Science.gov (United States)

Sheu, Feng-Ru

2011-01-01

Badminton is a growing sport with a limited amount of expertise both in players and coaches so attempts are being made to extend the expertise internationally. The purpose of this study is to gain an understanding of coaching expertise in badminton because such an understanding might have implications for a more general understanding of expertise,…

Competence and Professional Expertise

NARCIS (Netherlands)

Evers, A.T.; Heijden, B.I.J.M. van der; Mulder, M.

2017-01-01

Theoretical and empirical controversies exist about the understanding and potentials of the concepts of competence and professional expertise. In this chapter, both concepts will be thoroughly conceptualised and discussed. Competence and professional expertise are important as all professionals need

Competence and Professional Expertise

NARCIS (Netherlands)

Evers, Arnoud; Van der Heijden, Beatrice

2018-01-01

Theoretical and empirical controversies exist about the understanding and potentials of the concepts competence and professional expertise. In this chapter, both concepts will be thoroughly conceptualised and discussed. Competence and professional expertise are important as all professionals need to

Development of the CAI system for inheritance of maintenance expertise

International Nuclear Information System (INIS)

Hanafusa, Hidemitsu; Chigusa, Naoki; Furuta, Kazuo

2002-01-01

High quality maintenance is required in order to secure the safety of nuclear power plants. The engineers engaged in maintenance activities have to master various knowledge, including the explicit and tacit knowledge of experienced experts, through education and training. Moreover, it is also very important to prevent these knowledge from getting scattered and lost with a change of generation and to share the knowledge or expertise. The purpose of this study is to develop a support system for the next generation experts to help them master and make use of the knowledge of their predecessors. The knowledge or expertise consist of ''knowledge about the maintenance tasks'', ''knowledge about structure/function of plant system/equipment'', and ''individual knowledge based on trouble experience etc.''. The ways this knowledge could be represented were considered first, then this support system was developed based on such representation. (author)

Integrating LCA and EHS expertise in the assessment of nanoparticles

DEFF Research Database (Denmark)

Olsen, Stig Irving; Hankin, Steve; Chaudry, Qasim

DTU with their expertise in LCA have joined forces with IOM in two nanotechnology-related projects, one of which additionally involves and is lead by FERA. The first project, Nancore, includes the evaluation of health risks and environmental impacts over the life cycle concurrently with the devel......DTU with their expertise in LCA have joined forces with IOM in two nanotechnology-related projects, one of which additionally involves and is lead by FERA. The first project, Nancore, includes the evaluation of health risks and environmental impacts over the life cycle concurrently...... the overall environmental impacts of the technology. Through the concurrent assessments, the strengths of the two tools are combined to provide a more qualified assessment of both the health and safety aspects and the life cycle impacts. The overall aim of the second project, sponsored by Defra...

Evaluation of Patient Safety Culture and Organizational Culture as a Step in Patient Safety Improvement in a Hospital in Jakarta, Indonesia

Directory of Open Access Journals (Sweden)

Afrisya Iriviranty

2016-07-01

Full Text Available Introduction: Establishment of patient safety culture is the first step in the improvement of patient safety. As such, assessment of patient safety culture in hospitals is of paramount importance. Patient safety culture is an inherent component of organizational culture, so that the study of organizational culture is required in developing patient safety. This study aimed to evaluate patient safety culture among the clinical staff of a hospital in Jakarta, Indonesia and identify organizational culture profile. Materials and Methods: This cross-sectional, descriptive, qualitative study was conducted in a hospital in Jakarta, Indonesia in 2014. Sample population consisted of nurses, midwives, physicians, pediatricians, obstetrics and gynecology specialists, laboratory personnel, and pharmacy staff (n=152. Data were collected using the Hospital Survey on Patient Safety Culture developed by the Agency for Healthcare Research and Quality (AHRQ and Organizational Culture Assessment Instrument (OCAI. Results: Teamwork within units” was the strongest dimension of patient safety culture (91.7%, while “staffing” and “non-punitive response to error” were the weakest dimensions (22.7%. Moreover, clan culture was the most dominant type of organizational culture in the studied hospital. This culture serves as a guide for the changes in the healthcare organization, especially in the development of patient safety culture. Conclusion: According to the results of this study, healthcare providers were positively inclined toward the patient safety culture within the organization. As such, the action plan was designed through consensus decision-making and deemed effective in articulating patient safety in the vision and mission of the organization.

Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety.

Science.gov (United States)

McFadden, Kathleen L; Stock, Gregory N; Gowen, Charles R

2014-10-01

Successful amelioration of medical errors represents a significant problem in the health care industry. There is a need for greater understanding of the factors that lead to improved process quality and patient safety outcomes in hospitals. We present a research model that shows how transformational leadership, safety climate, and continuous quality improvement (CQI) initiatives are related to objective quality and patient safety outcome measures. The proposed framework is tested using structural equation modeling, based on data collected for 204 hospitals, and supplemented with objective outcome data from the Centers for Medicare and Medicaid Services. The results provide empirical evidence that a safety climate, which is connected to the chief executive officer's transformational leadership style, is related to CQI initiatives, which are linked to improved process quality. A unique finding of this study is that, although CQI initiatives are positively associated with improved process quality, they are also associated with higher hospital-acquired condition rates, a measure of patient safety. Likewise, safety climate is directly related to improved patient safety outcomes. The notion that patient safety climate and CQI initiatives are not interchangeable or universally beneficial is an important contribution to the literature. The results confirm the importance of using CQI to effectively enhance process quality in hospitals, and patient safety climate to improve patient safety outcomes. The overall pattern of findings suggests that simultaneous implementation of CQI initiatives and patient safety climate produces greater combined benefits.

Managing patient safety through NPSGs and employee performance.

Science.gov (United States)

Adair, Liberty

2010-01-01

Patient safety can only exist in a culture of patient safety, which implies it is a value perceived by all. Culture predicts safety outcomes and leadership predicts the culture. Leaders are obligated to continually mitigate hazard and take action consciously. Healthcare workers should focus on preventing and reporting mistakes with the National Patient Safety Goals (NPSGs) in mind. These include: accuracy of patient identification, effectiveness of communication among caregivers, improving safety of medications, reducing infections, reducing risk of falls, and encouraging patients to be involved in care. Poor performers and reckless behavior need to be mitigated. If employees recognize their roles in the process, feel empowered,and have appropriate tools, resources,and data to implement solutions, errors can be avoided and patient safety becomes paramount.

Laboratory test requesting appropriateness and patient safety

CERN Document Server

Blasco, Álvaro; Carratalá, Arturo; Lopez-Garrígos, Maite; Rodriguez-Borja, Enrique

2016-01-01

Patient Safety emphasizes the reporting, analysis and prevention of medical errors that very often leads to adverse healthcare situations.1 in 10 patients are impacted by medical errors.The WHO calls the patient safety issue an endemic concern. A number of well-known experts of all areas in the medical field have collectedvery valuable information for a better patient treatment and higher safety culture in all medical disciplines.

Regional aviation safety organisations : enhancing air transport safety through regional cooperation

NARCIS (Netherlands)

Ratajczyk, Mikołaj Andrzej

2014-01-01

Aviation safety is of global concern. Yet 43% of countries worldwide lack the expertise and administrative capacity to ensure effective safety oversight of the aviation activities for which they are responsible under international law. With air traffic predicted to double in the next 15 years and

From Formal Expertise to Co-expertise: Experience in the Field of Protection against Radiation

International Nuclear Information System (INIS)

Lochard, Jacques

2002-01-01

As a result of the growing difficulties confronting the heads of public and private high-risk activities, expertise practices have changed radically over the past years in the areas of risk assessment and management. In answer to the erosion of the credibility and legitimacy of traditional 'scientific' expertise, new forms of expertise based on citizen participation have emerged, particularly in fields involving public trust. The author's aim is to analyse the main changes in the field of radiological protection, on the basis of his 25 years of experience in the field. In conclusion, the author discusses the independence of expert assessment, an issue central to the present debate on the organization and practice of expertise in the field of high-risk activities

78 FR 17212 - Patient Safety Organizations: Voluntary Relinquishment From Universal Safety Solution PSO

Science.gov (United States)

2013-03-20

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety... Research and Quality (AHRQ), HHS. ACTION: Notice of delisting. SUMMARY: The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41, 42 U.S.C. 299b-21--b-26, provides for the...

The Danish patient safety experience: the Act on Patient Safety in the Danish Health care system

DEFF Research Database (Denmark)

Lundgaard, Mette; Rabøl, Louise; Jensen, Elisabeth Agnete Brøgger

2005-01-01

This paper describes the process that lead to the passing of the Act for Patient Safety in the Danisk health care sytem, the contents of the act and how the act is used in the Danish health care system. The act obligates frontline health care personnel to report adverse events, hospital owners...... to act on the reports and the National Board of Health to commuicate the learning nationally. The act protects health care providers from sanctions as a result of reporting. In January 2004, the Act on Patient Safety in the Danish health care system was put into force. In the first twelve months 5740...... adverse events were reported. the reports were analyzed locally (hospital and region), anonymized ad then sent to the National Board af Health. The Act on Patient Safety has driven the work with patient safety forward but there is room for improvement. Continuous and improved feedback from all parts...

The committee of scientific expertise coordination; Le comite de coordination d'expertise scientifique

Energy Technology Data Exchange (ETDEWEB)

NONE

2003-07-01

Placed under the MIES control, the Committee of scientific expertise coordination defines the needs, the contain and the planing of expertises realized in function of Climate national and international decisions and negotiations calendars. The Committee verifies the different expertises and offers the administrations, scientific tools and techniques useful for the negotiations. It can also define long-dated research needs which require the scientific community mobilization. This paper provides some document of the Committee: objectives, operating and priorities of the Committee, scenarios ''Factor 4'' and ''crack technology'', perceptions and practices, developing countries (China, India...), Euromed. (A.L.B.)

Patients' evaluations of patient safety in English general practices: a cross-sectional study.

Science.gov (United States)

Ricci-Cabello, Ignacio; Marsden, Kate S; Avery, Anthony J; Bell, Brian G; Kadam, Umesh T; Reeves, David; Slight, Sarah P; Perryman, Katherine; Barnett, Jane; Litchfield, Ian; Thomas, Sally; Campbell, Stephen M; Doos, Lucy; Esmail, Aneez; Valderas, Jose M

2017-07-01

Description of safety problems and harm in general practices has previously relied on information from health professionals, with scarce attention paid to experiences of patients. To examine patient-reported experiences and outcomes of patient safety in primary care. Cross-sectional study in 45 general practices across five regions in the north, centre, and south of England. A version of the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire was sent to a random sample of 6736 patients. Main outcome measures included 'practice activation' (what a practice does to create a safe environment); 'patient activation' (how proactive are patients in ensuring safe healthcare delivery); 'experiences of safety events' (safety errors); 'outcomes of safety' (harm); and 'overall perception of safety' (how safe patients rate their practice). Questionnaires were returned by 1244 patients (18.4%). Scores were high for 'practice activation' (mean [standard error] = 80.4 out of 100 [2.0]) and low for 'patient activation' (26.3 out of 100 [2.6]). Of the patients, 45% reported experiencing at least one safety problem in the previous 12 months, mostly related to appointments (33%), diagnosis (17%), patient provider communication (15%), and coordination between providers (14%). Twenty-three per cent of the responders reported some degree of harm in the previous 12 months. The overall assessment of level of safety of practices was generally high (86.0 out of 100 [16.8]). Priority areas for patient safety improvement in general practices in England include appointments, diagnosis, communication, coordination, and patient activation. © British Journal of General Practice 2017.

A research agenda on patient safety in primary care. Recommendations by the LINNEAUS collaboration on patient safety in primary care

Science.gov (United States)

Verstappen, Wim; Gaal, Sander; Bowie, Paul; Parker, Diane; Lainer, Miriam; Valderas, Jose M.; Wensing, Michel; Esmail, Aneez

2015-01-01

ABSTRACT Background: Healthcare can cause avoidable serious harm to patients. Primary care is not an exception, and the relative lack of research in this area lends urgency to a better understanding of patient safety, the future research agenda and the development of primary care oriented safety programmes. Objective: To outline a research agenda for patient safety improvement in primary care in Europe and beyond. Methods: The LINNEAUS collaboration partners analysed existing research on epidemiology and classification of errors, diagnostic and medication errors, safety culture, and learning for and improving patient safety. We discussed ideas for future research in several meetings, workshops and congresses with LINNEAUS collaboration partners, practising GPs, researchers in this field, and policy makers. Results: This paper summarizes and integrates the outcomes of the LINNEAUS collaboration on patient safety in primary care. It proposes a research agenda on improvement strategies for patient safety in primary care. In addition, it provides background information to help to connect research in this field with practicing GPs and other healthcare workers in primary care. Conclusion: Future research studies should target specific primary care domains, using prospective methods and innovative methods such as patient involvement. PMID:26339841

A research agenda on patient safety in primary care. Recommendations by the LINNEAUS collaboration on patient safety in primary care.

Science.gov (United States)

Verstappen, Wim; Gaal, Sander; Bowie, Paul; Parker, Diane; Lainer, Miriam; Valderas, Jose M; Wensing, Michel; Esmail, Aneez

2015-09-01

Healthcare can cause avoidable serious harm to patients. Primary care is not an exception, and the relative lack of research in this area lends urgency to a better understanding of patient safety, the future research agenda and the development of primary care oriented safety programmes. To outline a research agenda for patient safety improvement in primary care in Europe and beyond. The LINNEAUS collaboration partners analysed existing research on epidemiology and classification of errors, diagnostic and medication errors, safety culture, and learning for and improving patient safety. We discussed ideas for future research in several meetings, workshops and congresses with LINNEAUS collaboration partners, practising GPs, researchers in this field, and policy makers. This paper summarizes and integrates the outcomes of the LINNEAUS collaboration on patient safety in primary care. It proposes a research agenda on improvement strategies for patient safety in primary care. In addition, it provides background information to help to connect research in this field with practicing GPs and other healthcare workers in primary care. Future research studies should target specific primary care domains, using prospective methods and innovative methods such as patient involvement.

Applying importance-performance analysis to patient safety culture.

Science.gov (United States)

Lee, Yii-Ching; Wu, Hsin-Hung; Hsieh, Wan-Lin; Weng, Shao-Jen; Hsieh, Liang-Po; Huang, Chih-Hsuan

2015-01-01

The Sexton et al.'s (2006) safety attitudes questionnaire (SAQ) has been widely used to assess staff's attitudes towards patient safety in healthcare organizations. However, to date there have been few studies that discuss the perceptions of patient safety both from hospital staff and upper management. The purpose of this paper is to improve and to develop better strategies regarding patient safety in healthcare organizations. The Chinese version of SAQ based on the Taiwan Joint Commission on Hospital Accreditation is used to evaluate the perceptions of hospital staff. The current study then lies in applying importance-performance analysis technique to identify the major strengths and weaknesses of the safety culture. The results show that teamwork climate, safety climate, job satisfaction, stress recognition and working conditions are major strengths and should be maintained in order to provide a better patient safety culture. On the contrary, perceptions of management and hospital handoffs and transitions are important weaknesses and should be improved immediately. Research limitations/implications - The research is restricted in generalizability. The assessment of hospital staff in patient safety culture is physicians and registered nurses. It would be interesting to further evaluate other staff's (e.g. technicians, pharmacists and others) opinions regarding patient safety culture in the hospital. Few studies have clearly evaluated the perceptions of healthcare organization management regarding patient safety culture. Healthcare managers enable to take more effective actions to improve the level of patient safety by investigating key characteristics (either strengths or weaknesses) that healthcare organizations should focus on.

How to attain expertise in clinical communication?

Science.gov (United States)

Wouda, Jan C; van de Wiel, Harry B M

2013-12-01

Several factors complicate the attainment of expertise in clinical communication. Medical curricula and postgraduate training insufficiently provide the required learning conditions of deliberate practice to overcome these obstacles. In this paper we provide recommendations for learning objectives and teaching methods for the attainment of professional expertise in patient education. Firstly, we propose to use functional learning objectives derived from the goals and strategies of clinical communication. Secondly, we recommend using teaching and assessment methods which: (1) contain stimulating learning tasks with opportunities for immediate feedback, reflection and corrections, and (2) give ample opportunity for repetition, gradual refinements and practice in challenging situations. Video-on-the-job fits these requirements and can be used to improve the competency in patient education of residents and medical staff in clinical practice. However, video-on-the-job can only be successful if the working environment supports the teaching and learning of communication and if medical staff which supervises the residents, is motivated to improve their own communication and didactic skills. Copyright © 2013 Elsevier Ltd. All rights reserved.

Emotional influences in patient safety.

Science.gov (United States)

Croskerry, Pat; Abbass, Allan; Wu, Albert W

2010-12-01

The way that health care providers feel, both within themselves and toward their patients, may influence their clinical performance and impact patient safety, yet this aspect of provider behavior has received relatively little attention. How providers feel, their emotional or affective state, may exert a significant, unintended influence on their patients, and may compromise safety. We examined a broad literature across multiple disciplines to review the interrelationships between emotion, decision making, and behavior, and to assess their potential impact on patient safety. There is abundant evidence that the emotional state of the health care provider may be influenced by factors including characteristics of the patient, ambient conditions in the health care setting, diurnal, circadian, infradian, and seasonal variables, as well as endogenous disorders of the individual provider. These influences may lead to affective biases in decision making, resulting in errors and adverse events. Clinical reasoning and judgment may be particularly susceptible to emotional influence, especially those processes that rely on intuitive judgments. There are many ways that the emotional state of the health care provider can influence patient care. To reduce emotional errors, the level of awareness of these factors should be raised. Emotional skills training should be incorporated into the education of health care professionals. Specifically, clinical teaching should promote more openness and discussion about the provider's feelings toward patients. Strategies should be developed to help providers identify and de-bias themselves against emotional influences that may impact care, particularly in the emotionally evocative patient. Psychiatric conditions within the provider, which may compromise patient safety, need to be promptly detected, diagnosed, and managed.

[Operating Room Nurses' Experiences of Securing for Patient Safety].

Science.gov (United States)

Park, Kwang Ok; Kim, Jong Kyung; Kim, Myoung Sook

2015-10-01

This study was done to evaluate the experience of securing patient safety in hospital operating rooms. Experiential data were collected from 15 operating room nurses through in-depth interviews. The main question was "Could you describe your experience with patient safety in the operating room?". Qualitative data from the field and transcribed notes were analyzed using Strauss and Corbin's grounded theory methodology. The core category of experience with patient safety in the operating room was 'trying to maintain principles of patient safety during high-risk surgical procedures'. The participants used two interactional strategies: 'attempt continuous improvement', 'immersion in operation with sharing issues of patient safety'. The results indicate that the important factors for ensuring the safety of patients in the operating room are manpower, education, and a system for patient safety. Successful and safe surgery requires communication, teamwork and recognition of the importance of patient safety by the surgical team.

Culture matters: indigenizing patient safety in Bhutan.

Science.gov (United States)

Pelzang, Rinchen; Johnstone, Megan-Jane; Hutchinson, Alison M

2017-09-01

Studies show that if quality of healthcare in a country is to be achieved, due consideration must be given to the importance of the core cultural values as a critical factor in improving patient safety outcomes. The influence of Bhutan's traditional (core) cultural values on the attitudes and behaviours of healthcare professionals regarding patient care are not known. This study aimed to explore the possible influence of Bhutan's traditional cultural values on staff attitudes towards patient safety and quality care. Undertaken as a qualitative exploratory descriptive inquiry, a purposeful sample of 94 healthcare professionals and managers were recruited from three levels of hospitals, a training institute and the Ministry of Health. Interviews were transcribed verbatim and analysed using thematic analysis strategies. The findings of the study suggest that Bhutanese traditional cultural values have both productive and counterproductive influences on staff attitudes towards healthcare delivery and the processes that need to be in place to ensure patient safety. Productive influences encompassed: karmic incentives to avoid preventable harm and promote safe patient care; and the prospective adoption of the 'four harmonious friends' as a culturally meaningful frame for improving understanding of the role and importance of teamwork in enhancing patient safety. Counterproductive influences included: the adoption of hierarchical and authoritative styles of management; unilateral decision-making; the legitimization of karmic beliefs; differential treatment of patients; and preferences for traditional healing practices and rituals. Although problematic in some areas, Bhutan's traditional cultural values could be used positively to inform and frame an effective model for improving patient safety in Bhutan's hospitals. Such a model must entail the institution of an 'indigenized' patient safety program, with patient safety research and reporting systems framed around local

76 FR 7855 - Patient Safety Organizations: Voluntary Delisting From Community Medical Foundation for Patient...

Science.gov (United States)

2011-02-11

... Organizations: Voluntary Delisting From Community Medical Foundation for Patient Safety AGENCY: Agency for... Medical Foundation for Patient Safety, of its status as a Patient Safety Organization (PSO). The Patient... notification from Community Medical Foundation for Patient Safety, PSO number P0029, to voluntarily relinquish...

40 CFR 1508.26 - Special expertise.

Science.gov (United States)

2010-07-01

... 40 Protection of Environment 32 2010-07-01 2010-07-01 false Special expertise. 1508.26 Section 1508.26 Protection of Environment COUNCIL ON ENVIRONMENTAL QUALITY TERMINOLOGY AND INDEX § 1508.26 Special expertise. Special expertise means statutory responsibility, agency mission, or related program...

A prospective randomized trial of content expertise versus process expertise in small group teaching.

Science.gov (United States)

Peets, Adam D; Cooke, Lara; Wright, Bruce; Coderre, Sylvain; McLaughlin, Kevin

2010-10-14

Effective teaching requires an understanding of both what (content knowledge) and how (process knowledge) to teach. While previous studies involving medical students have compared preceptors with greater or lesser content knowledge, it is unclear whether process expertise can compensate for deficient content expertise. Therefore, the objective of our study was to compare the effect of preceptors with process expertise to those with content expertise on medical students' learning outcomes in a structured small group environment. One hundred and fifty-one first year medical students were randomized to 11 groups for the small group component of the Cardiovascular-Respiratory course at the University of Calgary. Each group was then block randomized to one of three streams for the entire course: tutoring exclusively by physicians with content expertise (n = 5), tutoring exclusively by physicians with process expertise (n = 3), and tutoring by content experts for 11 sessions and process experts for 10 sessions (n = 3). After each of the 21 small group sessions, students evaluated their preceptors' teaching with a standardized instrument. Students' knowledge acquisition was assessed by an end-of-course multiple choice (EOC-MCQ) examination. Students rated the process experts significantly higher on each of the instrument's 15 items, including the overall rating. Students' mean score (±SD) on the EOC-MCQ exam was 76.1% (8.1) for groups taught by content experts, 78.2% (7.8) for the combination group and 79.5% (9.2) for process expert groups (p = 0.11). By linear regression student performance was higher if they had been taught by process experts (regression coefficient 2.7 [0.1, 5.4], p teach first year medical students within a structured small group environment; preceptors with process expertise result in at least equivalent, if not superior, student outcomes in this setting.

78 FR 12065 - Patient Safety Organizations: Delisting for Cause for Independent Data Safety Monitoring, Inc.

Science.gov (United States)

2013-02-21

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety... Safety Monitoring, Inc. due to its failure to correct a deficiency. The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorizes the listing of PSOs, which are entities or component...

Exploring Integration in Action: Competencies as Building Blocks of Expertise.

Science.gov (United States)

Mylopoulos, Maria; Borschel, Debaroti Tina; O'Brien, Tara; Martimianakis, Sofia; Woods, Nicole N

2017-12-01

Competency frameworks such as the CanMEDS roles and the ACGME core competencies may lead to the implicit assumption that physicians can learn and practice individual competencies in isolation. In contrast, models of adaptive expertise suggest that the integration of competencies reflects the capabilities of an expert physician. Thus, educational programming aimed at teaching discrete roles or competencies might overlook expert physician capabilities that are central to patient care. To develop expertise, learning opportunities must reflect expert capabilities. To better understand the relationship between competency-based medical education and expert development, the authors sought to explore how integrated competencies are enacted during patient care by postgraduate medical trainees. Using a cognitive ethnographic approach, in 2014-2015 the authors conducted observations and-to refine and elaborate these observations-ad hoc informal interviews with 13 postgraduate trainee participants. Data collection resulted in 92 hours of observation, 26 patient case portraits, and a total of 220 pages of field notes for analysis. Through analysis, the authors identified and examined moments when postgraduate trainees appeared to be simultaneously enacting multiple competencies. The authors identified two key expert capabilities in moments of integrated competence: finding complexity and being patient-centered. They described two mechanisms for these forms of integration: valuing the patient's narrative of their illness, and integrated understanding. Understanding integrated competencies as the building blocks of expert capabilities, along with recognizing the importance of mechanisms that support integration, offers an opportunity to use existing competency-based frameworks to understand and teach adaptive expertise.

Beyond Faces and Expertise

Science.gov (United States)

Zhao, Mintao; Bülthoff, Heinrich H.; Bülthoff, Isabelle

2016-01-01

Holistic processing—the tendency to perceive objects as indecomposable wholes—has long been viewed as a process specific to faces or objects of expertise. Although current theories differ in what causes holistic processing, they share a fundamental constraint for its generalization: Nonface objects cannot elicit facelike holistic processing in the absence of expertise. Contrary to this prevailing view, here we show that line patterns with salient Gestalt information (i.e., connectedness, closure, and continuity between parts) can be processed as holistically as faces without any training. Moreover, weakening the saliency of Gestalt information in these patterns reduced holistic processing of them, which indicates that Gestalt information plays a crucial role in holistic processing. Therefore, holistic processing can be achieved not only via a top-down route based on expertise, but also via a bottom-up route relying merely on object-based information. The finding that facelike holistic processing can extend beyond the domains of faces and objects of expertise poses a challenge to current dominant theories. PMID:26674129

75 FR 57281 - Patient Safety Organizations: Voluntary delisting

Science.gov (United States)

2010-09-20

... Organizations: Voluntary delisting AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS ACTION: Notice... Patient Safety Corporation of its status as a Patient Safety Organization (PSO). The Patient Safety and... the listing of PSOs, which are entities or component organizations whose mission and primary activity...

Patient safety in otolaryngology: a descriptive review.

Science.gov (United States)

Danino, Julian; Muzaffar, Jameel; Metcalfe, Chris; Coulson, Chris

2017-03-01

Human evaluation and judgement may include errors that can have disastrous results. Within medicine and healthcare there has been slow progress towards major changes in safety. Healthcare lags behind other specialised industries, such as aviation and nuclear power, where there have been significant improvements in overall safety, especially in reducing risk of errors. Following several high profile cases in the USA during the 1990s, a report titled "To Err Is Human: Building a Safer Health System" was published. The report extrapolated that in the USA approximately 50,000 to 100,000 patients may die each year as a result of medical errors. Traditionally otolaryngology has always been regarded as a "safe specialty". A study in the USA in 2004 inferred that there may be 2600 cases of major morbidity and 165 deaths within the specialty. MEDLINE via PubMed interface was searched for English language articles published between 2000 and 2012. Each combined two or three of the keywords noted earlier. Limitations are related to several generic topics within patient safety in otolaryngology. Other areas covered have been current relevant topics due to recent interest or new advances in technology. There has been a heightened awareness within the healthcare community of patient safety; it has become a major priority. Focus has shifted from apportioning blame to prevention of the errors and implementation of patient safety mechanisms in healthcare delivery. Type of Errors can be divided into errors due to action and errors due to knowledge or planning. In healthcare there are several factors that may influence adverse events and patient safety. Although technology may improve patient safety, it also introduces new sources of error. The ability to work with people allows for the increase in safety netting. Team working has been shown to have a beneficial effect on patient safety. Any field of work involving human decision-making will always have a risk of error. Within

Neural basis of nonanalytical reasoning expertise during clinical evaluation

NARCIS (Netherlands)

Durning, S.J.; Costanzo, M.E.; Artino, A.R.; Graner, J.; Vleuten, C.P.M. van der; Beckman, T.J.; Wittich, C.M.; Roy, M.J.H.M. van; Holmboe, E.S.; Schuwirth, L.

2015-01-01

INTRODUCTION: Understanding clinical reasoning is essential for patient care and medical education. Dual-processing theory suggests that nonanalytic reasoning is an essential aspect of expertise; however, assessing nonanalytic reasoning is challenging because it is believed to occur on the

Implementation of patient safety strategies in European hospitals.

Science.gov (United States)

Suñol, R; Vallejo, P; Groene, O; Escaramis, G; Thompson, A; Kutryba, B; Garel, P

2009-02-01

This study is part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project on cross-border care, investigating quality improvement strategies in healthcare systems across the European Union (EU). To explore to what extent a sample of acute care European hospitals have implemented patient safety strategies and mechanisms and whether the implementation is related to the type of hospital. Data were collected on patient safety structures and mechanisms in 389 acute care hospitals in eight EU countries using a web-based questionnaire. Subsequently, an on-site audit was carried out by independent surveyors in 89 of these hospitals to assess patient safety outputs. This paper presents univariate and bivariate statistics on the implementation and explores the associations between implementation of patient safety strategies and hospital type using the chi(2) test and Fisher exact test. Structures and plans for safety (including responsibilities regarding patient safety management) are well developed in most of the hospitals that participated in this study. The study found greater variation regarding the implementation of mechanisms or activities to promote patient safety, such as electronic drug prescription systems, guidelines for prevention of wrong patient, wrong site and wrong surgical procedure, and adverse events reporting systems. In the sample of hospitals that underwent audit, a considerable proportion do not comply with basic patient safety strategies--for example, using bracelets for adult patient identification and correct labelling of medication.

