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 Culture

DEFF Research Database (Denmark)

Kristensen, Solvejg

of health care professional’s behaviour, habits, norms, values, and basic assumptions related to patient care; it is the way things are done. The patient safety culture guides the motivation, commitment to and know-how of the safety management, and how all members of a work place interact. This thesis......Patient safety is highly prioritised in the Danish health care system, never the less, patients are still exposed to risk and harmed every day. Implementation of a patient safety culture has been suggested an effective mean to protect patients against adverse events. Working strategically...

76 FR 71345 - Patient Safety Organizations: Voluntary Relinquishment From Child Health Patient Safety...

Science.gov (United States)

2011-11-17

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

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...

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).

Aviation safety and operation problems research and technology

Science.gov (United States)

Enders, J. H.; Strickle, J. W.

1977-01-01

Aircraft operating problems are described for aviation safety. It is shown that as aircraft technology improves, the knowledge and understanding of operating problems must also improve for economics, reliability and safety.

77 FR 42736 - Common Formats for Patient Safety Data Collection and Event Reporting

Science.gov (United States)

2012-07-20

... safety problems. The Patient Safety Act and Patient Safety Rule establish a framework by which doctors... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Common Formats... formats, specified by AHRQ, that allow health care providers to collect and submit standardized...

Problems of nuclear reactor safety. Vol. 1

International Nuclear Information System (INIS)

Shal'nov, A.V.

1995-01-01

Proceedings of the 9. Topical Meeting 'Problems of nuclear reactor safety' are presented. Papers include results of studies and developments associated with methods of calculation and complex computerized simulation for stationary and transient processes in nuclear power plants. Main problems of reactor safety are discussed as well as rector accidents on operating NPP's are analyzed

Problems in determining the optimal use of road safety measures

DEFF Research Database (Denmark)

Elvik, Rune

2014-01-01

for intervention that ensures maximum safety benefits. The third problem is how to develop policy options to minimise the risk of indivisibilities and irreversible choices. The fourth problem is how to account for interaction effects between road safety measures when determining their optimal use. The fifth......This paper discusses some problems in determining the optimal use of road safety measures. The first of these problems is how best to define the baseline option, i.e. what will happen if no new safety measures are introduced. The second problem concerns choice of a method for selection of targets...... problem is how to obtain the best mix of short-term and long-term measures in a safety programme. The sixth problem is how fixed parameters for analysis, including the monetary valuation of road safety, influence the results of analyses. It is concluded that it is at present not possible to determine...

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...

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

FLIGHT SAFETY MANAGEMENT PROBLEMS AND EVALUATION OF FLIGHT SAFETY LEVEL OF AN AVIATION ENTERPRISE

Directory of Open Access Journals (Sweden)

B. V. Zubkov

2017-01-01

Full Text Available This article is devoted to studying the problem of safety management system (SMS and evaluating safety level of an aviation enterprise.This article discusses the problems of SMS, presented at the 41st meeting of the Russian Aviation Production Commanders Club in June 2014 in St. Petersburg in connection with the verification of the status of the CA of the Russian Federation by the International Civil Aviation Organization (ICAO in the same year, a set of urgent measures to eliminate the deficiencies identified in the current safety management system by participants of this meeting were proposed.In addition, the problems of evaluating flight safety level based on operation data of an aviation enterprise were analyzed. This analysis made it possible to take into account the problems listed in this article as a tool for a comprehensive study of SMS parameters and allows to analyze the quantitative indicators of the flights safety level.The concepts of Acceptable Safety Level (ASL indicators are interpreted differently depending on the available/applicable methods of their evaluation and how to implement them in SMS. However, the indicators for assessing ASL under operational condition at the aviation enterprise should become universal. Currently, defined safety levels and safety indicators are not yet established functionally and often with distorted underrepresented models describing their contextual contents, as well as ways of integrating them into SMS aviation enterprise.The results obtained can be used for better implementation of SMS and solving problems determining the aviation enterprise technical level of flight safety.

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.

Safety: Science and technique in social problems

International Nuclear Information System (INIS)

Smit, W.A.

1982-01-01

The author describes in a simple and clearly written Dutch text the relationship between scientific and technical knowledge and the social problems concerning the safety of nuclear energy. He begins with the cooling system of reactors and the safety aspects of the associated pumps. He uses this example to illustrate that the quantative determination of failure risks need not necessarily be relevant for judging the acceptance of the risk but is always relevant as a method of judging the effect of technical improvements on safety values. The author then considers the radiological effects of the operation of a nuclear plant by presenting the doses of radioactivity released if a reactor is operating normally, if there are technical problems and in the case of accidents. The corresponding biological effects on man are also presented and in an appendix the radiological consequences of reactor accidents are considered in some detail. He describes a number of models used in such calculations - for metereological distribution, dosimetry for internal radiation, cancer induction - to illustrate the margins of uncertainty in the predictions. According to the author safety aspects should not just be seen as a purely technical problem, starting with the fact that nuclear energy is desirable and then ensuring that all required safety regulations are met. Safety aspects are a social problem and should be considered by first discussing whether nuclear energy is acceptable, taking into consideration such consequences as the effects of possible accidents and the long term effects of reactor operation. (C.F.)

Patient safety in otolaryngology: a descriptive review.

Science.gov (United States)

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

2017-03-01

Otolaryngology, although patient safety has evolved along similar themes as other surgical specialties; there are several specific high-risk areas. Medical error is a common problem and its human cost is of immense importance. Steps to reduce such errors require the identification of high-risk practice within a complex healthcare system. The commitment to patient safety and quality improvement in medicine depend on personal responsibility and professional accountability.

Problems of nuclear reactor safety. Vol. 2

International Nuclear Information System (INIS)

Goncharov, L.A.

1995-01-01

Theses of proceedings of the 9 Topical Meeting on problems of nuclear power plant safety are presented. Reports include results of neutron-physical experiments carried out for reactor safety justification. Concepts of advanced reactors with improved safety are considered. Results of researches on fuel cycles are given too

[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.

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...

Why is patient safety so hard? A selective review of ethnographic studies.

Science.gov (United States)

Dixon-Woods, Mary

2010-01-01

Ethnographic studies are valuable in studying patient safety. This is a narrative review of four reports of ethnographic studies of patient safety in UK hospitals conducted as part of the Patient Safety Research Programme. Three of these studies were undertaken in operating theatres and one in an A&E Department. The studies found that hospitals were rarely geared towards ensuring perfect performances. The coordination and mobilization of the large number of inter-dependent processes and resources needed to support the achievement of tasks was rarely optimal. This produced significant strain that staff learned to tolerate by developing various compensatory strategies. Teamwork and inter-professional communication did not always function sufficiently well to ensure that basic procedural information was shared or that the required sequence of events was planned. Staff did not always do the right things, for a wide range of different reasons, including contestations about what counted as the right thing. Structures of authority and accountability were not always clear or well-functioning. Patient safety incidents were usually not reported, though there were many different reasons for this. It can be concluded that securing patient safety is hard. There are multiple interacting influences on safety, and solutions need to be based on a sound understanding of the nature of the problems and which approaches are likely to be best suited to resolving them. Some solutions that appear attractive and straightforward are likely to founder. Addressing safety problems requires acknowledgement that patient safety is not simply a technical issue, but a site of organizational and professional politics.

An analysis of electronic health record-related patient safety incidents.

Science.gov (United States)

Palojoki, Sari; Mäkelä, Matti; Lehtonen, Lasse; Saranto, Kaija

2017-06-01

The aim of this study was to analyse electronic health record-related patient safety incidents in the patient safety incident reporting database in fully digital hospitals in Finland. We compare Finnish data to similar international data and discuss their content with regard to the literature. We analysed the types of electronic health record-related patient safety incidents that occurred at 23 hospitals during a 2-year period. A procedure of taxonomy mapping served to allow comparisons. This study represents a rare examination of patient safety risks in a fully digital environment. The proportion of electronic health record-related incidents was markedly higher in our study than in previous studies with similar data. Human-computer interaction problems were the most frequently reported. The results show the possibility of error arising from the complex interaction between clinicians and computers.

Pharmacist intervention in drug-related problems for patients with ...

African Journals Online (AJOL)

Trop J Pharm Res, October 2016; 15(10): 2275. Tropical Journal of ... medication errors in irrational drug use, while patient adherence ..... Drug-related problems identified from geriatric medication safety ... Ann. Pharmacother. 2005; 39:1423-.

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...

An Organizational Learning Framework for Patient Safety.

Science.gov (United States)

Edwards, Marc T

Despite concerted effort to improve quality and safety, high reliability remains a distant goal. Although this likely reflects the challenge of organizational change, persistent controversy over basic issues suggests that weaknesses in conceptual models may contribute. The essence of operational improvement is organizational learning. This article presents a framework for identifying leverage points for improvement based on organizational learning theory and applies it to an analysis of current practice and controversy. Organizations learn from others, from defects, from measurement, and from mindfulness. These learning modes correspond with contemporary themes of collaboration, no blame for human error, accountability for performance, and managing the unexpected. The collaborative model has dominated improvement efforts. Greater attention to the underdeveloped modes of organizational learning may foster more rapid progress in patient safety by increasing organizational capabilities, strengthening a culture of safety, and fixing more of the process problems that contribute to patient harm.

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...

Teamwork and communication: an effective approach to patient safety.

Science.gov (United States)

Mujumdar, Sandhya; Santos, Diana

2014-01-01

Teamwork and communication failures are leading causes of patient safety incidents in health care. Though health care providers must work in teams, they are not well-trained in teamwork and communication skills. Health care faces the problems of differences in communication styles, communication failures and poor teamwork. There is enough evidence in the literature to show that communication failure is detrimental to patient safety. It is estimated that 80% of serious medical errors worldwide take place because of miscommunication between medical providers. NUH recognizes that effective communication and teamwork are essential in the delivery of high quality safe patient care, especially in a complex organization. NUH is a good example, where there is a rich mix of nationalities and races, in staff and in patients, and there is a rapidly expanding care environment. NUH had to overcome these challenges by adopting a multi-pronged approach. The trials and tribulations of NUH in this journey were worthwhile as the patient safety climate survey scores improved over the years.

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.

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.

Patients' safety in the era of EMR/EHR automation

Directory of Open Access Journals (Sweden)

Bakheet Aldosari

2017-01-01

Full Text Available Accurate maintenance of the medical records of patients has become a worldwide problem with the rapid rise in the count of patients. Furthermore, providing them adequate health care keeping their safety in view is turning into a great challenge for physicians. As such, electronic health records (EHRs were developed to solve these issues by aiding physicians in imparting quality health care to patients as well as maintaining their safety. Nonetheless, rather than increasing their efficiency, EHRs have become a burden for the physicians as they ultimately increase their error rate and reduce output rate affecting patient safety. As health-IT is advancing progressively, new features are added to the existing EHRs with the aim to support physicians in providing better healthcare. Till date, some of the most advanced features include clinical support decision system (CDSS, computerized physician order entry (CPOE system, health information exchange (HIE, mobile documentation application, and a system of safety alerts on a dashboard. Proper training to the physicians on judiciously usage of these EHR functions is required to extract maximum benefit. Else, these can introduce a considerable number of medical errors, which can result in fatal outcomes for the patients.

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

Variability of patient safety culture in Belgian acute hospitals.

Science.gov (United States)

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.

Five Topics Health Care Simulation Can Address to Improve Patient Safety

DEFF Research Database (Denmark)

Sollid, Stephen J M; Dieckman, Peter; Aase, Karina

2017-01-01

OBJECTIVES: There is little knowledge about which elements of health care simulation are most effective in improving patient safety. When empirical evidence is lacking, a consensus statement can help define priorities in, for example, education and research. A consensus process was therefore...... initiated to define priorities in health care simulation that contribute the most to improve patient safety.  METHODS: An international group of experts took part in a 4-stage consensus process based on a modified nominal group technique. Stages 1 to 3 were based on electronic communication; stage 4 was a 2......-day consensus meeting at the Utstein Abbey in Norway. The goals of stage 4 were to agree on the top 5 topics in health care simulation that contribute the most to patient safety, identify the patient safety problems they relate to, and suggest solutions with implementation strategies...

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...

Fourth Annual Nursing Leadership Congress: "Driving Patient Safety Through Transformation" Conference proceedings.

Science.gov (United States)

Pinakiewicz, Diane; Smetzer, Judy; Thompson, Pamela; Navarra, Mary Beth; Lambert, Monique

2009-06-01

In September 2008, nurse executives from around the country met in Scottsdale, Ariz, to develop practical tools and recommendations for "Driving Patient Safety Through Transformation," the theme of the fourth annual Nursing Leadership Congress. The Congress was made possible through an educational grant from McKesson and Intel in collaboration with sponsorship from the American Organization of Nurse Executives, Institute for Safe Medication Practices and National Patient Safety Foundation. This paper summarizes the Congress plenary sessions and roundtable discussions. Plenaries included the following: *Transformational Leadership: The Role of Leaders in Managing Complex Problems *Using the Baldrige Business Model as the Infrastructure for Creating a Culture of Patient Safety *Prospects for Structural Reform in Health Care Roundtables included the following: *Joy and Meaning in Work *Managing Chronic Care Across the Continuum *The Future of Acute Care Delivery in Light of Changing Reimbursement* Leveraging Transparency to Drive Patient Safety *Collaborative Partnerships for Driving a Patient Safety Agenda *Innovative Solutions for Patient Safety *Implementing the Fundamentals of the Toyota Production Model forHealthcare

Patient safety is not enough: targeting quality improvements to optimize the health of the population.

Science.gov (United States)

Woolf, Steven H

2004-01-06

Ensuring patient safety is essential for better health care, but preoccupation with niches of medicine, such as patient safety, can inadvertently compromise outcomes if it distracts from other problems that pose a greater threat to health. The greatest benefit for the population comes from a comprehensive view of population needs and making improvements in proportion with their potential effect on public health; anything less subjects an excess of people to morbidity and death. Patient safety, in context, is a subset of health problems affecting Americans. Safety is a subcategory of medical errors, which also includes mistakes in health promotion and chronic disease management that cost lives but do not affect "safety." These errors are a subset of lapses in quality, which result not only from errors but also from systemic problems, such as lack of access, inequity, and flawed system designs. Lapses in quality are a subset of deficient caring, which encompasses gaps in therapeutics, respect, and compassion that are undetected by normative quality indicators. These larger problems arguably cost hundreds of thousands more lives than do lapses in safety, and the system redesigns to correct them should receive proportionately greater emphasis. Ensuring such rational prioritization requires policy and medical leaders to eschew parochialism and take a global perspective in gauging health problems. The public's well-being requires policymakers to view the system as a whole and consider the potential effect on overall population health when prioritizing care improvements and system redesigns.

Man as a safety problem in technical systems

International Nuclear Information System (INIS)

Compes, P.C.; Wolff, H.A.

1980-01-01

Safety engineering derives its justification from the success achieved in maintaining and enlarging safety, more precisely, from activities aimed at avoiding or preventing damage caused by accidents. Man is not only affected by accidents but is also the cause of accidents, either directly or indirectly, and thus is to be regarded as the actual cause or preventer of accidents. The Second International Summer Symposium of the Society for Safety Engineering (GfS) which was held at Duesseldorf in 1980 brought into focus this aspect and the importance to be attached to the individual man and the whole mankind in the field of accident prevention. 'Man as a safety problem in technical systems' - a great and weighty field of problems, the large extent of which and the complex content of which was to be discussed by the programme with its many different contributions, on the one hand by presenting an outline as completely as possible, and on the other hand by finding further-reaching solutions for at least some problems. This was the purpose of the dialogues held between theory and practice on the one hand, and between safety engineering and, in this case, the human sciences on the other hand. (orig./RW) [de

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

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.

Development of an evaluation framework for African-European hospital patient safety partnerships.

Science.gov (United States)

Rutter, Paul; Syed, Shamsuzzoha B; Storr, Julie; Hightower, Joyce D; Bagheri-Nejad, Sepideh; Kelley, Edward; Pittet, Didier

2014-04-01

Patient safety is recognised as a significant healthcare problem worldwide, and healthcare-associated infections are an important aspect. African Partnerships for Patient Safety is a WHO programme that pairs hospitals in Africa with hospitals in Europe with the objective to work together to improve patient safety. To describe the development of an evaluation framework for hospital-to-hospital partnerships participating in the programme. The framework was structured around the programme's three core objectives: facilitate strong interhospital partnerships, improve in-hospital patient safety and spread best practices nationally. Africa-based clinicians, their European partners and experts in patient safety were closely involved in developing the evaluation framework in an iterative process. The process defined six domains of partnership strength, each with measurable subdomains. We developed a questionnaire to measure these subdomains. Participants selected six indicators of hospital patient safety improvement from a short-list of 22 based on their relevance, sensitivity to intervention and measurement feasibility. Participants proposed 20 measures of spread, which were refined into a two-part conceptual framework, and a data capture tool created. Taking a highly participatory approach that closely involved its end users, we developed an evaluation framework and tools to measure partnership strength, patient safety improvements and the spread of best practice.

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

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.

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...

Privacy protection for patients with substance use problems

Directory of Open Access Journals (Sweden)

Hu LL

2011-12-01

Full Text Available Lianne Lian Hu1, Steven Sparenborg2, Betty Tai21Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, 2Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MDAbstract: Many Americans with substance use problems will have opportunities to receive coordinated health care through the integration of primary care and specialty care for substance use disorders under the Patient Protection and Affordable Care Act of 2010. Sharing of patient health records among care providers is essential to realize the benefits of electronic health records. Health information exchange through meaningful use of electronic health records can improve health care safety, quality, and efficiency. Implementation of electronic health records and health information exchange presents great opportunities for health care integration, but also makes patient privacy potentially vulnerable. Privacy issues are paramount for patients with substance use problems. This paper discusses major differences between two federal privacy laws associated with health care for substance use disorders, identifies health care problems created by privacy policies, and describes potential solutions to these problems through technology innovation and policy improvement.Keywords: substance abuse, patient privacy, electronic health records, health information exchange

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.

The way to solve the safety problems of nuclear power

International Nuclear Information System (INIS)

Qian Jihui; Zhang Senru

1991-01-01

Based on the safety problems that the current water cooled reactor nuclear power plants have the potential danger of core melt, the paper comments upon the safety behaviors of the advanced reactors (AP-600, SIR) and passive safety reactors (PIUS, MHTGR). According to design and user's requirements for next generation water cooled reactor, the paper put forward a new concept about self safety U-ZrH reactor (SUR) which is able to solve the safety problems for water cooled reactor nuclear power plant and become a development direction for world water cooled reactor nuclear power plants. This type of reactor has been studied in NPIC (Nuclear Power Institute of China)

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

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.

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

System analysis of vehicle active safety problem

Science.gov (United States)

Buznikov, S. E.

2018-02-01

The problem of the road transport safety affects the vital interests of the most of the population and is characterized by a global level of significance. The system analysis of problem of creation of competitive active vehicle safety systems is presented as an interrelated complex of tasks of multi-criterion optimization and dynamic stabilization of the state variables of a controlled object. Solving them requires generation of all possible variants of technical solutions within the software and hardware domains and synthesis of the control, which is close to optimum. For implementing the task of the system analysis the Zwicky “morphological box” method is used. Creation of comprehensive active safety systems involves solution of the problem of preventing typical collisions. For solving it, a structured set of collisions is introduced with its elements being generated also using the Zwicky “morphological box” method. The obstacle speed, the longitudinal acceleration of the controlled object and the unpredictable changes in its movement direction due to certain faults, the road surface condition and the control errors are taken as structure variables that characterize the conditions of collisions. The conditions for preventing typical collisions are presented as inequalities for physical variables that define the state vector of the object and its dynamic limits.

Economic evaluation in patient safety: a literature review of methods.

Science.gov (United States)

de Rezende, Bruna Alves; Or, Zeynep; Com-Ruelle, Laure; Michel, Philippe

2012-06-01

Patient safety practices, targeting organisational changes for improving patient safety, are implemented worldwide but their costs are rarely evaluated. This paper provides a review of the methods used in economic evaluation of such practices. International medical and economics databases were searched for peer-reviewed publications on economic evaluations of patient safety between 2000 and 2010 in English and French. This was complemented by a manual search of the reference lists of relevant papers. Grey literature was excluded. Studies were described using a standardised template and assessed independently by two researchers according to six quality criteria. 33 articles were reviewed that were representative of different patient safety domains, data types and evaluation methods. 18 estimated the economic burden of adverse events, 3 measured the costs of patient safety practices and 12 provided complete economic evaluations. Healthcare-associated infections were the most common subject of evaluation, followed by medication-related errors and all types of adverse events. Of these, 10 were selected that had adequately fulfilled one or several key quality criteria for illustration. This review shows that full cost-benefit/utility evaluations are rarely completed as they are resource intensive and often require unavailable data; some overcome these difficulties by performing stochastic modelling and by using secondary sources. Low methodological transparency can be a problem for building evidence from available economic evaluations. Investing in the economic design and reporting of studies with more emphasis on defining study perspectives, data collection and methodological choices could be helpful for strengthening our knowledge base on practices for improving patient safety.

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

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.

Perceived school safety is strongly associated with adolescent mental health problems.

Science.gov (United States)

Nijs, Miesje M; Bun, Clothilde J E; Tempelaar, Wanda M; de Wit, Niek J; Burger, Huibert; Plevier, Carolien M; Boks, Marco P M

2014-02-01

School environment is an important determinant of psychosocial function and may also be related to mental health. We therefore investigated whether perceived school safety, a simple measure of this environment, is related to mental health problems. In a population-based sample of 11,130 secondary school students, we analysed the relationship of perceived school safety with mental health problems using multiple logistic regression analyses to adjust for potential confounders. Mental health problems were defined using the clinical cut-off of the self-reported Strengths and Difficulties Questionnaire. School safety showed an exposure-response relationship with mental health problems after adjustment for confounders. Odds ratios increased from 2.48 ("sometimes unsafe") to 8.05 ("very often unsafe"). The association was strongest in girls and young and middle-aged adolescents. Irrespective of the causal background of this association, school safety deserves attention either as a risk factor or as an indicator of mental health problems.

FLIGHT SAFETY MANAGEMENT PROBLEMS AND EVALUATION OF FLIGHT SAFETY LEVEL OF AN AVIATION ENTERPRISE

OpenAIRE

B. V. Zubkov; H. E. Fourar

2017-01-01

This article is devoted to studying the problem of safety management system (SMS) and evaluating safety level of an aviation enterprise.This article discusses the problems of SMS, presented at the 41st meeting of the Russian Aviation Production Commanders Club in June 2014 in St. Petersburg in connection with the verification of the status of the CA of the Russian Federation by the International Civil Aviation Organization (ICAO) in the same year, a set of urgent measures to eliminate the def...

Problems in Food Safety of Hunan Province and Countermeasures

Institute of Scientific and Technical Information of China (English)

Fanfan; OUYANG; Fangming; DENG

2014-01-01

In recent years,serious food safety accidents are of frequent occurrence. Although government has taken many practical and feasible measures to contain food safety accidents,new food safety accidents still emerge in large numbers. In this situation,food safety control is a long-term and arduous task to be performed jointly by many government departments. Finally,it presents corresponding countermeasures and recommendations on the basis of current situations of food safety in Hunan Province,problem causes,in combination with control measures related to food safety both at home and abroad.

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 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.

Engaging Employees: The Importance of High-Performance Work Systems for Patient Safety.

Science.gov (United States)

Etchegaray, Jason M; Thomas, Eric J

2015-12-01

To develop and test survey items that measure high-performance work systems (HPWSs), report psychometric characteristics of the survey, and examine associations between HPWSs and teamwork culture, safety culture, and overall patient safety grade. We reviewed literature to determine dimensions of HPWSs and then asked executives to tell us which dimensions they viewed as most important for safety and quality. We then created a HPWSs survey to measure the most important HPWSs dimensions. We administered an anonymous, electronic survey to employees with direct patient care working at a large hospital system in the Southern United States and looked for linkages between HPWSs, culture, and outcomes. Similarities existed for the HPWS practices viewed as most important by previous researchers and health-care executives. The HPWSs survey was found to be reliable, distinct from safety culture and teamwork culture based on a confirmatory factor analysis, and was the strongest predictor of the extent to which employees felt comfortable speaking up about patient safety problems as well as patient safety grade. We used information from a literature review and executive input to create a reliable and valid HPWSs survey. Future research needs to examine whether HPWSs is associated with additional safety and quality outcomes.

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

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.

The impact of nursing leadership on patient safety in a developing country.

Science.gov (United States)

Stewart, Lee; Usher, Kim

2010-11-01

This article is a report of a study to identify the ways nursing leaders and managers in a developing country have an impact on patient safety. The attempt to address the problem of patient safety in health care is a global issue. Literature addressing the significant impact that nursing leadership has on patient safety is extensive and focuses almost exclusively on the developed world. A critical ethnography was conducted with senior registered nursing leaders and managers throughout the Fiji Islands, specifically those in the Head Office of the Fiji Ministry of Health and the most senior nurse in a hospital or community health service. Semi-structured interviews were conducted with senior nursing leaders and managers in Fiji. Thematic analysis of the interviews was undertaken from a critical theory perspective, with reference to the macro socio-political system of the Fiji Ministry of Health. Four interrelated issues regarding the nursing leaders and managers' impact on patient safety emerged from the study. Empowerment of nursing leaders and managers, an increased focus on the patient, the necessity to explore conditions for front-line nurses and the direct relationship between improved nursing conditions and increased patient safety mirrored literature from developed countries. The findings have significant implications for developing countries and it is crucial that support for patient safety in developing countries become a focus for the international nursing community. Nursing leaders and managers' increased focus on their own place in the hierarchy of the health care system and on nursing conditions as these affect patient safety could decrease adverse patient outcomes. The findings could assist the global nursing community to better support developing countries in pursuing a patient safety agenda. © 2010 Blackwell Publishing Ltd.

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.

On application of CFD codes to problems of nuclear reactor safety

International Nuclear Information System (INIS)

Muehlbauer, Petr

2005-01-01

The 'Exploratory Meeting of Experts to Define an Action Plan on the Application of Computational Fluid Dynamics (CFD) Codes to Nuclear Reactor Safety Problems' held in May 2002 at Aix-en-Province, France, recommended formation of writing groups to report the need of guidelines for use and assessment of CFD in single-phase nuclear reactor safety problems, and on recommended extensions to CFD codes to meet the needs of two-phase problems in nuclear reactor safety. This recommendations was supported also by Working Group on the Analysis and Management of Accidents and led to formation oaf three Writing Groups. The first writing Group prepared a summary of existing best practice guidelines for single phase CFD analysis and made a recommendation on the need for nuclear reactor safety specific guidelines. The second Writing Group selected those nuclear reactor safety applications for which understanding requires or is significantly enhanced by single-phase CFD analysis, and proposed a methodology for establishing assesment matrices relevant to nuclear reactor safety applications. The third writing group performed a classification of nuclear reactor safety problems where extension of CFD to two-phase flow may bring real benefit, a classification of different modeling approaches, and specification and analysis of needs in terms of physical and numerical assessments. This presentation provides a review of these activities with the most important conclusions and recommendations (Authors)

Intermodal safety research needs report of the sixth workshop on national transportation problems

Energy Technology Data Exchange (ETDEWEB)

Warshawer, A.J. (ed.)

1976-04-01

This conference brought together DOT policymakers, university principal investigators and other professionals to consider the intermodal safety research requirements of the Department of Transportation. The objectives of the conference were: (1) to highlight safety problems and needed transportation safety research identified by DOT modal safety managers and to stimulate university or university/industry teams to respond with research proposals which emphasize multi-modal applicability and a system view; and (2) to provide a forum for university research groups to inform DOT safety managers of promising new directions in transportation safety research and new tools with which to address safety related problems. The conference addressed the research requirements for safety as identified by the Statement of National Transportation Policy and by the modal safety managers in three principal contexts, each a workshop panel: I, Inter-Institutional Problems of Transportation Safety. Problems were described as: Federal-State, local; Federal-Industry; Federal-Public, Consumer groups. II, Goal Setting and Planning for Transportation Safety Programs. Issues were: modifying risk behavior, safety as a social value, and involving citizens in development of standards as a way of increasing probability of achieving program objectives. III, DOT Information, Management, and Evaluation Systems Requirements. Needs were: data requirements and analytic tools for management of safety programs.

Nuclear safety targets and problems of social acceptability

International Nuclear Information System (INIS)

Macgill, S.M.