42 CFR 3.212 - Nonidentification of patient safety work product.

Science.gov (United States)

2010-10-01

... 42 Public Health 1 2010-10-01 2010-10-01 false Nonidentification of patient safety work product. 3... PROVISIONS PATIENT SAFETY ORGANIZATIONS AND PATIENT SAFETY WORK PRODUCT Confidentiality and Privilege Protections of Patient Safety Work Product § 3.212 Nonidentification of patient safety work product. (a...

Patient safety in out-of-hours primary care: a review of patient records

Directory of Open Access Journals (Sweden)

Wensing Michel

2010-12-01

Full Text Available Abstract Background Most patients receive healthcare in primary care settings, but relatively little is known about patient safety. Out-of-hours contacts are of particular importance to patient safety. Our aim was to examine the incidence, types, causes, and consequences of patient safety incidents at general practice cooperatives for out-of-hours primary care and to examine which factors were associated with the occurrence of patient safety incidents. Methods A retrospective study of 1,145 medical records concerning patient contacts with four general practice cooperatives. Reviewers identified records with evidence of a potential patient safety incident; a physician panel determined whether a patient safety incident had indeed occurred. In addition, the panel determined the type, causes, and consequences of the incidents. Factors associated with incidents were examined in a random coefficient logistic regression analysis. Results In 1,145 patient records, 27 patient safety incidents were identified, an incident rate of 2.4% (95% CI: 1.5% to 3.2%. The most frequent incident type was treatment (56%. All incidents had at least partly been caused by failures in clinical reasoning. The majority of incidents did not result in patient harm (70%. Eight incidents had consequences for the patient, such as additional interventions or hospitalisation. The panel assessed that most incidents were unlikely to result in patient harm in the long term (89%. Logistic regression analysis showed that age was significantly related to incident occurrence: the likelihood of an incident increased with 1.03 for each year increase in age (95% CI: 1.01 to 1.04. Conclusion Patient safety incidents occur in out-of-hours primary care, but most do not result in harm to patients. As clinical reasoning played an important part in these incidents, a better understanding of clinical reasoning and guideline adherence at GP cooperatives could contribute to patient safety.

42 CFR 3.204 - Privilege of patient safety work product.

Science.gov (United States)

2010-10-01

... 42 Public Health 1 2010-10-01 2010-10-01 false Privilege of patient safety work product. 3.204... PROVISIONS PATIENT SAFETY ORGANIZATIONS AND PATIENT SAFETY WORK PRODUCT Confidentiality and Privilege Protections of Patient Safety Work Product § 3.204 Privilege of patient safety work product. (a) Privilege...

Nuclear safety and human factors: the French factory of expertise

International Nuclear Information System (INIS)

Rolina, G.

2009-01-01

The French regulation of the nuclear safety is based on the maintaining of a deep technical dialogue between the nuclear safety authority, the I.R.S.N. (Institute of radiation protection and nuclear safety) and the nuclear operators. This type of risk management is called 'french coking' by the Anglo-Saxons, followers of stricter regulatory approach, more readable by the civil society. This technical dialogue is not without quality, especially in the field of human and organizational factors where it allows to improve the know how situation that stays incomplete. (N.C.)

Musical expertise and second language learning.

Science.gov (United States)

Chobert, Julie; Besson, Mireille

2013-06-06

Increasing evidence suggests that musical expertise influences brain organization and brain functions. Moreover, results at the behavioral and neurophysiological levels reveal that musical expertise positively influences several aspects of speech processing, from auditory perception to speech production. In this review, we focus on the main results of the literature that led to the idea that musical expertise may benefit second language acquisition. We discuss several interpretations that may account for the influence of musical expertise on speech processing in native and foreign languages, and we propose new directions for future research.

Improving Patient Safety: Improving Communication.

Science.gov (United States)

Bittner-Fagan, Heather; Davis, Joshua; Savoy, Margot

2017-12-01

Communication among physicians, staff, and patients is a critical element in patient safety. Effective communication skills can be taught and improved through training and awareness. The practice of family medicine allows for long-term relationships with patients, which affords opportunities for ongoing, high-quality communication. There are many barriers to effective communication, including patient factors, clinician factors, and system factors, but tools and strategies exist to address these barriers, improve communication, and engage patients in their care. Use of universal precautions for health literacy, appropriate medical interpreters, and shared decision-making are evidence-based tools that improve communication and increase patient safety. Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.

Patient safety initiatives in Central and Eastern Europe: A mixed methods approach by the LINNEAUS collaboration on patient safety in primary care

Science.gov (United States)

Godycki-Cwirko, Maciek; Esmail, Aneez; Dovey, Susan; Wensing, Michel; Parker, Dianne; Kowalczyk, Anna; Błaszczyk, Honorata; Kosiek, Katarzyna

2015-01-01

ABSTRACT Background: Despite patient safety being recognized as an important healthcare issue in the European Union, there has been variable implementation of patient safety initiatives in Central and Eastern Europe (CEE). Objective: To assess the status of patient safety initiatives in countries in CEE; to describe a process of engagement in Poland, which can serve as a template for the implementation of patient safety initiatives in primary care. Methods: A mixed methods design was used. We conducted a review of literature focusing on publications from CEE, an inventory of patient safety initiatives in CEE countries, interviews with key informants, international survey, review of national reporting systems, and pilot demonstrator project in Poland with implementation of patient safety toolkits assessment. Results: There was no published patient safety research from Albania, Belarus, Greece, Latvia, Lithuania, Romania, or Russia. Nine papers were found from Bulgaria, Croatia, the Czech Republic, Poland, Serbia, and Slovenia. In most of the CEE countries, patient safety had been addressed at the policy level although the focus was mainly in hospital care. There was a dearth of activity in primary care. The use of patient improvement strategies was low. Conclusion: International cooperation as exemplified in the demonstrator project can help in the development and implementation of patient safety initiatives in primary care in changing the emphasis away from a blame culture to one where greater emphasis is placed on improvement and learning. PMID:26339839

Culture, language, and patient safety: Making the link.

Science.gov (United States)

Johnstone, Megan-Jane; Kanitsaki, Olga

2006-10-01

It has been well recognized internationally that hospitals are not as safe as they should be. In order to redress this situation, health care services around the world have turned their attention to strategically implementing robust patient safety and quality care programmes to identify circumstances that put patients at risk of harm and then acting to prevent or control those risks. Despite the progress that has been made in improving hospital safety in recent years, there is emerging evidence that patients of minority cultural and language backgrounds are disproportionately at risk of experiencing preventable adverse events while in hospital compared with mainstream patient groups. One reason for this is that patient safety programmes have tended to underestimate and understate the critical relationship that exists between culture, language, and the safety and quality of care of patients from minority racial, ethno-cultural, and language backgrounds. This article suggests that the failure to recognize the critical link between culture and language (of both the providers and recipients of health care) and patient safety stands as a 'resident pathogen' within the health care system that, if not addressed, unacceptably exposes patients from minority ethno-cultural and language backgrounds to preventable adverse events in hospital contexts. It is further suggested that in order to ensure that minority as well as majority patient interests in receiving safe and quality care are properly protected, the culture-language-patient-safety link needs to be formally recognized and the vulnerabilities of patients from minority cultural and language backgrounds explicitly identified and actively addressed in patient safety systems and processes.

Nurses' perceptions of patient safety culture in Jordanian hospitals.

Science.gov (United States)

Khater, W A; Akhu-Zaheya, L M; Al-Mahasneh, S I; Khater, R

2015-03-01

Patients' safety culture is a key aspect in determining healthcare organizations' ability to address and reduce risks of patients. Nurses play a major role in patients' safety because they are accountable for direct and continuous patient care. There is little known information about patients' safety culture in Jordanian hospitals, particularly from the perspective of healthcare providers. The study aimed to assess patient safety culture in Jordanian hospitals from nurses' perspective. A cross-sectional, descriptive design was utilized. A total number of 658 nurses participated in the current study. Data were collected using an Arabic version of the hospital survey of patients' safety culture. Teamwork within unit dimensions had a high positive response, and was perceived by nurses to be the only strong suit in Jordanian hospitals. Areas that required improvement, as perceived by nurses, are as follows: communication openness, staffing, handoff and transition, non-punitive responses to errors, and teamwork across units. Regression analysis revealed factors, from nurses' perspectives, that influenced patients' safety culture in Jordanian hospital. Factors included age, total years of experience, working in university hospitals, utilizing evidence-based practice and working in hospitals that consider patient safety to be a priority. Participants in this study were limited to nurses. Therefore, there is a need to assess patient safety culture from other healthcare providers' perspectives. Moreover, the use of a self-reported questionnaire introduced the social desirability biases. The current study provides insight into how nurses perceive patient safety culture. Results of this study have revealed that there is a need to replace the traditional culture of shame/blame with a non-punitive culture. Study results implied that improving patient safety culture requires a fundamental transformation of nurses' work environment. New policies to improve collaboration between

The Importance of Domain-Specific Expertise in Creativity

Science.gov (United States)

Baer, John

2015-01-01

Although creativity and expertise are related, they are nonetheless very different things. Expertise does not usually require creativity, but creativity generally does require a certain level of expertise. There are similarities in the relationships of both expertise and creativity to domains, however. Research has shown that just as expertise in…

Safety Culture Perspective. Managing the pre Managing the pre-operational phases of new NPPs and creating the safety culture

International Nuclear Information System (INIS)

Cowan, Pamela B.; Oh, Chaewoon; Dahlgren Persson, Kerstin; Carnino, Annick

2008-01-01

Nuclear safety is a key for the revival of nuclear energy future programmes. Lots of competent people will be needed worldwide for ensuring the safety of the installations both existing ones and future ones. Their expertise should range from design to operation, from regulatory role to operators, from fuel fabrication to waste disposal. The challenge in front of us will be to prepare for the right recruitment, the development of the needed expertise in order to face the demand in developed countries, in countries with economies in transition and in developing countries. Time allocated for the panel does not allow for covering all aspects but the panelists will cover some of the important aspects of the challenge in terms of needs, of new competencies, of learning from operation and licensing requirements including for new designs. The key objectives of the panel are: 1- Maintaining safe operation, learning from experience, licensing including aging management and re-licensing with safety improvements for existing installations: - Presentation by Junko Ogawa of the experience and lessons learned from the earthquake on Kashiwasaki Kariwa NPP: effects in terms of manpower involved in the investigation, effects on regulations and licensing, expertise used. - Presentation by Pamela Cowan of her experience in preparing licensing actions, regulatory compliance and interface with the Regulator for both operating plants and modern requirements for constructing new ones. 2 - Special training needed for the human aspect of safety: what are the challenges in areas of safety culture and management of safety: - Presentation by Chae Woon Oh of the Korean safety culture features developed nationally, at the regulator and at the operating organizations and their integration within the safety training programmes. - Presentation by Kerstin Dahlgren Person of the needs in terms of safety culture and safety management, in terms of expertise, practitioners and assessors. 3 - How to

Safety Culture Perspective. Managing the pre Managing the pre-operational phases of new NPPs and creating the safety culture

Energy Technology Data Exchange (ETDEWEB)

Cowan, Pamela B. [Exelon Generation, 200 Exelon Way, 19348 Kennett Square, PA 19348 (United States); Oh, Chaewoon [Korea Institute of Nuclear Safety, 19 Gusung-Dong, Yuseong-Ku, 305-338 Daejeon (Korea, Republic of); Dahlgren Persson, Kerstin [International Atomic Energy Agency, Wagramer Strasse 5, PO BOX 100 A-1400 Vienna (Austria); Carnino, Annick [IAEA, Division of Nuclear Installation Safety, Wagramer Strasse 5, PO BOX 100 A-1400 Vienna (Austria)

2008-07-01

Nuclear safety is a key for the revival of nuclear energy future programmes. Lots of competent people will be needed worldwide for ensuring the safety of the installations both existing ones and future ones. Their expertise should range from design to operation, from regulatory role to operators, from fuel fabrication to waste disposal. The challenge in front of us will be to prepare for the right recruitment, the development of the needed expertise in order to face the demand in developed countries, in countries with economies in transition and in developing countries. Time allocated for the panel does not allow for covering all aspects but the panelists will cover some of the important aspects of the challenge in terms of needs, of new competencies, of learning from operation and licensing requirements including for new designs. The key objectives of the panel are: 1- Maintaining safe operation, learning from experience, licensing including aging management and re-licensing with safety improvements for existing installations: - Presentation by Junko Ogawa of the experience and lessons learned from the earthquake on Kashiwasaki Kariwa NPP: effects in terms of manpower involved in the investigation, effects on regulations and licensing, expertise used. - Presentation by Pamela Cowan of her experience in preparing licensing actions, regulatory compliance and interface with the Regulator for both operating plants and modern requirements for constructing new ones. 2 - Special training needed for the human aspect of safety: what are the challenges in areas of safety culture and management of safety: - Presentation by Chae Woon Oh of the Korean safety culture features developed nationally, at the regulator and at the operating organizations and their integration within the safety training programmes. - Presentation by Kerstin Dahlgren Person of the needs in terms of safety culture and safety management, in terms of expertise, practitioners and assessors. 3 - How to

Talent in the taxi: a model system for exploring expertise.

Science.gov (United States)

Woollett, Katherine; Spiers, Hugo J; Maguire, Eleanor A

2009-05-27

While there is widespread interest in and admiration of individuals with exceptional talents, surprisingly little is known about the cognitive and neural mechanisms underpinning talent, and indeed how talent relates to expertise. Because many talents are first identified and nurtured in childhood, it can be difficult to determine whether talent is innate, can be acquired through extensive practice or can only be acquired in the presence of the developing brain. We sought to address some of these issues by studying healthy adults who acquired expertise in adulthood. We focused on the domain of memory and used licensed London taxi drivers as a model system. Taxi drivers have to learn the layout of 25,000 streets in London and the locations of thousands of places of interest, and pass stringent examinations in order to obtain an operating licence. Using neuropsychological assessment and structural and functional magnetic resonance imaging, we addressed a range of key questions: in the context of a fully developed brain and an average IQ, can people acquire expertise to an exceptional level; what are the neural signatures, both structural and functional, associated with the use of expertise; does expertise change the brain compared with unskilled control participants; does it confer any cognitive advantages, and similarly, does it come at a cost to other functions? By studying retired taxi drivers, we also consider what happens to their brains and behaviour when experts stop using their skill. Finally, we discuss how the expertise of taxi drivers might relate to the issue of talent and innate abilities. We suggest that exploring talent and expertise in this manner could have implications for education, rehabilitation of patients with cognitive impairments, understanding individual differences and possibly conditions such as autism where exceptional abilities can be a feature.

Reactor Safety Analysis

International Nuclear Information System (INIS)

Arien, B.

2000-01-01

The objective of SCK-CEN's programme on reactor safety is to develop expertise in probabilistic and deterministic reactor safety analysis. The research programme consists of two main activities, in particular the development of software for reliability analysis of large systems and participation in the international PHEBUS-FP programme for severe accidents. Main achievements in 1999 are reported

Anticorruption expertise of law-enforcement acts

Directory of Open Access Journals (Sweden)

Sergey B. Polyakov

2015-12-01

Full Text Available Objective to substantiate public necessity to define the subject methodological and organizational capabilities of anticorruption expertise of law enforcement acts. Methods universal dialecticmaterialistic method was used to study the needs in anticorruption expertise of law enforcement acts in the mechanism of legal regulation based on it general scientific and special formal legal and comparative legal methods of research used for the definition of subjectmatter of the proposed expertise. Results the value of anticorruption expertise of law enforcement was shown corruption factors and corruption indicators enabling legislation were identified ways of conducting such examinations were proposed. Scientific novelty the article examines the need and the subject proposes methods of a new type of anticorruption expertise. Practical significance the conditions of corruption are defined which are created in law enforcement activities and methods for their detection are proposed. nbsp

Ethnic inequalities in patient safety in Dutch hospital care

NARCIS (Netherlands)

van Rosse, F.

2015-01-01

This thesis shows the first results of Dutch studies on the relation between ethnicity and patient safety. We used mixed methods to identify patient safety outcomes and patient safety risks in a cohort study in 4 urban hospitals among 763 Dutch patients and 576 ethnic minority patients. In a record

Relational Expertise in Participatory Design

DEFF Research Database (Denmark)

Dindler, Christian; Iversen, Ole Sejer

2014-01-01

This paper positions relation expertise as a core competence in participatory design. It is an expertise that demands the participatory designer to stimulate the emergence of loosely coupled knotworks, and obtain symbiotic agreement between participants disregarding their professional and social...

An integrative review of patient safety in studies on the care and safety of patients with communication disabilities in hospital.

Science.gov (United States)

Hemsley, Bronwyn; Georgiou, Andrew; Hill, Sophie; Rollo, Megan; Steel, Joanne; Balandin, Susan

2016-04-01

To review the research literature on the experiences of patients with communication disabilities in hospital according to the Generic Model of patient safety. In 2014 and 2015, we searched four scientific databases for studies with an aim or result relevant to safety of hospital patients with communication disabilities. The review included 27 studies. A range of adverse event types were outlined in qualitative research. Little detail was provided about contributing or protective factors for safety incidents in hospital for these patients or the impact of the incidents on the patient or organisations involved. Further research addressing the safety of patients with communication disabilities is needed. Sufficient detail is required to identify the nature, timing, and detection of incidents; factors that contribute to or prevent adverse events; and detail the impact of the adverse events. In order to provide safe and effective care to people with communication disabilities in hospital, a priority for health and disability services must be the design and evaluation of ecologically appropriate and evidence-based interventions to improve patient care, communication, and reduce the risk of costly and harmful patient safety incidents. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Measuring and improving patient safety through health information technology: The Health IT Safety Framework.

Science.gov (United States)

Singh, Hardeep; Sittig, Dean F

2016-04-01

Health information technology (health IT) has potential to improve patient safety but its implementation and use has led to unintended consequences and new safety concerns. A key challenge to improving safety in health IT-enabled healthcare systems is to develop valid, feasible strategies to measure safety concerns at the intersection of health IT and patient safety. In response to the fundamental conceptual and methodological gaps related to both defining and measuring health IT-related patient safety, we propose a new framework, the Health IT Safety (HITS) measurement framework, to provide a conceptual foundation for health IT-related patient safety measurement, monitoring, and improvement. The HITS framework follows both Continuous Quality Improvement (CQI) and sociotechnical approaches and calls for new measures and measurement activities to address safety concerns in three related domains: 1) concerns that are unique and specific to technology (e.g., to address unsafe health IT related to unavailable or malfunctioning hardware or software); 2) concerns created by the failure to use health IT appropriately or by misuse of health IT (e.g. to reduce nuisance alerts in the electronic health record (EHR)), and 3) the use of health IT to monitor risks, health care processes and outcomes and identify potential safety concerns before they can harm patients (e.g. use EHR-based algorithms to identify patients at risk for medication errors or care delays). The framework proposes to integrate both retrospective and prospective measurement of HIT safety with an organization's existing clinical risk management and safety programs. It aims to facilitate organizational learning, comprehensive 360 degree assessment of HIT safety that includes vendor involvement, refinement of measurement tools and strategies, and shared responsibility to identify problems and implement solutions. A long term framework goal is to enable rigorous measurement that helps achieve the safety

The committee of scientific expertise coordination; Le comite de coordination d'expertise scientifique

Energy Technology Data Exchange (ETDEWEB)

NONE

2003-07-01

Placed under the MIES control, the Committee of scientific expertise coordination defines the needs, the contain and the planing of expertises realized in function of Climate national and international decisions and negotiations calendars. The Committee verifies the different expertises and offers the administrations, scientific tools and techniques useful for the negotiations. It can also define long-dated research needs which require the scientific community mobilization. This paper provides some document of the Committee: objectives, operating and priorities of the Committee, scenarios ''Factor 4'' and ''crack technology'', perceptions and practices, developing countries (China, India...), Euromed. (A.L.B.)

Improving patient safety: lessons from rock climbing.

Science.gov (United States)

Robertson, Nic

2012-02-01

How to improve patient safety remains an intractable problem, despite large investment and some successes. Academics have argued that the root of the problem is a lack of a comprehensive 'safety culture' in hospitals. Other safety-critical industries such as commercial aviation invest heavily in staff training to develop such a culture, but comparable programmes are almost entirely absent from the health care sector. In rock climbing and many other dangerous activities, the 'buddy system' is used to ensure that safety systems are adhered to despite adverse circumstances. This system involves two or more people using simple checks and clear communication to prevent problems causing harm. Using this system as an example could provide a simple, original and entertaining way of introducing medical students to the idea that human factors are central to ensuring patient safety. Teaching the buddy system may improve understanding and acceptance of other patient safety initiatives, and could also be used by junior doctors as a tool to improve the safety of their practice. © Blackwell Publishing Ltd 2012.

76 FR 7854 - Patient Safety Organizations: Voluntary Delisting From Lumetra PSO

Science.gov (United States)

2011-02-11

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety... Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act... delivery. The Patient Safety and Quality Improvement Final Rule (Patient Safety Rule), 42 CFR part 3...

Effects of the Smartphone Application "Safe Patients" on Knowledge of Patient Safety Issues Among Surgical Patients.

Science.gov (United States)

Cho, Sumi; Lee, Eunjoo

2017-12-01

Recently, the patient's role in preventing adverse events has been emphasized. Patients who are more knowledgeable about safety issues are more likely to engage in safety initiatives. Therefore, nurses need to develop techniques and tools that increase patients' knowledge in preventing adverse events. For this reason, an educational smartphone application for patient safety called "Safe Patients" was developed through an iterative process involving a literature review, expert consultations, and pilot testing of the application. To determine the effect of "Safe Patients," it was implemented for patients in surgical units in a tertiary hospital in South Korea. The change in patients' knowledge about patient safety was measured using seven true/false questions developed in this study. A one-group pretest and posttest design was used, and a total of 123 of 190 possible participants were tested. The percentage of correct answers significantly increased from 64.5% to 75.8% (P effectively improve patients' knowledge of safety issues. This will ultimately empower patients to engage in safe practices and prevent adverse events related to surgery.

Patient safety: break the silence.

Science.gov (United States)

Johnson, Hope L; Kimsey, Diane

2012-05-01

A culture of patient safety requires commitment and full participation from all staff members. In 2008, results of a culture of patient safety survey conducted in the perioperative division of the Lehigh Valley Health Network in Pennsylvania revealed a lack of patient-centered focus, teamwork, and positive communication. As a result, perioperative leaders assembled a multidisciplinary team that designed a safety training program focusing on Crew Resource Management, TeamSTEPPS, and communication techniques. The team used video vignettes and an audience response system to engage learners and promote participation. Topics included using preprocedural briefings and postprocedural debriefings, conflict resolution, and assertiveness techniques. Postcourse evaluations showed that the majority of respondents believed they were better able to question the decisions or actions of someone with more authority. The facility has experienced a marked decrease in the number of incidents requiring a root cause analysis since the program was conducted. Copyright © 2012 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Development and testing of an objective structured clinical exam (OSCE) to assess socio-cultural dimensions of patient safety competency

Science.gov (United States)

Ginsburg, Liane R; Tregunno, Deborah; Norton, Peter G; Smee, Sydney; de Vries, Ingrid; Sebok, Stefanie S; VanDenKerkhof, Elizabeth G; Luctkar-Flude, Marian; Medves, Jennifer

2015-01-01

Background Patient safety (PS) receives limited attention in health professional curricula. We developed and pilot tested four Objective Structured Clinical Examination (OSCE) stations intended to reflect socio-cultural dimensions in the Canadian Patient Safety Institute's Safety Competency Framework. Setting and participants 18 third year undergraduate medical and nursing students at a Canadian University. Methods OSCE cases were developed by faculty with clinical and PS expertise with assistance from expert facilitators from the Medical Council of Canada. Stations reflect domains in the Safety Competency Framework (ie, managing safety risks, culture of safety, communication). Stations were assessed by two clinical faculty members. Inter-rater reliability was examined using weighted κ values. Additional aspects of reliability and OSCE performance are reported. Results Assessors exhibited excellent agreement (weighted κ scores ranged from 0.74 to 0.82 for the four OSCE stations). Learners’ scores varied across the four stations. Nursing students scored significantly lower (p<0.05) than medical students on three stations (nursing student mean scores=1.9, 1.9 and 2.7; medical student mean scores=2.8, 2.9 and 3.5 for stations 1, 2 and 3, respectively where 1=borderline unsatisfactory, 2=borderline satisfactory and 3=competence demonstrated). 7/18 students (39%) scored below ‘borderline satisfactory’ on one or more stations. Conclusions Results show (1) four OSCE stations evaluating socio-cultural dimensions of PS achieved variation in scores and (2) performance on this OSCE can be evaluated with high reliability, suggesting a single assessor per station would be sufficient. Differences between nursing and medical student performance are interesting; however, it is unclear what factors explain these differences. PMID:25398630

Knowledge Representation in Patient Safety Reporting: An Ontological Approach

OpenAIRE

Liang Chen; Yang Gong

2016-01-01

Purpose: The current development of patient safety reporting systems is criticized for loss of information and low data quality due to the lack of a uniformed domain knowledge base and text processing functionality. To improve patient safety reporting, the present paper suggests an ontological representation of patient safety knowledge. Design/methodology/approach: We propose a framework for constructing an ontological knowledge base of patient safety. The present paper describes our desig...

Patient Safety Threat - Syringe Reuse

Science.gov (United States)

... Safety Stakeholder Meeting December 2009 The One & Only Campaign Patient Notification Toolkit Developing Documents for a Patient Notification Planning Media and Communication Strategies Writing for the Media Spokesperson Preparation Planning the ...

76 FR 60494 - Patient Safety Organizations: Voluntary Relinquishment From HPI-PSO

Science.gov (United States)

2011-09-29

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety... a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient... delivery. The Patient Safety and Quality Improvement Final Rule (Patient Safety Rule), 42 CFR Part 3...

The Automation-by-Expertise-by-Training Interaction.

Science.gov (United States)

Strauch, Barry

2017-03-01

I introduce the automation-by-expertise-by-training interaction in automated systems and discuss its influence on operator performance. Transportation accidents that, across a 30-year interval demonstrated identical automation-related operator errors, suggest a need to reexamine traditional views of automation. I review accident investigation reports, regulator studies, and literature on human computer interaction, expertise, and training and discuss how failing to attend to the interaction of automation, expertise level, and training has enabled operators to commit identical automation-related errors. Automated systems continue to provide capabilities exceeding operators' need for effective system operation and provide interfaces that can hinder, rather than enhance, operator automation-related situation awareness. Because of limitations in time and resources, training programs do not provide operators the expertise needed to effectively operate these automated systems, requiring them to obtain the expertise ad hoc during system operations. As a result, many do not acquire necessary automation-related system expertise. Integrating automation with expected operator expertise levels, and within training programs that provide operators the necessary automation expertise, can reduce opportunities for automation-related operator errors. Research to address the automation-by-expertise-by-training interaction is needed. However, such research must meet challenges inherent to examining realistic sociotechnical system automation features with representative samples of operators, perhaps by using observational and ethnographic research. Research in this domain should improve the integration of design and training and, it is hoped, enhance operator performance.

Fundamentals of a patient safety program

International Nuclear Information System (INIS)

Frush, Karen S.

2008-01-01

Thousands of people are injured or die from medical errors and adverse events each year, despite being cared for by hard-working, intelligent and well-intended health care professionals, working in the highly complex and high-risk environment of the American health care system. Patient safety leaders have described a need for health care organizations to make error prevention a major strategic objective while at the same time recognizing the importance of transforming the traditional health care culture. In response, comprehensive patient safety programs have been developed with the aim of reducing medical errors and adverse events and acting as a catalyst in the development of a culture of safety. Components of these programs are described, with an emphasis on strategies to improve pediatric patient safety. Physicians, as leaders of the health care team, have a unique opportunity to foster the culture and commitment required to address the underlying systems causes of medical error and harm. (orig.)

Patient safety and nutrition: is there a connection? | Nieuwoudt ...

African Journals Online (AJOL)

Nutrition care is not always recognised as a patient safety issue. This article explores the origins of the patient safety initiative and seeks to identify possible connections between nutrition care and patient safety. Examples of tools that can be used to improve the safety of nutrition care are provided. This is also a call to action ...