1989-01-01

The following are among the factors which make the problem of setting acceptable safety targets for societal protection from possible nuclear accidents one of such formidable proportion: The varied and often conflicting positions among and between the many constituencies with a claim to interest in the problem: local, national and international populations; lay, workplace and professional communities; private and public interests; active environmental lobbies and intentionally passive publics; powerful influences and politically unprivileged classes; press and mass media. To seek 'acceptability' of safety targets through common consensus is problematised by the difficulty in overcoming the immense social and historical forces that give rise to the prevailing contrariety among different people's positions. To seek resolution of differences by some appropriate weighting of the different views of different constituencies is problematised by the lack of unique identification of what the constituencies are, by the difficulty in faithfully representing their views, and by the absence of 'laws of social entitlement' vis-a-vis the weight that should be given to each. In sum, the problem of setting socially acceptable safety targets is itself bound up with inherently open ended questions of democracy and representation. (author)

[Patient safety and errors in medicine: development, prevention and analyses of incidents].

Science.gov (United States)

Rall, M; Manser, T; Guggenberger, H; Gaba, D M; Unertl, K

2001-06-01

"Patient safety" and "errors in medicine" are issues gaining more and more prominence in the eyes of the public. According to newer studies, errors in medicine are among the ten major causes of death in association with the whole area of health care. A new era has begun incorporating attention to a "systems" approach to deal with errors and their causes in the health system. In other high-risk domains with a high demand for safety (such as the nuclear power industry and aviation) many strategies to enhance safety have been established. It is time to study these strategies, to adapt them if necessary and apply them to the field of medicine. These strategies include: to teach people how errors evolve in complex working domains and how types of errors are classified; the introduction of critical incident reporting systems that are free of negative consequences for the reporters; the promotion of continuous medical education; and the development of generic problem-solving skills incorporating the extensive use of realistic simulators wherever possible. Interestingly, the field of anesthesiology--within which realistic simulators were developed--is referred to as a model for the new patient safety movement. Despite this proud track record in recent times though, there is still much to be done even in the field of anesthesiology. Overall though, the most important strategy towards a long-term improvement in patient safety will be a change of "culture" throughout the entire health care system. The "culture of blame" focused on individuals should be replaced by a "safety culture", that sees errors and critical incidents as a problem of the whole organization. The acceptance of human fallability and an open-minded non-punitive analysis of errors in the sense of a "preventive and proactive safety culture" should lead to solutions at the systemic level. This change in culture can only be achieved with a strong commitment from the highest levels of an organization. Patient

[Analysis of patient complaints in Primary Care: An opportunity to improve clinical safety].

Science.gov (United States)

Añel-Rodríguez, R M; Cambero-Serrano, M I; Irurzun-Zuazabal, E

2015-01-01

To determine the prevalence and type of the clinical safety problems contained in the complaints made by patients and users in Primary Care. An observational, descriptive, cross-sectional study was conducted by analysing both the complaint forms and the responses given to them in the period of one year. At least 4.6% of all claims analysed in this study contained clinical safety problems. The family physician is the professional who received the majority of the complaints (53.6%), and the main reason was the problems related to diagnosis (43%), mainly the delay in diagnosis. Other variables analysed were the severity of adverse events experienced by patients (in 68% of cases the patient suffered some harm), the subsequent impact on patient care, which was affected in 39% of cases (7% of cases even requiring hospital admission), and the level of preventability of adverse events (96% avoidable) described in the claims. Finally the type of response issued to each complaint was analysed, being purely bureaucratic in 64% of all cases. Complaints are a valuable source of information about the deficiencies identified by patients and healthcare users. There is considerable scope for improvement in the analysis and management of claims in general, and those containing clinical safety issues in particular. To date, in our area, there is a lack of appropriate procedures for processing these claims. Likewise, we believe that other pathways or channels should be opened to enable communication by patients and healthcare users. Copyright © 2015 SECA. Published by Elsevier Espana. All rights reserved.

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

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

Prioritizing medication safety in care of people with cancer: clinicians’ views on main problems and solutions

Science.gov (United States)

Car, Lorainne Tudor; Papachristou, Nikolaos; Urch, Catherine; Majeed, Azeem; Atun, Rifat; Car, Josip; Vincent, Charles

2017-01-01

Background Cancer care is liable to medication errors due to the complex nature of cancer treatment, the common presence of comorbidities and the involvement of a number of clinicians in cancer care. While the frequency of medication errors in cancer care has been reported, little is known about their causal factors and effective prevention strategies. With a unique insight into the main safety issues in cancer treatment, frontline staff can help close this gap. In this study, we aimed to identify medication safety priorities in cancer patient care according to clinicians in North West London using PRIORITIZE, a novel priority–setting approach. Methods The project steering group determined the scope, the context and the criteria for prioritization. We then invited North West London cancer care clinicians to identify and prioritize main causes for, and solutions to, medication errors in cancer care. Forty cancer care providers submitted their suggestions which were thematically synthesized into a composite list of 20 distinct problems and 22 solutions. A group of 26 clinicians from the initial cohort ranked the composite list of suggestions using predetermined criteria. Results The top ranked problems focused on patients’ poor understanding of treatments due to language or education difficulties, clinicians’ insufficient attention to patients’ psychological distress, and inadequate information sharing among health care providers. The top ranked solutions were provision of guidance to patients and their carers on what to do when unwell, pre–chemotherapy work–up for all patients and better staff training. Overall, clinicians considered improved communication between health care providers, quality assurance procedures (during prescription and monitoring stages) and patient education as key strategies for improving cancer medication safety. Prescribing stage was identified as the most vulnerable to medication safety threats. The highest ranked suggestions

Safety of pressurized water reactors: problems and corresponding studies

International Nuclear Information System (INIS)

Cogne, F.

1976-01-01

The author recalls the safety problems subject to researches in the CEA, either because of their importance or because studies made abroad were not sufficiently developed or were classified or in order to acquire an independent judgement when safety is concerned. Those problems and studies are submitted referring to the 3 existing shields between man and dangerous materials: fuel element can, thermal shield, (pressure vessel and pipes), biological shield of which the behaviour is studied in connection with outside aggressions such as earthquakes, plane crashes, chemical explosions.. [fr

Patient-reported experiences of patient safety incidents need to be utilized more systematically in promoting safe care.

Science.gov (United States)

Sahlström, Merja; Partanen, Pirjo; Turunen, Hannele

2018-04-16

To analyze patient safety incidents (PSIs) reported by patients and their use in Finnish healthcare organizations. Cross-sectional study. About 15 Finnish healthcare organizations ranging from specialized hospital care to home care, outpatient and inpatient clinics, and geographically diverse areas of Finland. The study population included all Finnish patients who had voluntarily reported PSI via web-based system in 2009-15. Quantitative analysis of patients' safety reports, inductive content analysis of patients' suggestions to prevent the reoccurrence incidents and how those suggestions were used in healthcare organizations. Patients reported 656 PSIs, most of which were classified by the healthcare organizations' analysts as problems associated with information flow (32.6%) and medications (18%). Most of the incidents (65%) did not cause any harm to patients. About 76% of the reports suggested ways to prevent reoccurrence of PSIs, most of which were feasible, system-based amendments of processes for reviewing or administering treatment, anticipating risks or improving diligence in patient care. However, only 6% had led to practical implementation of corrective actions in the healthcare organizations. The results indicate that patients report diverse PSIs and suggest practical systems-based solutions to prevent their reoccurrence. However, patients' reports rarely lead to corrective actions documented in the registering system, indicating that there is substantial scope to improve utilization of patients' reports. There is also a need for strong patient safety management, including willingness and commitment of HCPs and leaders to learn from safety incidents.

Keeping patients safe in healthcare organizations: a structuration theory of safety culture.

Science.gov (United States)

Groves, Patricia S; Meisenbach, Rebecca J; Scott-Cawiezell, Jill

2011-08-01

This paper presents a discussion of the use of structuration theory to facilitate understanding and improvement of safety culture in healthcare organizations. Patient safety in healthcare organizations is an important problem worldwide. Safety culture has been proposed as a means to keep patients safe. However, lack of appropriate theory limits understanding and improvement of safety culture. The proposed structuration theory of safety culture was based on a critique of available English-language literature, resulting in literature published from 1983 to mid-2009. CINAHL, Communication and Mass Media Complete, ABI/Inform and Google Scholar databases were searched using the following terms: nursing, safety, organizational culture and safety culture. When viewed through the lens of structuration theory, safety culture is a system involving both individual actions and organizational structures. Healthcare organization members, particularly nurses, share these values through communication and enact them in practice, (re)producing an organizational safety culture system that reciprocally constrains and enables the actions of the members in terms of patient safety. This structurational viewpoint illuminates multiple opportunities for safety culture improvement. Nurse leaders should be cognizant of competing value-based culture systems in the organization and attend to nursing agency and all forms of communication when attempting to create or strengthen a safety culture. Applying structuration theory to the concept of safety culture reveals a dynamic system of individual action and organizational structure constraining and enabling safety practice. Nurses are central to the (re)production of this safety culture system. © 2011 Blackwell Publishing Ltd.

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

Laboratory errors and patient safety.

Science.gov (United States)

Miligy, Dawlat A

2015-01-01

Laboratory data are extensively used in medical practice; consequently, laboratory errors have a tremendous impact on patient safety. Therefore, programs designed to identify and reduce laboratory errors, as well as, setting specific strategies are required to minimize these errors and improve patient safety. The purpose of this paper is to identify part of the commonly encountered laboratory errors throughout our practice in laboratory work, their hazards on patient health care and some measures and recommendations to minimize or to eliminate these errors. Recording the encountered laboratory errors during May 2008 and their statistical evaluation (using simple percent distribution) have been done in the department of laboratory of one of the private hospitals in Egypt. Errors have been classified according to the laboratory phases and according to their implication on patient health. Data obtained out of 1,600 testing procedure revealed that the total number of encountered errors is 14 tests (0.87 percent of total testing procedures). Most of the encountered errors lay in the pre- and post-analytic phases of testing cycle (representing 35.7 and 50 percent, respectively, of total errors). While the number of test errors encountered in the analytic phase represented only 14.3 percent of total errors. About 85.7 percent of total errors were of non-significant implication on patients health being detected before test reports have been submitted to the patients. On the other hand, the number of test errors that have been already submitted to patients and reach the physician represented 14.3 percent of total errors. Only 7.1 percent of the errors could have an impact on patient diagnosis. The findings of this study were concomitant with those published from the USA and other countries. This proves that laboratory problems are universal and need general standardization and bench marking measures. Original being the first data published from Arabic countries that

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 ...

Effects of a multicentre teamwork and communication programme on patient outcomes: results from the Triad for Optimal Patient Safety (TOPS) project.

Science.gov (United States)

Auerbach, Andrew D; Sehgal, Niraj L; Blegen, Mary A; Maselli, Judith; Alldredge, Brian K; Vittinghoff, Eric; Wachter, Robert M

2012-02-01

Improving communication between caregivers is an important approach to improving safety. To implement teamwork and communication interventions and evaluate their impact on patient outcomes. A prospective, interrupted time series of a three-phase a run-in period (phase 1), during which a training programme was given to providers and staff on each unit; phase 2, which focused on unit-based safety teams to identify and address care problems using skills from phase 1; and phase 3, which focused on engaging patients in communication efforts. General medical inpatient units at three northern California hospitals. Administrative data were collected from all adults admitted to the target units, and a convenience sample of patients interviewed during and after hospitalisation. Readmission, length of stay and patient reports of teamwork, problems with care, and overall satisfaction. 10 977 patients were admitted; 581 patients (5.3% of total sample) were interviewed in hospital, and 313 (2.9% overall, 53.8% of interviewed patients) completed 1-month surveys. No phase of the study was associated with adjusted differences in readmission or length of stay. The phase 2 intervention appeared to be associated with improvement in reports of whether physicians treated them with respect, whether nurses treated them with respect or understood their needs (pcommunication may improve patients' perception of team functions, but may also increase patients' perception of safety gaps.

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

Safe patient care - safety culture and risk management in otorhinolaryngology.

Science.gov (United States)

St Pierre, Michael

2013-12-13

Safety culture is positioned at the heart of an organization's vulnerability to error because of its role in framing organizational awareness to risk and in providing and sustaining effective strategies of risk management. Safety related attitudes of leadership and management play a crucial role in the development of a mature safety culture ("top-down process"). A type marker for organizational culture and thus a predictor for an organization's maturity in respect to safety is information flow and in particular an organization's general way of coping with information that suggests anomaly. As all values and beliefs, relationships, learning, and other aspects of organizational safety culture are about sharing and processing information, safety culture has been termed "informed culture". An informed culture is free of blame and open for information provided by incidents. "Incident reporting systems" are the backbone of a reporting culture, where good information flow is likely to support and encourage other kinds of cooperative behavior, such as problem solving, innovation, and inter-departmental bridging. Another facet of an informed culture is the free flow of information during perioperative patient care. The World Health Organization's safe surgery checklist" is the most prevalent example of a standardized information exchange aimed at preventing patient harm due to information deficit. In routine tasks mandatory standard operating procedures have gained widespread acceptance in guaranteeing the highest possible process quality. Technical and non-technical skills of healthcare professionals are the decisive human resource for an efficient and safe delivery of patient care and the avoidance of errors. The systematic enhancement of staff qualification by providing training opportunities can be a major investment in patient safety. In recent years several otorhinolaryngology departments have started to incorporate stimulation based team trainings into their

[Safe patient care: safety culture and risk management in otorhinolaryngology].

Science.gov (United States)

St Pierre, M

2013-04-01

Safety culture is positioned at the heart of an organisation's vulnerability to error because of its role in framing organizational awareness to risk and in providing and sustaining effective strategies of risk management. Safety related attitudes of leadership and management play a crucial role in the development of a mature safety culture ("top-down process"). A type marker for organizational culture and thus a predictor for an organizations maturity in respect to safety is information flow and in particular an organization's general way of coping with information that suggests anomaly. As all values and beliefs, relationships, learning, and other aspects of organizational safety culture are about sharing and processing information, safety culture has been termed "informed culture". An informed culture is free of blame and open for information provided by incidents. "Incident reporting systems" are the backbone of a reporting culture, where good information flow is likely to support and encourage other kinds of cooperative behavior, such as problem solving, innovation, and inter-departmental bridging. Another facet of an informed culture is the free flow of information during perioperative patient care. The World Health Organisation's "safe surgery checklist" is the most prevalent example of a standardized information exchange aimed at preventing patient harm due to information deficit. In routine tasks mandatory standard operating procedures have gained widespread acceptance in guaranteeing the highest possible process quality.Technical and non-technical skills of healthcare professionals are the decisive human resource for an efficient and safe delivery of patient care and the avoidance of errors. The systematic enhancement of staff qualification by providing training opportunities can be a major investment in patient safety. In recent years several otorhinolaryngology departments have started to incorporate simulation based team trainings into their curriculum

Shoe concerns and foot problems of wearers of safety footwear.

Science.gov (United States)

Marr, S J; Quine, S

1993-05-01

In Australia workers in many industries are required to wear safety footwear (footwear incorporating a steel toe cap). An investigation of the problems reported by 321 workers (70 per cent male) employed in a broad range of work activities and required to wear safety footwear was conducted in 1990 and 1991. Respondents were interviewed by a professionally trained podiatrist using a structured questionnaire followed by a foot examination. An extremely high percentage (91 per cent) of subjects reported one or more foot problems (which were verified by the podiatrist), and most considered that the safety footwear either caused the problem or adversely affected an existing foot condition. The main shoe concerns reported were excessive heat (65 per cent of all respondents), inflexible soles (52 per cent), weight (48 per cent) and pressure from steel toe cap (47 per cent). Certain gender differences were identified. General recommendations are made.

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...

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.

Safety problems with abandoned explosive facilities

International Nuclear Information System (INIS)

Courtright, W.C.

1969-01-01

Procedures were developed for the safe removal of explosive and radioactive contaminated materials structures and drains from abandoned sites, including explosives processing and service buildings with a goal to return the entire area to its natural state and to permit public access. The safety problems encountered in the cleanup and their solutions are applicable to modification and maintenance work in operating explosive facilities. (U.S.)

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…

The work environment and empowerment as predictors of patient safety culture in Turkey.

Science.gov (United States)

Dirik, Hasan Fehmi; Intepeler, Seyda Seren

2017-05-01

As scant research based information is available regarding the work environment, empowerment and patient safety culture, this study from a developing country (Turkey) in which health care institutions are in a state of transition, aimed to investigate further the relationships between these three variables. A cross-sectional descriptive design was employed. The sample comprised 274 nurse participants working in a university hospital located in Izmir (Turkey). In data evaluation, descriptive statistics and hierarchical regression analyses were applied. The work environment and structural empowerment were related to the patient safety culture and explained 55% of the variance in patient safety culture perceptions. 'Support for optimal patient care', 'nurse/physician relationships' and 'staff involvement in organisational affairs' were the significant predictors. An enhancement of the work environment and providing access to empowerment structures may help health care organisations improve the patient safety culture. In light of the findings, the following actions can be recommended to inform health care leaders: providing necessary resources for nursing practise, encouraging nurses' participation in decision-making, strengthening communication within the team and giving nurses the opportunities to cope with challenging work problems to learn and grow. © 2017 John Wiley & Sons Ltd.

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.

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.

Personal, situational and organizational aspects that influence the impact of patient safety incidents: A qualitative study.

Science.gov (United States)

Van Gerven, E; Deweer, D; Scott, S D; Panella, M; Euwema, M; Sermeus, W; Vanhaecht, K

2016-07-01

When a patient safety incident (PSI) occurs, not only the patient, but also the involved health professional can suffer. This study focused on this so-called "second victim" of a patient safety incident and aimed to examine: (1) experienced symptoms in the aftermath of a patient safety incident; (2) applied coping strategies; (3) the received versus needed support and (4) the aspects that influenced whether one becomes a second victim. Thirty-one in-depth interviews were performed with physicians, nurses and midwives who have been involved in a patient safety incident. The symptoms were categorized under personal and professional impact. Both problem focused and emotion focused coping strategies were used in the aftermath of a PSI. Problem focused strategies such as performing a root cause analysis and the opportunity to learn from what happened were the most appreciated, but negative emotional responses such as repression and flight were common. Support from colleagues and supervisors who were involved in the same event, peer supporters or professional experts were the most needed. A few individuals described emotional support from the healthcare institution as unwanted. Rendered support was largely dependent on the organizational culture, a stigma remained among healthcare professionals to openly discuss patient safety incidents. Three aspects influenced the extent to which a healthcare professional became a second victim: personal, situational and organizational aspects. These findings indicated that a multifactorial approach including individual and emotional support to second victims is crucial. Copyright © 2016 SECA. Publicado por Elsevier España, S.L.U. All rights reserved.

Application of patient safety indicators internationally: a pilot study among seven countries.

Science.gov (United States)

Drösler, Saskia E; Klazinga, Niek S; Romano, Patrick S; Tancredi, Daniel J; Gogorcena Aoiz, Maria A; Hewitt, Moira C; Scobie, Sarah; Soop, Michael; Wen, Eugene; Quan, Hude; Ghali, William A; Mattke, Soeren; Kelley, Edward

2009-08-01

To explore the potential for international comparison of patient safety as part of the Health Care Quality Indicators project of the Organization for Economic Co-operation and Development (OECD) by evaluating patient safety indicators originally published by the US Agency for Healthcare Research and Quality (AHRQ). A retrospective cross-sectional study. Acute care hospitals in the USA, UK, Sweden, Spain, Germany, Canada and Australia in 2004 and 2005/2006. Routine hospitalization-related administrative data from seven countries were analyzed. Using algorithms adapted to the diagnosis and procedure coding systems in place in each country, authorities in each of the participating countries reported summaries of the distribution of hospital-level and overall (national) rates for each AHRQ Patient Safety Indicator to the OECD project secretariat. Each country's vector of national indicator rates and the vector of American patient safety indicators rates published by AHRQ (and re-estimated as part of this study) were highly correlated (0.821-0.966). However, there was substantial systematic variation in rates across countries. This pilot study reveals that AHRQ Patient Safety Indicators can be applied to international hospital data. However, the analyses suggest that certain indicators (e.g. 'birth trauma', 'complications of anesthesia') may be too unreliable for international comparisons. Data quality varies across countries; undercoding may be a systematic problem in some countries. Efforts at international harmonization of hospital discharge data sets as well as improved accuracy of documentation should facilitate future comparative analyses of routine databases.

Problems of Rural Food Safety and Strategies of Constructing Supervision System

Institute of Scientific and Technical Information of China (English)

2011-01-01

This paper expounds the practical necessity of constructing diversified rural food safety supervision system as follows: it is the necessary requirements of guaranteeing people’s health and life safety; it is an important component of governmental function of social management and the logical extension of administrative responsibilities; it is the basis of maintaining order of rural society and constructing harmonious society. The main problems existing in the supervision of rural food safety are analyzed as follows: first, the legislative work of rural food safety lags behind to some extent; second, the supervision of governmental departments on rural food safety is insufficient; third, the industrial supervision mechanism of rural food security is not perfect; fourth, the role of rural social organizations in supervising food safety is limited; fifth, the farmers’ awareness of food safety supervision is not strong. Based on these problems, the targeted strategies of constructing diversified rural food safety supervision system are put forward as follows: accelerate the legislation of rural food safety, and ensure that there are laws to go by; give play to the dominant role of government, and strengthen administrative supervision on rural food safety; perfect industrial convention of rural food safety, and improve industrial supervision mechanism; actively support the fostering of social organizations, and give play to the role of supervision of organizations; cultivate correct concept of rights and obligations of farmers, and form awareness of food safety supervision.

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...

Problem of evaluating the safety of an explosive

International Nuclear Information System (INIS)

Smith, L.C.

1977-01-01

Some general considerations on the problem of evaluating the safety of an explosive lead to the reasons why the much-criticized drop-weight impact machine remains an important tool in most explosive research and development laboratories. Problems related to the design, calibration, and use of such machines, and certain misconceptions concerning the interpretation of the test data, are discussed. The results of an unsuccessful attempt to construct a more comprehensive hazards scale also are described

Problems with quantification of safety culture

International Nuclear Information System (INIS)

Kozuh, M.; Mavko, B.

1995-01-01

For the qualitative part of the method for the Safety Culture assessment we quantitative part was developed based on expert judgement and statistical methods. The quantitative assessment should go in parallel with the qualitative part already presented. The essential part is based on expert opinion which organizational factors are the most important for certain risk significant components and how well are they implemented. The problems with getting the ratings are described in the paper. (author)

Hydrogen problems in reactor safety research

International Nuclear Information System (INIS)

Casper, H.

1984-01-01

The BMFT and BMI have initiated a workshop 'Hydrogen Problems in Reactor Safety Research' that took place October 3./4., 1983. The objective of this workshop was to present the state of the art in the main areas - Hydrogen-Production - Hydrogen-Distribution - Hydrogen-Ignition - Hydrogen-Burning and Containment Behaviour - Mitigation Measures. The lectures on the different areas are compiled. The most important results of the final discussion are summarized as well. (orig.) [de

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...

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.

Collaboration and patient safety at an emergency department - a qualitative case study.

Science.gov (United States)

Pedersen, Anna Helene Meldgaard; Rasmussen, Kurt; Grytnes, Regine; Nielsen, Kent Jacob

2018-03-19

Purpose The purpose of this paper is to examine how conflicts about collaboration between staff at different departments arose during the establishment of a new emergency department and how these conflicts affected the daily work and ultimately patient safety at the emergency department. Design/methodology/approach This qualitative single case study draws on qualitative semi-structured interviews and participant observation. The theoretical concepts "availability" and "receptiveness" as antecedents for collaboration will be applied in the analysis. Findings Close collaboration between departments was an essential precondition for the functioning of the new emergency department. The study shows how a lack of antecedents for collaboration affected the working relation and communication between employees and departments, which spurred negative feelings and reproduced conflicts. This situation was seen as a potential threat for the safety of the emergency patients. Research limitations/implications This study presents a single case study, at a specific point in time, and should be used as an illustrative example of how contextual and situational factors affect the working environment and through that patient safety. Originality/value Few studies provide an in-depth investigation of what actually takes place when collaboration between professional groups goes wrong and escalates, and how problems in collaboration may affect patient safety.

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.

Problems of nuclear energetics safety in the Soviet Union

International Nuclear Information System (INIS)

Kovalevitsh, O.M.

1991-01-01

Authors describe present state of Soviet nuclear energy. They don't cover problems relative to its development and that reasons made so bleak picture of this economic branch. They pay particular attention to low level of nuclear safety in nuclear power plants. The improvement of this situation they see in enacting of atomic low, as quickly as possible, which will make a basis of safety development in nuclear industry

Patient safety culture in China: a case study in an outpatient setting in Beijing.

Science.gov (United States)

Liu, Chaojie; Liu, Weiwei; Wang, Yuanyuan; Zhang, Zhihong; Wang, Peng

2014-07-01

To investigate the patient safety culture in an outpatient setting in Beijing and explore the meaning and implications of the safety culture from the perspective of health workers and patients. A mixed methods approach involving a questionnaire survey and in-depth interviews was adopted. Among the 410 invited staff members, 318 completed the Hospital Survey of Patient Safety Culture (HSOPC). Patient safety culture was described using 12 subscale scores. Inter-subscale correlation analysis, ANOVA and stepwise multivariate regression analyses were performed to identify the determinants of the patient safety culture scores. Interviewees included 22 patients selected through opportunity sampling and 27 staff members selected through purposive sampling. The interview data were analysed thematically. The survey respondents perceived high levels of unsafe care but had personally reported few events. Lack of 'communication openness' was identified as a major safety culture problem, and a perception of 'penalty' was the greatest barrier to the encouragement of error reporting. Cohesive 'teamwork within units', while found to be an area of strength, conversely served as a protective and defensive mechanism for medical practice. Low levels of trust between providers and consumers and lack of management support constituted an obstacle to building a positive patient safety culture. This study in China demonstrates that a punitive approach to error is still widespread despite increasing awareness of unsafe care, and managers have been slow in acknowledging the importance of building a positive patient safety culture. Strong 'teamwork within units', a common area of strength, could fuel the concealment of errors. 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.

Ecological Congress and the safety problems of the Rostov region

International Nuclear Information System (INIS)

Madoyan, A.A.

2001-01-01

A brief description of activities of the 3 research and technical conference Ecological Congress (April 16-17, 2001), dealing with problems of reliability and safety of the Rostov NPP operation, is provided. More than 25 reports on problems pertaining to radiation safety and ecology, development and introduction for new research and technical approaches, reliability of building structures, account of human factor during operation of industrial facilities, etc. were submitted. By and large, participants to the conference supported construction for facilities necessary for regional economy upsurge like the Rostov NPP, on condition of high-quality construction and safe operation [ru

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

Safety and usability evaluation of a web-based insulin self-titration system for patients with type 2 diabetes mellitus.

Science.gov (United States)

Simon, Airin C R; Holleman, Frits; Gude, Wouter T; Hoekstra, Joost B L; Peute, Linda W; Jaspers, Monique W M; Peek, Niels

2013-09-01

The rising incidence of type 2 diabetes mellitus (T2DM) induces severe challenges for the health care system. Our research group developed a web-based system named PANDIT that provides T2DM patients with insulin dosing advice using state of the art clinical decision support technology. The PANDIT interface resembles a glucose diary and provides advice through pop-up messages. Diabetes nurses (DNs) also have access to the system, allowing them to intervene when needed. The objective of this study was to establish whether T2DM patients can safely use PANDIT at home. To this end, we assessed whether patients experience usability problems with a high risk of compromising patient safety when interacting with the system, and whether PANDIT's insulin dosing advice are clinically safe. The study population consisted of patients with T2DM (aged 18-80) who used a once daily basal insulin as well as DNs from a university hospital. The usability evaluation consisted of think-aloud sessions with four patients and three DNs. Video data, audio data and verbal utterances were analyzed for usability problems encountered during PANDIT interactions. Usability problems were rated by a physician and a usability expert according to their potential impact on patient safety. The usability evaluation was followed by an implementation with a duration of four weeks. This implementation took place at the patients' homes with ten patients to evaluate clinical safety of PANDIT advice. PANDIT advice were systematically compared with DN advice. Deviating advice were evaluated with respect to patient safety by a panel of experienced physicians, which specialized in diabetes care. We detected seventeen unique usability problems, none of which was judged to have a high risk of compromising patient safety. Most usability problems concerned the lay-out of the diary, which did not clearly indicate which data entry fields had to be entered in order to obtain an advice. 27 out of 74 (36.5%) PANDIT advice

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...

Social capital and knowledge sharing: effects on patient safety.