Patient safety improvement programmes for primary care. Review of a Delphi procedure and pilot studies by the LINNEAUS collaboration on patient safety in primary care

Science.gov (United States)

Verstappen, Wim; Gaal, Sander; Esmail, Aneez; Wensing, Michel

2015-01-01

ABSTRACT Background: To improve patient safety it is necessary to identify the causes of patient safety incidents, devise solutions and measure the (cost-) effectiveness of improvement efforts. Objective: This paper provides a broad overview with practical guidance on how to improve patient safety. Methods: We used modified online Delphi procedures to reach consensus on methods to improve patient safety and to identify important features of patient safety management in primary care. Two pilot studies were carried out to assess the value of prospective risk analysis (PRA), as a means of identifying the causes of a patient safety incident. Results: A range of different methods can be used to improve patient safety but they have to be contextually specific. Practice organization, culture, diagnostic errors and medication safety were found to be important domains for further improvement. Improvement strategies for patient safety could benefit from insights gained from research on implementation of evidence-based practice. Patient involvement and prospective risk analysis are two promising and innovative strategies for improving patient safety in primary care. Conclusion: A range of methods is available to improve patient safety, but there is no ‘magic bullet.’ Besides better use of the available methods, it is important to use new and potentially more effective strategies, such as prospective risk analysis. PMID:26339837

Dimensions of patient safety culture in family practice.

Science.gov (United States)

Palacios-Derflingher, Luz; O'Beirne, Maeve; Sterling, Pam; Zwicker, Karen; Harding, Brianne K; Casebeer, Ann

2010-01-01

Safety culture has been shown to affect patient safety in healthcare. While the United States and United Kingdom have studied the dimensions that reflect patient safety culture in family practice settings, to date, this has not been done in Canada. Differences in the healthcare systems between these countries and Canada may affect the dimensions found to be relevant here. Thus, it is important to identify and compare the dimensions from the United States and the United Kingdom in a Canadian context. The objectives of this study were to explore the dimensions of patient safety culture that relate to family practice in Canada and to determine if differences and similarities exist between dimensions found in Canada and those found in previous studies undertaken in the United States and the United Kingdom. A qualitative study was undertaken applying thematic analysis using focus groups with family practice offices and supplementary key stakeholders. Analysis of the data indicated that most of the dimensions from the United States and United Kingdom are appropriate in our Canadian context. Exceptions included owner/managing partner/leadership support for patient safety, job satisfaction and overall perceptions of patient safety and quality. Two unique dimensions were identified in the Canadian context: disclosure and accepting responsibility for errors. Based on this early work, it is important to consider differences in care settings when understanding dimensions of patient safety culture. We suggest that additional research in family practice settings is critical to further understand the influence of context on patient safety culture.

The paradox of scientific expertise

DEFF Research Database (Denmark)

Alrøe, Hugo Fjelsted; Noe, Egon

2011-01-01

Modern societies depend on a growing production of scientific knowledge, which is based on the functional differentiation of science into still more specialised scientific disciplines and subdisciplines. This is the basis for the paradox of scientific expertise: The growth of science leads to a f...... cross-disciplinary research and in the collective use of different kinds of scientific expertise, and thereby make society better able to solve complex, real-world problems.......Modern societies depend on a growing production of scientific knowledge, which is based on the functional differentiation of science into still more specialised scientific disciplines and subdisciplines. This is the basis for the paradox of scientific expertise: The growth of science leads...... to a fragmentation of scientific expertise. To resolve this paradox, the present paper investigates three hypotheses: 1) All scientific knowledge is perspectival. 2) The perspectival structure of science leads to specific forms of knowledge asymmetries. 3) Such perspectival knowledge asymmetries must be handled...

77 FR 42738 - Patient Safety Organizations: Voluntary Relinquishment From the Coalition for Quality and Patient...

Science.gov (United States)

2012-07-20

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety Organizations: Voluntary Relinquishment From the Coalition for Quality and Patient Safety of Chicagoland (CQPS.... SUMMARY: The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41,42...

Patient safety trilogy: perspectives from clinical engineering.

Science.gov (United States)

Gieras, Izabella; Sherman, Paul; Minsent, Dennis

2013-01-01

This article examines the role a clinical engineering or healthcare technology management (HTM) department can play in promoting patient safety from three different perspectives: a community hospital, a national government health system, and an academic medical center. After a general overview, Izabella Gieras from Huntington Hospital in Pasadena, CA, leads off by examining the growing role of human factors in healthcare technology, and describing how her facility uses clinical simulations in medical equipment evaluations. A section by Paul Sherman follows, examining patient safety initiatives from the perspective of the Veterans Health Administration with a focus on hazard alerts and recalls. Dennis Minsent from Oregon Health & Science University writes about patient safety from an academic healthcare perspective, and details how clinical engineers can engage in multidisciplinary safety opportunities.

Expertise and Intuitions about Reference

Directory of Open Access Journals (Sweden)

Edouard Machery

2012-01-01

Full Text Available Many philosophers hold that experts’ semantic intuitions are more reliable and provide better evidence than lay people’s intuitions—a thesis commonly called “the Expertise Defense.” Focusing on the intuitions about the reference of proper names, this article critically assesses the Expertise Defense.

Digital gaming expertise

DEFF Research Database (Denmark)

Toft-Nielsen, Claus

In a digitally saturated environment digital media users of all kinds, engaged in different areas of activity, are increasingly categorized in terms of their ability to appropriate and use digital media – they are regarded as non-users, experts, natives, or literates for instance. Within communic......In a digitally saturated environment digital media users of all kinds, engaged in different areas of activity, are increasingly categorized in terms of their ability to appropriate and use digital media – they are regarded as non-users, experts, natives, or literates for instance. Within...... communication and game studies there are multiple understandings of how digital expertise is expressed and performed, and subsequently how these expressions and performances can be valued, understood and theorized within the research community. Among other things expertise with and within digital games has......-of-game (Schrøder, 2003) in a three-year-long study of men and women (couples and singles) playing the largest Massively Multiplayer Online Role-Playing Game to date, World of Warcraft. In focusing on how different aspects of gaming expertise are articulated, negotiated, and performed, I aim to illustrate how...

42 CFR 3.208 - Continued protection of patient safety work product.

Science.gov (United States)

2010-10-01

... 42 Public Health 1 2010-10-01 2010-10-01 false Continued protection of patient safety work product... GENERAL PROVISIONS PATIENT SAFETY ORGANIZATIONS AND PATIENT SAFETY WORK PRODUCT Confidentiality and Privilege Protections of Patient Safety Work Product § 3.208 Continued protection of patient safety work...

Technical safety Organisations (TSO) contribute to European Nuclear Safety

International Nuclear Information System (INIS)

Repussard, J.

2010-01-01

Nuclear safety and radiation protection rely on science to achieve high level prevention objectives, through the analysis of safety files proposed by the licensees. The necessary expertise needs to be exercised so as to ensure adequate independence from nuclear operators, appropriate implementation of state of the art knowledge, and a broad spectrum of analysis, adequately ranking the positive and negative points of the safety files. The absence of a Europe-wide nuclear safety regime is extremely costly for an industry which has to cope with a highly competitive and open international environment, but has to comply with fragmented national regulatory systems. Harmonization is therefore critical, but such a goal is difficult to achieve. Only a gradual policy, made up of planned steps in each of the three key dimensions of the problem (energy policy at EU level, regulatory harmonization, consolidation of Europe-wide technical expertise capability) can be successful to achieve the required integration on the basis of the highest safety levels. TSO's contribute to this consolidation, with the support of the EC, in the fields of research (EURATOM-Programmes), of experience feedback analysis (European Clearinghouse), of training and knowledge management (European Training and Tutoring Institute, EUROSAFE). The TSO's network, ETSON, is becoming a formal organisation, able to enter into formal dialogue with EU institutions. However, nuclear safety nevertheless remains a world wide issue, requiring intensive international cooperation, including on TSO issues. (author)

A patient safety objective structured clinical examination.

Science.gov (United States)

Singh, Ranjit; Singh, Ashok; Fish, Reva; McLean, Don; Anderson, Diana R; Singh, Gurdev

2009-06-01

There are international calls for improving education for health care workers around certain core competencies, of which patient safety and quality are integral and transcendent parts. Although relevant teaching programs have been developed, little is known about how best to assess their effectiveness. The objective of this work was to develop and implement an objective structured clinical examination (OSCE) to evaluate the impact of a patient safety curriculum. The curriculum was implemented in a family medicine residency program with 47 trainees. Two years after commencing the curriculum, a patient safety OSCE was developed and administered at this program and, for comparison purposes, to incoming residents at the same program and to residents at a neighboring residency program. All 47 residents exposed to the training, all 16 incoming residents, and 10 of 12 residents at the neighboring program participated in the OSCE. In a standardized patient case, error detection and error disclosure skills were better among trained residents. In a chart-based case, trained residents showed better performance in identifying deficiencies in care and described more appropriate means of addressing them. Third year residents exposed to a "Systems Approach" course performed better at system analysis and identifying system-based solutions after the course than before. Results suggest increased systems thinking and inculcation of a culture of safety among residents exposed to a patient safety curriculum. The main weaknesses of the study are its small size and suboptimal design. Much further investigation is needed into the effectiveness of patient safety curricula.

From Safe Systems to Patient Safety

DEFF Research Database (Denmark)

Aarts, J.; Nøhr, C.

2010-01-01

for the third conference with the theme: The ability to design, implement and evaluate safe, useable and effective systems within complex health care organizations. The theme for this conference was "Designing and Implementing Health IT: from safe systems to patient safety". The contributions have reflected...... and implementation of safe systems and thus contribute to the agenda of patient safety? The contributions demonstrate how the health informatics community has contributed to the performance of significant research and to translating research findings to develop health care delivery and improve patient safety......This volume presents the papers from the fourth International Conference on Information Technology in Health Care: Socio-technical Approaches held in Aalborg, Denmark in June 2010. In 2001 the first conference was held in Rotterdam, The Netherlands with the theme: Sociotechnical' approaches...

Are long physician working hours harmful to patient safety?

Science.gov (United States)

Ehara, Akira

2008-04-01

Pediatricians of Japanese hospitals including not only residents but also attending physicians work long hours, and 8% work for >79 h per week. Most of them work consecutively for >or=32 h when they are on call. The aim of the present study was to evaluate the effect of long work hours on patient safety. The electronic databases MEDLINE and EMBASE to searched identify the English- and Japanese-language literature for studies on work hours, medical errors, patient safety, and malpractice for years 1966-2005. Studies that analyzed the relationship between physician work hours and outcomes directly related to patient safety were selected. Seven studies met the criteria. Four studies suggest that reduction of work hours has a favorable effect on patient safety indicators. In the other three studies no significant changes of the indicators were observed, but no report found that shorter work hours were harmful to patient safety. Decrease of physician work hours is not harmful but favorable to patient safety.

Ethical issues in patient safety: Implications for nursing management.

Science.gov (United States)

Kangasniemi, Mari; Vaismoradi, Mojtaba; Jasper, Melanie; Turunen, Hannele

2013-12-01

The purpose of this article is to discuss the ethical issues impacting the phenomenon of patient safety and to present implications for nursing management. Previous knowledge of this perspective is fragmented. In this discussion, the main drivers are identified and formulated in 'the ethical imperative' of patient safety. Underlying values and principles are considered, with the aim of increasing their visibility for nurse managers' decision-making. The contradictory nature of individual and utilitarian safety is identified as a challenge in nurse management practice, together with the context of shared responsibility and identification of future challenges. As a conclusion, nurse managers play a strategic role in patient safety. Their role is to incorporate ethical values of patient safety into decision-making at all levels in an organization, and also to encourage clinical nurses to consider values in the provision of care to patients. Patient safety that is sensitive to ethics provides sustainable practice where the humanity and dignity of all stakeholders are respected.

Flight nursing expertise: towards a middle-range theory

Science.gov (United States)

Reimer, Andrew P.; Moore, Shirley M.

2010-01-01

Aim This paper presents a middle-range Theory of Flight Nursing Expertise. Background Rotary-wing (helicopter) medical transport has grown rapidly in the USA since its introduction, particularly during the past 5 years. Patients once considered too sick to transport are now being transported more frequently and over longer distances. Many limitations are imposed by the air medical transport environment and these require nurses to alter their practice. Data sources A literature search was conducted using Pubmed, Medline, CINAHL, secondary referencing and an Internet search from 1960 to 2008 for studies related to the focal concepts in flight nursing. Discussion The middle-range Theory of Flight Nursing Expertise is composed of nine concepts (experience, training, transport environment of care, psychomotor skills, flight nursing knowledge, cue recognition, pattern recognition, decision-making and action) and their relationships. Five propositions describe the relationships between those concepts and how they apply to flight nursing expertise. Implications for nursing After empirical testing, this theory may be a useful tool to assist novice flight nurses to attain the skills necessary to provide safe and competent care more efficiently, and may aid in designing curricula and programmes of research. Conclusion Research is needed to determine the usefulness of this theory in both rotary and fixed-wing medical transport settings, and to examine the similarities and differences related to expertise needed for different flight nurse team compositions. Curriculum and training innovations can result from increased understanding of the concepts and relationships proposed in this theory. PMID:20337803

Global reach: Red Deer oilfield expertise, not least in taming disasters, lures international clientele

Energy Technology Data Exchange (ETDEWEB)

Lorenz, A.

2002-10-07

The rise to international prominence of two Red Deer, Alberta, firms --Safety Boss and Red Flame -- by performing heroic feats in Kuwait's flaming oil fields, are chronicled. These two firms, along with several others in Red Deer, provide expertise in fire fighting that is sought after by petroleum companies in the farthest corners of the world. Red Deer companies can be found training Kazakhs, Russians, Kuwaitis, Iranians, and Turkmen in fighting oil well fires. Red Flame, for example developed a method called 'hot-tapping' while fighting blazing oil well fires in Kuwait, which they have since extended by developing hot-tapping equipment that would work on the highest pressure wells in the world. Last summer Red Flame personnel trained a Schlumberger crew in Kazakhstan working on custom-designed equipment that could perform at pressures of 5,000 psi. Red Flame also designed 'extended reach' hot-tapping in response to a request from Petro-Canada. Meanwhile, Safety Boss, the oldest and best known oil well fire fighting company in Canada, boasts of having extinguished 180 wells in their 1991 stint in Kuwait, while their closest competitor, Texas-based Wild Well, doused only 117. With improved safety policies and procedures the number of oil well blow-outs diminished dramatically in recent years, but there are always opportunities for the Red Deer expertise somewhere around the world.

S-TEAMS: A Truly Multiprofessional Course Focusing on Nontechnical Skills to Improve Patient Safety in the Operating Theater.

Science.gov (United States)

Stewart-Parker, Emma; Galloway, Robert; Vig, Stella

Possessing adequate nontechnical skills (NTS) in operating theaters is of increasing interest to health care professionals, yet these are rarely formally taught. Teams make human errors despite technical expertise and knowledge, compromising patient safety. We designed a 1-day, multiprofessional, multidisciplinary course to teach, practice, and apply these skills through simulation. The course, "S-TEAMS," comprised a morning of lectures, case studies, and interactive teamworking exercises. The afternoon divided the group into multiprofessional teams to rotate around simulated scenarios. During the scenarios, teams were encouraged to focus on NTS, including communication strategies, situational awareness, and prompts such as checklists. A thorough debrief with experienced clinician observers followed. Data was collected through self-assessments, immediate and 6-month feedback to assess whether skills continued to be used and their effect on safety. In total, 68 health care professionals have completed the course thus far. All participants felt the course had a clear structure and that learning objectives were explicit. Overall, 95% felt the scenarios had good or excellent relevance to clinical practice. Self-assessments revealed a 55% increase in confidence for "speaking up" in difficult situations. Long-term data revealed 97% of the participants continued to use the skills, with 88% feeling the course had prevented them from making errors. Moreover, 94% felt the course had directly improved patient safety. There is a real demand and enthusiasm for developing NTS within the modern theater team. The simple and easily reproducible format of S-TEAMS is sustainable and inclusive, and crucially, the skills taught continue to be used in long term to improve patient safety and teamworking. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Influence of workplace demands on nurses' perception of patient safety.

Science.gov (United States)

Ramanujam, Rangaraj; Abrahamson, Kathleen; Anderson, James G

2008-06-01

Patient safety is an ongoing challenge in the design and delivery of health-care services. As registered nurses play an integral role in patient safety, further examination of the link between nursing work and patient safety is warranted. The present study examines the relationship between nurses' perceptions of job demands and nurses' perceptions of patient safety. Structural equation modeling is used to analyze the data collected from a survey of 430 registered nurses at two community hospitals in the USA. As hypothesized, nurses' perception of patient safety decreases as the job demands increase. The level of personal control over practice directly affects nurses' perception of the ability to assure patient well-being. Nurses who work full-time and are highly educated have a decreased perception of patient safety, as well. The significant relationship between job demands and patient safety confirms that nurses make a connection between their working conditions and the ability to deliver safe care.

Collaborating with nurse leaders to develop patient safety practices.

Science.gov (United States)

Kanerva, Anne; Kivinen, Tuula; Lammintakanen, Johanna

2017-07-03

Purpose The organisational level and leadership development are crucial elements in advancing patient safety, because patient safety weaknesses are often caused by system failures. However, little is known about how frontline leader and director teams can be supported to develop patient safety practices. The purpose of this study is to describe the patient safety development process carried out by nursing leaders and directors. The research questions were: how the chosen development areas progressed in six months' time and how nursing leaders view the participatory development process. Design/methodology/approach Participatory action research was used to engage frontline nursing leaders and directors into developing patient safety practices. Semi-structured group interviews ( N = 10) were used in data collection at the end of a six-month action cycle, and data were analysed using content analysis. Findings The participatory development process enhanced collaboration and gave leaders insights into patient safety as a part of the hospital system and their role in advancing it. The chosen development areas advanced to different extents, with the greatest improvements in those areas with simple guidelines to follow and in which the leaders were most participative. The features of high-reliability organisation were moderately identified in the nursing leaders' actions and views. For example, acting as a change agent to implement patient safety practices was challenging. Participatory methods can be used to support leaders into advancing patient safety. However, it is important that the participants are familiar with the method, and there are enough facilitators to steer development processes. Originality/value Research brings more knowledge of how leaders can increase their effectiveness in advancing patient safety and promoting high-reliability organisation features in the healthcare organisation.

Assessing the relationship between patient safety culture and EHR strategy.

Science.gov (United States)

Ford, Eric W; Silvera, Geoffrey A; Kazley, Abby S; Diana, Mark L; Huerta, Timothy R

2016-07-11

Purpose - The purpose of this paper is to explore the relationship between hospitals' electronic health record (EHR) adoption characteristics and their patient safety cultures. The "Meaningful Use" (MU) program is designed to increase hospitals' adoption of EHR, which will lead to better care quality, reduce medical errors, avoid unnecessary cost, and promote a patient safety culture. To reduce medical errors, hospital leaders have been encouraged to promote safety cultures common to high-reliability organizations. Expecting a positive relationship between EHR adoption and improved patient safety cultures appears sound in theory, but it has yet to be empirically demonstrated. Design/methodology/approach - Providers' perceptions of patient safety culture and counts of patient safety incidents are explored in relationship to hospital EHR adoption patterns. Multi-level modeling is employed to data drawn from the Agency for Healthcare Research and Quality's surveys on patient safety culture (level 1) and the American Hospital Association's survey and healthcare information technology supplement (level 2). Findings - The findings suggest that the early adoption of EHR capabilities hold a negative association to the number of patient safety events reported. However, this relationship was not present in providers' perceptions of overall patient safety cultures. These mixed results suggest that the understanding of the EHR-patient safety culture relationship needs further research. Originality/value - Relating EHR MU and providers' care quality attitudes is an important leading indicator for improved patient safety cultures. For healthcare facility managers and providers, the ability to effectively quantify the impact of new technologies on efforts to change organizational cultures is important for pinpointing clinical areas for process improvements.

Patient Safety, Present and Future

International Nuclear Information System (INIS)

Amalberti, R.

2016-01-01

Health care tends to oversimplify patient safety concepts. We tend to think about patient safety as a linear dimension that is only associated with the progressive reduction in the number of errors and accidents, with the simple notion that fewer are always better. We consider figures in isolation from the underlying context and prerequisites that drive safety models and the reality of the clinical fields. There is no one ultimate reference model of safety, but many models that can be adapted to fit the various clinical fields requirements and constraints. It is therefore not necessarily a bad result to observe a lower safety figure in a medical domain compared to the figures obtained in nonmedical ultra-safe models. The poor figures may represent the best local safety optimization while coping with the special health care requirements such as a high frequency of unplanned and nonstandard challenges. The paper distinguishes three classes of safety models that fit different field demands: the resilient and adaptive model, the high reliability (HRO) model, and the ultra-safe model. The lecture benchmarks the traits of each model while highlighting the specific dimensions for optimization. The conclusion is that firstly, that since the task requirements dictate the relevance and choice of the model and not the other way around, it is counterproductive to impose a model that is inadequate for the task requirements. Either you move the requirements and change the model, or you keep the constraints, and try to locally optimize the model to the clinical and organizational needs. (author)

21 CFR 312.88 - Safeguards for patient safety.

Science.gov (United States)

2010-04-01

... 21 Food and Drugs 5 2010-04-01 2010-04-01 false Safeguards for patient safety. 312.88 Section 312... Severely-debilitating Illnesses § 312.88 Safeguards for patient safety. All of the safeguards incorporated within parts 50, 56, 312, 314, and 600 of this chapter designed to ensure the safety of clinical testing...

Teamwork, organizational learning, patient safety and job outcomes.

Science.gov (United States)

Goh, Swee C; Chan, Christopher; Kuziemsky, Craig

2013-01-01

This article aims to encourage healthcare administrators to consider the learning organization concept and foster collaborative learning among teams in their attempt to improve patient safety. Relevant healthcare, organizational behavior and human resource management literature was reviewed. A patient safety culture, fostered by healthcare leaders, should include an organizational culture that encourages collaborative learning, replaces the blame culture, prioritizes patient safety and rewards individuals who identify serious mistakes. As healthcare institution staffs are being asked to deliver more complex medical services with fewer resources, there is a need to understand how hospital staff can learn from other organizational settings, especially the non-healthcare sectors. The paper provides suggestions for improving patient safety which are drawn from the health and business management literature.

Patient Drug Safety Reporting: Diabetes Patients' Perceptions of Drug Safety and How to Improve Reporting of Adverse Events and Product Complaints.

Science.gov (United States)

Patel, Puja; Spears, David; Eriksen, Betina Østergaard; Lollike, Karsten; Sacco, Michael

2018-03-01

Global health care manufacturer Novo Nordisk commissioned research regarding awareness of drug safety department activities and potential to increase patient feedback. Objectives were to examine patients' knowledge of pharmaceutical manufacturers' responsibilities and efforts regarding drug safety, their perceptions and experiences related to these efforts, and how these factors influence their thoughts and behaviors. Data were collected before and after respondents read a description of a drug safety department and its practices. We conducted quantitative survey research across 608 health care consumers receiving treatment for diabetes in the United States, Germany, United Kingdom, and Italy. This research validated initial, exploratory qualitative research (across 40 comparable consumers from the same countries) which served to guide design of the larger study. Before reading a drug safety department description, 55% of respondents were unaware these departments collect safety information on products and patients. After reading the description, 34% reported the department does more than they expected to ensure drug safety, and 56% reported "more confidence" in the industry as a whole. Further, 66% reported themselves more likely to report an adverse event or product complaint, and 60% reported that they were more likely to contact a drug safety department with questions. The most preferred communication methods were websites/online forums (39%), email (27%), and telephone (25%). Learning about drug safety departments elevates consumers' confidence in manufacturers' safety efforts and establishes potential for patients to engage in increased self-monitoring and reporting. Study results reveal potentially actionable insights for the industry across patient and physician programs and communications.

Electronic health records and patient safety: co-occurrence of early EHR implementation with patient safety practices in primary care settings.

Science.gov (United States)

Tanner, C; Gans, D; White, J; Nath, R; Pohl, J

2015-01-01

The role of electronic health records (EHR) in enhancing patient safety, while substantiated in many studies, is still debated. This paper examines early EHR adopters in primary care to understand the extent to which EHR implementation is associated with the workflows, policies and practices that promote patient safety, as compared to practices with paper records. Early adoption is defined as those who were using EHR prior to implementation of the Meaningful Use program. We utilized the Physician Practice Patient Safety Assessment (PPPSA) to compare primary care practices with fully implemented EHR to those utilizing paper records. The PPPSA measures the extent of adoption of patient safety practices in the domains: medication management, handoffs and transition, personnel qualifications and competencies, practice management and culture, and patient communication. Data from 209 primary care practices responding between 2006-2010 were included in the analysis: 117 practices used paper medical records and 92 used an EHR. Results showed that, within all domains, EHR settings showed significantly higher rates of having workflows, policies and practices that promote patient safety than paper record settings. While these results were expected in the area of medication management, EHR use was also associated with adoption of patient safety practices in areas in which the researchers had no a priori expectations of association. Sociotechnical models of EHR use point to complex interactions between technology and other aspects of the environment related to human resources, workflow, policy, culture, among others. This study identifies that among primary care practices in the national PPPSA database, having an EHR was strongly empirically associated with the workflow, policy, communication and cultural practices recommended for safe patient care in ambulatory settings.

Science, expertise, and democracy.

Science.gov (United States)

Weinberg, Justin; Elliott, Kevin C

2012-06-01

The combination of government's significant involvement in science, science's significant effects on the public, and public ignorance (of both politics and science) raise important challenges for reconciling scientific expertise with democratic governance. Nevertheless, there have recently been a variety of encouraging efforts to make scientific activity more responsive to social values and to develop citizens' capacity to engage in more effective democratic governance of science. This essay introduces a special issue of the Kennedy Institute of Ethics Journal, "Science, Expertise, and Democracy," consisting of five papers that developed from the inaugural Three Rivers Philosophy conference held at the University of South Carolina in April 2011. The pieces range from a general analysis of the in-principle compatibility of scientific expertise and democracy to much more concrete studies of the intersection between scientific practices and democratic values in areas such as weight-of-evidence analysis, climate science, and studies of locally undesirable land uses.

The relationship between patient safety climate and occupational safety climate in healthcare - A multi-level investigation.

Science.gov (United States)

Pousette, Anders; Larsman, Pernilla; Eklöf, Mats; Törner, Marianne

2017-06-01

Patient safety climate/culture is attracting increasing research interest, but there is little research on its relation with organizational climates regarding other target domains. The aim of this study was to investigate the relationship between patient safety climate and occupational safety climate in healthcare. The climates were assessed using two questionnaires: Hospital Survey on Patient Safety Culture and Nordic Occupational Safety Climate Questionnaire. The final sample consisted of 1154 nurses, 886 assistant nurses, and 324 physicians, organized in 150 work units, within hospitals (117units), primary healthcare (5units) and elderly care (28units) in western Sweden, which represented 56% of the original sample contacted. Within each type of safety climate, two global dimensions were confirmed in a higher order factor analysis; one with an external focus relative the own unit, and one with an internal focus. Two methods were used to estimate the covariation between the global climate dimensions, in order to minimize the influence of bias from common method variance. First multilevel analysis was used for partitioning variances and covariances in a within unit part (individual level) and a between unit part (unit level). Second, a split sample technique was used to calculate unit level correlations based on aggregated observations from different respondents. Both methods showed associations similar in strength between the patient safety climate and the occupational safety climate domains. The results indicated that patient safety climate and occupational safety climate are strongly positively related at the unit level, and that the same organizational processes may be important for the development of both types of organizational climate. Safety improvement interventions should not be separated in different organizational processes, but be planned so that both patient safety and staff safety are considered concomitantly. Copyright © 2017 National Safety

Expertise seeking

DEFF Research Database (Denmark)

Hertzum, Morten

2014-01-01

used sources. Studies repeatedly show the influence of the social network – of friendships and personal dislikes – on the expertise-seeking network of organisations. In addition, people are no less prominent than documentary sources, in work contexts as well as daily-life contexts. The relative...

Teacher expertise

DEFF Research Database (Denmark)

Rasmussen, Jens

Teacher Expertise: How to improve the relationship between Theory and Practice in Teacher Education Jens Rasmussen, Department of Education, Aarhus University In several studies and reports it has been nailed over and over that teachers’ matter. So this is not the question in this study. The ques......Teacher Expertise: How to improve the relationship between Theory and Practice in Teacher Education Jens Rasmussen, Department of Education, Aarhus University In several studies and reports it has been nailed over and over that teachers’ matter. So this is not the question in this study....... The question is how teacher preparation leads to effective teachers. The study Expert in Teaching paid special attention to the intention of connecting coursework more directly to practice in pre-service teacher education. The overall objective of the study was to strengthen the relationship between theory...... that the three parties (college teachers, practice teachers and teacher students) found it difficult to perform and maintain their different roles....

Beyond Faces and Expertise: Facelike Holistic Processing of Nonface Objects in the Absence of Expertise.