Science.gov (United States)

Chang, Chia-Wen; Huang, Heng-Chiang; Chiang, Chi-Yun; Hsu, Chiu-Ping; Chang, Chia-Chen

2012-08-01

This article is a report on a study that empirically examines the influence of social capital on knowledge sharing and the impact of knowledge sharing on patient safety. Knowledge sharing is linked to many desirable managerial outcomes, including learning and problem-solving, which are essential for patient safety. Rather than studying the tangible effects of rewards, this study examines whether social capital (including social interaction, trust and shared vision) directly supports individual knowledge sharing in an organization. This cross-sectional study analysed data collected through a questionnaire survey of nurses from a major medical centre in northern Taiwan. The data were collected over a 9-month period from 2008 to 2009. The data analysis was conducted using the Partial Least Squares Graph v3.0 program to evaluate the measurement properties and the structural relationships specified in the research model. Based on a large-scale survey, empirical results indicate that Registered Nurses' perceptions of trust and shared vision have statistically significant and direct effects on knowledge sharing. In addition, knowledge sharing is significantly and positively associated with patient safety. The findings suggest that hospital administrators should foster group trust and initiate a common vision among Registered Nurses. In addition, administrators and chief knowledge officers of hospitals should encourage positive intentions towards knowledge sharing. © 2011 The Authors. Journal of Advanced Nursing © 2011 Blackwell Publishing Ltd.

Evaluation by the Department de Surete Nucleaire of unsolved PWR safety problems

International Nuclear Information System (INIS)

Dupuis, M.C.; Cayol, A.; Fourest, B.

1980-04-01

The deterministic or probabilistic methods of safety analysis and the analysis of accidents used at the design and construction stage have enabled certain safety problems connected with the PWR programme in France to be identified. Some of these problems have already been stressed by the NRC whereas others are specific to the safety approach practised in France. These problems have led to the adoption of special measurements on the reactors already in operation and should be accounted for in the design of future installations. Analysis of running experience and of incidents should be used to check the validity of the steps taken at the design stage and to identify the weak points of the facilities, especially in their piloting and at the man-machine interface [fr

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...

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...

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.

Environmental problems related to winter traffic safety conditions

OpenAIRE

Hääl, Maire-Liis; Sürje, Peep

2006-01-01

The changeable Nordic climate has added problems to road maintenance and the environment to ensure traffic safety under winter conditions. The widespread use of salt (NaCl) for snow and ice removal from roads has resulted in environmental impacts in many areas. Some of the problems associated with the use of NaCl are the corrosion of bridges, road surfaces and vehicles and damage to roadside vegetation and aquatic system that are affected by water from de-iced roads. Accumulation of hard meta...

Contribution of maintainability and maintenance to problems of safety evaluation

International Nuclear Information System (INIS)

Adnot, Serge; Meriaux, Pierre.

1977-10-01

A method has been developed for defining the contribution of Maintainability and the Maintenance Studies to Safety evaluation problems. The efficiency of this method is shown and results obtained are given for two theoretical examples approximating reality. For repairable systems, the risk defined according to such given safety criterion, becomes a characteristic of the systems in operation [fr

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...

Implementation and evaluation of a prototype consumer reporting system for patient safety events.

Science.gov (United States)

Weingart, Saul N; Weissman, Joel S; Zimmer, Karen P; Giannini, Robert C; Quigley, Denise D; Hunter, Lauren E; Ridgely, M Susan; Schneider, Eric C

2017-08-01

No methodologically robust system exists for capturing consumer-generated patient safety reports. To address this challenge, we developed and pilot-tested a prototype consumer reporting system for patient safety, the Health Care Safety Hotline. Mixed methods evaluation. The Hotline was implemented in two US healthcare systems from 1 February 2014 through 30 June 2015. Patients, family members and caregivers associated with two US healthcare systems. A consumer-oriented incident reporting system for telephone or web-based administration was developed to elicit medical mistakes and care-related injuries. Key informant interviews, measurement of website traffic and analysis of completed reports. Key informants indicated that Hotline participation was motivated by senior leaders' support and alignment with existing quality and safety initiatives. During the measurement period from 1 October 2014 through 30 June 2015, the home page had 1530 visitors with a unique IP address. During its 17 months of operation, the Hotline received 37 completed reports including 20 mistakes without harm and 15 mistakes with injury. The largest category of mistake concerned problems with diagnosis or advice from a health practitioner. Hotline reports prompted quality reviews, an education intervention, and patient follow-ups. While generating fewer reports than its capacity to manage, the Health Care Safety Hotline demonstrated the feasibility of consumer-oriented patient safety reporting. Further research is needed to understand how to increase consumers' use of these systems. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

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

Problems of making decisions with account of risk and safety factors

Energy Technology Data Exchange (ETDEWEB)

Larichev, O I

1987-01-01

New trends in making decisions on accidents when using large-scale technologies-NPPs, chemical plants etc., are considered. Three main directions in the investigations in this field are distinguished. One of them consists in risk measuring (its perception by people, ways of its quantitative determination). The second direction consists in increasing the safety of large-scale production systems. Here the following questions are considered: risk assessment (the safety standard statement), site selection for new systems, man-machine interaction problems, development of safer technologies, cost benefit safety analysis. The third direction is connected with the problem of accidents and their analysis. This direction includes considering the reasons and process of the accident development, preparing for the possible accidents, monitoring under extreme conditions, accident effect analysis.

Problems of making decisions with account of risk and safety factors

International Nuclear Information System (INIS)

Larichev, O.I.

1987-01-01

New trends in making decisions on accidents when using large-scale technologies-NPPs, chemical plants etc., are considered. Three main directions in the investigations in this field are distinguished. One of them consists in risk measuring (its perception by people, ways of its quantitative determination). The second direction consists in increasing the safety of large-scale production systems. Here the following questions are considered: risk assessment (the safety standard statement), site selection for new systems, man-machine interaction problems, development of safer technologies, cost benefit safety analysis. The third direction is connected with the problem of accidents and their analysis. This direction includes considering the reasons and process of the accident development, preparing for the possible accidents, monitoring under extreme conditions, accident effect analysis

Sociological refigurations of patient safety; ontologies of improvement and 'acting with' quality collaboratives in healthcare.

Science.gov (United States)

Zuiderent-Jerak, Teun; Strating, Mathilde; Nieboer, Anna; Bal, Roland

2009-12-01

The increasing focus on patient safety in the field of health policy is accompanied by research programs that articulate the role of the social sciences as one of contributing to enhancing safety in healthcare. Through these programs, new approaches to studying safety are facing a narrow definition of 'usefulness' in which researchers are to discover the factors that support or hamper the implementation of existing policy agendas. This is unfortunate since such claims for useful involvement in predefined policy agendas may undo one of the strongest assets of good social science research: the capacity to complexify the taken-for-granted conceptualizations of the object of study. As an alternative to this definition of 'usefulness', this article proposes a focus on multiple ontologies in the making when studying patient safety. Through such a focus, the role of social scientists becomes the involvement in refiguring the problem space of patient safety, the relations between research subjects and objects, and the existing policy agendas. This role gives medical sociologists the opportunity to focus on the question of which practices of 'effective care' are being enacted through different approaches for dealing with patient safety and what their consequences are for the care practices under study. In order to explore these questions, this article draws on empirical material from an ongoing evaluation of a large quality improvement collaborative for the care sectors in the Netherlands. It addresses how issues like 'effectiveness' and 'client participation' are at present articulated in this collaborative and shows that alternative figurations of these notions dissolve many 'implementation problems' presently experienced. Further it analyzes how such a focus of medical sociology on multiple ontologies engenders new potential for exploring particular spaces for 'acting with' quality improvement agents.

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

Safety of superconducting fusion magnets: twelve problem areas

International Nuclear Information System (INIS)

Turner, L.R.

1979-05-01

Twelve problem areas of superconducting magnets for fusion reaction are described. These are: Quench Detection and Energy Dump, Stationary Normal Region of Conductor, Current Leads, Electrical Arcing, Electrical Shorts, Conductor Joints, Forces from Unequal Currents, Eddy Current Effects, Cryostat Rupture, Vacuum Failure, Fringing Field and Instrumentation for Safety. Each is described under the five categories: Identification and Definition, Possible Safety Effects, Current Practice, Adequacy of Current Practice for Fusion Magnets and Areas Requiring Further Analytical and Experimental Study. Priorities among these areas are suggested; application is made to the Large Coil Project at Oak Ridge National Laboratory

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

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.

Media-safety of children as important social-pedagogical problem of modern times

Directory of Open Access Journals (Sweden)

Yuliia Semeniako

2017-02-01

Full Text Available In the article the relevance of media-safety as a socio-pedagogical problems. The introduction of media education in the practice of work of preschool educational institutions, the author identified as one of the strategies for overcoming negative influences of media on the younger generation. The concept of “information security”, “pre-school media education”, “media informational security” and identified the main tasks of media education  at the present stage in Ukraine. Determined main problems, the overcoming of which may provide media-safety of preschoolers.Key words: media education, media-safety media, information and communication technology, information security.

Plant Operations. OSHA on Campus: Campus Safety Officers Discuss Problems and Potentials

Science.gov (United States)

Kuchta, Joseph F.; And Others

1973-01-01

The Occupation Safety and Health Act (OSHA) has presented campus safety officers with new problems, but it is also offering them new potentials, which were explored at the recent national conference on Campus Security. (Editor)

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.

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 in the operating room: an intervention study on latent risk factors

Directory of Open Access Journals (Sweden)

van Beuzekom Martie

2012-06-01

Full Text Available Abstract Background Patient safety is one of the greatest challenges in healthcare. In the operating room errors are frequent and often consequential. This article describes an approach to a successful implementation of a patient safety program in the operating room, focussing on latent risk factors that influence patient safety. We performed an intervention to improve these latent risk factors (LRFs and increase awareness of patient safety issues amongst OR staff. Methods Latent risk factors were studied using a validated questionnaire applied to the OR staff before and after an intervention. A pre-test/post-test control group design with repeated measures was used to evaluate the effects of the interventions. The staff from one operating room of an university hospital acted as the intervention group. Controls consisted of the staff of the operating room in another university hospital. The outcomes were the changes in LRF scores, perceived incident rate, and changes in incident reports between pre- and post-intervention. Results Based on pre-test scores and participants’ key concerns about organizational factors affecting patient safety in their department the intervention focused on the following LRFs: Material Resources, Training and Staffing Recourses. After the intervention, the intervention operating room - compared to the control operating room - reported significantly fewer problems on Material Resources and Staffing Resources and a significantly lower score on perceived incident rate. The contribution of technical factors to incident causation decreased significantly in the intervention group after the intervention. Conclusion The change of state of latent risk factors can be measured using a patient safety questionnaire aimed at these factors. The change of the relevant risk factors (Material and Staffing resources concurred with a decrease in perceived and reported incident rates in the relevant categories. We conclude that

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...

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

Safety of superconducting fusion magnets: twelve problem areas

International Nuclear Information System (INIS)

Turner, L.R.

1979-01-01

Twelve problem areas of superconducting magnets for fusion reaction are described. These are: quench detection and energy dump, stationary normal region of conductor, current leads, electrical arcing, electrical shorts, conductor joints, forces from unequal currents, eddy current effects, cryostat rupture, vacuum failure, fringing field and instrumentation for safety. Priorities among these areas are suggested

Safety of superconducting fusion magnets: twelve problem areas

International Nuclear Information System (INIS)

Turner, L.R.

1979-01-01

Twelve problem areas of superconducting magnets for fusion reaction are described. These are: Quench Detection and Energy Dump, Stationary Normal Region of Conductor, Current Leads, Electrical Arcing, Electrical Shorts, Conductor Joints, Forces from Unequal Currents, Eddy Current Effects, Cryostat Rupture, Vacuum Failure, Fringing Field and Instrumentation for Safety. Priorities among these areas are suggested

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.

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...

THE PROBLEM OF THE USE OF NEW ORAL ANTICOAGULANTS IN CANCER PATIENTS RECEIVING CHEMOTHERAPY

Directory of Open Access Journals (Sweden)

A. A. Rumyantsev

2015-09-01

Full Text Available Despite large number of known risk factors of venous thromboembolism (VTE in cancer patients existing prediction models do not allow definite identification of cancer patients that have indications for anticoagulant prevention. Besides, heparin and warfarin use for VTE prevention in cancer is accompanied by some problems. New oral anticoagulants (NOAC are promising drugs for use in oncology practice; however their use is complicated by the lack of data on efficacy and safety in these patients, potential drug interactions and the possibility of unpredictable changes in effect during chemotherapy. Widespread use of NOAC for the prevention and treatment of tumor-associated VTE prior to phase III trials is not recommended. However, the criteria for selection of patients for whom the study of the efficacy and safety of NOAC is a priority can now be developed.

THE PROBLEM OF THE USE OF NEW ORAL ANTICOAGULANTS IN CANCER PATIENTS RECEIVING CHEMOTHERAPY

Directory of Open Access Journals (Sweden)

A. A. Rumyantsev

2014-01-01

Full Text Available Despite large number of known risk factors of venous thromboembolism (VTE in cancer patients existing prediction models do not allow definite identification of cancer patients that have indications for anticoagulant prevention. Besides, heparin and warfarin use for VTE prevention in cancer is accompanied by some problems. New oral anticoagulants (NOAC are promising drugs for use in oncology practice; however their use is complicated by the lack of data on efficacy and safety in these patients, potential drug interactions and the possibility of unpredictable changes in effect during chemotherapy. Widespread use of NOAC for the prevention and treatment of tumor-associated VTE prior to phase III trials is not recommended. However, the criteria for selection of patients for whom the study of the efficacy and safety of NOAC is a priority can now be developed.

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.

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...

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.

Flightdeck Automation Problems (FLAP) Model for Safety Technology Portfolio Assessment

Science.gov (United States)

Ancel, Ersin; Shih, Ann T.

2014-01-01

NASA's Aviation Safety Program (AvSP) develops and advances methodologies and technologies to improve air transportation safety. The Safety Analysis and Integration Team (SAIT) conducts a safety technology portfolio assessment (PA) to analyze the program content, to examine the benefits and risks of products with respect to program goals, and to support programmatic decision making. The PA process includes systematic identification of current and future safety risks as well as tracking several quantitative and qualitative metrics to ensure the program goals are addressing prominent safety risks accurately and effectively. One of the metrics within the PA process involves using quantitative aviation safety models to gauge the impact of the safety products. This paper demonstrates the role of aviation safety modeling by providing model outputs and evaluating a sample of portfolio elements using the Flightdeck Automation Problems (FLAP) model. The model enables not only ranking of the quantitative relative risk reduction impact of all portfolio elements, but also highlighting the areas with high potential impact via sensitivity and gap analyses in support of the program office. Although the model outputs are preliminary and products are notional, the process shown in this paper is essential to a comprehensive PA of NASA's safety products in the current program and future programs/projects.

Critical roles of orthopaedic surgeon leadership in healthcare systems to improve orthopaedic surgical patient safety.