Science.gov (United States)

Zhao, Mintao; Bülthoff, Heinrich H; Bülthoff, Isabelle

2016-02-01

Holistic processing-the tendency to perceive objects as indecomposable wholes-has long been viewed as a process specific to faces or objects of expertise. Although current theories differ in what causes holistic processing, they share a fundamental constraint for its generalization: Nonface objects cannot elicit facelike holistic processing in the absence of expertise. Contrary to this prevailing view, here we show that line patterns with salient Gestalt information (i.e., connectedness, closure, and continuity between parts) can be processed as holistically as faces without any training. Moreover, weakening the saliency of Gestalt information in these patterns reduced holistic processing of them, which indicates that Gestalt information plays a crucial role in holistic processing. Therefore, holistic processing can be achieved not only via a top-down route based on expertise, but also via a bottom-up route relying merely on object-based information. The finding that facelike holistic processing can extend beyond the domains of faces and objects of expertise poses a challenge to current dominant theories. © The Author(s) 2015.

[Innovative training for enhancing patient safety. Safety culture and integrated concepts].

Science.gov (United States)

Rall, M; Schaedle, B; Zieger, J; Naef, W; Weinlich, M

2002-11-01

Patient safety is determined by the performance safety of the medical team. Errors in medicine are amongst the leading causes of death of hospitalized patients. These numbers call for action. Backgrounds, methods and new forms of training are introduced in this article. Concepts from safety research are transformed to the field of emergency medical treatment. Strategies from realistic patient simulator training sessions and innovative training concepts are discussed. The reasons for the high numbers of errors in medicine are not due to a lack of medical knowledge, but due to human factors and organisational circumstances. A first step towards an improved patient safety is to accept this. We always need to be prepared that errors will occur. A next step would be to separate "error" from guilt (culture of blame) allowing for a real analysis of accidents and establishment of meaningful incident reporting systems. Concepts with a good success record from aviation like "crew resource management" (CRM) training have been adapted my medicine and are ready to use. These concepts require theoretical education as well as practical training. Innovative team training sessions using realistic patient simulator systems with video taping (for self reflexion) and interactive debriefing following the sessions are very promising. As the need to reduce error rates in medicine is very high and the reasons, methods and training concepts are known, we are urged to implement these new training concepts widely and consequently. To err is human - not to counteract it is not.

Powering Ideas through Expertise

DEFF Research Database (Denmark)

Seabrooke, Leonard; Wigan, Duncan

2016-01-01

policy. Corporate reporting for tax purposes is an area where the European Union, Organization for Economic Co-operation and Development, the United Nations, large global accountancy firms and non-governmental organizations have been active. The point of contention here is what form of financial...... reporting multinational corporations should provide to ensure they pay their fair share of tax. Ideas powered by expertise contain shared causal beliefs, as well as principled beliefs about value systems. We demonstrate that professionals can contest the established order when demonstrations of expertise...

The complexity of patient safety reporting systems in UK dentistry.

Science.gov (United States)

Renton, T; Master, S

2016-10-21

Since the 'Francis Report', UK regulation focusing on patient safety has significantly changed. Healthcare workers are increasingly involved in NHS England patient safety initiatives aimed at improving reporting and learning from patient safety incidents (PSIs). Unfortunately, dentistry remains 'isolated' from these main events and continues to have a poor record for reporting and learning from PSIs and other events, thus limiting improvement of patient safety in dentistry. The reasons for this situation are complex.This paper provides a review of the complexities of the existing systems and procedures in relation to patient safety in dentistry. It highlights the conflicting advice which is available and which further complicates an overly burdensome process. Recommendations are made to address these problems with systems and procedures supporting patient safety development in dentistry.

Evaluation and Customization of WHO Safety Checklist for Patient Safety in Otorhinolaryngology.

Science.gov (United States)

Dabholkar, Yogesh; Velankar, Haritosh; Suryanarayan, Sneha; Dabholkar, Twinkle Y; Saberwal, Akanksha A; Verma, Bhavika

2018-03-01

The WHO has designed a safe surgery checklist to enhance communication and awareness of patient safety during surgery and to minimise complications. WHO recommends that the check-list be evaluated and customised by end users as a tool to promote safe surgery. The aim of present study was to evaluate the impact of WHO safety checklist on patient safety awareness in otorhinolaryngology and to customise it for the speciality. A prospective structured questionnaire based study was done in ENT operating room for duration of 1 month each for cases, before and after implementation of safe surgery checklist. The feedback from respondents (surgeons, nurses and anaesthetists) was used to arrive at a customised checklist for otolaryngology as per WHO guidelines. The checklist significantly improved team member's awareness of patient's identity (from 17 to 86%) and each other's identity and roles (from 46 to 94%) and improved team communication (from 73 to 92%) in operation theatre. There was a significant improvement in preoperative check of equipment and critical events were discussed more frequently. The checklist could be effectively customised to suit otolaryngology needs as per WHO guidelines. The modified checklist needs to be validated by otolaryngology associations. We conclude from our study that the WHO Surgical safety check-list has a favourable impact on patient safety awareness, team-work and communication of operating team and can be customised for otolaryngology setting.

Validating the Danish adaptation of the World Health Organization's International Classification for Patient Safety classification of patient safety incident types

DEFF Research Database (Denmark)

Mikkelsen, Kim Lyngby; Thommesen, Jacob; Andersen, Henning Boje

2013-01-01

Objectives Validation of a Danish patient safety incident classification adapted from the World Health Organizaton's International Classification for Patient Safety (ICPS-WHO). Design Thirty-three hospital safety management experts classified 58 safety incident cases selected to represent all types.......513 (range: 0.193–0.804). Kappa and ICC showed high correlation (r = 0.99). An inverse correlation was found between the prevalence of type and inter-rater reliability. Results are discussed according to four factors known to determine the inter-rater agreement: skill and motivation of raters; clarity...

Latest expertise investigations in nuclear dismantling and industrial applications

International Nuclear Information System (INIS)

Gallozzi Ulmann, Adrien; Chazalet, Julien; Couturier, Pierre; Touzain, Etienne; Amgarou, Khalil; Menaa, Nabil

2013-06-01

During the last decades, CANBERRA has developed know-how, expertise and intervention strategies based on its feedback experiences in many countries. This document covers a wide range of applications involving nuclear characterization, for which CANBERRA is able to provide measurement set-up and results, activity characterization and radioactive source localization, as well as to guarantee safety or process thresholds corresponding to the customer's needs. To improve processes best-in-class methodology, know-how and tools have been used in complex examples described in this paper. CANBERRA has demonstrated its ability to better and efficiently prepare for and execute decontamination and dismantling activities. (authors)

Using safety crosses for patient self-reflection.

Science.gov (United States)

Silverton, Sarah

The Productive Mental Health Ward programme has been developed to improve efficiency and safety in the NHS. Patients in a medium-secure mental health unit used patient safety crosses as a tool for self-reflection as part of their recovery journey. This article describes how the project was set up as well as initial findings.

Improving patient safety in radiation oncology

International Nuclear Information System (INIS)

Hendee, William R.; Herman, Michael G.

2011-01-01

Beginning in the 1990s, and emphasized in 2000 with the release of an Institute of Medicine report, healthcare providers and institutions have dedicated time and resources to reducing errors that impact the safety and well-being of patients. But in January 2010 the first of a series of articles appeared in the New York Times that described errors in radiation oncology that grievously impacted patients. In response, the American Association of Physicists in Medicine and the American Society of Radiation Oncology sponsored a working meeting entitled ''Safety in Radiation Therapy: A Call to Action''. The meeting attracted 400 attendees, including medical physicists, radiation oncologists, medical dosimetrists, radiation therapists, hospital administrators, regulators, and representatives of equipment manufacturers. The meeting was cohosted by 14 organizations in the United States and Canada. The meeting yielded 20 recommendations that provide a pathway to reducing errors and improving patient safety in radiation therapy facilities everywhere.

Knowledge Representation in Patient Safety Reporting: An Ontological Approach

Directory of Open Access Journals (Sweden)

Liang Chen

2016-10-01

Full Text Available Purpose: The current development of patient safety reporting systems is criticized for loss of information and low data quality due to the lack of a uniformed domain knowledge base and text processing functionality. To improve patient safety reporting, the present paper suggests an ontological representation of patient safety knowledge. Design/methodology/approach: We propose a framework for constructing an ontological knowledge base of patient safety. The present paper describes our design, implementation, and evaluation of the ontology at its initial stage. Findings: We describe the design and initial outcomes of the ontology implementation. The evaluation results demonstrate the clinical validity of the ontology by a self-developed survey measurement. Research limitations: The proposed ontology was developed and evaluated using a small number of information sources. Presently, US data are used, but they are not essential for the ultimate structure of the ontology. Practical implications: The goal of improving patient safety can be aided through investigating patient safety reports and providing actionable knowledge to clinical practitioners. As such, constructing a domain specific ontology for patient safety reports serves as a cornerstone in information collection and text mining methods. Originality/value: The use of ontologies provides abstracted representation of semantic information and enables a wealth of applications in a reporting system. Therefore, constructing such a knowledge base is recognized as a high priority in health care.

How student models of expertise and innovation impact the development of adaptive expertise in medicine.

Science.gov (United States)

Mylopoulos, Maria; Regehr, Glenn

2009-02-01

The ability to innovate new solutions in response to daily workplace challenges is an important component of adaptive expertise. Exploring how to optimally develop this skill is therefore of paramount importance to education researchers. This is certainly no less true in health care, where optimal patient care is contingent on the continuous efforts of doctors and other health care workers to provide the best care to their patients through the development and incorporation of new knowledge. Medical education programmes must therefore foster the skills and attitudes necessary to engage future doctors in the systematic development of innovative problem solving. The aim of this paper is to describe the perceptions and experiences of medical students in their third and fourth years of training, and to explore their understanding of their development as adaptive experts. A sample of 25 medical students participated in individual 45-60-minute semi-structured interviews. Interviews were audiotaped, transcribed and entered into NVivo qualitative data analysis software to facilitate a thematic analysis. The analysis was both inductive, in that themes were generated from the data, and deductive, in that our data were meaningful when interpreted in the context of theories of adaptive expertise. Participants expressed a general belief that, as learners in the health care system, exerting any effort to be innovative was beyond the scope of their responsibilities. Generally, students suggested that innovative practice was the prerogative of experts and an outcome of expert development centred on the acquisition of knowledge and experience. Students' perceptions of themselves as having no responsibility to be innovative in their learning process have implications for their learning trajectories as adaptive experts.

77 FR 25179 - Patient Safety Organizations: Expired Listing for Medkinetics, LLC

Science.gov (United States)

2012-04-27

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety... Medkinetics, LLC of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorizes the listing of PSOs, which are entities or component...

Patient-reported safety incidents in older patients with long-term conditions: a large cross-sectional study.

Science.gov (United States)

Panagioti, Maria; Blakeman, Thomas; Hann, Mark; Bower, Peter

2017-05-30

Increasing evidence suggests that patient safety is a serious concern for older patients with long-term conditions. Despite this, there is a lack of research on safety incidents encountered by this patient group. In this study, we sought to examine patient reports of safety incidents and factors associated with reports of safety incidents in older patients with long-term conditions. The baseline cross-sectional data from a longitudinal cohort study were analysed. Older patients (n=3378 aged 65 years and over) with a long-term condition registered in general practices were included in the study. The main outcome was patient-reported safety incidents including availability and appropriateness of medical tests and prescription of wrong types or doses of medication. Binary univariate and multivariate logistic regression analyses were undertaken to examine factors associated with patient-reported safety incidents. Safety incidents were reported by 11% of the patients. Four factors were significantly associated with patient-reported safety incidents in multivariate analyses. The experience of multiple long-term conditions (OR=1.09, 95% CI 1.05 to 1.13), a probable diagnosis of depression (OR=1.36, 95% CI 1.06 to 1.74) and greater relational continuity of care (OR=1.28, 95% CI 1.08 to 1.52) were associated with increased odds for patient-reported safety incidents. Perceived greater support and involvement in self-management was associated with lower odds for patient-reported safety incidents (OR=0.95, 95% CI 0.93 to 0.97). We found that older patients with multimorbidity and depression are more likely to report experiences of patient safety incidents. Improving perceived support and involvement of patients in their care may help prevent patient-reported safety incidents. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Training and Action for Patient Safety: Embedding Interprofessional Education for Patient Safety within an Improvement Methodology

Science.gov (United States)

Slater, Beverley L.; Lawton, Rebecca; Armitage, Gerry; Bibby, John; Wright, John

2012-01-01

Introduction: Despite an explosion of interest in improving safety and reducing error in health care, one important aspect of patient safety that has received little attention is a systematic approach to education and training for the whole health care workforce. This article describes an evaluation of an innovative multiprofessional, team-based…

CERN safety reaches out to medicine

CERN Document Server

2001-01-01

What do CERN and other scientific organizations like ESA and ESO have in common with neurosurgery and airlines? At first sight, not much. But all require sound safety management. CERN's expertise in this field was recently highlighted when two CERN engineers were invited to talk at an international conference on Quality Management and Risk Control in Neurosurgery.CERN has long been recognised as a centre of excellence in physics, and its spin-offs in fields such as medicine have been widely hailed. But increasingly, the Laboratory's expertise in the management of large international collaborations is also being recognised. Contacts between CERN and organizations like ESA and ESO, as well as with industry, bear witness to this fact. One recent example comes from Airbus Industrie, which organized a meeting in 1998 with CERN to compare notes on project management, safety, and quality assurance. Safety management is a recognised speciality in the field of project management and at CERN, TIS and the safety offici...

Healthcare professionals’ views of feedback on patient safety culture assessment.

OpenAIRE

Zwijnenberg, N.C.; Hendriks, M.; Hoogervorst-Schilp, J.; Wagner, C.

2016-01-01

Background: By assessing patient safety culture, healthcare providers can identify areas for improvement in patient safety culture. To achieve this, these assessment outcomes have to be relevant and presented clearly. The aim of our study was to explore healthcare professionals’ views on the feedback of a patient safety culture assessment. Methods: Twenty four hospitals participated in a patient safety culture assessment in 2012. Hospital departments received feedback in a report and on a web...

Improving patient safety: patient-focused, high-reliability team training.

Science.gov (United States)

McKeon, Leslie M; Cunningham, Patricia D; Oswaks, Jill S Detty

2009-01-01

Healthcare systems are recognizing "human factor" flaws that result in adverse outcomes. Nurses work around system failures, although increasing healthcare complexity makes this harder to do without risk of error. Aviation and military organizations achieve ultrasafe outcomes through high-reliability practice. We describe how reliability principles were used to teach nurses to improve patient safety at the front line of care. Outcomes include safety-oriented, teamwork communication competency; reflections on safety culture and clinical leadership are discussed.

What does physicians' clinical expertise contribute to oncologic decision-making? A qualitative interview study.

Science.gov (United States)

Salloch, Sabine; Otte, Ina; Reinacher-Schick, Anke; Vollmann, Jochen

2018-02-01

Physicians' clinical expertise forms an exclusive body of competences, which helps them to find the appropriate diagnostics and treatment for each individual patient. Empirical evidence, however, suggests that there is an inverse relationship between the number of years in practice and the quality of care provided by a physician. Knowledge and adherence to professional standards (such as clinical guidelines) are often used as indicators in previous research. Semistructured interviews and the Q method were used for an explorative study on oncologists' views on the interplay between their own clinical expertise, intuition, and the external evidence incorporated in clinical guidelines. The interviews were audio recorded, transcribed ad verbatim, and analysed using qualitative content analysis. Data analysis shows the complex character of clinical expertise with respect to experience, professional development, and intuition. An irreplaceable role is attributed to personal and bodily experience during the providing of care for a patient. Professional experience becomes important, particularly in those situations that lie out of the focus of "guideline medicine." Intuition is regarded as having a strong emotional component and helps for deciding which therapeutic option the patient can deal with. Using measurable knowledge and adherence to standards as indicators does not account for the complexity of clinical expertise. Other factors, such as the importance of bodily experience and physicians' intuitive knowledge, must be considered, also with respect to the occurrence of treatment biases. © 2017 John Wiley & Sons, Ltd.

Sources of Safety Data and Statistical Strategies for Design and Analysis: Clinical Trials.

Science.gov (United States)

Zink, Richard C; Marchenko, Olga; Sanchez-Kam, Matilde; Ma, Haijun; Jiang, Qi

2018-03-01

There has been an increased emphasis on the proactive and comprehensive evaluation of safety endpoints to ensure patient well-being throughout the medical product life cycle. In fact, depending on the severity of the underlying disease, it is important to plan for a comprehensive safety evaluation at the start of any development program. Statisticians should be intimately involved in this process and contribute their expertise to study design, safety data collection, analysis, reporting (including data visualization), and interpretation. In this manuscript, we review the challenges associated with the analysis of safety endpoints and describe the safety data that are available to influence the design and analysis of premarket clinical trials. We share our recommendations for the statistical and graphical methodologies necessary to appropriately analyze, report, and interpret safety outcomes, and we discuss the advantages and disadvantages of safety data obtained from clinical trials compared to other sources. Clinical trials are an important source of safety data that contribute to the totality of safety information available to generate evidence for regulators, sponsors, payers, physicians, and patients. This work is a result of the efforts of the American Statistical Association Biopharmaceutical Section Safety Working Group.

The sociotechnical configuration of the problem of Patient Safety

DEFF Research Database (Denmark)

Danholt, Peter

2010-01-01

Abstract. This paper presents and discusses two approaches to “the sociotechnical”, one coming from the Tavistock tradition and the other from actor network theory. These two differ in important ways and from the latter it follows that what patient safety means must be scrutinized and unpacked....... The paper thus rudimentarily discusses central contributions to the problematization of patient safety. Last it is argued that research that provide data on the processes of medical interventions where events, decisions and entities become transformed through their interactions is needed in order to further...... nuance the problem of patient safety. Keywords. Sociotechnical, patient safety, actor network theory, adverse events....

Patient safety in undergraduate radiography curricula: A European perspective

International Nuclear Information System (INIS)

England, A.; Azevedo, K.B.; Bezzina, P.; Henner, A.; McNulty, J.P.

2016-01-01

Purpose: To establish an understanding of patient safety within radiography education across Europe by surveying higher education institutions registered as affiliate members of the European Federation of Radiographer Societies (EFRS). Method: An online survey was developed to ascertain data on: programme type, patient safety definitions, relevant safety topics, specific areas taught, teaching and assessment methods, levels of teaching and curriculum drivers. Responses were identifiable in terms of educational institution and country. All 54 affiliated educational institutions were invited to participate. Descriptive and thematic analyses are reported. Results: A response rate of 61.1% (n = 33) was achieved from educational institutions representing 19 countries. Patient safety topics appear to be extremely well covered across curricula, however, topics including radiation protection and optimisation were not reported as being taught at an ‘advanced level’ by five and twelve respondents, respectively. Respondents identified the clinical department as the location of most patient safety-related teaching. Conclusions: Patient safety topics are deeply embedded within radiography curricula across Europe. Variations exist in terms of individual safety topics including, teaching and assessment methods, and the depth in which subjects are taught. Results from this study provide a baseline for assessing developments in curricula and can also serve as a benchmark for comparisons. - Highlights: • First European report on patient safety (PS). • PS deeply embedded within training curricula. • Terms and definitions largely consistent. • Some variety in the delivery and assessment methods. • Report provides baseline and opportunities for comparisons.

The impact of health information technology on patient safety.

Science.gov (United States)

Alotaibi, Yasser K; Federico, Frank

2017-12-01

Since the original Institute of Medicine (IOM) report was published there has been an accelerated development and adoption of health information technology with varying degrees of evidence about the impact of health information technology on patient safety.  This article is intended to review the current available scientific evidence on the impact of different health information technologies on improving patient safety outcomes. We conclude that health information technology improves patient's safety by reducing medication errors, reducing adverse drug reactions, and improving compliance to practice guidelines. There should be no doubt that health information technology is an important tool for improving healthcare quality and safety. Healthcare organizations need to be selective in which technology to invest in, as literature shows that some technologies have limited evidence in improving patient safety outcomes.

76 FR 60495 - Patient Safety Organizations: Voluntary Relinquishment From Illinois PSO

Science.gov (United States)

2011-09-29

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety... voluntary relinquishment from the Illinois PSO of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41, 42 U.S.C. 299b...

Towards an international classification for patient safety : the conceptual framework

NARCIS (Netherlands)

Sherman, H.; Castro, G.; Fletcher, M.; Hatlie, M.; Hibbert, P.; Jakob, R.; Koss, R.; Lewalle, P.; Loeb, J.; Perneger, Th.; Runciman, W.; Thomson, R.; Schaaf, van der T.W.; Virtanen, M.

2009-01-01

Global advances in patient safety have been hampered by the lack of a uniform classification of patient safety concepts. This is a significant barrier to developing strategies to reduce risk, performing evidence-based research and evaluating existing healthcare policies relevant to patient safety.

Implementing Protocols to Improve Patient Safety in the Medical Imaging Department.

Science.gov (United States)

Carrizales, Gwen; Clark, Kevin R

2015-01-01

Patient safety is a focal point in healthcare because of recent changes issued by CMS. Hospital reimbursement rates have fallen, and these reimbursement rates are governed by CMS mandates regarding patient safety procedures. Reimbursement changes are reflected in the National Patient Safety Goals (NPSGs) administered annually by The Joint Commission. Medical imaging departments have multiple areas of patient safety concerns including effective handoff communication, proper patient identification, and safe medication/contrast administration. This literature review examines those areas of patient safety within the medical imaging department and reveals the need for continued protocol and policy changes to keep patients safe.

2011 John M. Eisenberg Patient Safety and Quality Awards. The effect of a novel Housestaff Quality Council on quality and patient safety. Innovation in patient safety and quality at the local level.

Science.gov (United States)

Fleischut, Peter M; Faggiani, Susan L; Evans, Adam S; Brenner, Samantha; Liebowitz, Richard S; Forese, Laura; Kerr, Gregory E; Lazar, Eliot J

2012-07-01

In 2008 New York-Presbyterian Hospital (NYP)/Weill Cornell Medical Center, New York City, the largest not-for-profit, nonsectarian hospital in the United States, created and implemented a novel approach--the Housestaff Quality Council (HQC)--to engaging house-staff in quality and patient safety activities. The HQC represented an innovative collaboration between the housestaff, the Department of Anesthesiology, the Division of Quality and Patient Safety, the Office of Graduate Medical Education, and senior leadership. As key managers of patient care, the housestaff sought to become involved in the quality and patient safety decision- and policy-making processes at the hospital. Its members were determined to decrease or minimize adverse events by facilitating multimodal communication, ensuring smart work flow, and measuring outcomes to determine best practices. The HQC, which also included frontline hospital staff or managers from areas such as nursing, pharmacy, and information technology, aligned its initiatives with those of the division of quality and patient safety and embarked on two projects--medication reconciliation and use of the electronic medical record. More than three years later, the resulting improvements have been sustained and three new projects--hand hygiene, central line-associated bloodstream infections, and patient handoffs--have been initiated. The HQC model is highly replicable at other teaching institutions as a complementary approach to their other quality and patient safety initiatives. However, the ability to sustain positive momentum is dependent on the ability of residents to invest time and effort in the face of a demanding residency training schedule and focus on specialty-specific clinical and research activities.

The committee of scientific expertise coordination

International Nuclear Information System (INIS)

2003-01-01

Placed under the MIES control, the Committee of scientific expertise coordination defines the needs, the contain and the planing of expertises realized in function of Climate national and international decisions and negotiations calendars. The Committee verifies the different expertises and offers the administrations, scientific tools and techniques useful for the negotiations. It can also define long-dated research needs which require the scientific community mobilization. This paper provides some document of the Committee: objectives, operating and priorities of the Committee, scenarios ''Factor 4'' and ''crack technology'', perceptions and practices, developing countries (China, India...), Euromed. (A.L.B.)

Development of professional expertise in optometry.

Science.gov (United States)

Faucher, Caroline

2011-04-01

Development of professional expertise is the gradual transition from novice to expert within a profession. Studies on expertise in the profession of optometry have never been published. However, many studies have been performed in other health professions (e.g., nursing, medicine, physical therapy, occupational therapy). This report is an overview of the development of professional expertise that will highlight some applications for optometry. A 5-level scale of professional expertise development, divided into 2 parts, is described. The first part is the progression of students during their professional studies (novice, intermediate, competent). The second part is the professional development occurring during the practice years (advanced, expert). Personal and collective efforts are required to foster the progression toward expertise. Great interest for the profession, motivation, and deliberate practice are individual attitudes that help this progression. The "optometric community of practice," by means of university (professional) training, continuing education, and collaboration between colleagues, also contributes to this process. Professional development is an integral part of the Optometric Oath. Each clinical case is a potential learning experience contributing to one's professional development. Optometrists' attitudes are predominant factors in the progression from one level to another. Copyright © 2011 American Optometric Association. Published by Elsevier Inc. All rights reserved.

Explaining Ethnic Disparities in Patient Safety: A Qualitative Analysis

NARCIS (Netherlands)

Suurmond, Jeanine; Uiters, Ellen; de Bruijne, Martine C.; Stronks, Karien; Essink-Bot, Marie-Louise

2010-01-01

Objectives. We explored characteristics of in-hospital care and treatment of immigrant patients to better understand the processes underlying ethnic disparities in patient safety. Methods. We conducted semistructured interviews with care providers regarding patient safety events involving immigrant

Focus on patient safety all day, every day.

Science.gov (United States)

2015-06-01

Case managers may think their job doesn't involve patient safety, but they promote safety by ensuring a safe discharge and are in a position to see safety breaches and mistakes all over the hospital. CMS includes discharge planning in its worksheets for surveyors to use to assess a hospital's compliance with Medicare Conditions of Participation. Because they work with patients from admission to discharge, case managers know which clinicians are competent, those who are not, and may observe safety breaches like failure to wash hands and leaving the catheter in too long. Case managers should spend enough time with their patients to know their situations at home and their support systems and use the information to create workable and safe discharge plans. Hospitals should create an environment and a culture where case managers and other clinicians feel comfortable speaking up when they see safety breaches.

Emergent Expertise?

Science.gov (United States)

McGivern, Patrick

2014-01-01

The concept of emergence appears in various places within the literature on expertise and expert practice. Here, I examine some of these applications of emergence in the light of two prominent accounts of emergence from the philosophy of science and philosophy of mind. I evaluate these accounts with respect to several specific contexts in which…

76 FR 67020 - Railroad Safety Advisory Committee; Notice of Meeting

Science.gov (United States)

2011-10-28

... Device Distraction, Critical Incident, Track Safety Standards, Dark Territory, Passenger Safety, and... requisite range of views and expertise necessary to discharge its responsibilities. See the RSAC Web site...

75 FR 57477 - Patient Safety Organizations: Voluntary Delisting

Science.gov (United States)

2010-09-21

... Organizations: Voluntary Delisting AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION... Creighton Center for Health Services Research and Patient Safety (CHRP) Patient Safety Organization (PSO... the listing of PSOs, which are entities or component organizations whose mission and primary activity...

Expediting Clinician Adoption of Safety Practices: The UCSF Venous Access Patient Safety Interdisciplinary Education Project

National Research Council Canada - National Science Library

Donaldson, Nancy E; Plank, Rosemary K; Williamson, Ann; Pearl, Jeffrey; Kellogg, Jerry; Ryder, Marcia

2005-01-01

...) Venous Access Device (VAD) Patient Safety Interdisciplinary Education Project was to develop a 30-hour/one clinical academic unit VAD patient safety course with the aim of expediting clinician adoption of critical concepts...

Patient Education May Improve Perioperative Safety.

NARCIS (Netherlands)

de Haan, L.S.; Calsbeek, H; Wolff, André

2016-01-01

Importance: There is a growing interest in enabling ways for patients to participate in their own care to improve perioperative safety, but little is known about the effectiveness of interventions enhancing an active patient role. Objective: To evaluate the effect of patient participation on

[Does simulator-based team training improve patient safety?].

Science.gov (United States)

Trentzsch, H; Urban, B; Sandmeyer, B; Hammer, T; Strohm, P C; Lazarovici, M

2013-10-01

Patient safety became paramount in medicine as well as in emergency medicine after it was recognized that preventable, adverse events significantly contributed to morbidity and mortality during hospital stay. The underlying errors cannot usually be explained by medical technical inadequacies only but are more due to difficulties in the transition of theoretical knowledge into tasks under the conditions of clinical reality. Crew Resource Management and Human Factors which determine safety and efficiency of humans in complex situations are suitable to control such sources of error. Simulation significantly improved safety in high reliability organizations, such as the aerospace industry.Thus, simulator-based team training has also been proposed for medical areas. As such training is consuming in cost, time and human resources, the question of the cost-benefit ratio obviously arises. This review outlines the effects of simulator-based team training on patient safety. Such course formats are not only capable of creating awareness and improvements in safety culture but also improve technical team performance and emphasize team performance as a clinical competence. A few studies even indicated improvement of patient-centered outcome, such as a reduced rate of adverse events but further studies are required in this respect. In summary, simulator-based team training should be accepted as a suitable strategy to improve patient safety.

Identifying organizational cultures that promote patient safety.