Science.gov (United States)

Kuo, Calvin C; Robb, William J

2013-06-01

The prevention of medical and surgical harm remains an important public health problem despite increased awareness and implementation of safety programs. Successful introduction and maintenance of surgical safety programs require both surgeon leadership and collaborative surgeon-hospital alignment. Documentation of success of such surgical safety programs in orthopaedic practice is limited. We describe the scope of orthopaedic surgical patient safety issues, define critical elements of orthopaedic surgical safety, and outline leadership roles for orthopaedic surgeons needed to establish and sustain a culture of safety in contemporary healthcare systems. We identified the most common causes of preventable surgical harm based on adverse and sentinel surgical events reported to The Joint Commission. A comprehensive literature review through a MEDLINE(®) database search (January 1982 through April 2012) to identify pertinent orthopaedic surgical safety articles found 14 articles. Where gaps in orthopaedic literature were identified, the review was supplemented by 22 nonorthopaedic surgical references. Our final review included 36 articles. Six important surgical safety program elements needed to eliminate preventable surgical harm were identified: (1) effective surgical team communication, (2) proper informed consent, (3) implementation and regular use of surgical checklists, (4) proper surgical site/procedure identification, (5) reduction of surgical team distractions, and (6) routine surgical data collection and analysis to improve the safety and quality of surgical patient care. Successful surgical safety programs require a culture of safety supported by all six key surgical safety program elements, active surgeon champions, and collaborative hospital and/or administrative support designed to enhance surgical safety and improve surgical patient outcomes. Further research measuring improvements from such surgical safety systems in orthopaedic care is needed.

Safety problems, symptomatic oriented accident regulations, influence of nuclear energetic on ecology of the Slovak Republic

International Nuclear Information System (INIS)

Palenikova, M.

2002-01-01

IAEA initiated in 1990 the program on help of the countries of Eastern Europe and of the former Soviet Union at evaluating of the safety of their first generation nuclear power reactors of the type WWER 440/223. The main aim of this program was to identify the main design and operational safety problems, to determine international consensus on priorities of safety improvements, to provide the help in the assessment of completeness and adequacy of programs of safety improvements: What are the safety problems; What is the safety importance of problems; What is done for prevention from damage of nuclear power plant; and of three barriers: the tasks MOD V-2 NPP; What is done for reducing of damage consequences; PHP, PASS (post-accidental directives and post-accidental monitoring). (author)

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.

The main chemical safety problems in main process of nuclear fuel reprocessing plant

International Nuclear Information System (INIS)

Song Fengli; Zhao Shangui; Liu Xinhua; Zhang Chunlong; Lu Dan; Liu Yuntao; Yang Xiaowei; Wang Shijun

2014-01-01

There are many chemical reactions in the aqueous process of nuclear fuel reprocessing. The reaction conditions and the products are different so that the chemical safety problems are different. In the paper the chemical reactions in the aqueous process of nuclear fuel reprocessing are described and the main chemical safety problems are analyzed. The reference is offered to the design and accident analysis of the nuclear fuel reprocessing plant. (authors)

Patient safety in a service of medical physics. Key indicators

International Nuclear Information System (INIS)

Font Gomez, J. A.; Gandia Martinez, A.; Jimenez Albericio, F. J.; Andres Redondo, M. M.; Mengual Gil, M. A.

2013-01-01

The key indicators are those that endure over time to monitor the degree of compliance with the criteria in the processes that are considered key in the service. In the case of our service, define key indicators within the framework of ISO 9001 certification in the process of clinical dosimetry. All problems do not have same casuistry or not, have the same detrimental to the safety of the patient. We have prioritized some of the problems and opportunities for improvement have been found. Standard refers to the value of the indicator that we should or would like to achieve in such a way that if not achieved, action of improvement will be required. (Author)

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.

Criticality Safety Problems Related to Storage of Highly Active Liquid Waste

International Nuclear Information System (INIS)

Amin, E.

1999-01-01

The geometries of liquid waste storage tanks are not generally safe against criticality. Normally, this does not cause problems as fissile materials exist in nitric acid solution only as depleted uranium or in insignificant concentration of the originally reprocessed inventory of plutonium. However, if sedimentation of solid particles would occur, the deposited material would cause criticality safety problems. Particularly, non-horizontal installation of the storage tanks would increase the Eigen value. The effect of the storage tank inclination and the presence of transplutonium elements on the criticality safety are investigated using the NCNSRC code packages. The results are compared well with a similar German published results

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.

Safety and problems in using radioactive drugs in hospitals

International Nuclear Information System (INIS)

Arimizu, Noboru

1975-01-01

The safety and the control problem of non-closed RI (radiopharmaceuticals) of which use has rapidly been increased, were studied. At present, the hospitals with an independent clinic for the nuclear medicine are very limited and many doctors, nurses and safety controllers who are working in the clinic belong to other clinics. As for the diagnosis using RI examination, the dangers of the persons who are working with radioimmunoassay, especially using Au-antigen kit were studied. Furthermore, the problems concerning the reduction of exposure dose by the use of a short half-life RI, such as sup(99m)Tc and the dangers of external exposure on the persons who use the isotope were studied. In addition, the control of RI ward for RI therapy was discussed. The author considered the specialization and fixation of doctors, nurses and technicians are becoming of necessity with the advancement of RI therapy. In addition, the necessity of training nurses for the nuclear medicine was insisted on. (Tsukamoto, Y.)

Safety and problems in using radioactive drugs in hospitals

Energy Technology Data Exchange (ETDEWEB)

Arimizu, N [National Inst. of Radiological Sciences, Chiba (Japan)

1975-01-01

The safety and the control problem of non-closed RI (radiopharmaceuticals) of which use has rapidly been increased, were studied. At present, the hospitals with an independent clinic for the nuclear medicine are very limited and many doctors, nurses and safety controllers who are working in the clinic belong to other clinics. As for the diagnosis using RI examination, the dangers of the persons who are working with radioimmunoassay, especially using Au-antigen kit were studied. Furthermore, the problems concerning the reduction of exposure dose by the use of a short half-life RI, such as sup(99m)Tc and the dangers of external exposure on the persons who use the isotope were studied. In addition, the control of RI ward for RI therapy was discussed. The author considered the specialization and fixation of doctors, nurses and technicians are becoming of necessity with the advancement of RI therapy. In addition, the necessity of training nurses for the nuclear medicine was insisted on.

Problems of nuclear reactor safety. Vol. 1; Problemy bezopasnosti yaderno-ehnergeticheskikh ustanovok. Tom 1

Energy Technology Data Exchange (ETDEWEB)

Shal` nov, A V [Moskovskij Inzhenerno-Fizicheskij Inst., Moscow (Russian Federation)

1996-12-31

Proceedings of the 9. Topical Meeting `Problems of nuclear reactor safety` are presented. Papers include results of studies and developments associated with methods of calculation and complex computerized simulation for stationary and transient processes in nuclear power plants. Main problems of reactor safety are discussed as well as rector accidents on operating NPP`s are analyzed.

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.

PROBLEMS OF APPLYING FIXED FORMULAE TO SAFETY CRITERIA AND SITE SELECTION

Energy Technology Data Exchange (ETDEWEB)

Davis, W. K.

1963-10-15

The problem of developing a formula or calculation procedure for that could more-or-less automatically indicate whether or not a nuclear plant would be considered safe at a particular location is discussed. The difficulties and impossibilities of any sach formula for making decisions on siting and safety involving large amounts of money and public safety are considered. (P.C.H.)

Key Problems of Fire Safety Enforcement in Traffic and Communication Centers (TCC)

Science.gov (United States)

Medyanik, M.; Zosimova, O.

2017-10-01

A Traffic and Communication Center (TCC) means facilities designed and used to distribute and redirect flows of humans and motor vehicles while they get serviced and operate. This paper sets forth the basic problems of fire safety enforcement on the TCC, and the causes that slow down human and vehicle traffic speeds. It proposes ways to solve the problems of fire safety enforcement on the TCC, in the Russian Federation and elsewhere. Engineering solutions are proposed for TCC design, with key outlooks of TCC future development as an alternative way to organize access in transportation.

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

Patient Safety Culture Status From The Perspective Medical Staff Of Yasuj Hospitals In 2015

Directory of Open Access Journals (Sweden)

M Rezaean

2016-01-01

Full Text Available Background & aim: One of the most important problems in the health sector, particularly in clinical centers, is the quality of healthcare. Patient safety is one of the most important elements in creating health care quality due to the fact that it is a critical component to the quality of health care and many errors are present in patient care and treatment practices..                                                               Thus, the aim of the present study was to determine the status of the patient safety culture and its relationship with events reported in Yasuj hospitals. Methods: The present descriptive cross-sectional study was conducted on 361 medical staff of Yasuj hospitals. The data were collected through a hospital survey on patient safety culture. The collected data were analyzed by using SPSS statistics soft ware version 21, using Descriptive methods, Pearson Coefficient, ANOVA, and T-Test. Results: The results of the present study revealed that the teamwork among hospital units (71/89percent, with expectations and management measures (66/38% in the case of safety obtained the most score and non-punitive response to errors (48/79% and manager support (55/88 percent obtained the least score. 73/7% of employees of three hospitals in the past 12 months did not report any event. In addition, there was a meaningful statistical relationship between the total score of safety culture and reporting the events. In this study, 15.5 % of respondents assess their safety culture in work as good, 44.3 % as acceptable and 30.5 percent reported poor. The overall safety culture among the three studied hospitals was 61.81 %. Results confirmed that the culture safety of patient in studied hospitals was average. Conclusions: The hospitals may rely on their strong points in terms of patient safety culture and try to remove their weak points to form a safe environment and appropriate

[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.

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...

Identification of Patient Safety Risks Associated with Electronic Health Records: A Software Quality Perspective.

Science.gov (United States)

Virginio, Luiz A; Ricarte, Ivan Luiz Marques

2015-01-01

Although Electronic Health Records (EHR) can offer benefits to the health care process, there is a growing body of evidence that these systems can also incur risks to patient safety when developed or used improperly. This work is a literature review to identify these risks from a software quality perspective. Therefore, the risks were classified based on the ISO/IEC 25010 software quality model. The risks identified were related mainly to the characteristics of "functional suitability" (i.e., software bugs) and "usability" (i.e., interface prone to user error). This work elucidates the fact that EHR quality problems can adversely affect patient safety, resulting in errors such as incorrect patient identification, incorrect calculation of medication dosages, and lack of access to patient data. Therefore, the risks presented here provide the basis for developers and EHR regulating bodies to pay attention to the quality aspects of these systems that can result in patient harm.

High field MRI: safety and protection problems related to the installation and the management of a 4T equipment

International Nuclear Information System (INIS)

Russo, A.; Speranza, A.; DELIA, R.; ANTOLINI, R.; FERRARI, P.; FILIPPI, M.

2006-01-01

The Physics Department of Trento University (Italy), in collaboration with Bruker Biospin decided to set up a 4 T MR system for research in the neurological field as well as on the biological effects of high field MRI. Nowadays the number of similar apparatus set up in the world is very low, several of these operate in the USA, some in Australia and one in Israel. Due to the very low diffusion of these equipments and to the few knowledge today available about the biological effects by clinical application of high field MRI, the problems related to the installation of the apparatus from the safety point of view are not well standardized. Therefore, in Trento, it has been necessary to deal with many problems regarding the set up of the MRI apparatus, taking also into account the current law in Italy with respect the safety and protection in MRI applications. In the present paper the Authors show the carried out studies and analyses, in relation to the organization of the safety aspects. These studies have resulted in arranging specific guidelines for: working in controlled way; emergency procedures for the patient advanced life support; procedures for the protocol of patient protection; rules for the safety of the operators, patients and general public. The carried out analyses have mainly taken into account the danger identification and the risk evaluation. For this reason it was set up a test protocol regarding:the performing tests, the very detailed test modalities for their periodic performance and the test sequence. For the patient safety and protection it has been necessary to put care, in the first step of the survey, to the subjects in critical situations, due to: working activity, clinical history, health conditions of the patient at the moment of the examination. So it has been necessary to set up an anamnesis questionnaire for the patient, finalized to spot: (1) the patients with particular contraindications for the MR examination; (2) the patients which

High field MRI: safety and protection problems related to the installation and the management of a 4T equipment

Energy Technology Data Exchange (ETDEWEB)

Russo, A.; Speranza, A. [National Research Council, Institute of Bioimaging and Biostructures- Dep.of Biomorphological and Functional Sciences - University Federico II, Napoli (Italy); DELIA, R. [University of Rome - Medicine and Surgery Faculty - La Sapienza Sez. Rieti (Italy); ANTOLINI, R. [University of Trento - Department of Physics, Trento (Italy); FERRARI, P. [University of Trento - Direction of Polo di Rovereto, Trento (Italy); FILIPPI, M. [University of Trento Prevention and Protection Service, Trento (Italy)

2006-07-01

The Physics Department of Trento University (Italy), in collaboration with Bruker Biospin decided to set up a 4 T MR system for research in the neurological field as well as on the biological effects of high field MRI. Nowadays the number of similar apparatus set up in the world is very low, several of these operate in the USA, some in Australia and one in Israel. Due to the very low diffusion of these equipments and to the few knowledge today available about the biological effects by clinical application of high field MRI, the problems related to the installation of the apparatus from the safety point of view are not well standardized. Therefore, in Trento, it has been necessary to deal with many problems regarding the set up of the MRI apparatus, taking also into account the current law in Italy with respect the safety and protection in MRI applications. In the present paper the Authors show the carried out studies and analyses, in relation to the organization of the safety aspects. These studies have resulted in arranging specific guidelines for: working in controlled way; emergency procedures for the patient advanced life support; procedures for the protocol of patient protection; rules for the safety of the operators, patients and general public. The carried out analyses have mainly taken into account the danger identification and the risk evaluation. For this reason it was set up a test protocol regarding:the performing tests, the very detailed test modalities for their periodic performance and the test sequence. For the patient safety and protection it has been necessary to put care, in the first step of the survey, to the subjects in critical situations, due to: working activity, clinical history, health conditions of the patient at the moment of the examination. So it has been necessary to set up an anamnesis questionnaire for the patient, finalized to spot: (1) the patients with particular contraindications for the MR examination; (2) the patients which

Safety problems of nuclear power plants with channel-type graphite boiling water reactors

International Nuclear Information System (INIS)

Emel'yanov, I.Ya.; Vasilevskij, V.P.; Volkov, V.P.; Gavrilov, P.A.; Kramerov, A.Ya.; Kuznetsov, S.P.; Kunegin, E.P.; Rybakov, N.Z.