Science.gov (United States)

Singer, Sara J; Falwell, Alyson; Gaba, David M; Meterko, Mark; Rosen, Amy; Hartmann, Christine W; Baker, Laurence

2009-01-01

Safety climate refers to shared perceptions of what an organization is like with regard to safety, whereas safety culture refers to employees' fundamental ideology and orientation and explains why safety is pursued in the manner exhibited within a particular organization. Although research has sought to identify opportunities for improving safety outcomes by studying patterns of variation in safety climate, few empirical studies have examined the impact of organizational characteristics such as culture on hospital safety climate. This study explored how aspects of general organizational culture relate to hospital patient safety climate. In a stratified sample of 92 U.S. hospitals, we sampled 100% of senior managers and physicians and 10% of other hospital workers. The Patient Safety Climate in Healthcare Organizations and the Zammuto and Krakower organizational culture surveys measured safety climate and group, entrepreneurial, hierarchical, and production orientation of hospitals' culture, respectively. We administered safety climate surveys to 18,361 personnel and organizational culture surveys to a 5,894 random subsample between March 2004 and May 2005. Secondary data came from the 2004 American Hospital Association Annual Hospital Survey and Dun & Bradstreet. Hierarchical linear regressions assessed relationships between organizational culture and safety climate measures. Aspects of general organizational culture were strongly related to safety climate. A higher level of group culture correlated with a higher level of safety climate, but more hierarchical culture was associated with lower safety climate. Aspects of organizational culture accounted for more than threefold improvement in measures of model fit compared with models with controls alone. A mix of culture types, emphasizing group culture, seemed optimal for safety climate. Safety climate and organizational culture are positively related. Results support strategies that promote group orientation and

Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiotherapy institute.

Science.gov (United States)

Simons, Pascale A M; Houben, Ruud; Vlayen, Annemie; Hellings, Johan; Pijls-Johannesma, Madelon; Marneffe, Wim; Vandijck, Dominique

2015-02-01

The importance of a safety culture to maximize safety is no longer questioned. However, achieving sustainable culture improvements are less evident. Evidence is growing for a multifaceted approach, where multiple safety interventions are combined. Lean management is such an integral approach to improve safety, quality and efficiency and therefore, could be expected to improve the safety culture. This paper presents the effects of lean management activities on the patient safety culture in a radiotherapy institute. Patient safety culture was evaluated over a three year period using triangulation of methodologies. Two surveys were distributed three times, workshops were performed twice, data from an incident reporting system (IRS) was monitored and results were explored using structured interviews with professionals. Averages, chi-square, logistical and multi-level regression were used for analysis. The workshops showed no changes in safety culture, whereas the surveys showed improvements on six out of twelve dimensions of safety climate. The intention to report incidents not reaching patient-level decreased in accordance with the decreasing number of reports in the IRS. However, the intention to take action in order to prevent future incidents improved (factorial survey presented β: 1.19 with p: 0.01). Due to increased problem solving and improvements in equipment, the number of incidents decreased. Although the intention to report incidents not reaching patient-level decreased, employees experienced sustained safety awareness and an increased intention to structurally improve. The patient safety culture improved due to the lean activities combined with an organizational restructure, and actual patient safety outcomes might have improved as well. Copyright © 2014 Elsevier Ltd. All rights reserved.

75 FR 75471 - Patient Safety Organizations: Voluntary Delisting

Science.gov (United States)

2010-12-03

... Organizations: Voluntary Delisting AGENCY: Agency for Healthcare Research and Quality, HHS. ACTION: Notice of..., LLC of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement... or component organizations whose mission and primary activity is to conduct activities to improve...

75 FR 57048 - Patient Safety Organizations: Voluntary Delisting

Science.gov (United States)

2010-09-17

... Organizations: Voluntary Delisting AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS. ACTION... Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109... the listing of PSOs, which are entities or component organizations whose mission and primary activity...

42 CFR 3.206 - Confidentiality of patient safety work product.

Science.gov (United States)

2010-10-01

... 42 Public Health 1 2010-10-01 2010-10-01 false Confidentiality of patient safety work product. 3... individually identifiable health information in such patient safety work product, the direct identifiers listed at 45 CFR 164.514(e)(2) have been removed. (5) Disclosure of nonidentifiable patient safety work...

Managing risk in healthcare: understanding your safety culture using the Manchester Patient Safety Framework (MaPSaF).

Science.gov (United States)

Parker, Dianne

2009-03-01

To provide sufficient information about the Manchester Patient Safety Framework (MaPSaF) to allow healthcare professionals to assess its potential usefulness. The assessment of safety culture is an important aspect of risk management, and one in which there is increasing interest among healthcare organizations. Manchester Patient Safety Framework offers a theory-based framework for assessing safety culture, designed specifically for use in the NHS. The framework covers multiple dimensions of safety culture, and five levels of safety culture development. This allows the generation of a profile of an organization's safety culture in terms of areas of relative strength and challenge, which can be used to identify focus issues for change and improvement. Manchester Patient Safety Framework provides a useful method for engaging healthcare professionals in assessing and improving the safety culture in their organization, as part of a programme of risk management.

[Patient safety culture in Family practice residents of Galicia].

Science.gov (United States)

Portela Romero, Manuel; Bugarín González, Rosendo; Rodríguez Calvo, María Sol

To determine the views held by Family practice (FP) residents on the different dimensions of patient safety, in order to identify potential areas for improvement. A cross-sectional study. Seven FP of Galicia teaching units. 182 FP residents who completed the Medical Office Survey on Patient Safety Culture questionnaire. The Medical Office Survey on Patient Safety Culture questionnaire was chosen because it is translated, validated, and adapted to the Spanish model of Primary Care. The results were grouped into 12 composites assessed by the mentioned questionnaire. The study variables were the socio-demographic dimensions of the questionnaire, as well as occupational/professional variables: age, gender, year of residence, and teaching unit of FP of Galicia. The "Organisational learning" and "Teamwork" items were considered strong areas. However, the "Patient safety and quality issues", "Information exchange with other settings", and "Work pressure and pace" items were considered areas with significant potential for improvement. First-year residents obtained the best results and the fourth-year ones the worst. The results may indicate the need to include basic knowledge on patient safety in the teaching process of FP residents in order to increase and consolidate the fragile patient safety culture described in this study. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.

[Traumatic brain injuries--forensic and expertise aspects].

Science.gov (United States)

Vuleković, Petar; Simić, Milan; Misić-Pavkov, Gordana; Cigić, Tomislav; Kojadinović, Zeljko; Dilvesi, Dula

2008-01-01

Traumatic brain injuries have major socio-economic importance due to their frequency, high mortality and serious consequences. According to their nature the consequences of these injuries may be classified as neurological, psychiatric and esthetic. Various lesions of brain structures cause neurological consequences such as disturbance of motor functions, sensibility, coordination or involuntary movements, speech disturbances and other deviations, as well as epilepsy. Psychiatric consequences include cognitive deficit, emotional disturbances and behavior disturbances. CRIMINAL-LEGAL ASPECT OF TRAUMATIC BRAIN INJURIES AND LITIGATION: Criminal-legal aspect of traumatic brain injuries expertise understands the qualification of these injuries as mild, serious and qualified serious body injuries as well as the expertise about the mechanisms of their occurrence. Litigation expertise includes the estimation of pain, fear, diminished, i.e. lost vital activity and disability, esthetic marring, and psychological suffer based on the diminished general vital activity and esthetic marring. Evaluation of consequences of traumatic brain injuries should be performed only when it can be positively confirmed that they are permanent, i.e. at least one year after the injury. Expertise of these injuries is interdisciplinary. Among clinical doctors the most competent medical expert is the one who is in charge for diagnostics and injury treatment, with the recommendation to avoid, if possible, the doctor who conducted treatment. For the estimation of general vital activity, the neurological consequences, pain and esthetic marring expertise, the most competent doctors are neurosurgeon and neurologist. Psychological psychiatric consequences and fear expertise have to be performed by the psychiatrist. Specialists of forensic medicine contribute with knowledge of criminal low and legal expertise.

Safety coaches in radiology: decreasing human error and minimizing patient harm

Energy Technology Data Exchange (ETDEWEB)

Dickerson, Julie M.; Adams, Janet M. [Cincinnati Children' s Hospital Medical Center, Department of Radiology, MLC 5031, Cincinnati, OH (United States); Koch, Bernadette L.; Donnelly, Lane F. [Cincinnati Children' s Hospital Medical Center, Department of Radiology, MLC 5031, Cincinnati, OH (United States); Cincinnati Children' s Hospital Medical Center, Department of Pediatrics, Cincinnati, OH (United States); Goodfriend, Martha A. [Cincinnati Children' s Hospital Medical Center, Department of Quality Improvement, Cincinnati, OH (United States)

2010-09-15

Successful programs to improve patient safety require a component aimed at improving safety culture and environment, resulting in a reduced number of human errors that could lead to patient harm. Safety coaching provides peer accountability. It involves observing for safety behaviors and use of error prevention techniques and provides immediate feedback. For more than a decade, behavior-based safety coaching has been a successful strategy for reducing error within the context of occupational safety in industry. We describe the use of safety coaches in radiology. Safety coaches are an important component of our comprehensive patient safety program. (orig.)

Safety coaches in radiology: decreasing human error and minimizing patient harm

International Nuclear Information System (INIS)

Dickerson, Julie M.; Adams, Janet M.; Koch, Bernadette L.; Donnelly, Lane F.; Goodfriend, Martha A.

2010-01-01

Successful programs to improve patient safety require a component aimed at improving safety culture and environment, resulting in a reduced number of human errors that could lead to patient harm. Safety coaching provides peer accountability. It involves observing for safety behaviors and use of error prevention techniques and provides immediate feedback. For more than a decade, behavior-based safety coaching has been a successful strategy for reducing error within the context of occupational safety in industry. We describe the use of safety coaches in radiology. Safety coaches are an important component of our comprehensive patient safety program. (orig.)

Safety coaches in radiology: decreasing human error and minimizing patient harm.

Science.gov (United States)

Dickerson, Julie M; Koch, Bernadette L; Adams, Janet M; Goodfriend, Martha A; Donnelly, Lane F

2010-09-01

Successful programs to improve patient safety require a component aimed at improving safety culture and environment, resulting in a reduced number of human errors that could lead to patient harm. Safety coaching provides peer accountability. It involves observing for safety behaviors and use of error prevention techniques and provides immediate feedback. For more than a decade, behavior-based safety coaching has been a successful strategy for reducing error within the context of occupational safety in industry. We describe the use of safety coaches in radiology. Safety coaches are an important component of our comprehensive patient safety program.

The role of the ward manager in promoting patient safety.

Science.gov (United States)

Pinnock, David

In this article the role of the ward manager in promoting patient safety is explored. The background to the development of the patient safety agenda is briefly discussed and the relationship between quality and safety is illustrated. The pivotal importance of the role of the ward manager in delivering services to patients is underlined and literature on patient safety is examined to identify what a ward manager can do to make care safer. Possible actions of the ward manager to improve safety discussed in the literature are structured around the Leadership Framework. This framework identifies seven domains for the leadership of service delivery. Ward managers use their personal qualities, and network and work within teams, while managing performance and facilitating innovation, change and measurement for improvement. The challenge of promoting patient safety for ward managers is briefly explored and recommendations for further research are made.

Assessing patient safety culture in hospitals across countries

NARCIS (Netherlands)

Wagner, C.; Smits, M.; Sorra, J.; Huang, C.C.

2013-01-01

Objective. It is believed that in order to reduce the number of adverse events, hospitals have to stimulate a more open culture and reflective attitude towards errors and patient safety. The objective is to examine similarities and differences in hospital patient safety culture in three countries:

Assessing patient safety culture in hospitals across countries.

NARCIS (Netherlands)

Wagner, C.; Smits, M.; Sorra, J.; Huang, C.C.

2013-01-01

Objective: It is believed that in order to reduce the number of adverse events, hospitals have to stimulate a more open culture and reflective attitude towards errors and patient safety. The objective is to examine similarities and differences in hospital patient safety culture in three countries:

Assessing patient safety culture in hospitals across countries

NARCIS (Netherlands)

Wagner, C.; Smits, M.; Sorra, J.; Huang, C.C.

2013-01-01

OBJECTIVE: It is believed that in order to reduce the number of adverse events, hospitals have to stimulate a more open culture and reflective attitude towards errors and patient safety. The objective is to examine similarities and differences in hospital patient safety culture in three countries:

75 FR 63498 - Patient Safety Organizations: Voluntary Delisting

Science.gov (United States)

2010-10-15

... Healthcare Technology Foundation of its status as a Patient Safety Organization (PSO). The Patient Safety and... notification from the ACCE Healthcare Technology Foundation, PSO number P0017, to voluntarily relinquish its status as a PSO. Accordingly, the ACCE Healthcare Technology Foundation was delisted effective at 12:00...

75 FR 75473 - Patient Safety Organizations: Voluntary Delisting

Science.gov (United States)

2010-12-03

... Organizations: Voluntary Delisting AGENCY: Agency for Healthcare Research and Quality, HHS. ACTION: Notice of... entity of Harbor Medical, Inc., of its status as a Patient Safety Organization (PSO). The Patient Safety... the listing of PSOs, which are entities or component organizations whose mission and primary activity...

75 FR 75472 - Patient Safety Organizations: Voluntary Delisting

Science.gov (United States)

2010-12-03

... Organizations: Voluntary Delisting AGENCY: Agency for Healthcare Research and Quality, HHS. ACTION: Notice of.... Patient Safety Group (A Component of Helmet Fire, Inc. of its status as a Patient Safety Organization (PSO... the listing of PSOs, which are entities or component organizations whose mission and primary activity...

Detangling Value: A study into the benefits of using in-house CSR expertise compared with the benefits of using CSR consultancy expertise

OpenAIRE

MacCarthy, Jennifer

2007-01-01

Abstract The topic of Corporate Social Responsibility (CSR) is an area with an increasing breadth of literature. However, literature regarding how CSR expertise is sourced for developing CSR projects and programmes within companies is distinctly weak. This study takes, arguably, the two most predominant forms of CSR expertise, in-house CSR expertise and CSR consultancies, and investigates what value these different types of expertise offer in sourcing for CSR activities. Bey...

Ensuring a proactive, evidence-based, patient safety approach to patient assessment.

Science.gov (United States)

Considine, Julie; Currey, Judy

2015-01-01

To argue that if all nurses were to adopt the primary survey approach (assessment of airway, breathing, circulation and disability) as the first element of patient assessment, they would be more focused on active detection of clinical deterioration rather than passive collection of patient data. Nurses are the professional group that carry the highest level of responsibility for patient assessment, accurate data collection and interpretation. The timely recognition of, and response to deteriorating patients, is dependent on the measurement and interpretation of pertinent physiological data by nurses. Discursive paper. Traditionally taught and commonly used approaches to patient assessment such as 'vital signs' and 'body systems' are not evidence-based nor framed in patient safety. The primary survey approach as the first element in patient assessment has three major advantages: (1) data are collected according to clinical importance; (2) data are collected using the same framework as most organisation's rapid response system activation criteria; and (3) the primary survey acts as a patient safety checklist, thereby decreasing the risk of failure to recognise, and therefore respond to, deteriorating patients. The vital signs and body systems approaches to patient assessment have significant limitations in identifying clinical deterioration. The primary survey approach provides nurses with a consistent, evidence-based and sequenced approach to patient assessment in every clinical setting. All nurses should use a primary survey approach as the first element of patient assessment in every patient encounter as a patient safety strategy. © 2014 John Wiley & Sons Ltd.

Strengthening leadership as a catalyst for enhanced patient safety culture

DEFF Research Database (Denmark)

Kristensen, Solvejg; Christensen, Karl Bang; Jaquet, Annette

2016-01-01

OBJECTIVES: Current literature emphasises that clinical leaders are in a position to enable a culture of safety, and that the safety culture is a performance mediator with the potential to influence patient outcomes. This paper aims to investigate staff's perceptions of patient safety culture...... in a Danish psychiatric department before and after a leadership intervention. METHODS: A repeated cross-sectional experimental study by design was applied. In 2 surveys, healthcare staff were asked about their perceptions of the patient safety culture using the 7 patient safety culture dimensions...... in the Safety Attitudes Questionnaire. To broaden knowledge and strengthen leadership skills, a multicomponent programme consisting of academic input, exercises, reflections and discussions, networking, and action learning was implemented among the clinical area level leaders. RESULTS: In total, 358 and 325...

Measuring safety culture: Application of the Hospital Survey on Patient Safety Culture to radiation therapy departments worldwide.

Science.gov (United States)

Leonard, Sarah; O'Donovan, Anita

Minimizing errors and improving patient safety has gained prominence worldwide in high-risk disciplines such as radiation therapy. Patient safety culture has been identified as an important factor in reducing the incidence of adverse events and improving patient safety in the health care setting. The aim of distributing the Hospital Survey on Patient Safety Culture (HSPSC) to radiation therapy departments worldwide was to assess the current status of safety culture, identify areas for improvement and areas that excel, examine factors that influence safety culture, and raise staff awareness. The safety culture in radiation therapy departments worldwide was evaluated by distributing the HSPSC. A total of 266 participants were recruited from radiation therapy departments and included radiation oncologists, radiation therapists, physicists, and dosimetrists. The positive percent scores for the 12 dimensions of the HSPSC varied from 50% to 79%. The highest composite score among the 12 dimensions was teamwork within units; the lowest composite score was handoffs and transitions. The results indicated that health care professionals in radiation therapy departments felt positively toward patient safety. The HSPSC was successfully applied to radiation therapy departments and provided valuable insight into areas of potential improvement such as teamwork across units, staffing, and handoffs and transitions. Managers and policy makers in radiation therapy may use this assessment tool for focused improvement efforts toward patient safety culture. Copyright © 2017 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

Designing Education for Professional Expertise Development

Science.gov (United States)

Elvira, Quincy; Imants, Jeroen; Dankbaar, Ben; Segers, Mien

2017-01-01

How to facilitate learning by novices (students) on their road to expertise has attracted the attention of a vast number of researchers in cognitive and educational psychology as well in the field of learning and instruction. Although many studies have investigated the phenomenon of expertise development, the implications of the findings for…

[Electronic patient record as the tool for better patient safety].

Science.gov (United States)

Schneider, Henning

2015-01-01

Recent studies indicate again that there is a deficit in the use of electronic health records (EHR) in German hospitals. Despite good arguments in favour of their use, such as the rapid availability of data, German hospitals shy away from a wider implementation. The reason is the high cost of installing and maintaining the EHRs, for the benefit is difficult to evaluate in monetary terms for the hospital. Even if a benefit can be shown it is not necessarily evident within the hospital, but manifests itself only in the health system outside. Many hospitals only manage to partly implement EHR resulting in increased documentation requirements which reverse their positive effect.In the United States, electronic medical records are also viewed in light of their positive impact on patient safety. In particular, electronic medication systems prove the benefits they can provide in the context of patient safety. As a result, financing systems have been created to promote the digitalisation of hospitals in the United States. This has led to a large increase in the use of IT systems in the United States in recent years. The Universitätsklinikum Eppendorf (UKE) introduced electronic patient records in 2009. The benefits, in particular as regards patient safety, are numerous and there are many examples to illustrate this position. These positive results are intended to demonstrate the important role EHR play in hospitals. A financing system of the ailing IT landscape based on the American model is urgently needed to benefit-especially in terms of patient safety-from electronic medical records in the hospital.

Health IT for Patient Safety and Improving the Safety of Health IT.

Science.gov (United States)

Magrabi, Farah; Ong, Mei-Sing; Coiera, Enrico

2016-01-01

Alongside their benefits health IT applications can pose new risks to patient safety. Problems with IT have been linked to many different types of clinical errors including prescribing and administration of medications; as well as wrong-patient, wrong-site errors, and delays in procedures. There is also growing concern about the risks of data breach and cyber-security. IT-related clinical errors have their origins in processes undertaken to design, build, implement and use software systems in a broader sociotechnical context. Safety can be improved with greater standardization of clinical software and by improving the quality of processes at different points in the technology life cycle, spanning design, build, implementation and use in clinical settings. Oversight processes can be set up at a regional or national level to ensure that clinical software systems meet specific standards. Certification and regulation are two mechanisms to improve oversight. In the absence of clear standards, guidelines are useful to promote safe design and implementation practices. Processes to identify and mitigate hazards can be formalised via a safety management system. Minimizing new patient safety risks is critical to realizing the benefits of IT.

Assessment of Patient Safety Culture in a Selected Number of Pharmacies Affiliated to Mashhad University of Medical Sciences Using the Pharmacy Survey on Patient Safety Culture (SOPS

Directory of Open Access Journals (Sweden)

Sara Jamili

2016-07-01

Conclusion: According to the results of this study, commitment of healthcare authorities to patient safety culture is the most important factor in the promotion of organizational patient safety. Considering that the lowest score of patient safety culture belonged to the dimension of “overall perceptions of patient safety”,it is recommended that related training interventions be implemented for healthcare staff in order to establish and promote the patient safety culture in pharmacies.

Reactor Safety Analysis

International Nuclear Information System (INIS)

Arien, B.

1998-01-01

The objective of SCK-CEN's programme on reactor safety is to develop expertise in probabilistic and deterministic reactor safety analysis. The research programme consists of four main activities, in particular the development of software for reliability analysis of large systems and participation in the international PHEBUS-FP programme for severe accidents, the development of an expert system for the aid to diagnosis; the development and application of a probabilistic reactor dynamics method. Main achievements in 1999 are reported

Workplace engagement and workers' compensation claims as predictors for patient safety culture.

Science.gov (United States)

Thorp, Jonathon; Baqai, Waheed; Witters, Dan; Harter, Jim; Agrawal, Sangeeta; Kanitkar, Kirti; Pappas, James

2012-12-01

Demonstrate the relationship between employee engagement and workplace safety for predicting patient safety culture. Patient safety is an issue for the U.S. health-care system, and health care has some of the highest rates of nonfatal workplace injuries. Understanding the types of injuries sustained by health-care employees, the type of safety environment employees of health-care organizations work in, and how employee engagement affects patient safety is vital to improving the safety of both employees and patients. The Gallup Q survey and an approved, abbreviated, and validated subset of questions from the Hospital Survey on Patient Safety Culture were administered to staff at a large tertiary academic medical center in 2007 and 2009. After controlling for demographic variables, researchers conducted a longitudinal, hierarchical linear regression analysis to study the unique contributions of employee engagement, changes in employee engagement, and employee safety in predicting patient safety culture. Teams with higher baseline engagement, more positive change in engagement, fewer workers' compensation claims, and fewer part-time associates in previous years had stronger patient safety cultures in 2009. Baseline engagement and change in engagement were the strongest independent predictors of patient safety culture in 2009. Engagement and compensation claims were additive and complimentary predictors, independent of other variables in the analysis, including the demographic composition of the workgroups in the study. A synergistic effect exists between employee engagement and decreased levels of workers' compensation claims for improving patient safety culture. Organizations can improve engagement and implement safety policies, procedures, and devices for employees with an ultimate effect of improving patient safety culture.

Assessing medical students' perceptions of patient safety: the medical student safety attitudes and professionalism survey.

Science.gov (United States)

Liao, Joshua M; Etchegaray, Jason M; Williams, S Tyler; Berger, David H; Bell, Sigall K; Thomas, Eric J

2014-02-01

To develop and test the psychometric properties of a survey to measure students' perceptions about patient safety as observed on clinical rotations. In 2012, the authors surveyed 367 graduating fourth-year medical students at three U.S. MD-granting medical schools. They assessed the survey's reliability and construct and concurrent validity. They examined correlations between students' perceptions of organizational cultural factors, organizational patient safety measures, and students' intended safety behaviors. They also calculated percent positive scores for cultural factors. Two hundred twenty-eight students (62%) responded. Analyses identified five cultural factors (teamwork culture, safety culture, error disclosure culture, experiences with professionalism, and comfort expressing professional concerns) that had construct validity, concurrent validity, and good reliability (Cronbach alphas > 0.70). Across schools, percent positive scores for safety culture ranged from 28% (95% confidence interval [CI], 13%-43%) to 64% (30%-98%), while those for teamwork culture ranged from 47% (32%-62%) to 74% (66%-81%). They were low for error disclosure culture (range: 10% [0%-20%] to 27% [20%-35%]), experiences with professionalism (range: 7% [0%-15%] to 23% [16%-30%]), and comfort expressing professional concerns (range: 17% [5%-29%] to 38% [8%-69%]). Each cultural factor correlated positively with perceptions of overall patient safety as observed in clinical rotations (r = 0.37-0.69, P safety behavioral intent item. This study provided initial evidence for the survey's reliability and validity and illustrated its applicability for determining whether students' clinical experiences exemplify positive patient safety environments.

Examination of the relationship between management and clinician perception of patient safety climate and patient satisfaction.

Science.gov (United States)

Mazurenko, Olena; Richter, Jason; Kazley, Abby Swanson; Ford, Eric

2017-04-25

The aim of this study was to explore the relationship between managers and clinicians' agreement on deeming the patient safety climate as high or low and the patients' satisfaction with those organizations. We used two secondary data sets: the Hospital Survey on Patient Safety Culture (2012) and the Hospital Consumer Assessment of Healthcare Providers and Systems (2012). We used ordinary least squares regressions to analyze the relationship between the extent of agreement between managers and clinicians' perceptions of safety climate in relationship to patient satisfaction. The dependent variables were four Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction scores: communication with nurses, communication with doctors, communication about medicines, and discharge information. The main independent variables were four groups that were formed based on the extent of managers and clinicians' agreement on four patient safety climate domains: communication openness, feedback and communication about errors, teamwork within units, and teamwork across units. After controlling for hospital and market-level characteristics, we found that patient satisfaction was significantly higher if managers and clinicians reported that patient safety climate is high or if only clinicians perceived the climate as high. Specifically, manager and clinician agreement on high levels of communication openness (β = 2.25, p = .01; β = 2.46, p = .05), feedback and communication about errors (β = 3.0, p = .001; β = 2.89, p = .01), and teamwork across units (β = 2.91, p = .001; β = 3.34, p = .01) was positively and significantly associated with patient satisfaction with discharge information and communication about medication. In addition, more favorable perceptions about patient safety climate by clinicians only yielded similar findings. Organizations should measure and examine patient safety climate from multiple perspectives and be aware that individuals

Nurse working conditions and patient safety outcomes.

Science.gov (United States)

Stone, Patricia W; Mooney-Kane, Cathy; Larson, Elaine L; Horan, Teresa; Glance, Laurent G; Zwanziger, Jack; Dick, Andrew W

2007-06-01

System approaches, such as improving working conditions, have been advocated to improve patient safety. However, the independent effect of many working condition variables on patient outcomes is unknown. To examine effects of a comprehensive set of working conditions on elderly patient safety outcomes in intensive care units. Observational study, with patient outcome data collected using the National Nosocomial Infection Surveillance system protocols and Medicare files. Several measures of health status and fixed setting characteristics were used to capture distinct dimensions of patient severity of illness and risk for disease. Working condition variables included organizational climate measured by nurse survey; objective measures of staffing, overtime, and wages (derived from payroll data); and hospital profitability and magnet accreditation. The sample comprised 15,846 patients in 51 adult intensive care units in 31 hospitals depending on the outcome analyzed; 1095 nurses were surveyed. Central line associated bloodstream infections (CLBSI), ventilator-associated pneumonia, catheter-associated urinary tract infections, 30-day mortality, and decubiti. Units with higher staffing had lower incidence of CLBSI, ventilator-associated pneumonia, 30-day mortality, and decubiti (P working conditions were associated with all outcomes measured. Improving working conditions will most likely promote patient safety. Future researchers and policymakers should consider a broad set of working condition variables.

[Patient safety in education and training of healthcare professionals in Germany].

Science.gov (United States)

Hoffmann, Barbara; Siebert, H; Euteneier, A

2015-01-01

In order to improve patient safety, healthcare professionals who care for patients directly or indirectly are required to possess specific knowledge and skills. Patient safety education is not or only poorly represented in education and examination regulations of healthcare professionals in Germany; therefore, it is only practiced rarely and on a voluntary basis. Meanwhile, several training curricula and concepts have been developed in the past 10 years internationally and recently in Germany, too. Based on these concepts the German Coalition for Patient Safety developed a catalogue of core competencies required for safety in patient care. This catalogue will serve as an important orientation when patient safety is to be implemented as a subject of professional education in Germany in the future. Moreover, teaching staff has to be trained and educational and training activities have to be evaluated. Patient safety education and training for (undergraduate) healthcare professional will require capital investment.

Can we improve patient safety?