1977-01-01

Construction of nuclear power plants in a highly populated region near large industrial centres necessitates to pay a special attention to their nuclear and radiation safety. Safety problems of nuclear reactor operation are discussed, in particular, they are: reliable stoppage of fission chain reaction at any emergency cases; reliable core cooling with failure of various equipment; emergency core cooling with breached pipes of a circulating circuit; and prevention of radioactive coolant release outside the nuclear power plant in amount exceeding the values adopted. Channel-type water boiling reactors incorporate specific features requiring a new approach to safety operation of a reactor and a nuclear power plant. These include primarily a rather large steam volume in the coolant circuit, large amount of accumulated heat, void reactivity coefficient. Channel-type reactors characterized by fair neutron balance and flexible fuel cycle, have a series of advantages alleviating the problem of ensuring their safety. The possibility of reliable control over the state of each channel allows to replace failed fuel elements by the new ones, when operating on-load, to increase the number of circulating loops and reduce the diameter of main pipelines, simplifies significantly the problem of channel emergency cooling and localization of a radioactive coolant release from a breached circuit. The concept of channel-type reactors is based on the solution of three main problems. First, plant safety should be assured in emergency switch off of separate units and, if possible, energy conditions should be maintained, this is of particular importance considering the increase in unit power. Second, the system of safety and emergency cooling should eliminate a great many failures of fuel elements in case of potential breaches of any tube in the circulating circuit. Finally, rugged boxes and localizing devices should be provided to exclude damage of structural elements of the nuclear power

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.

[Psychosocial problems and needs among cancer patients].

Science.gov (United States)

Mehlsen, Mimi Yung; Jensen, Anders Bonde; Zachariae, Bobby

2007-04-30

Cancer can have a serious impact on patient well-being and quality of life. The international literature reports a higher prevalence of psychosocial problems among cancer patients; primarily problems associated with difficulties in the family, duties in the household, work and leisure, sexuality and finances. The prevalence of these problems among Danish cancer patients is still unknown. A questionnaire assessing psychosocial problems and needs was mailed out to all patients who had been at the Department of Oncology, Aarhus Hospital in week 35, 2004. A total of 71%, i.e. 515 patients (34% men and 66% women) in active treatment and control returned the questionnaire. High levels of emotional distress were reported by 39% of the patients. High levels of distress were primarily related to problems with worries about their spouses, household duties, financial problems and experiences of insufficient collaboration between health care and social services. Between 19% and 25% of the patients required further help to handle emotional problems, legal and financial problems and practical problems in the home. A considerable proportion of oncology patients experience significant levels of distress. This group of distressed patients also report unmet needs for psychosocial support.

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.

Nurses' perceptions and problems in the usability of a medication safety app.

Science.gov (United States)

Ankem, Kalyani; Cho, Sookyung; Simpson, Diana

2017-10-16

The majority of medication apps support medication adherence. Equally, if not more important, is medication safety. Few apps report on medication safety, and fewer studies have been conducted with these apps. The usability of a medication safety app was tested with nurses to reveal their perceptions of the graphical user interface and to discover problems they encountered in using the app. Usability testing of the app was conducted with RN-BSN students and informatics students (n = 18). Perceptions of the graphical components were gathered in pretest and posttest questionnaires, and video recordings of the usability testing were transcribed. The significance of the difference in mean performance time for 8 tasks was tested, and qualitative analysis was deployed to identify problems encountered and to rate the severity of each problem. While all participants perceived the graphical user interface as easy to understand, nurses took significantly more time to complete certain tasks. More nurses found the medication app to be lacking in intuitiveness of user interface design, in capability to match real-world data, and in providing optimal information architecture. To successfully integrate mobile devices in healthcare, developers must address the problems that nurses encountered in use of the app.

Public opinion confronted by the safety problems associated with different energy source

Energy Technology Data Exchange (ETDEWEB)

Otway, H J; Thomas, K

1978-09-01

Model study of public opinion 'for' and 'against' the various energy sources - oil, coal, solar and nuclear power. Attitudes are examined from four aspects: psychology - economic advantages, sociopolitical problems, environmental problems and safety. The investigation focuses on nuclear energy. (13 refs.) (In French)

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…

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...

[Peripheral venous catheter use in the emergency department: reducing adverse events in patients and biosafety problems for staff].

Science.gov (United States)

Tomás Vecina, Santiago; Mozota Duarte, Julián; Ortega Marcos, Miguel; Gracia Ruiz Navarro, María; Borillo, Vicente; San Juan Gago, Leticia; Roqueta Egea, Fermin; Chanovas Borrás, Manuel

2016-01-01

To test a strategy to reduce the rate of adverse events in patients and safety problems for emergency department staff who insert peripheral venous catheters (PVCs). The strategy consisted of training, implementing a protocol, and introducing safety-engineered PVCs. Prospective, multicenter, observational, preauthorization study in patients requiring PVC placement in an emergency department. The study had 2 phases. The first consisted of training, implementing a protocol for using conventional PVCs, and monitoring practice. The second phase introduced safety-engineered PVC sets. The number of adverse events in patients and threats to safety for staff were compared between the 2 phases. A total of 520 patients were included, 180 in the first phase and 340 in the second. We detected breaches in aseptic technique, failure to maintain a sterile field, and improper management of safety equipment and devices. Some practices improved significantly during the second phase. Eighty-six adverse events occurred in the first phase and 52 (15.4%) in the second; the between-phase difference was not statistically significant. The incidence of postinfusion phlebitis was 50% lower in the second phase. Seven splash injuries and 1 accidental puncture occurred with conventional PVCs in the first phase; 2 splash injuries occurred with the safety-engineered PVCs in the second phase (36% decrease, P = .04). Differences were particularly noticeable for short-term PVC placements (P = .02). Combining training, a protocol, and the use of safety-engineered PVC sets offers an effective strategy for improving patient and staff safety.

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.

Potential problems will drillstring safety valves

Energy Technology Data Exchange (ETDEWEB)

NONE

1996-06-01

In the paper titled ``New generation drill string safety valves,`` presented at the IADC Well Control Conference for Europe, Aberdeen, May 22--24, 1996, documented limitations of presently available drillstring safety valves commonly used as kelly valves and stabbing valves were presented, and industry efforts to develop solutions to these problems were described. Authors of the paper are B.A. Tarr and R.A. Sukup (Mobil E and P Technology Center, Dallas), Dr. R. Luy (ITE, Clausthal, Germany), G. Rabby (Hi-Kalibre, Edmonton, Alberta) and J. Mertsch (ITAG, Celle, Germany). In 1995, the Task Group developed a draft of a new spec, and a DSSV testing program was initiated as a joint industry project, with the Gas Research Institute (GRI) as the major sponsor. Two manufacturers, Hi-Kalibre and ITAG, agreed to build new valves for the testing program. Hi-Kalibre, Edmonton, Alberta, supplied an already-commercial twin floating ball valve for November 1995 testing. This product is being used by Tesco in its portable top drive system. ITAG of Germany supplied a radically improved DSSV design, which was tested in December, and was to be retested in May following modifications.

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.

Electronic distractions of the respiratory therapist and their impact on patient safety.

Science.gov (United States)

Papadakos, Peter J

2014-08-01

Over the last decade, data from the lay press, government agencies, and the business world have identified ever-growing problems with electronic distraction and changes in human relationships in this electronically interconnected planet. As health professionals, we are well aware of the epidemic growth of injuries and deaths related to texting and driving. It should not surprise us that this distracted behavior has affected all levels of health-care providers and has impacted patient care. This advent of “distracted doctoring” was first coined by the Pulitzer Prize-winning correspondent Matt Richtel in a landmark article in the New York Times, “As doctors use more devices, potential for distraction grows.” This article was a flashpoint for professional organizations to reflect on this change in behavior and how it will impact patient safety and how we relate to patients. The explosion in technology (both personnel and hospital-based), coupled with a rapid social shift, creates an environment that constantly tempts health-care workers to surf the internet, check social media outlets, or respond to e-mails. Studies and commentaries in the medical literature only support how this is a growing problem in patient safety and may both increase medical errors and affects costs and the way we relate to patients and fellow staff. The Emergency Care Research Institute (ECRI) released its annual list of technology hazards for 2013, and three ring true for United States caregivers: distractions from smartphones and mobile devices, alarm hazards, and patient/data mismatches in electronic medical records and other health IT systems, all being in the top 10. How do we begin to address these new technological threats to our patients? First and foremost, we accept that this problem exists. We begin by educating our students and staff that this electronic explosion affects our behavior through addiction and the environment within our hospital through the use of electronic

Harnessing implementation science to improve care quality and patient safety: a systematic review of targeted literature.

Science.gov (United States)

Braithwaite, Jeffrey; Marks, Danielle; Taylor, Natalie

2014-06-01

Getting greater levels of evidence into practice is a key problem for health systems, compounded by the volume of research produced. Implementation science aims to improve the adoption and spread of research evidence. A linked problem is how to enhance quality of care and patient safety based on evidence when care settings are complex adaptive systems. Our research question was: according to the implementation science literature, which common implementation factors are associated with improving the quality and safety of care for patients? We conducted a targeted search of key journals to examine implementation science in the quality and safety domain applying PRISMA procedures. Fifty-seven out of 466 references retrieved were considered relevant following the application of exclusion criteria. Included articles were subjected to content analysis. Three reviewers extracted and documented key characteristics of the papers. Grounded theory was used to distil key features of the literature to derive emergent success factors. Eight success factors of implementation emerged: preparing for change, capacity for implementation-people, capacity for implementation-setting, types of implementation, resources, leverage, desirable implementation enabling features, and sustainability. Obstacles in implementation are the mirror image of these: for example, when people fail to prepare, have insufficient capacity for implementation or when the setting is resistant to change, then care quality is at risk, and patient safety can be compromised. This review of key studies in the quality and safety literature discusses the current state-of-play of implementation science applied to these domains. © The Author 2014. Published by Oxford University Press in association with the International Society for Quality in Health Care; 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.

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

Safety problems relating to plutonium recycling in light water reactors

International Nuclear Information System (INIS)

Devillers, C.; Frison, J.M.; Mercier, J.P.; Revais, J.P.

1991-01-01

This paper describes the specific nature, as regards safety, of the mixed oxide (MOX) fuel cycle, with the exception of safety problems relating to the operation of nuclear power plants. These specific characteristics are due mainly to the presence of plutonium in fresh fuel and to the higher plutonium and transuranic element content in spent fuel assemblies. The fuel cycle steps analysed here are the transport of plutonium oxide, the manufacture of MOX fuel assemblies, the transport of fresh and spent fuel assemblies and the processing of spent fuel assemblies

Safety problems relating to plutonium recycling in light water reactors

International Nuclear Information System (INIS)

Devillers, C.; Frison, J.M.; Mercier, J.P.; Revais, J.P

1991-01-01

This paper describes the specific nature, as regards safety, of the mixed oxide (MOX) fuel cycle, with the exception of safety problems relating to the operation of nuclear power plants. These specific characteristics are due mainly to the presence of plutonium in fresh fuel and to the higher plutonium and transuranic element content in spent fuel assemblies. The fuel cycle steps analysed here are the transport of plutonium oxide, the manufacture of MOX fuel assemblies, the transport of fresh and spent fuel assemblies and the processing of spent fuel assemblies. (author) [fr

30-th anniversary of nuclear power engineering in the USSR. Safety problems of nuclear engineering

International Nuclear Information System (INIS)

Kulov, E.V.; Sidorenko, V.A.; Kovalevich, O.M.

1984-01-01

The problems of safety and protection of personnel, population and environments from the NPP radiation effect in the Soviet Union in cases of possible accidents and in the course of normal operation are discussed. The problem of safety assurance includes scientific technological and organizational aspects. The necessity of accounting the ''national factor'' in the form of a possible NPP location, existing legislation experience gained, etc. is noted. The main trends in ensuring safety are a high quality of equipment manufacturing and assembly, quality control of equipment at all stages of operation, development and realization of efficient protective measures and devices, assurance of safety precautions at all stages of designing equipment production, NPP operation and maintenance, functioning of the system of state control of NPP safety assurance. The skill and training of personnel are necessary prerequisite for ensuring safety of nuclear power plants

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.

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.

Safety management in multiemployer worksites in the manufacturing industry: opinions on co-operation and problems encountered.

Science.gov (United States)

Nenonen, Sanna; Vasara, Juha

2013-01-01

Co-operation between different parties and effective safety management play an important role in ensuring safety in multiemployer worksites. This article reviews safety co-operation and factors complicating safety management in Finnish multiemployer manufacturing worksites. The paper focuses on the service providers' opinions; however, a comparison of the customers' views is also presented. The results show that safety-related co-operation between providers and customers is generally considered as successful but strongly dependent on the partner. Safety co-operation is provided through, e.g., training, orientation and risk analysis. Problems encountered include ensuring adequate communication, identifying hazards, co-ordinating work tasks and determining responsibilities. The providers and the customers encounter similar safety management problems. The results presented in this article can help companies to focus their efforts on the most problematic points of safety management and to avoid common pitfalls.

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...

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.

[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.

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.

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

A Few Examples of ISPs Addressing Specific Reactor Safety Problems

International Nuclear Information System (INIS)

Reocreux, M.

2008-01-01

Four International Standard Problems which were related to safety reactor problems are briefly discussed. ISP-20 (Steam Generator Tube Rupture in DOEL 2) is a unique ISP as it is based on a real incident which occurred in a commercial Power Plant. This ISP clearly illustrated the special problems of an ISP based on a real plant, namely limited access to precise plant data, some lack in the detailed knowledge of sensor behaviour, etc. ISP-26 (ROSA IV-LSTF small break test) was an open ISP. A qualitatively good prediction of the measured events was obtained even if some modelling deficiencies were identified. ISP-27 (BETHSY Exp. 9.1 B) was a blind ISP. All important trends observed during the test were qualitatively calculated by most computer codes. However, some deficiencies in calculating some variables were evident. ISP-33 (PACTEL Natural Circulation) was an exercise with a test facility modelled on the basis of a Russian VVER 440 and with participations from Eastern and Western organisations. ISP-33 was a double-blind exercise. The simulation of some variables caused some problems although they were in principle not too complicated. Post-test calculations demonstrated significant improvements. For all the four ISPs, the influence of the code user was evident and caused some scatter in the results. A specific study was performed in ISP-26 to clarify from where those user effects were coming. The reactor safety problems related to those ISPs are detailed and the specific contribution of the ISPs to bring solutions is discussed.