Science.gov (United States)

Corbally, Martin Thomas

2014-01-01

Despite greater awareness of patient safety issues especially in the operating room and the widespread implementation of surgical time out World Health Organization (WHO), errors, especially wrong site surgery, continue. Most such errors are due to lapses in communication where decision makers fail to consult or confirm operative findings but worryingly where parental concerns over the planned procedure are ignored or not followed through. The WHO Surgical Pause/Time Out aims to capture these errors and prevent them, but the combination of human error and complex hospital environments can overwhelm even robust safety structures and simple common sense. Parents are the ultimate repository of information on their child's condition and planned surgery but are traditionally excluded from the process of Surgical Pause and Time Out, perhaps to avoid additional stress. In addition, surgeons, like pilots, are subject to the phenomenon of "plan-continue-fail" with potentially disastrous outcomes. If we wish to improve patient safety during surgery and avoid wrong site errors then we must include parents in the Surgical Pause/Time Out. A recent pilot study has shown that neither staff nor parents found it added to their stress, but, moreover, 100% of parents considered that it should be a mandatory component of the Surgical Pause nor does it add to the stress of surgery. Surgeons should be required to confirm that the planned procedure is in keeping with the operative findings especially in extirpative surgery and this "step back" should be incorporated into the standard Surgical Pause. It is clear that we must improve patient safety further and these simple measures should add to that potential.

Designing a Safety Reporting Smartphone Application to Improve Patient Safety After Total Hip Arthroplasty.

Science.gov (United States)

Krumsvik, Ole Andreas; Babic, Ankica

2017-01-01

This paper presents a safety reporting smartphone application which is expected to reduce the occurrence of postoperative adverse events after total hip arthroplasty (THA). A user-centered design approach was utilized to facilitate optimal user experience. Two main implemented functionalities capture patient pain levels and well-being, the two dimensions of patient status that are intuitive and commonly checked. For these and other functionalities, mobile technology could enable timely safety reporting and collection of patient data out of a hospital setting. The HCI expert, and healthcare professionals from the Haukeland University Hospital in Bergen have assessed the design with respect to the interaction flow, information content, and self-reporting functionalities. They have found it to be practical, intuitive, sufficient and simple for users. Patient self-reporting could help recognizing safety issues and adverse events.

The impact of health information technology on patient safety

Directory of Open Access Journals (Sweden)

Yasser K. Alotaibi

2017-12-01

Full Text Available Since the original Institute of Medicine (IOM report was published there has been an accelerated development and adoption of health information technology with varying degrees of evidence about the impact of health information technology on patient safety. This article is intended to review the current available scientific evidence on the impact of different health information technologies on improving patient safety outcomes. We conclude that health information technology improves patient’s safety by reducing medication errors, reducing adverse drug reactions, and improving compliance to practice guidelines. There should be no doubt that health information technology is an important tool for improving healthcare quality and safety. Healthcare organizations need to be selective in which technology to invest in, as literature shows that some technologies have limited evidence in improving patient safety outcomes.

Patient safety problem identification and solution sharing among rural community pharmacists.

Science.gov (United States)

Galt, Kimberly A; Fuji, Kevin T; Faber, Jennifer

2013-01-01

To implement a communication network for safety problem identification and solution sharing among rural community pharmacists and to report participating pharmacists' perceived value and impact of the network on patient safety after 1 year of implementation. Action research study. Rural community pharmacies in Nebraska from January 2010 to April 2011. Rural community pharmacists who voluntarily agreed to join the Pharmacists for Patient Safety Network in Nebraska. Pharmacists reported errors, near misses, and safety concerns through Web-based event reporting. A rapid feedback process was used to provide patient safety solutions to consider implementing across the network. Qualitative interviews were conducted 1 year after program implementation with participating pharmacists to assess use of the reporting system, value of the disseminated safety solutions, and perceived impact on patient safety in pharmacies. 30 of 38 pharmacists participating in the project completed the interviews. The communication network improved pharmacist awareness, promoted open discussion and knowledge sharing, contributed to practice vigilance, and led to incorporation of proactive safety prevention practices. Despite low participation in error and near-miss reporting, a dynamic communication network designed to rapidly disseminate evidence-based patient safety strategies to reduce risk was valued and effective at improving patient safety practices in rural community pharmacies.

Patient Safety and Workplace Bullying: An Integrative Review.

Science.gov (United States)

Houck, Noreen M; Colbert, Alison M

Workplace bullying is strongly associated with negative nursing outcomes, such as work dissatisfaction, turnover, and intent to leave; however, results of studies examining associations with specific patient safety outcomes are limited or nonspecific. This integrative review explores and synthesizes the published articles that address the impact of workplace nurse bullying on patient safety.

Involvement of patients with cancer in patient safety: a qualitative study of current practices, potentials and barriers.

Science.gov (United States)

Martin, Helle Max; Navne, Laura Emdal; Lipczak, Henriette

2013-10-01

Patient involvement in patient safety is widely advocated but knowledge regarding implementation of the concept in clinical practice is sparse. To investigate existing practices for patient involvement in patient safety, and opportunities and barriers for further involvement. A qualitative study of patient safety involvement practices in patient trajectories for prostate, uterine and colorectal cancer in Denmark. Observations from four hospital wards and interviews with 25 patients with cancer, 11 hospital doctors, 10 nurses, four general practitioners and two private practicing gynaecologists were conducted using ethnographic methodology. Patient safety was not a topic of attention for patients or dominant in communication between patients and healthcare professionals. The understanding of patient safety in clinical practice is almost exclusively linked to disease management. Involvement of patients is not systematic, but healthcare professionals and patients express willingness to engage. Invitation and encouragement of patients to become involved could be further systematised and developed. Barriers include limited knowledge of patient safety, of specific patient safety involvement techniques and concern regarding potential negative impact on doctor-patient relationship. Involvement of patients in patient safety must take into account that despite stated openness to the idea of involvement, patients and health professionals may not in practice show immediate concern. Lack of systematic involvement can also be attributed to limited knowledge about how to implement involvement beyond the focus of self-monitoring and compliance and a concern about the consequences of patient involvement for treatment outcomes. To realise the potential of patients' and health professionals' shared openness towards involvement, there is a need for more active facilitation and concrete guidance on how involvement can be practiced by both parties.

Understanding adolescent development: implications for driving safety.

Science.gov (United States)

Keating, Daniel P

2007-01-01

The implementation of Graduated Driver Licensing (GDL) programs has significantly improved the crash and fatality rates of novice teen drivers, but these rates remain unacceptably high. A review of adolescent development research was undertaken to identify potential areas of improvement. Research support for GDL was found to be strong, particularly regarding early acquisition of expertise in driving safety (beyond driving skill), and to limitations that reduce opportunities for distraction. GDL regimes are highly variable, and no US jurisdictions have implemented optimal regimes. Expanding and improving GDL to enhance acquisition of expertise and self-regulation are indicated for implementation and for applied research. Driver training that effectively incorporates safety goals along with driving skill is another target. The insurance industry will benefit from further GDL enhancements. Benefits may accrue to improved driver training, improved simulation devices during training, and automated safety feedback instrumentation.

Lay Crowd-Sourced Expertise (LCE) and Its Influence on the New Role of Patients: Ethical and Societal Issues.

Science.gov (United States)

Lamas, Eugenia; Salinas, Rodrigo; Ferrer, Marcela; Bousquet, Cedric; Vuillaume, Dominique

2016-01-01

The emergence of social media on the Internet allows patients to discuss about their chronic diseases within online communities sharing common interests. This allows patients to gather other patients' experience, and gain new knowledge that is usually not shared by healthcare professionals. In this context, further studies are required on the actual impact of the use of social networks on the quality of life of patients participating in these online communities, focusing on the evolving role and impact of Lay Crowdsourced expertise (LCE) in improving disease management and control. We present a study on a large number of posts from social networks of different online communities. This study allowed us to choose four pathologies, with distinctive characteristics relevant for our future analysis, and to define the themes that will be covered in future work by online questionnaires. The analysis of responses from patients, who volunteer to participate, will help us in exploring how interactions between patients, on these online communities, may help them to gain useful information for managing their conditions and improving their quality of life. Furthermore, we will identify new ethical issues that arise in the sharing of health data.

78 FR 70560 - Patient Safety Organizations: Voluntary Relinquishment From GE-PSO

Science.gov (United States)

2013-11-26

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety...), HHS. ACTION: Notice of delisting. SUMMARY: The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41, 42 U.S.C. 299b-21-b-26, provides for the formation of Patient...

77 FR 26280 - Patient Safety Organizations: Voluntary Relinquishment From CareRise LLC

Science.gov (United States)

2012-05-03

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety... relinquishment from CareRise LLC of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorizes the listing of PSOs, which are entities or...

Healthcare professionals? views on feedback of a patient safety culture assessment

OpenAIRE

Zwijnenberg, Nicolien C.; Hendriks, Michelle; Hoogervorst-Schilp, Janneke; Wagner, Cordula

2016-01-01

Background By assessing patient safety culture, healthcare providers can identify areas for improvement in patient safety culture. To achieve this, these assessment outcomes have to be relevant and presented clearly. The aim of our study was to explore healthcare professionals? views on the feedback of a patient safety culture assessment. Methods Twenty four hospitals participated in a patient safety culture assessment in 2012. Hospital departments received feedback in a report and on a websi...

Improving patient safety in Libya: insights from a British health system perspective.

Science.gov (United States)

Elmontsri, Mustafa; Almashrafi, Ahmed; Dubois, Elizabeth; Banarsee, Ricky; Majeed, Azeem

2018-04-16

Purpose Patient safety programmes aim to make healthcare safe for both patients and health professionals. The purpose of this paper is to explore the UK's patient safety improvement programmes over the past 15 years and explore what lessons can be learnt to improve Libyan healthcare patient safety. Design/methodology/approach Publications focusing on UK patient safety were searched in academic databases and content analysed. Findings Several initiatives have been undertaken over the past 15 years to improve British healthcare patient safety. Many stakeholders are involved, including regulatory and professional bodies, educational providers and non-governmental organisations. Lessons can be learnt from the British journey. Practical implications Developing a national patient safety strategy for Libya, which reflects context and needs is paramount. Above all, Libyan patient safety programmes should reference internationally approved guidelines, evidence, policy and learning from Britain's unique experience. Originality/value This review examines patient safety improvement strategies adopted in Britain to help developing country managers to progress local strategies based on lessons learnt from Britain's unique experience.

The effect of organisational culture on patient safety.

Science.gov (United States)

Kaufman, Gerri; McCaughan, Dorothy

This article explores the links between organisational culture and patient safety. The key elements associated with a safety culture, most notably effective leadership, good teamwork, a culture of learning and fairness, and fostering patient-centred care, are discussed. The broader aspects of a systems approach to promoting quality and safety, with specific reference to clinical governance, human factors, and ergonomics principles and methods, are also briefly explored, particularly in light of the report of the public inquiry into care failings at Mid Staffordshire NHS Foundation Trust.

Denying a patient's final will: public safety vs. medical confidentiality and patient autonomy.

Science.gov (United States)

Gaertner, Jan; Vent, Julia; Greinwald, Ralf; Rothschild, Markus A; Ostgathe, Christoph; Kessel, Rene; Voltz, Raymond

2011-12-01

Especially when caring for patients approaching the end of life, physicians and nursing staff feel committed to fulfilling as many patient desires as possible. However, sometimes a patient's "final will" may threaten public safety. This can lead to severe conflicts, outweighing the physician's obligation and dedication to care for the patient and to respect his autonomy. Yet, public safety can be threatened if confidentiality is not broken. This article provides a concise summary of the medicolegal and ethical fundamentals concerning this difficult situation. If the patient's and others' health and safety are at risk, physicians may (and in some countries must) break medical confidentiality and disclose confidential patient information to the police and other authorities. Physicians should be able to professionally deal with such a conflict in all patients, not only in patients with advanced illness. Copyright © 2011 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Perception is reality: How patients contribute to poor workplace safety perceptions.

Science.gov (United States)

McCaughey, Deirdre; McGhan, Gwen; DelliFraine, Jami L; Brannon, S Diane

2011-01-01

Nurses and aides are among the occupational subgroups with the highest injury rates and workdays lost to illness and injury in North America. Many studies have shown that these incidents frequently happen during provision of patient care. Moreover, health care workplaces are a source of numerous safety risks that contribute to worker injuries. These findings identify health care as a high-risk occupation for employee injury or illness. The purpose of this study was to examine the relationships among patient care, employee safety perceptions, and employee stress. Using the National Institute for Occupational Safety and Health Model of Job Stress and Health as a foundation, we developed and tested a conceptual workplace safety climate-stress model that explicates how caring for high-risk patients is a safety stressor that has negative outcomes for health care providers, including poor workplace safety perceptions and increasing stress levels. We introduced the concept of "high-risk patients" and define them as those who put providers at greater risk for injury or illness. Using a nonexperimental survey design, we examined patient types and safety perceptions of health care providers (nurses, aides, and allied health) in an acute care hospital. Health care providers who care for high-risk patients more frequently have poor safety climate perceptions and higher stress levels. Safety climate was found to mediate the relationship between high-risk patients and stress. These findings bring insight into actions health care organizations can pursue to improve health care provider well-being. Recognizing that different patients present different risks and pursuing staffing, training, and equipment to minimize employee risk of injury will help reduce the staggering injury rates experienced by these employees. Moreover, minimizing employee stress over poor workplace safety is achievable through comprehensive workplace safety climate programs that include supervisor, management

[The road to patient safety: facts and desire].

Science.gov (United States)

Aibar-Remón, Carlos; Barrasa-Villar, Ignacio; Moliner-Lahoz, Javier; Gutiérrez-Cía, Isabel; Aibar-Villán, Laura; Obón-Azuara, Blanca; Mareca-Doñate, Rosa; Ríos-Faure, David

2018-01-27

To evaluate differences between the need and degree of implementation of safe practices recommended for patient safety and to check the usefulness of traffic sign iconicity to promote their implementation. The study was developed in two stages: 1) review of safe practices recommended by different organizations and 2) a survey to assess the perceptions for the need and implementation of them and the usefulness of signs to improve their implementation. The sample consisted of professionals from Spain and Latin America working in healthcare settings and in the academic field related to patient safety. 365 questionnaires were collected. All safe practices included were considered necessary (mean and lower limit of confidence interval over 3 out of 5 points). However, in six of the patient safety practices evaluated the implementation was considered insufficient: illegible handwriting, medication reconciliation, standardization of communication systems, early warning systems, procedures performed or equipment used only by trained people, and compliance with patient preferences at the end of life. Improve compliance of with hand hygiene and barrier precautions to prevent infections, ensure the correct identification of patients and the use of checklists are the four practices in which more than 75% of respondents found a high degree of consensus on the usefulness of traffic sings to broaden their use. The differences between perceived need and actual implementation in some safe practices indicate areas for improvement in patient safety. With this aim, the common language and the iconicity of traffic signs could constitute a simple instrument to improve compliance with safe practices for patient safety. Copyright © 2018 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.

Bilateral effects of hospital patient-safety procedures on nurses' job satisfaction.

Science.gov (United States)

Inoue, T; Karima, R; Harada, K

2017-09-01

The aim of this study was to examine how hospital patient-safety procedures affect the job satisfaction of hospital nurses. Additionally, we investigated the association between perceived autonomy and hospital patient-safety procedures and job satisfaction. Recently, measures for patient safety have been recognized as an essential requirement in hospitals. Hospital patient-safety procedures may enhance the job satisfaction of nurses by improving the quality of their work. However, such procedures may also decrease their job satisfaction by imposing excessive stress on nurses because they cannot make mistakes. The participants included 537 nurses at 10 private hospitals in Japan (The surveys were collected from March to July 2012). Factors related to hospital patient-safety procedures were demonstrated using factor analysis, and the associations between these factors and nurses' self-perceived autonomy and job satisfaction were examined using structural equation modelling. Five factors regarding hospital patient-safety procedures were extracted. Additionally, structural equation modelling revealed statistically significant associations between these factors and the nurses' self-perceived autonomy and job satisfaction. The findings showed that nurses' perceived autonomy of the workplace enhanced their job satisfaction and that their perceptions of hospital patient-safety procedures promoted their job satisfaction. However, some styles of chief nurses' leadership regarding patient safety restrict nurses' independent and autonomous decision-making and actions, resulting in a lowering of job satisfaction. This study demonstrated that hospital patient-safety procedures have ambiguous effects on nurses' job satisfaction. In particular, chief nurses' leadership relating to patient safety can have a positive or negative effect on nurses' job satisfaction. The findings indicated that hospital managers should demonstrate positive attitudes to improve patient safety for

Patient Safety Based Knowledge Management SECI to Improve Nusrsing Students Competency

Directory of Open Access Journals (Sweden)

Joanggi Wiriatarina Harianto

2015-10-01

Full Text Available Introduction: Patient safety is an important component of health services quality,and  basic principles of patient care. Nursing students also have a great potential to make an action that could endanger the patient, because hospital is one of student practice area. The purpose of this study was to improve the nursing students competency in patient safety by using knowledge management SECI approached. Method: The study used exploratory survey, and quasy experiment. The samples were some of nursing students of STIKes Muhammadiyah Samarinda who were on internship programme that selected using simple random sampling technique, in total of 54 students. This research’s variables were the knowledge management SECI based-patient safety and nursing student’s competency. The data were collected by using questionnaires and observation. The data were analyze by using Partial Least Square (PLS. Result: The result showed that there were significant influence the implementation of a model patient safety based knowledge management seci on increased competence nursing students. Discussion: Improved student competency in patient safety using SECI knowledge management was carried out in four phases, that is Socialization, Externalization, Combination, and Internalization. The result was a new knowledge related to patient safety that able to improve the student’s competency.. Keywords: Patient safety, Knowledge management, SECI, competency

76 FR 74788 - Patient Safety Organizations: Voluntary Relinquishment From HealthWatch, Inc.

Science.gov (United States)

2011-12-01

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety... relinquishment from HealthWatch, Inc. of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41, 42 U.S.C. 299b-21--b-26...

76 FR 7853 - Patient Safety Organizations: Voluntary Delisting From HealthDataPSO

Science.gov (United States)

2011-02-11

... Medical Error Management, LLC, of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41, 42 U.S.C. 299b-21--b-26... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety...

Powering Ideas through Expertise

DEFF Research Database (Denmark)

Seabrooke, Leonard; Wigan, Duncan

2016-01-01

This contribution discusses how ideas are powered through expertise and moral authority. Professionals compete with each other to power ideas by linking claims to expertise, how things best work, to moral claims about how things should be. To show how, we draw on a case of battles over global tax...... policy. Corporate reporting for tax purposes is an area where the European Union, Organization for Economic Co-operation and Development, the United Nations, large global accountancy firms and non-governmental organizations have been active. The point of contention here is what form of financial...... can be fused with claims to moral authority. Such a constellation is more likely when political conditions are favourable....

Trust, temporality and systems: how do patients understand patient safety in primary care? A qualitative study.

Science.gov (United States)

Rhodes, Penny; Campbell, Stephen; Sanders, Caroline

2016-04-01

Patient safety research has tended to focus on hospital settings, although most clinical encounters occur in primary care, and to emphasize practitioner errors, rather than patients' own understandings of safety. To explore patients' understandings of safety in primary care. Qualitative interviews were conducted with patients recruited from general practices in northwest England. Participants were asked basic socio-demographic information; thereafter, topics were largely introduced by interviewees themselves. Transcripts were coded and analysed using NVivo10 (qualitative data software), following a process of constant comparison. Thirty-eight people (14 men, 24 women) from 19 general practices in rural, small town and city locations were interviewed. Many of their concerns (about access, length of consultation, relationship continuity) have been discussed in terms of quality, but, in the interviews, were raised as matters of safety. Three broad themes were identified: (i) trust and psycho-social aspects of professional-patient relationships; (ii) choice, continuity, access, and the temporal underpinnings of safety; and (iii) organizational and systems-level tensions constraining safety. Conceptualizations of safety included common reliance on a bureaucratic framework of accreditation, accountability, procedural rules and regulation, but were also individual and context-dependent. For patients, safety is not just a property of systems, but personal and contingent and is realized in the interaction between doctor and patient. However, it is the systems approach that has dominated safety thinking, and patients' individualistic and relational conceptualizations are poorly accommodated within current service organization. © 2015 The Authors Health Expectations Published by John Wiley & Sons Ltd.

Assessment of patient safety culture in private and public hospitals in Peru.

Science.gov (United States)

Arrieta, Alejandro; Suárez, Gabriela; Hakim, Galed

2018-04-01

To assess the patient safety culture in Peruvian hospitals from the perspective of healthcare professionals, and to test for differences between the private and public healthcare sectors. Patient safety is defined as the avoidance and prevention of patient injuries or adverse events resulting from the processes of healthcare delivery. A non-random cross-sectional study conducted online. An online survey was administered from July to August 2016, in Peru. This study reports results from Lima and Callao, which are the capital and the port region of Peru. A total of 1679 healthcare professionals completed the survey. Participants were physicians, medical residents and nurses working in healthcare facilities from the private sector and public sector. Assessment of the degree of patient safety and 12 dimensions of patient safety culture in hospital units as perceived by healthcare professionals. Only 18% of healthcare professionals assess the degree of patient safety in their unit of work as excellent or very good. Significant differences are observed between the patient safety grades in the private sector (37%) compared to the public sub-sectors (13-15%). Moreover, in all patient safety culture dimensions, healthcare professionals from the private sector give more favorable responses for patient safety, than those from the public sub-systems. The most significant difference in support comes from patient safety administrators through communication and information about errors. Overall, the degree of patient safety in Peru is low, with significant gaps that exist between the private and the public sectors.

Nurses' Perceptions of Patient Safety Culture in Three Hospitals in Saudi Arabia.

Science.gov (United States)

Alquwez, Nahed; Cruz, Jonas Preposi; Almoghairi, Ahmed Mohammed; Al-Otaibi, Raid Salman; Almutairi, Khalid Obaid; Alicante, Jerico G; Colet, Paolo C

2018-05-14

To assess the present patient safety culture of three general hospitals in Saudi Arabia, as perceived by nurses. This study utilized a descriptive, cross-sectional design. A convenience sample of 351 nurses working in three general hospitals in the central region of Saudi Arabia was surveyed in this study using the Hospital Survey of Patients' Safety Culture (HSOPSC) from October 2016 to April 2017. From the 12 composites of the HSOPSC, the nurses perceived only the following two patient safety areas as strengths: teamwork within units and organizational learning-continuous improvement. Six areas of patient safety were identified as weaknesses, namely overall perception of patient safety, handoffs and transitions, communication openness, staffing, frequency of events reported, and nonpunitive response to errors. Nationality, educational attainment, hospital, length of service in the hospital, work area or unit, length of service in the current work area or unit, current position, and direct patient contact or interaction were significant predictors of the nurses' perceived patient safety culture. The findings in this study clarify the current status of patient safety culture in three hospitals in the Kingdom of Saudi Arabia. The present findings should be considered by policymakers, hospital leaders, and nurse executives in creating interventions aimed at improving the patient safety culture in hospitals. A multidimensional network intervention targeting the different dimensions of patient safety culture and involving different organizational levels should be implemented to improve patient safety. © 2018 Sigma Theta Tau International.

Colorectal Cancer Safety Net: Is It Catching Patients Appropriately?

Science.gov (United States)

Althans, Alison R; Brady, Justin T; Times, Melissa L; Keller, Deborah S; Harvey, Alexis R; Kelly, Molly E; Patel, Nilam D; Steele, Scott R

2018-01-01

Disparities in access to colorectal cancer care are multifactorial and are affected by socioeconomic elements. Uninsured and Medicaid patients present with advanced stage disease and have worse outcomes compared with similar privately insured patients. Safety net hospitals are a major care provider to this vulnerable population. Few studies have evaluated outcomes for safety net hospitals compared with private institutions in colorectal cancer. The purpose of this study was to compare demographics, screening rates, presentation stage, and survival rates between a safety net hospital and a tertiary care center. Comparative review of patients at 2 institutions in the same metropolitan area were conducted. The study included colorectal cancer care delivered either at 1 safety net hospital or 1 private tertiary care center in the same city from 2010 to 2016. A total of 350 patients with colorectal cancer from each hospital were evaluated. Overall survival across hospital systems was measured. The safety net hospital had significantly more uninsured and Medicaid patients (46% vs 13%; p presentation, a similar percentage of patients at each hospital presented with stage IV disease (26% vs 20%; p = 0.06). For those undergoing resection, final pathologic stage distribution was similar across groups (p = 0.10). After a comparable median follow-up period (26.6 mo for safety net hospital vs 29.2 mo for tertiary care center), log-rank test for overall survival favored the safety net hospital (p = 0.05); disease-free survival was similar between hospitals (p = 0.40). This was a retrospective review, reporting from medical charts. Our results support the value of safety net hospitals for providing quality colorectal cancer care, with survival and recurrence outcomes equivalent or improved compared with a local tertiary care center. Because safety net hospitals can provide equivalent outcomes despite socioeconomic inequalities and financial constraints, emphasis should be focused

Evaluation of Patient and Family Engagement Strategies to Improve Medication Safety.

Science.gov (United States)

Kim, Julia M; Suarez-Cuervo, Catalina; Berger, Zackary; Lee, Joy; Gayleard, Jessica; Rosenberg, Carol; Nagy, Natalia; Weeks, Kristina; Dy, Sydney

2018-04-01

Patient and family engagement (PFE) is critical for patient safety. We systematically reviewed types of PFE strategies implemented and their impact on medication safety. We searched MEDLINE, EMBASE, reference lists and websites to August 2016. Two investigators independently reviewed all abstracts and articles, and articles were additionally reviewed by two senior investigators for selection. One investigator abstracted data and two investigators reviewed the data for accuracy. Study quality was determined by consensus. Investigators developed a framework for defining the level of patient engagement: informing patients about medications (Level 1), informing about engagement with health care providers (Level 2), empowering patients with communication tools and skills (Level 3), partnering with patients in their care (Level 4), and integrating patients as full care team members (Level 5). We included 19 studies that mostly targeted older adults taking multiple medications. The median level of engagement was 2, ranging from 2-4. We identified no level 5 studies. Key themes for patient engagement strategies impacting medication safety were patient education and medication reconciliation, with a subtheme of patient portals. Most studies (84%) reported implementation outcomes. The most commonly reported medication safety outcomes were medication errors, including near misses and discrepancies (47%), and medication safety knowledge (37%). Most studies (63%) were of medium to low quality, and risk of bias was generally moderate. Among the 11 studies with control groups, 55% (n = 6) reported statistically significant improvement on at least one medication safety outcome. Further synthesis of medication safety measures was limited due to intervention and outcome heterogeneity. Key strategies for engaging patients in medication safety are education and medication reconciliation. Patient engagement levels were generally low, as defined by a novel framework for determining

Patient safety: lessons learned

International Nuclear Information System (INIS)

Bagian, James P.

2006-01-01

The traditional approach to patient safety in health care has ranged from reticence to outward denial of serious flaws. This undermines the otherwise remarkable advances in technology and information that have characterized the specialty of medical practice. In addition, lessons learned in industries outside health care, such as in aviation, provide opportunities for improvements that successfully reduce mishaps and errors while maintaining a standard of excellence. This is precisely the call in medicine prompted by the 1999 Institute of Medicine report ''To Err Is Human: Building a Safer Health System.'' However, to effect these changes, key components of a successful safety system must include: (1) communication, (2) a shift from a posture of reliance on human infallibility (hence ''shame and blame'') to checklists that recognize the contribution of the system and account for human limitations, and (3) a cultivation of non-punitive open and/or de-identified/anonymous reporting of safety concerns, including close calls, in addition to adverse events. (orig.)

Editorial: Advances in healthcare provider and patient training to improve the quality and safety of patient care

Directory of Open Access Journals (Sweden)

Elizabeth M. Borycki

2015-09-01

Full Text Available This special issue of the Knowledge Management & E-Learning: An International Journal is dedicated to describing “Advances in Healthcare Provider and Patient Training to Improve the Quality and Safety of Patient Care.” Patient safety is an important and fundamental requirement of ensuring the quality of patient care. Training and education has been identified as a key to improving healthcare provider patient safety competencies especially when working with new technologies such as electronic health records and mobile health applications. Such technologies can be harnessed to improve patient safety; however, if not used properly they can negatively impact on patient safety. In this issue we focus on advances in training that can improve patient safety and the optimal use of new technologies in healthcare. For example, use of clinical simulations and online computer based training can be employed both to facilitate learning about new clinical discoveries as well as to integrate technology into day to day healthcare practices. In this issue we are publishing papers that describe advances in healthcare provider and patient training to improve patient safety as it relates to the use of educational technologies, health information technology and on-line health resources. In addition, in the special issue we describe new approaches to training and patient safety including, online communities, clinical simulations, on-the-job training, computer based training and health information systems that educate about and support safer patient care in real-time (i.e. when health professionals are providing care to patients. These educational and technological initiatives can be aimed at health professionals (i.e. students and those who are currently working in the field. The outcomes of this work are significant as they lead to safer care for patients and their family members. The issue has both theoretical and applied papers that describe advances in patient

Can patients report patient safety incidents in a hospital setting? A systematic review.

Science.gov (United States)

Ward, Jane K; Armitage, Gerry

2012-08-01

Patients are increasingly being thought of as central to patient safety. A small but growing body of work suggests that patients may have a role in reporting patient safety problems within a hospital setting. This review considers this disparate body of work, aiming to establish a collective view on hospital-based patient reporting. This review asks: (a) What can patients report? (b) In what settings can they report? (c) At what times have patients been asked to report? (d) How have patients been asked to report? 5 databases (MEDLINE, EMBASE, CINAHL, (Kings Fund) HMIC and PsycINFO) were searched for published literature on patient reporting of patient safety 'problems' (a number of search terms were utilised) within a hospital setting. In addition, reference lists of all included papers were checked for relevant literature. 13 papers were included within this review. All included papers were quality assessed using a framework for comparing both qualitative and quantitative designs, and reviewed in line with the study objectives. Patients are clearly in a position to report on patient safety, but included papers varied considerably in focus, design and analysis, with all papers lacking a theoretical underpinning. In all papers, reports were actively solicited from patients, with no evidence currently supporting spontaneous reporting. The impact of timing upon accuracy of information has yet to be established, and many vulnerable patients are not currently being included in patient reporting studies, potentially introducing bias and underestimating the scale of patient reporting. The future of patient reporting may well be as part of an 'error detection jigsaw' used alongside other methods as part of a quality improvement toolkit.

[Patient safety in home care - A review of international recommendations].

Science.gov (United States)

Czakert, Judith; Lehmann, Yvonne; Ewers, Michael

2018-06-08

In recent years there has been a growing trend towards nursing care at home in general as well as towards intensive home care being provided by specialized home care services in Germany. However, resulting challenges for patient safety have rarely been considered. Against this background we aimed to explore whether international recommendations for patient safety in home care in general and in intensive home care in particular already exist and how they can stimulate further practice development in Germany. A review of online English documents containing recommendations for patient safety in intensive home care was conducted. Available documents were analyzed and compared in terms of their form and content. Overall, a small number of relevant documents could be identified. None of these documents exclusively refer to the intensive home care sector. Despite their differences, however, the analysis of four selected documents showed similarities, e. g., regarding specific topics of patient safety (communication, involvement of patients and their relatives, risk assessment, medication management, qualification). Furthermore, strengths and weaknesses of the documents became apparent: e. g., an explicit understanding of patient safety, a literature-based introduction to safety topics or an adaptation of the recommendations to the specific features of home care were occasionally lacking. This document analysis provides interesting input to the formal and content-related development of specific recommendations and to practice development in Germany to improve patient safety in home care. Copyright © 2018. Published by Elsevier GmbH.

Exploring relationships between patient safety culture and patients' assessments of hospital care.

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Sorra, Joann; Khanna, Kabir; Dyer, Naomi; Mardon, Russ; Famolaro, Theresa

2014-10-01

The purpose of this study was to examine relationships among 2 Agency for Healthcare Research and Quality measures of hospital patient safety and quality, which reflect different perspectives on hospital performance: the Hospital Survey on Patient Safety Culture (Hospital SOPS)--a hospital employee patient safety culture survey--and the Consumer Assessment of Healthcare Providers and Systems Hospital Survey (CAHPS Hospital Survey)--a survey of the experiences of adult inpatients with hospital care and services. Our hypothesis was that these 2 measures would be positively related. We performed multiple regressions to examine the relationships between the Hospital SOPS measures and CAHPS Hospital Survey measures, controlling for hospital bed size and ownership. Analyses were conducted at the hospital level with each survey's measures using data from 73 hospitals that administered both surveys during similar periods. Higher overall Hospital SOPS composite average scores were associated with higher overall CAHPS Hospital Survey composite average scores (r = 0.41, P G 0.01). Twelve of 15 Hospital SOPS measures were positively related to the CAHPS Hospital Survey composite average score after controlling for bed size and ownership, with significant standardized regression coefficients ranging from 0.25 to 0.38. None of the Hospital SOPS measures were significantly correlated with either of the two single-item CAHPS Hospital Survey measures (hospital rating and willingness to recommend). This study found that hospitals where staff have more positive perceptions of patient safety culture tend to have more positive assessments of care from patients. This finding helps validate both surveys and suggests that improvements in patient safety culture may lead to improved patient experience with care. Further research is needed to determine the generalizability of these results to larger sets of hospitals, to hospital units, and to other settings of care.

Variability of patient safety culture in Belgian acute hospitals.

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Vlayen, Annemie; Schrooten, Ward; Wami, Welcome; Aerts, Marc; Barrado, Leandro Garcia; Claes, Neree; Hellings, Johan

2015-06-01

The aim of this study was to measure differences in safety culture perceptions within Belgian acute hospitals and to examine variability based on language, work area, staff position, and work experience. The Hospital Survey on Patient Safety Culture was distributed to hospitals participating in the national quality and safety program (2007-2009). Hospitals were invited to participate in a comparative study. Data of 47,136 respondents from 89 acute hospitals were used for quantitative analysis. Percentages of positive response were calculated on 12 dimensions. Generalized estimating equations models were fitted to explore differences in safety culture. Handoffs and transitions, staffing, and management support for patient safety were considered as major problem areas. Dutch-speaking hospitals had higher odds of positive perceptions for most dimensions in comparison with French-speaking hospitals. Safety culture scores were more positive for respondents working in pediatrics, psychiatry, and rehabilitation compared with the emergency department, operating theater, and multiple hospital units. We found an important gap in safety culture perceptions between leaders and assistants within disciplines. Administration and middle management had lower perceptions toward patient safety. Respondents working less than 1 year in the current hospital had more positive safety culture perceptions in comparison with all other respondents. Large comparative databases provide the opportunity to identify distinct high and low scoring groups. In our study, language, work area, and profession were identified as important safety culture predictors. Years of experience in the hospital had only a small effect on safety culture perceptions.

Systems Thinking and Patient Safety

National Research Council Canada - National Science Library

Schyve, Paul M

2005-01-01

Patient safety is a prominent theme in health care delivery today. This should come as no surprise, given that "first, do no harm" has been the ethical watchword throughout the history of medicine, nursing, and pharmacy...

Applying health education theory to patient safety programs: three case studies.

Science.gov (United States)

Gilkey, Melissa B; Earp, Jo Anne L; French, Elizabeth A

2008-04-01

Program planning for patient safety is challenging because intervention-oriented surveillance data are not yet widely available to those working in this nascent field. Even so, health educators are uniquely positioned to contribute to patient safety intervention efforts because their theoretical training provides them with a guide for designing and implementing prevention programs. This article demonstrates the utility of applying health education concepts from three prominent patient safety campaigns, including the concepts of risk perception, community participation, and social marketing. The application of these theoretical concepts to patient safety programs suggests that health educators possess a knowledge base and skill set highly relevant to patient safety and that their perspective should be increasingly brought to bear on the design and evaluation of interventions that aim to protect patients from preventable medical error.

The Development of Sport Expertise: From Leeds to MVP Legend.

Science.gov (United States)

Thomas, Katherine Thomas

1994-01-01

Contributions of motor skill and cognition to sport performance change across age, expertise, and sports. Knowledge and decision making should not limit the development of expertise. Specific strategies for teachers may help students develop expertise. The paper discusses the contribution of knowledge and skill to expertise and its development.…

Survey of factors associated with nurses' perception of patient safety.

Science.gov (United States)

Park, Sun A; Lee, Sui Jin; Choi, Go Un

2011-01-01

To describe the nurses' perception of hospital organization related to cultural issues on the safety of the patient and reporting medical errors. In addition, to identify factors associated with the safety of the patient and the nurse. A survey conducted during December 2008-Jannuary 2009, with 126 nurses using the Korean version of the AHRQ patient safety survey, a self-report 5-point Likert scale. Stata 10.0 was used for descriptive analysis, ANOVA (Analysis of variance) and logistic regression. National Cancer Center in Korea. The means for a working environment related to patient safety was 3.4 (±0.62). The associated factors of duration were at a present hospital, a special area, and direct contact with patients. Among organizational culture factors related to patient safety, the means were 3.81(±0.54) for the boss/manager's perception of patient safety and 3.37(±0.49) for the cooperation/collaboration between units. The frequent number of errors reported by nurses were 1~2(22.2%) times over the past 12 months. For incidence reporting, the items that the 'nurses perceived for communication among clinicians as fair' had a means of 3.23(±0.40) and the 'overall evaluation of patient safety was a good' 3.34(±0.73). The nurses' perception of cooperation and collaboration between units were associated with the direct contact between the patient and the nurse. The frequency of incidence reporting was associated with the duration of working hours at the present hospital and also their work experience. The nurses' perception of hospital environment, organizational culture, and incidence reporting was above average and mostly associated with organizational culture.

The Anesthesia Patient Safety Foundation at 25: a pioneering success in safety, 25th anniversary provokes reflection, anticipation.

Science.gov (United States)

Eichhorn, John H

2012-04-01

The Anesthesia Patient Safety Foundation (APSF) was created in 1985. Its founders coined the term "patient safety" in its modern public usage and created the very first patient safety organization, igniting a movement that is now universal in all of health care. Driven by the vision "that no patient shall be harmed by anesthesia," the APSF has worked tirelessly for more than a quarter century to promote safety education and communication through its widely read Newsletter, its programs, and its presentations. The APSF's extensive research grant program has supported a great many projects leading to key safety improvements and, in particular, was central in the development of high-fidelity mannequin simulation as a research and teaching tool. With its pioneering collaboration, the APSF is unique in incorporating the talents and resources of anesthesia professionals of all types, safety scientists, pharmaceutical and equipment manufacturers, regulators, liability insurance companies, and also surgeons. Specific alerts, campaigns, discussions, and projects have targeted a host of safety issues and dangers over the years, starting with minimal intraoperative monitoring in 1986 and all the way up to beach-chair position cerebral perfusion pressure, operating room medication errors, and the extremely popular DVD on operating room fire safety in 2010; the list is long and expansive. The APSF has served as a model and inspiration for subsequent patient safety organizations and has been recognized nationally as having a dramatic positive impact on the safety of anesthesia care. Recognizing that the work is not over, that systems, organizations, and equipment still at times fail, that basic preventable human errors still do sometimes occur, and that "production pressure" in anesthesia practice threatens past safety gains, the APSF is firmly committed and continues to work hard both on established tenets and new patient safety principles.

Using Highlighting to Train Attentional Expertise.

Science.gov (United States)

Roads, Brett; Mozer, Michael C; Busey, Thomas A

2016-01-01

Acquiring expertise in complex visual tasks is time consuming. To facilitate the efficient training of novices on where to look in these tasks, we propose an attentional highlighting paradigm. Highlighting involves dynamically modulating the saliency of a visual image to guide attention along the fixation path of a domain expert who had previously viewed the same image. In Experiment 1, we trained naive subjects via attentional highlighting on a fingerprint-matching task. Before and after training, we asked subjects to freely inspect images containing pairs of prints and determine whether the prints matched. Fixation sequences were automatically scored for the degree of expertise exhibited using a Bayesian discriminative model of novice and expert gaze behavior. Highlighted training causes gaze behavior to become more expert-like not only on the trained images but also on transfer images, indicating generalization of learning. In Experiment 2, to control for the possibility that the increase in expertise is due to mere exposure, we trained subjects via highlighting of fixation sequences from novices, not experts, and observed no transition toward expertise. In Experiment 3, to determine the specificity of the training effect, we trained subjects with expert fixation sequences from images other than the one being viewed, which preserves coarse-scale statistics of expert gaze but provides no information about fine-grain features. Observing at least a partial transition toward expertise, we obtain only weak evidence that the highlighting procedure facilitates the learning of critical local features. We discuss possible improvements to the highlighting procedure.

Using Highlighting to Train Attentional Expertise.

Directory of Open Access Journals (Sweden)

Brett Roads

Full Text Available Acquiring expertise in complex visual tasks is time consuming. To facilitate the efficient training of novices on where to look in these tasks, we propose an attentional highlighting paradigm. Highlighting involves dynamically modulating the saliency of a visual image to guide attention along the fixation path of a domain expert who had previously viewed the same image. In Experiment 1, we trained naive subjects via attentional highlighting on a fingerprint-matching task. Before and after training, we asked subjects to freely inspect images containing pairs of prints and determine whether the prints matched. Fixation sequences were automatically scored for the degree of expertise exhibited using a Bayesian discriminative model of novice and expert gaze behavior. Highlighted training causes gaze behavior to become more expert-like not only on the trained images but also on transfer images, indicating generalization of learning. In Experiment 2, to control for the possibility that the increase in expertise is due to mere exposure, we trained subjects via highlighting of fixation sequences from novices, not experts, and observed no transition toward expertise. In Experiment 3, to determine the specificity of the training effect, we trained subjects with expert fixation sequences from images other than the one being viewed, which preserves coarse-scale statistics of expert gaze but provides no information about fine-grain features. Observing at least a partial transition toward expertise, we obtain only weak evidence that the highlighting procedure facilitates the learning of critical local features. We discuss possible improvements to the highlighting procedure.

Effects of expertise on football betting.

Science.gov (United States)

Khazaal, Yasser; Chatton, Anne; Billieux, Joël; Bizzini, Lucio; Monney, Grégoire; Fresard, Emmanuelle; Thorens, Gabriel; Bondolfi, Guido; El-Guebaly, Nady; Zullino, Daniele; Khan, Riaz

2012-05-11

Football (soccer) is one of the most popular sports in the world, including Europe. It is associated with important betting activities. A common belief, widely spread among those who participate in gambling activities, is that knowledge and expertise on football lead to better prediction skills for match outcomes. If unfounded, however, this belief should be considered as a form of "illusion of control." The aim of this study was to examine whether football experts are better than nonexperts at predicting football match scores. Two hundred and fifty-eight persons took part in the study: 21.3% as football experts, 54.3% as laypersons (non-initiated to football), and 24.4% as football amateurs. They predicted the scores of the first 10 matches of the 2008 UEFA European Football Championship. Logistic regressions were carried out to assess the link between the accuracy of the forecasted scores and the expertise of the participants (expert, amateur, layperson), controlling for age and gender. The variables assessed did not predict the accuracy of scoring prognosis (R2 ranged from 1% to 6%). Expertise, age, and gender did not appear to have an impact on the accuracy of the football match prognoses. Therefore, the belief that football expertise improves betting skills is no more than a cognitive distortion called the "illusion of control." Gamblers may benefit from psychological interventions that target the illusion of control related to their believed links between betting skills and football expertise. Public health policies may need to consider the phenomenon in order to prevent problem gambling related to football betting.

Role of a quality management system in improving patient safety - laboratory aspects.

Science.gov (United States)

Allen, Lynn C

2013-09-01

The aim of this study is to describe how implementation of a quality management system (QMS) based on ISO 15189 enhances patient safety. A literature review showed that several European hospitals implemented a QMS based on ISO 9001 and assessed the impact on patient safety. An Internet search showed that problems affecting patient safety have occurred in a number of laboratories across Canada. The requirements of a QMS based on ISO 15189 are outlined, and the impact of the implementation of each requirement on patient safety is summarized. The Quality Management Program - Laboratory Services in Ontario is briefly described, and the experience of Ontario laboratories with Ontario Laboratory Accreditation, based on ISO 15189, is outlined. Several hospitals that implemented ISO 9001 reported either a positive impact or no impact on patient safety. Patient safety problems in Canadian laboratories are described. Implementation of each requirement of the QMS can be seen to have a positive effect on patient safety. Average laboratory conformance on Ontario Laboratory Accreditation is very high, and laboratories must address and resolve any nonconformities. Other standards, practices, and quality requirements may also contribute to patient safety. Implementation of a QMS based on ISO 15189 provides a solid foundation for quality in the laboratory and enhances patient safety. It helps to prevent patient safety issues; when such issues do occur, effective processes are in place for investigation and resolution. Patient safety problems in Canadian laboratories might have been prevented had effective QMSs been in place. Ontario Laboratory Accreditation has had a positive impact on quality in Ontario laboratories. Copyright © 2013 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

Development and implementation of a hospital-based patient safety program

International Nuclear Information System (INIS)

Frush, Karen S.; Alton, Michael; Frush, Donald P.

2006-01-01

Evidence from numerous studies indicates that large numbers of patients are harmed by medical errors while receiving health-care services in the United States today. The 1999 Institute of Medicine report on medical errors recommended that hospitals and health-care agencies ''establish safety programs to act as a catalyst for the development of a culture of safety'' [1]. In this article, we describe one approach to successful implementation of a hospital-based patient safety program. Although our experience at Duke University Health System will be used as an example, the needs, principles, and solutions can apply to a variety of other health-care practices. Key components include the development of safety teams, provision of tools that teams can use to support an environment of safety, and ongoing program modification to meet patient and staff needs and respond to changing priorities. By moving patient safety to the forefront of all that we do as health-care providers, we can continue to improve our delivery of health care to children and adults alike. This improvement is fostered when we enhance the culture of safety, develop a constant awareness of the possibility of human and system errors in the delivery of care, and establish additional safeguards to intercept medical errors in order to prevent harm to patients. (orig.)

Measurement tools and process indicators of patient safety culture in primary care. A mixed methods study by the LINNEAUS collaboration on patient safety in primary care

Science.gov (United States)

Parker, Dianne; Wensing, Michel; Esmail, Aneez; Valderas, Jose M

2015-01-01

ABSTRACT Background: There is little guidance available to healthcare practitioners about what tools they might use to assess the patient safety culture. Objective: To identify useful tools for assessing patient safety culture in primary care organizations in Europe; to identify those aspects of performance that should be assessed when investigating the relationship between safety culture and performance in primary care. Methods: Two consensus-based studies were carried out, in which subject matter experts and primary healthcare professionals from several EU states rated (a) the applicability to their healthcare system of several existing safety culture assessment tools and (b) the appropriateness and usefulness of a range of potential indicators of a positive patient safety culture to primary care settings. The safety culture tools were field-tested in four countries to ascertain any challenges and issues arising when used in primary care. Results: The two existing tools that received the most favourable ratings were the Manchester patient safety framework (MaPsAF primary care version) and the Agency for healthcare research and quality survey (medical office version). Several potential safety culture process indicators were identified. The one that emerged as offering the best combination of appropriateness and usefulness related to the collection of data on adverse patient events. Conclusion: Two tools, one quantitative and one qualitative, were identified as applicable and useful in assessing patient safety culture in primary care settings in Europe. Safety culture indicators in primary care should focus on the processes rather than the outcomes of care. PMID:26339832

Establishing a culture for patient safety - the role of education.

Science.gov (United States)

Milligan, Frank J

2007-02-01

This paper argues that the process of making significant moves towards a patient safety culture requires changes in healthcare education. Improvements in patient safety are a shared international priority as too many errors and other forms of unnecessary harm are currently occurring in the process of caring for and treating patients. A description of the patient safety agenda is given followed by a brief analysis of human factors theory and its use in other safety critical industries, most notably aviation. The all too common problem of drug administration errors is used to illustrate the relevance of human factors theory to healthcare education with specific mention made of the Human Factors Analysis and Classification System (HFACS).

Organizational change and human expertise in nuclear power plants: some implications for training and error prevention

International Nuclear Information System (INIS)

Masson, M.; Malaise, N.; Housiaux, A.; Keyser, V. de

1993-01-01

Reliability and safety are two very important goals, which depend on technical and organizational factors, but also on human expertise. How to ensure a safe functioning of a nuclear power plant in a changing context, and what might be the role and aspects of training and transfer of knowledge? These are the questions we shall deal with in this paper, on the basis of two field studies. The two field studies stress the needs for setting up case based training, which best ensure the acquisition of know-how. Furthermore, as shown by the second one, gaining expertise involves developing large repertoires of highly skilled, semi-routinized activities. Supporting expert operators not only should tackle problem solving activities but should thus also include the prevention of routine errors, which go along with skill acquisition. (orig.)

Patient safety culture among medical students in Singapore and Hong Kong.

Science.gov (United States)

Leung, Gilberto Ka Kit; Ang, Sophia Bee Leng; Lau, Tang Ching; Neo, Hong Jye; Patil, Nivritti Gajanan; Ti, Lian Kah

2013-09-01

Undergraduate education in medical schools plays an important role in promoting patient safety. Medical students from different backgrounds may have different perceptions and attitudes toward issues concerning safety. This study aimed to investigate whether patient safety cultures differed between students from two Asian countries, and if they did, to find out how they differed. This study also aimed to identify the educational needs of these students. A voluntary, cross-sectional and self-administered questionnaire survey was conducted on 259 students from two medical schools - one in Hong Kong and the other in Singapore. None of the students had received any formal teaching on patient safety. We used a validated survey instrument, the Attitudes to Patient Safety Questionnaire III (APSQ-III), which was designed specifically for students and covered nine key factors of patient safety culture. Of the 259 students, 81 (31.3%) were from Hong Kong and 178 (68.7%) were from Singapore. The overall response rate was 66.4%. Significant differences between the two groups of students were found for two key factors - 'patient safety training', with Hong Kong students being more likely to report having received more of such training (p = 0.007); and 'error reporting confidence', which Singapore students reported having less of (p working hours and professional incompetence were important causes of medical errors. The importance of patient involvement and team functioning were ranked relatively lower by the students. Students from different countries with no prior teaching on patient safety may differ in their baseline patient safety cultures and educational needs. Our findings serve as a reference for future longitudinal studies on the effects of different teaching and healthcare development programmes.

Patient safety manifesto: a professional imperative for prelicensure nursing education.

Science.gov (United States)

Debourgh, Gregory A; Prion, Susan K

2012-01-01

Nurses in practice and students in training often fear hurting a patient or doing something wrong. Experienced nurses have developed assessment skills and clinical intuition to recognize and intervene to prevent patient risk and harm. Beginning nursing students have not yet had the opportunity to develop an awareness of patient risk, safety concerns, or a clear sense of their accountability in the nurse role as the primary advocate for patient safety. In this Safety Manifesto, the authors call for educators to critically review their prelicensure curricula for inclusion of teaching and learning activities that are focused on patient safety and offer recommendations for curricular changes with an emphasis on integration of instructional strategies that develop students' skills for clinical reasoning and judgment. Copyright © 2012 Elsevier Inc. All rights reserved.

Assessing Patient Activation among High-Need, High-Cost Patients in Urban Safety Net Care Settings.

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Napoles, Tessa M; Burke, Nancy J; Shim, Janet K; Davis, Elizabeth; Moskowitz, David; Yen, Irene H

2017-12-01

We sought to examine the literature using the Patient Activation Measure (PAM) or the Patient Enablement Instrument (PEI) with high-need, high-cost (HNHC) patients receiving care in urban safety net settings. Urban safety net care management programs serve low-income, racially/ethnically diverse patients living with multiple chronic conditions. Although many care management programs track patient progress with the PAM or the PEI, it is not clear whether the PAM or the PEI is an effective and appropriate tool for HNHC patients receiving care in urban safety net settings in the United States. We searched PubMed, EMBASE, Web of Science, and PsycINFO for articles published between 2004 and 2015 that used the PAM and between 1998 and 2015 that used the PEI. The search was limited to English-language articles conducted in the United States and published in peer-reviewed journals. To assess the utility of the PAM and the PEI in urban safety net care settings, we defined a HNHC patient sample as racially/ethnically diverse, low socioeconomic status (SES), and multimorbid. One hundred fourteen articles used the PAM. All articles using the PEI were conducted outside the U.S. and therefore were excluded. Nine PAM studies (8%) included participants similar to those receiving care in urban safety net settings, three of which were longitudinal. Two of the three longitudinal studies reported positive changes following interventions. Our results indicate that research on patient activation is not commonly conducted on racially and ethnically diverse, low SES, and multimorbid patients; therefore, there are few opportunities to assess the appropriateness of the PAM in such populations. Investigators expressed concerns with the potential unreliability and inappropriate nature of the PAM on multimorbid, older, and low-literacy patients. Thus, the PAM may not be able to accurately assess patient progress among HNHC patients receiving care in urban safety net settings. Assessing

Expertise and age-related changes in components of intelligence.

Science.gov (United States)

Masunaga, H; Horn, J

2001-06-01

In a sample of 263 male GO players at 48 levels of expertise and ranging from 18 to 78 years of age, it was found that factors of expertise deductive reasoning (EDR) and expertise working memory (EWM) were independent of factors of fluid reasoning (Gf) and short-term working memory (STWM) that, along with cognitive speed (Gs), have been found to characterize decline of intelligence in adulthood. The main effects of analyses of cross-sectional age differences indicated age-related decline in EDR and EWM as well as in Gf, STWM, and Gs. However, interaction and partialing analyses indicated that decline in EDR and EWM decreased to no decline with increase in level of expertise. The results thus suggest that with increase in factors known to raise the level of expertise--particularly, intensive, well-designed practice--there may be no age-related decline in the intelligence that is measured in the abilities of expertise.

Thoughts on Expertise.

Science.gov (United States)

Glaser, Robert

This paper briefly reviews research on tasks in knowledge-rich domains including developmental studies, work in artificial intelligence, studies of expert/novice problem solving, and information processing analysis of aptitude test tasks that have provided increased understanding of the nature of expertise. Particularly evident is the finding that…

78 FR 17212 - Patient Safety Organizations: Voluntary Relinquishment From QAISys, Inc.

Science.gov (United States)

2013-03-20

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety... (AHRQ), HHS. ACTION: Notice of delisting. SUMMARY: The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41, 42 U.S.C. 299b-21-- b-26, provides for the formation of...

Patient handover in orthopaedics, improving safety using Information Technology.

Science.gov (United States)

Pearkes, Tim

2015-01-01

Good inpatient handover ensures patient safety and continuity of care. An adjunct to this is the patient list which is routinely managed by junior doctors. These lists are routinely created and managed within Microsoft Excel or Word. Following the merger of two orthopaedic departments into a single service in a new hospital, it was felt that a number of safety issues within the handover process needed to be addressed. This quality improvement project addressed these issues through the creation and implementation of a new patient database which spanned the department, allowing trouble free, safe, and comprehensive handover. Feedback demonstrated an improved user experience, greater reliability, continuity within the lists and a subsequent improvement in patient safety.

A qualitative exploration of patients' attitudes towards the 'Participate Inform Notice Know' (PINK) patient safety video.

Science.gov (United States)

Pinto, Anna; Vincent, Charles; Darzi, Ara; Davis, Rachel

2013-02-01

To explore patients' attitudes towards the PINK video, a patient education video aimed at encouraging hospital patients' involvement in safety-relevant behaviours. Qualitative semi-structured interviews. Detailed field notes were taken during the interviews which were analysed using content analysis. One National Health System (NHS) teaching hospital based in London, UK. Thirty-six in-patients aged between 20 and 79 years, 18 of them males. The PINK video is a short animated educational video aimed at encouraging patients to be involved in the safety of their care during hospitalization. Patients' perceptions of how informative, relevant and acceptable the video is; attitudes towards participating in the recommended safety-related behaviours and; potential negative side effects of watching the video. Overall the video was received favourably among the interviewees. Commonly cited benefits included raising awareness and facilitating patients to be involved in their care during their hospital stay. More variability was found in participants' views with regard to the video's role as a patient safety enhancement tool. A number of suggestions for improvement of the video were provided relating to tailoring its content and design to meet the needs of individual patients and their circumstances. Educational videos such as PINK have significant potential to empower patients in the safety and quality of their care. However, efforts to implement patient safety educational videos in practice need to consider different patient groups' needs and characteristics instead of trying to adopt 'a one size fits all' approach.

Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review.

Science.gov (United States)

Hall, Louise H; Johnson, Judith; Watt, Ian; Tsipa, Anastasia; O'Connor, Daryl B

2016-01-01

To determine whether there is an association between healthcare professionals' wellbeing and burnout, with patient safety. Systematic research review. PsychInfo (1806 to July 2015), Medline (1946 to July 2015), Embase (1947 to July 2015) and Scopus (1823 to July 2015) were searched, along with reference lists of eligible articles. Quantitative, empirical studies that included i) either a measure of wellbeing or burnout, and ii) patient safety, in healthcare staff populations. Forty-six studies were identified. Sixteen out of the 27 studies that measured wellbeing found a significant correlation between poor wellbeing and worse patient safety, with six additional studies finding an association with some but not all scales used, and one study finding a significant association but in the opposite direction to the majority of studies. Twenty-one out of the 30 studies that measured burnout found a significant association between burnout and patient safety, whilst a further four studies found an association between one or more (but not all) subscales of the burnout measures employed, and patient safety. Poor wellbeing and moderate to high levels of burnout are associated, in the majority of studies reviewed, with poor patient safety outcomes such as medical errors, however the lack of prospective studies reduces the ability to determine causality. Further prospective studies, research in primary care, conducted within the UK, and a clearer definition of healthcare staff wellbeing are needed. This review illustrates the need for healthcare organisations to consider improving employees' mental health as well as creating safer work environments when planning interventions to improve patient safety. PROSPERO registration number: CRD42015023340.

How to Improve Patient Safety Culture in Croatian Hospitals?