Problems of probabilistic safety assessment after Fukushima Daiichi nuclear power plant accident

International Nuclear Information System (INIS)

Sugiyama, Naoki

2011-01-01

Probabilistic safety assessment (PSA) methodology to assure nuclear safety is had great expectations of lessons learned from Fukushima Daiichi nuclear power plant (NPP) accident and on the other hand this accident made actualized technical problems of PSA. Effectiveness of current PSA methodology for risk assessment was confirmed by comparing the accident development with accident scenario of PSA and equipment failure rate. From a viewpoint of nuclear safety objective and defense in depth approach of IAEA, technical problems of PSA were (1) extension of PSA for spent fuel pool and waste disposal system as well as level 3PSA for broader environmental contamination and (2) overlapping of accident scenario of plural unit site, balance of high quality plant management and preceding negation, treatment of uncertainty of external events, severe accident measure and human reliability analysis and reflection of disaster prevention capability to level 3PSA. In order to upgrade PSA technology, six proposals were described for nuclear safety and defense in depth, comprehensive evaluation scope and catch-up of latest technology, necessity of strategic preparation of PSA standard, human resources fostering and risk communication. (T. Tanaka)

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.

Using a multi-method, user centred, prospective hazard analysis to assess care quality and patient safety in a care pathway

Directory of Open Access Journals (Sweden)

Escoto Kamisha

2007-06-01

Full Text Available Abstract Background Care pathways can be complex, often involving multiple care providers and as such are recognised as containing multiple opportunities for error. Prospective hazard analysis methods may be useful for evaluating care provided across primary and secondary care pathway boundaries. These methods take into account the views of users (staff and patients when determining where potential hazards may lie. The aim of this study is to evaluate the feasibility of prospective hazard analysis methods when assessing quality and safety in care pathways that lie across primary and secondary care boundaries. Methods Development of a process map of the care pathway for patients entering into a Chronic Obstructive Pulmonary Disease (COPD supported discharge programme. Triangulation of information from: care process mapping, semi-structured interviews with COPD patients, semi-structured interviews with COPD staff, two round modified Delphi study and review of prioritised quality and safety challenges by health care staff. Results Interview themes emerged under the headings of quality of care and patient safety. Quality and safety concerns were mostly raised in relation to communication, for example, communication with other hospital teams. The three highest ranked safety concerns from the modified Delphi review were: difficulties in accessing hospital records, information transfer to primary care and failure to communicate medication changes to primary care. Conclusion This study has demonstrated the feasibility of using mixed methods to review the quality and safety of care in a care pathway. By using multiple research methods it was possible to get a clear picture of service quality variations and also to demonstrate which points in the care pathway had real potential for patient safety incidents or system failures to occur. By using these methods to analyse one condition specific care pathway it was possible to uncover a number of hospital

[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.

Safety and protection problems in the management of a plant with cyclotron, radiopharmacy laboratory and PET/CT equipment

Energy Technology Data Exchange (ETDEWEB)

Russo, A.; Speranza, A.; Panico, M. [University Federico-2, National Research Council - Institute of Biostructures and Bioimaging and Dept. of Bio-morphological and Functional Sciences, Napoli (Italy); Delia, R. [University La Sapienza - sez. Rieti, Faculty of Medicine, Rome (Italy); Casale, M. [University Federico-2, Dept. of Physics - Health Physics School, Napoli (Italy); Salvatore, M. [University Federico-2 and National Research Council - Institute of Biostructures and Bioimaging, Dept. of Bio-morphological and Functional Sciences, Napoli (Italy)

2006-07-01

The importance of Positron Emission Tomography (PET) is spreading and increasing in many clinical diagnostic fields, as well as the oncology, the cardiology, the neurology and so on. A strong input to the diffusion of this imaging technique from the research field to clinical one has been given either by the development of knowledge about PET or the modern technologies, which allow to set up at very suitable prices and in very little volumes, like in an hospital site, complete systems, which consist of: Cyclotron; Radiopharmacy Laboratory; one or more either PET or PET/CT. Such set-up arrangement allows to carry out highly innovative diagnostic examinations with a remarkable achievement of diagnostic quality and large number of daily examinations. In this paper the authors show the achieved know-how with respect to radioprotection for the set-up and running management of two systems such as PET/CT tomography unit, cyclotron and radiopharmacy laboratory, installed one in the Imaging Diagnostic Department of the Hospital of Naples University and used only for medical and research purposes, and the other one in A.C.O.M. (Advanced Center of Oncology in Macerata), used for commercial and research purposes. The following safety problems have been considered: the facility lay-out; the optimisation of the paths either for the operator, or the patients and the radiotracers; the guide lines for the protection and the safety of the patients, operators and general population, in relation to the utilization and the management of either the more common radiotracers (18 F and 11 C) or those in research progress, for example 64 Cu and 124 I; the protocol set up for the image quality control in relation to the patient protection and safety. The above problems have also been considered, taking into account the Italian regulation and the International Recommendations. (authors)

Safety and protection problems in the management of a plant with cyclotron, radiopharmacy laboratory and PET/CT equipment

International Nuclear Information System (INIS)

Russo, A.; Speranza, A.; Panico, M.; Delia, R.; Casale, M.; Salvatore, M.

2006-01-01

The importance of Positron Emission Tomography (PET) is spreading and increasing in many clinical diagnostic fields, as well as the oncology, the cardiology, the neurology and so on. A strong input to the diffusion of this imaging technique from the research field to clinical one has been given either by the development of knowledge about PET or the modern technologies, which allow to set up at very suitable prices and in very little volumes, like in an hospital site, complete systems, which consist of: Cyclotron; Radiopharmacy Laboratory; one or more either PET or PET/CT. Such set-up arrangement allows to carry out highly innovative diagnostic examinations with a remarkable achievement of diagnostic quality and large number of daily examinations. In this paper the authors show the achieved know-how with respect to radioprotection for the set-up and running management of two systems such as PET/CT tomography unit, cyclotron and radiopharmacy laboratory, installed one in the Imaging Diagnostic Department of the Hospital of Naples University and used only for medical and research purposes, and the other one in A.C.O.M. (Advanced Center of Oncology in Macerata), used for commercial and research purposes. The following safety problems have been considered: the facility lay-out; the optimisation of the paths either for the operator, or the patients and the radiotracers; the guide lines for the protection and the safety of the patients, operators and general population, in relation to the utilization and the management of either the more common radiotracers (18 F and 11 C) or those in research progress, for example 64 Cu and 124 I; the protocol set up for the image quality control in relation to the patient protection and safety. The above problems have also been considered, taking into account the Italian regulation and the International Recommendations. (authors)

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 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.

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...

Learning from positively deviant wards to improve patient safety: an observational study protocol.

Science.gov (United States)

Baxter, Ruth; Taylor, Natalie; Kellar, Ian; Lawton, Rebecca

2015-12-11

Positive deviance is an asset-based approach to improvement which has recently been adopted to improve quality and safety within healthcare. The approach assumes that solutions to problems already exist within communities. Certain groups or individuals identify these solutions and succeed despite having the same resources as others. Within healthcare, positive deviance has previously been applied at individual or organisational levels to improve specific clinical outcomes or processes of care. This study explores whether the positive deviance approach can be applied to multidisciplinary ward teams to address the broad issue of patient safety among elderly patients. Preliminary work analysed National Health Service (NHS) Safety Thermometer data from 34 elderly medical wards to identify 5 'positively deviant' and 5 matched 'comparison' wards. Researchers are blinded to ward status. This protocol describes a multimethod, observational study which will (1) assess the concurrent validity of identifying positively deviant elderly medical wards using NHS Safety Thermometer data and (2) generate hypotheses about how positively deviant wards succeed. Patient and staff perceptions of safety will be assessed on each ward using validated surveys. Correlation and ranking analyses will explore whether this survey data aligns with the routinely collected NHS Safety Thermometer data. Staff focus groups and researcher fieldwork diaries will be completed and qualitative thematic content analysis will be used to generate hypotheses about the strategies, behaviours, team cultures and dynamics that facilitate the delivery of safe patient care. The acceptability and sustainability of strategies identified will also be explored. The South East Scotland Research Ethics Committee 01 approved this study (reference: 14/SS/1085) and NHS Permissions were granted from all trusts. Findings will be published in peer-reviewed, scientific journals, and presented at academic conferences. This study

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.

Probabilist methods applied to electric source problems in nuclear safety

International Nuclear Information System (INIS)

Carnino, A.; Llory, M.

1979-01-01

Nuclear Safety has frequently been asked to quantify safety margins and evaluate the hazard. In order to do so, the probabilist methods have proved to be the most promising. Without completely replacing determinist safety, they are now commonly used at the reliability or availability stages of systems as well as for determining the likely accidental sequences. In this paper an application linked to the problem of electric sources is described, whilst at the same time indicating the methods used. This is the calculation of the probable loss of all the electric sources of a pressurized water nuclear power station, the evaluation of the reliability of diesels by event trees of failures and the determination of accidental sequences which could be brought about by the 'total electric source loss' initiator and affect the installation or the environment [fr

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

[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.

Science.gov (United States)

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.

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.

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.

Beyond usability: designing effective technology implementation systems to promote patient safety.

Science.gov (United States)

Karsh, B-T

2004-10-01

Evidence is emerging that certain technologies such as computerized provider order entry may reduce the likelihood of patient harm. However, many technologies that should reduce medical errors have been abandoned because of problems with their design, their impact on workflow, and general dissatisfaction with them by end users. Patient safety researchers have therefore looked to human factors engineering for guidance on how to design technologies to be usable (easy to use) and useful (improving job performance, efficiency, and/or quality). While this is a necessary step towards improving the likelihood of end user satisfaction, it is still not sufficient. Human factors engineering research has shown that the manner in which technologies are implemented also needs to be designed carefully if benefits are to be realized. This paper reviews the theoretical knowledge on what leads to successful technology implementation and how this can be translated into specifically designed processes for successful technology change. The literature on diffusion of innovations, technology acceptance, organisational justice, participative decision making, and organisational change is reviewed and strategies for promoting successful implementation are provided. Given the rapid and ever increasing pace of technology implementation in health care, it is critical for the science of technology implementation to be understood and incorporated into efforts to improve patient safety.

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.)

Non-Technical Skills (NTS) for enhancing patient safety: achievements and future directions

OpenAIRE

Kodate, Naonori; Ross, Anthony; Anderson, Janet E.; Flin, R.

2012-01-01

Problems in team communication and decision making have been implicated in accidents in high risk industries such as aviation, off shore oil processing, nuclear power generation. Recognition of the role that breakdowns in communication and teamwork play in patient safety incidents has led to a plethora of studies in the area of what has come to be widely known as non-technical skills (NTS); a term initially used in European aviation (1). This has led to increasing interest in i...

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

Safety problems in decommissioning of nuclear power plants

International Nuclear Information System (INIS)

1975-12-01

The safety problems in decommissioning are presented by the example of light water reactors with an electric power of 1300 MW and 40 years of preceding specified operation. In such a plant the radioactivity in the form of activation and contamination is of the order of 10 7 Ci one year after final shut-down. The fuel elements are not taken into account. During the work at the reactor vessel dose rates of some 10 4 rem/h may occur at the flange level. According to a rough estimation the dose accumulated by the decommissioning personnel during dismantling of the radioactive components amounts to 1200 rem. During the decommissioning work the problems are caused predominantly by the direct radiation from the radioactive components and systems as well as from the release of radioactive particles, aerosols and liquids on cutting them up. In designing new plants the extent of later decommissioning problems can be reduced above all by selection of suitable materials and by decommissioning-minded design and arrangement of the components and parts of the plant. (orig./RW) [de

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.

Science.gov (United States)

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

Workplace training for senior trainees: a systematic review and narrative synthesis of current approaches to promote patient safety.

Science.gov (United States)

Walton, Merrilyn; Harrison, Reema; Burgess, Annette; Foster, Kirsty

2015-10-01

Preventable harm is one of the top six health problems in the developed world. Developing patient safety skills and knowledge among advanced trainee doctors is critical. Clinical supervision is the main form of training for advanced trainees. The use of supervision to develop patient safety competence has not been established. To establish the use of clinical supervision and other workplace training to develop non-technical patient safety competency in advanced trainee doctors. Keywords, synonyms and subject headings were used to search eight electronic databases in addition to hand-searching of relevant journals up to 1 March 2014. Titles and abstracts of retrieved publications were screened by two reviewers and checked by a third. Full-text articles were screened against the eligibility criteria. Data on design, methods and key findings were extracted. Clinical supervision documents were assessed against components common to established patient safety frameworks. Findings from the reviewed articles and document analysis were collated in a narrative synthesis. Clinical supervision is not identified as an avenue for embedding patient safety skills in the workplace and is consequently not evaluated as a method to teach trainees these skills. Workplace training in non-technical patient safety skills is limited, but one-off training courses are sometimes used. Clinical supervision is the primary avenue for learning in postgraduate medical education but the most overlooked in the context of patient safety learning. The widespread implementation of short courses is not matched by evidence of rigorous evaluation. Supporting supervisors to identify teaching moments during supervision and to give weight to non-technical skills and technical skills equally is critical. 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.

Intensive care unit nurses' perceptions of safety after a highly specific safety intervention.

Science.gov (United States)

Elder, N C; Brungs, S M; Nagy, M; Kudel, I; Render, M L

2008-02-01

It is unknown if successful changes in specific safety practices in the intensive care unit (ICU) generalize to broader concepts of patient safety by staff nurses. To explore perceptions of patient safety among nursing staff in ICUs following participation in a safety project that decreased hospital acquired infections. After implementation of practices that reduced catheter-related bloodstream infections in ICUs at four community hospitals, ICU nurses participated in focus groups to discuss patient safety. Audiotapes from the focus groups were transcribed, and two independent reviewers categorised the data which were triangulated with responses from selected questions of safety climate surveys and with the safety checklists used by management leadership on walk rounds. Thirty-three nurses attended eight focus groups; 92 nurses and managers completed safety climate surveys, and three separate leadership checklists were reviewed. In focus groups, nurses predominantly related patient safety to dangers in the physical environment (eg, bed rails, alarms, restraints, equipment, etc.) and to medication administration. These areas also represented 47% of checklist items from leadership walk rounds. Nurses most frequently mentioned self-initiated "double checking" as their main safety task. Focus-group participants and survey responses both noted inconsistency between management's verbal and written commitment compared with their day-to-day support of patient safety issues. ICU nurses who participated in a project to decrease hospital acquired infections did not generalize their experience to other aspects of patient safety or relate it to management's interest in patient safety. These findings are consistent with many adult learning theories, where self-initiated tasks, combined with immediate, but temporary problem-solving, are stronger learning forces than management-led activities with delayed feedback.