Science.gov (United States)

Šklebar, Ivan; Mustajbegović, Jadranka; Šklebar, Duška; Cesarik, Marijan; Milošević, Milan; Brborović, Hana; Šporčić, Krunoslav; Petrić, Petar; Husedžinović, Ino

2016-09-01

Patient safety culture (PCS) has a crucial impact on the safety practices of healthcare delivery systems. The purpose of this study was to assess the state of PSC in Croatian hospitals and compare it with hospitals in the United States. The study was conducted in three public general hospitals in Croatia using the Croatian translation of the Hospital Survey of Patient Safety Culture (HSOPSC). A comparison of the results from Croatian and American hospitals was performed using a T-square test. We found statistically significant differences in all 12 PSC dimensions. Croatian responses were more positive in the two dimensions of Handoff s and Transitions and Overall Perceptions of Patient Safety. In the remaining ten dimensions, Croatian responses were less positive than in US hospitals, with the most prominent areas being Nonpunitive Response to Error, Frequency of Events Reported, Communication Openness, Teamwork within Units, Feedback & Communication about Error, Management Support for Patient Safety, and Staffing. Our findings show that PSC is significantly lower in Croatian than in American hospitals, particularly in the areas of Nonpunitive Response to Error, Leadership, Teamwork, Communication Openness and Staffing. This suggests that a more comprehensive system for the improvement of patient safety within the framework of the Croatian healthcare system needs to be developed. Our findings also help confirm that HSOPSC is a useful and appropriate tool for the assessment of PSC. HSOPSC highlights the PSC components in need of improvement and should be considered for use in national and international benchmarking.

Aviation and healthcare: a comparative review with implications for patient safety.

Science.gov (United States)

Kapur, Narinder; Parand, Anam; Soukup, Tayana; Reader, Tom; Sevdalis, Nick

2016-01-01

Safety in aviation has often been compared with safety in healthcare. Following a recent article in this journal, the UK government set up an Independent Patient Safety Investigation Service, to emulate a similar well-established body in aviation. On the basis of a detailed review of relevant publications that examine patient safety in the context of aviation practice, we have drawn up a table of comparative features and a conceptual framework for patient safety. Convergence and divergence of safety-related behaviours across aviation and healthcare were derived and documented. Key safety-related domains that emerged included Checklists, Training, Crew Resource Management, Sterile Cockpit, Investigation and Reporting of Incidents and Organisational Culture. We conclude that whilst healthcare has much to learn from aviation in certain key domains, the transfer of lessons from aviation to healthcare needs to be nuanced, with the specific characteristics and needs of healthcare borne in mind. On the basis of this review, it is recommended that healthcare should emulate aviation in its resourcing of staff who specialise in human factors and related psychological aspects of patient safety and staff wellbeing. Professional and post-qualification staff training could specifically include Cognitive Bias Avoidance Training, as this appears to play a key part in many errors relating to patient safety and staff wellbeing.

Patient Handoffs in Obstetrics and Gynecology: A Vital Link in Patient Safety

Directory of Open Access Journals (Sweden)

John Yeh

2009-01-01

Full Text Available Inadequate patient handoffs have been an area of focus for patient safety improvement. Insufficient communication and risks or “shortcuts” taken by staff members during handoffs could negatively affect the safety of patients in a department of obstetrics and gynecology. Other factors that contribute to inadequate handoffs are the caregiver feeling fatigued or stressed, level of urgency, volume of information, language barriers, noise, lighting, ambiguity of describing treatment, not allotting enough time for questions asked, and/or interruptions from other staff members. There have been several methods developed for improving the handoff process, such as the mnemonic devices SBAR, SHARQ, I PASS THE BATON, and the 5 P's. A new method for improving the quality of patient handoffs has been developed and presented in this article. It is a mnemonic device entitled “HANDOFFS”. It covers key aspects of what a handoff process should entail. Teamwork is essential to effective communication, and by using a mnemonic such as this, team members can work together in a more positive and accessible environment that will result in improved patient safety.

A Quantitative Analysis of Nursing Students' Perceptions of Patient Safety Competencies

Science.gov (United States)

Steighner, Tammy Rose

2017-01-01

The purpose of the study was to determine nursing students' perceptions of patient safety competencies as it related to Quality and Safety Education for Nurses (QSEN) competencies and the Safety Competencies Framework developed by The Canadian Patient Safety Institute. The study determined if nursing students knew how to provide safe patient care…

Conflict Resolution and Public Participation Center of Expertise

Data.gov (United States)

Federal Laboratory Consortium — On October 17, 2008, the Conflict Resolution and Public Participation Center (CPCX) was named a Corps Center of Expertise (CX) and Directory of Expertise (DX). The...

Patient safety principles in family medicine residency accreditation standards and curriculum objectives

Science.gov (United States)

Kassam, Aliya; Sharma, Nishan; Harvie, Margot; O’Beirne, Maeve; Topps, Maureen

2016-01-01

Abstract Objective To conduct a thematic analysis of the College of Family Physicians of Canada’s (CFPC’s) Red Book accreditation standards and the Triple C Competency-based Curriculum objectives with respect to patient safety principles. Design Thematic content analysis of the CFPC’s Red Book accreditation standards and the Triple C curriculum. Setting Canada. Main outcome measures Coding frequency of the patient safety principles (ie, patient engagement; respectful, transparent relationships; complex systems; a just and trusting culture; responsibility and accountability for actions; and continuous learning and improvement) found in the analyzed CFPC documents. Results Within the analyzed CFPC documents, the most commonly found patient safety principle was patient engagement (n = 51 coding references); the least commonly found patient safety principles were a just and trusting culture (n = 5 coding references) and complex systems (n = 5 coding references). Other patient safety principles that were uncommon included responsibility and accountability for actions (n = 7 coding references) and continuous learning and improvement (n = 12 coding references). Conclusion Explicit inclusion of patient safety content such as the use of patient safety principles is needed for residency training programs across Canada to ensure the full spectrum of care is addressed, from community-based care to acute hospital-based care. This will ensure a patient safety culture can be cultivated from residency and sustained into primary care practice. PMID:27965349

Core competencies for patient safety research: a cornerstone for global capacity strengthening

Science.gov (United States)

Andermann, Anne; Ginsburg, Liane; Norton, Peter; Arora, Narendra; Bates, David; Wu, Albert

2011-01-01

Background Tens of millions of patients worldwide suffer disabling injuries or death every year due to unsafe medical care. Nonetheless, there is a scarcity of research evidence on how to tackle this global health priority. The shortage of trained researchers is a major limitation, particularly in developing and transitional countries. Objectives As a first step to strengthen capacity in this area, the authors developed a set of internationally agreed core competencies for patient safety research worldwide. Methods A multistage process involved developing an initial framework, reviewing the existing literature relating to competencies in patient safety research, conducting a series of consultations with potential end users and international experts in the field from over 35 countries and finally convening a global consensus conference. Results An initial draft list of competencies was grouped into three themes: patient safety, research methods and knowledge translation. The competencies were considered by the WHO Patient Safety task force, by potential end users in developing and transitional countries and by international experts in the field to be relevant, comprehensive, clear, easily adaptable to local contexts and useful for training patient safety researchers internationally. Conclusions Reducing patient harm worldwide will require long-term sustained efforts to build capacity to enable practical research that addresses local problems and improves patient safety. The first edition of Competencies for Patient Safety Researchers is proposed by WHO Patient Safety as a foundation for strengthening research capacity by guiding the development of training programmes for researchers in the area of patient safety, particularly in developing and transitional countries, where such research is urgently needed. PMID:21228081

Effects of expertise on football betting

Directory of Open Access Journals (Sweden)

Khazaal Yasser

2012-05-01

Full Text Available Abstract Background Football (soccer is one of the most popular sports in the world, including Europe. It is associated with important betting activities. A common belief, widely spread among those who participate in gambling activities, is that knowledge and expertise on football lead to better prediction skills for match outcomes. If unfounded, however, this belief should be considered as a form of “illusion of control.” The aim of this study was to examine whether football experts are better than nonexperts at predicting football match scores. Methods Two hundred and fifty-eight persons took part in the study: 21.3% as football experts, 54.3% as laypersons (non-initiated to football, and 24.4% as football amateurs. They predicted the scores of the first 10 matches of the 2008 UEFA European Football Championship. Logistic regressions were carried out to assess the link between the accuracy of the forecasted scores and the expertise of the participants (expert, amateur, layperson, controlling for age and gender. Results The variables assessed did not predict the accuracy of scoring prognosis (R2 ranged from 1% to 6%. Conclusions Expertise, age, and gender did not appear to have an impact on the accuracy of the football match prognoses. Therefore, the belief that football expertise improves betting skills is no more than a cognitive distortion called the “illusion of control.” Gamblers may benefit from psychological interventions that target the illusion of control related to their believed links between betting skills and football expertise. Public health policies may need to consider the phenomenon in order to prevent problem gambling related to football betting.

Toward a multifactorial model of expertise: beyond born versus made.

Science.gov (United States)

Hambrick, David Z; Burgoyne, Alexander P; Macnamara, Brooke N; Ullén, Fredrik

2018-02-15

The debate over the origins of individual differences in expertise has raged for over a century in psychology. The "nature" view holds that expertise reflects "innate talent"-that is, genetically determined abilities. The "nurture" view counters that, if talent even exists, its effects on ultimate performance are negligible. While no scientist takes seriously a strict nature-only view of expertise, the nurture view has gained tremendous popularity over the past several decades. This environmentalist view holds that individual differences in expertise reflect training history, with no important contribution to ultimate performance by innate ability ("talent"). Here, we argue that, despite its popularity, this view is inadequate to account for the evidence concerning the origins of expertise that has accumulated since the view was first proposed. More generally, we argue that the nature versus nurture debate in research on expertise is over-or certainly should be, as it has been in other areas of psychological research for decades. We describe a multifactorial model for research on the nature and nurture of expertise, which we believe will provide a progressive direction for future research on expertise. © 2018 New York Academy of Sciences.

Assessment of patient safety culture in viewpoints of Kashan hospitals nurses 2016

Directory of Open Access Journals (Sweden)

Mohammad Reza Sharif

2016-11-01

Full Text Available Patient safety, i.e. prevention of any hurt to the patient, is one of the main factors of health care quality. Improving patient safety culture through the implementation of systems and processes necessary to work can play an important role in preventing errors and improving the quality. For this purpose, the status of patient safety culture in Kashsn hospitals was examined. This cross - sectional study was performed in five hospitals of Kashan University of Medical Sciences and one Social Security Hospital, by a 42-item standard patient safety questionnaire with a random sampling of 200 nurses available in 2016. Mean age, experience, experience in the last unit of work, experience in nursing profession, work hours per week were obtained 34.28 ± 6.89, 7.72 ± 5.1, 5.87 ± 4.2, 10.42±7.93years and 62.8±26.8hours, respectively. Average of safety culture and its dimensions including teamwork within the units, in line with expectations and the head of patient safety, patient safety management support, organizational learning and continuous improvement, the general perception of patient safety, communication and feedback about errors were obtained 2.88±0.56, 3.04±069, 2.87±0.79, 3.08±0.88, 2.96±0.54, 2.87±0.98, 2.81±0.59, 2.52±0.98, 2.91±0.43, 3.14±1.04, 2.99±0.54, respectively. According to the obtained results, the status of safety culture in hospitals was deemed unfavorable and seemed to need development by training and proper guidelines in order to establish a culture of patient safety and prevention of hurt to patients in order to assure their safety at the hospitals.

The Eurosafe Forum 2003: Nuclear expertise and challenges of the enlargement of the European Union

Energy Technology Data Exchange (ETDEWEB)

Lacronique, Jean-Francois; Repussard, Jacques [Institut de Radioprotection et de Surete Nucleaire, IRSN, B.P. 17, F - 92262 Fontenay-aux-Roses Cedex (France); Hahn, Lothar [Gesellschaft fuer Anlagen- und Reaktorsicherheit mbH, GRS, Schwertnergasse 1, D - 50667 Koeln (Germany)

2003-07-01

EUROSAFE is an international forum for discussions among experts from technical safety organisations, research institutes, safety authorities, utilities, the industry, public authorities and non-governmental organisations concerning the status of and recent achievements in nuclear installation safety, waste management, radiation safety and nuclear material security. The Eurosafe Forum 2003 - the fifth of its kind - was held at the Palais Brongniart in Paris on November 25 and 26, 2003. This year's theme was: 'Nuclear expertise and challenges of the enlargement of the European Union: speakers in the various European countries about the environmental scan before enlargement, development and structuring perspectives within the enlarged Europe'. The event brought together 445 experts and researchers from around the world (including 124 from Germany, 184 from France, 88 from Eastern Europe, as well as representatives from Korea, Japan, the United States, Canada, Cuba, and Armenia. The proceedings of the symposium can now be consulted online. The fifth edition of the forum focused on nuclear expertise and the challenge of EU-enlargement and the latest work carried out by GRS, IRSN and their partners from the European Union, Switzerland and Eastern Europe. Nuclear energy contributes approximately one third of European electricity production. A high level of nuclear safety is a priority for the countries of Europe. The technical safety organisations play an important role in contributing to that objective through appropriate approaches to major safety issues as part of their assessments and research activities. The challenges to nuclear safety are increasingly international. Changes in underlying technologies such as instrumentation and control, the impact of electricity market deregulation, demands for improved safety, the ageing of nuclear facilities, waste management, maintaining and improving scientific and technical knowledge and the need for greater transparency

The Eurosafe Forum 2003: Nuclear expertise and challenges of the enlargement of the European Union

International Nuclear Information System (INIS)

Lacronique, Jean-Francois; Repussard, Jacques

2003-01-01

EUROSAFE is an international forum for discussions among experts from technical safety organisations, research institutes, safety authorities, utilities, the industry, public authorities and non-governmental organisations concerning the status of and recent achievements in nuclear installation safety, waste management, radiation safety and nuclear material security. The Eurosafe Forum 2003 - the fifth of its kind - was held at the Palais Brongniart in Paris on November 25 and 26, 2003. This year's theme was: 'Nuclear expertise and challenges of the enlargement of the European Union: speakers in the various European countries about the environmental scan before enlargement, development and structuring perspectives within the enlarged Europe'. The event brought together 445 experts and researchers from around the world (including 124 from Germany, 184 from France, 88 from Eastern Europe, as well as representatives from Korea, Japan, the United States, Canada, Cuba, and Armenia. The proceedings of the symposium can now be consulted online. The fifth edition of the forum focused on nuclear expertise and the challenge of EU-enlargement and the latest work carried out by GRS, IRSN and their partners from the European Union, Switzerland and Eastern Europe. Nuclear energy contributes approximately one third of European electricity production. A high level of nuclear safety is a priority for the countries of Europe. The technical safety organisations play an important role in contributing to that objective through appropriate approaches to major safety issues as part of their assessments and research activities. The challenges to nuclear safety are increasingly international. Changes in underlying technologies such as instrumentation and control, the impact of electricity market deregulation, demands for improved safety, the ageing of nuclear facilities, waste management, maintaining and improving scientific and technical knowledge and the need for greater transparency

The Eurosafe Forum 2003: Nuclear expertise and challenges of the enlargement of the European Union

Energy Technology Data Exchange (ETDEWEB)

Lacronique, Jean-Francois; Repussard, Jacques (eds.) [Institut de Radioprotection et de Surete Nucleaire, IRSN, B.P. 17, F - 92262 Fontenay-aux-Roses Cedex (France); Hahn, Lothar (ed.) [Gesellschaft fuer Anlagen- und Reaktorsicherheit mbH, GRS, Schwertnergasse 1, D - 50667 Koeln (Germany)

2003-07-01

EUROSAFE is an international forum for discussions among experts from technical safety organisations, research institutes, safety authorities, utilities, the industry, public authorities and non-governmental organisations concerning the status of and recent achievements in nuclear installation safety, waste management, radiation safety and nuclear material security. The Eurosafe Forum 2003 - the fifth of its kind - was held at the Palais Brongniart in Paris on November 25 and 26, 2003. This year's theme was: 'Nuclear expertise and challenges of the enlargement of the European Union: speakers in the various European countries about the environmental scan before enlargement, development and structuring perspectives within the enlarged Europe'. The event brought together 445 experts and researchers from around the world (including 124 from Germany, 184 from France, 88 from Eastern Europe, as well as representatives from Korea, Japan, the United States, Canada, Cuba, and Armenia. The proceedings of the symposium can now be consulted online. The fifth edition of the forum focused on nuclear expertise and the challenge of EU-enlargement and the latest work carried out by GRS, IRSN and their partners from the European Union, Switzerland and Eastern Europe. Nuclear energy contributes approximately one third of European electricity production. A high level of nuclear safety is a priority for the countries of Europe. The technical safety organisations play an important role in contributing to that objective through appropriate approaches to major safety issues as part of their assessments and research activities. The challenges to nuclear safety are increasingly international. Changes in underlying technologies such as instrumentation and control, the impact of electricity market deregulation, demands for improved safety, the ageing of nuclear facilities, waste management, maintaining and improving scientific and technical knowledge and the need for greater

Patient safety competency and educational needs of nursing educators in South Korea

Science.gov (United States)

2017-01-01

Background Nursing educators must be qualified to teach patient safety to nursing students to ensure patient safety in the clinical field. The purpose of this study was to assess nursing educators’ competencies and educational needs for patient safety in hospitals and nursing schools. Method A mixed-methods sequential explanatory design employed a survey and focus group interview with nursing educators (school clinical instructors and hospital nurse preceptors). Thirty-eight questionnaires filled out by clinical instructors from six four-year nursing universities and 106 questionnaires from nurse preceptors from three high-level general hospitals in the Seoul metropolitan area were analyzed to obtain quantitative data. Focus group interviews were conducted among six clinical instructors from one nursing school and four nurse preceptors from one high-level general hospital in Seoul. Results Nursing educators had higher levels of attitude compared with relatively lower levels of skill and knowledge regarding patient safety. They reported educational needs of “medication” and “infection prevention” as being higher and “human factors” and “complexity of systems” as being lower. Nursing educators desired different types of education for patient safety. Conclusion It is necessary to enhance nursing educators’ patient safety skills and knowledge by developing and providing an integrated program of patient safety, with various teaching methods to meet their educational needs. The findings of this study provide the basic information needed to reform patient safety education programs appropriately to fit nursing educators' needs and their patient safety competencies in both clinical practice and academia. Furthermore, the findings have revealed the importance of effective communication between clinical and academic settings in making patient safety education seamless. PMID:28873099

Patient safety competency and educational needs of nursing educators in South Korea.

Directory of Open Access Journals (Sweden)

Haena Jang

Full Text Available Nursing educators must be qualified to teach patient safety to nursing students to ensure patient safety in the clinical field. The purpose of this study was to assess nursing educators' competencies and educational needs for patient safety in hospitals and nursing schools.A mixed-methods sequential explanatory design employed a survey and focus group interview with nursing educators (school clinical instructors and hospital nurse preceptors. Thirty-eight questionnaires filled out by clinical instructors from six four-year nursing universities and 106 questionnaires from nurse preceptors from three high-level general hospitals in the Seoul metropolitan area were analyzed to obtain quantitative data. Focus group interviews were conducted among six clinical instructors from one nursing school and four nurse preceptors from one high-level general hospital in Seoul.Nursing educators had higher levels of attitude compared with relatively lower levels of skill and knowledge regarding patient safety. They reported educational needs of "medication" and "infection prevention" as being higher and "human factors" and "complexity of systems" as being lower. Nursing educators desired different types of education for patient safety.It is necessary to enhance nursing educators' patient safety skills and knowledge by developing and providing an integrated program of patient safety, with various teaching methods to meet their educational needs. The findings of this study provide the basic information needed to reform patient safety education programs appropriately to fit nursing educators' needs and their patient safety competencies in both clinical practice and academia. Furthermore, the findings have revealed the importance of effective communication between clinical and academic settings in making patient safety education seamless.

Tracing the foundations of a conceptual framework for a patient safety ontology

DEFF Research Database (Denmark)

Runciman, William B; Baker, G Ross; Michel, Philippe

2010-01-01

In work for the World Alliance for Patient Safety on research methods and measures and on defining key concepts for an International Patient Safety Classification (ICPS), it became apparent that there was a need to try to understand how the meaning of patient safety and underlying concepts relate...... to the existing safety and quality frameworks commonly used in healthcare....

[Patient safety culture in directors and managers of a health service].

Science.gov (United States)

Giménez-Júlvez, Teresa; Hernández-García, Ignacio; Aibar-Remón, Carlos; Gutiérrez-Cía, Isabel; Febrel-Bordejé, Mercedes

To assess patient safety culture in directors/managers. Cross-sectional descriptive study carried out from February to June 2011 among the executive/managing staff of the Aragón Health Service through semi-structured interviews. A total of 12 interviews were carried out. All the respondents admitted that there were many patient safety problems and agreed that patient safety was a priority from a theoretical rather than practical perspective. The excessive changes in executive positions was considered to be an important barrier which made it difficult to establish long-term strategies and achieve medium-term continuity. This study recorded perceptions on patient safety culture in directors, an essential factor to improve patient safety culture in this group and in the organisations they run. Copyright © 2017 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.

Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review

Science.gov (United States)

Hall, Louise H.; Johnson, Judith; Watt, Ian; Tsipa, Anastasia; O’Connor, Daryl B.

2016-01-01

Objective To determine whether there is an association between healthcare professionals’ wellbeing and burnout, with patient safety. Design Systematic research review. Data Sources PsychInfo (1806 to July 2015), Medline (1946 to July 2015), Embase (1947 to July 2015) and Scopus (1823 to July 2015) were searched, along with reference lists of eligible articles. Eligibility Criteria for Selecting Studies Quantitative, empirical studies that included i) either a measure of wellbeing or burnout, and ii) patient safety, in healthcare staff populations. Results Forty-six studies were identified. Sixteen out of the 27 studies that measured wellbeing found a significant correlation between poor wellbeing and worse patient safety, with six additional studies finding an association with some but not all scales used, and one study finding a significant association but in the opposite direction to the majority of studies. Twenty-one out of the 30 studies that measured burnout found a significant association between burnout and patient safety, whilst a further four studies found an association between one or more (but not all) subscales of the burnout measures employed, and patient safety. Conclusions Poor wellbeing and moderate to high levels of burnout are associated, in the majority of studies reviewed, with poor patient safety outcomes such as medical errors, however the lack of prospective studies reduces the ability to determine causality. Further prospective studies, research in primary care, conducted within the UK, and a clearer definition of healthcare staff wellbeing are needed. Implications This review illustrates the need for healthcare organisations to consider improving employees’ mental health as well as creating safer work environments when planning interventions to improve patient safety. Systematic Review Registration PROSPERO registration number: CRD42015023340. PMID:27391946

Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review.

Directory of Open Access Journals (Sweden)

Louise H Hall

Full Text Available To determine whether there is an association between healthcare professionals' wellbeing and burnout, with patient safety.Systematic research review.PsychInfo (1806 to July 2015, Medline (1946 to July 2015, Embase (1947 to July 2015 and Scopus (1823 to July 2015 were searched, along with reference lists of eligible articles.Quantitative, empirical studies that included i either a measure of wellbeing or burnout, and ii patient safety, in healthcare staff populations.Forty-six studies were identified. Sixteen out of the 27 studies that measured wellbeing found a significant correlation between poor wellbeing and worse patient safety, with six additional studies finding an association with some but not all scales used, and one study finding a significant association but in the opposite direction to the majority of studies. Twenty-one out of the 30 studies that measured burnout found a significant association between burnout and patient safety, whilst a further four studies found an association between one or more (but not all subscales of the burnout measures employed, and patient safety.Poor wellbeing and moderate to high levels of burnout are associated, in the majority of studies reviewed, with poor patient safety outcomes such as medical errors, however the lack of prospective studies reduces the ability to determine causality. Further prospective studies, research in primary care, conducted within the UK, and a clearer definition of healthcare staff wellbeing are needed.This review illustrates the need for healthcare organisations to consider improving employees' mental health as well as creating safer work environments when planning interventions to improve patient safety.PROSPERO registration number: CRD42015023340.

Negotiating knowledges and expertise in refugee resettlement organizations

Directory of Open Access Journals (Sweden)

Sarah Steimel

2016-12-01

Full Text Available Interviews with both refugees and organizational staff in two nonprofit refugee resettlement organizations in the United States reveal the ways in which knowledge(s and expertise are crafted, threatened, and understood in refugee organizations. Refugee-participants described the need for knowledgeable communication, barriers to the communication of knowledge, and processes of negotiating whose expertise is involved. Organizational staff participants described the duty of communicating expert knowledge, the limits of knowledge as expertise, and alternative communications of expertise. These tensions surrounding “knowing” in refugee resettlement organizations highlights the need for a more complex theoretical understanding of the processes of knowing present in refugee resettlement. These tensions also suggest areas in which refugee resettlement agencies and other nonprofit staff can make on-the-ground changes to better facilitate refugee resettlement processes.

Editorial: Advances in healthcare provider and patient training to improve the quality and safety of patient care

OpenAIRE

Elizabeth M. Borycki

2015-01-01

This special issue of the Knowledge Management & E-Learning: An International Journal is dedicated to describing “Advances in Healthcare Provider and Patient Training to Improve the Quality and Safety of Patient Care.” Patient safety is an important and fundamental requirement of ensuring the quality of patient care. Training and education has been identified as a key to improving healthcare provider patient safety competencies especially when working with new technologies such as electronic ...

Establishing research priorities for patient safety in emergency medicine: a multidisciplinary consensus panel.

Science.gov (United States)

Plint, Amy C; Stang, Antonia S; Calder, Lisa A

2015-01-01

Patient safety in the context of emergency medicine is a relatively new field of study. To date, no broad research agenda for patient safety in emergency medicine has been established. The objective of this study was to establish patient safety-related research priorities for emergency medicine. These priorities would provide a foundation for high-quality research, important direction to both researchers and health-care funders, and an essential step in improving health-care safety and patient outcomes in the high-risk emergency department (ED) setting. A four-phase consensus procedure with a multidisciplinary expert panel was organized to identify, assess, and agree on research priorities for patient safety in emergency medicine. The 19-member panel consisted of clinicians, administrators, and researchers from adult and pediatric emergency medicine, patient safety, pharmacy, and mental health; as well as representatives from patient safety organizations. In phase 1, we developed an initial list of potential research priorities by electronically surveying a purposeful and convenience sample of patient safety experts, ED clinicians, administrators, and researchers from across North America using contact lists from multiple organizations. We used simple content analysis to remove duplication and categorize the research priorities identified by survey respondents. Our expert panel reached consensus on a final list of research priorities through an in-person meeting (phase 3) and two rounds of a modified Delphi process (phases 2 and 4). After phases 1 and 2, 66 unique research priorities were identified for expert panel review. At the end of phase 4, consensus was reached for 15 research priorities. These priorities represent four themes: (1) methods to identify patient safety issues (five priorities), (2) understanding human and environmental factors related to patient safety (four priorities), (3) the patient perspective (one priority), and (4) interventions for

76 FR 7854 - Patient Safety Organizations: Voluntary Delisting From Quality Excellence, Inc./PSO

Science.gov (United States)

2011-02-11

... Arkansas Foundation for Medical Care, of its status as a Patient Safety Organization (PSO). The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), Public Law 109-41, 42 U.S.C. 299b-21--b... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Patient Safety...

Patient Safety Outcomes in Small Urban and Small Rural Hospitals

Science.gov (United States)

Vartak, Smruti; Ward, Marcia M.; Vaughn, Thomas E.

2010-01-01

Purpose: To assess patient safety outcomes in small urban and small rural hospitals and to examine the relationship of hospital and patient factors to patient safety outcomes. Methods: The Nationwide Inpatient Sample and American Hospital Association annual survey data were used for analyses. To increase comparability, the study sample was…

Assessment of patient safety culture in primary care setting, Al-Mukala, Yemen.

Science.gov (United States)

Webair, Hana H; Al-Assani, Salwa S; Al-Haddad, Reema H; Al-Shaeeb, Wafa H; Bin Selm, Manal A; Alyamani, Abdulla S

2015-10-13

Patient safety culture in primary care is the first step to achieve high quality health care. This study aims to provide a baseline assessment of patient safety culture in primary care settings in Al-Mukala, Yemen as a first published study from a least developed country. A survey was conducted in primary healthcare centres and units in Al-Mukala District, Yemen. A comprehensive sample from the available 16 centres was included. An Arabic version of the Medical Office Survey on Patient Safety Culture was distributed to all health workers (110). Participants were physicians, nurses and administrative staff. The response rate from the participating centres was 71 %. (N = 78). The percent positive responses of the items is equal to the percentage of participants who answered positively. Composite scores were calculated by averaging the percent positive response on the items within a dimension. Positive safety culture was defined as 60 % or more positive responses on items or dimensions. Patient safety culture was perceived to be generally positive with the exception of the dimensions of 'Communication openness', 'Work pressure and pace' and 'Patient care tracking/follow-up', as the percent positive response of these dimensions were 58, 57, and 52 % respectively. Overall, positive rating on quality and patient safety were low (49 and 46 % respectively). Although patient safety culture in Al-Mukala primary care setting is generally positive, patient safety and quality rating were fairly low. Implementation of a safety and quality management system in Al-Mukala primary care setting are paramount. Further research is needed to confirm the applicability of the Medical Office Survey on Patient Safety Culture (MOSPSC) for Al-Mukala primary care.