Sample records for patient safety reporting
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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
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Exploring relationships between hospital patient safety culture and Consumer Reports safety scores.
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.
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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.
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Knowledge Representation in Patient Safety Reporting: An Ontological Approach
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...
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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.
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The complexity of patient safety reporting systems in UK dentistry.
Renton, T; Master, S
2016-10-21
Since the 'Francis Report', UK regulation focusing on patient safety has significantly changed. Healthcare workers are increasingly involved in NHS England patient safety initiatives aimed at improving reporting and learning from patient safety incidents (PSIs). Unfortunately, dentistry remains 'isolated' from these main events and continues to have a poor record for reporting and learning from PSIs and other events, thus limiting improvement of patient safety in dentistry. The reasons for this situation are complex.This paper provides a review of the complexities of the existing systems and procedures in relation to patient safety in dentistry. It highlights the conflicting advice which is available and which further complicates an overly burdensome process. Recommendations are made to address these problems with systems and procedures supporting patient safety development in dentistry.
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Can patients report patient safety incidents in a hospital setting? A systematic review.
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.
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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.
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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.
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The Impact of a Patient Safety Program on Medical Error Reporting
2005-05-01
307 The Impact of a Patient Safety Program on Medical Error Reporting Donald R. Woolever Abstract Background: In response to the occurrence of...a sentinel event—a medical error with serious consequences—Eglin U.S. Air Force (USAF) Regional Hospital developed and implemented a patient safety...communication, teamwork, and reporting. Objective: To determine the impact of a patient safety program on patterns of medical error reporting. Methods: This
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Patient-Reported Safety Information: A Renaissance of Pharmacovigilance?
Härmark, Linda; Raine, June; Leufkens, Hubert; Edwards, I Ralph; Moretti, Ugo; Sarinic, Viola Macolic; Kant, Agnes
2016-10-01
The role of patients as key contributors in pharmacovigilance was acknowledged in the new EU pharmacovigilance legislation. This contains several efforts to increase the involvement of the general public, including making patient adverse drug reaction (ADR) reporting systems mandatory. Three years have passed since the legislation was introduced and the key question is: does pharmacovigilance yet make optimal use of patient-reported safety information? Independent research has shown beyond doubt that patients make an important contribution to pharmacovigilance signal detection. Patient reports provide first-hand information about the suspected ADR and the circumstances under which it occurred, including medication errors, quality failures, and 'near misses'. Patient-reported safety information leads to a better understanding of the patient's experiences of the ADR. Patients are better at explaining the nature, personal significance and consequences of ADRs than healthcare professionals' reports on similar associations and they give more detailed information regarding quality of life including psychological effects and effects on everyday tasks. Current methods used in pharmacovigilance need to optimise use of the information reported from patients. To make the most of information from patients, the systems we use for collecting, coding and recording patient-reported information and the methodologies applied for signal detection and assessment need to be further developed, such as a patient-specific form, development of a severity grading and evolution of the database structure and the signal detection methods applied. It is time for a renaissance of pharmacovigilance.
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Patient participation in patient safety still missing: Patient safety experts' views.
Sahlström, Merja; Partanen, Pirjo; Rathert, Cheryl; Turunen, Hannele
2016-10-01
The aim of this study was to elicit patient safety experts' views of patient participation in promoting patient safety. Data were collected between September and December in 2014 via an electronic semi-structured questionnaire and interviews with Finnish patient safety experts (n = 21), then analysed using inductive content analysis. Patient safety experts regarded patients as having a crucial role in promoting patient safety. They generally deemed the level of patient safety as 'acceptable' in their organizations, but reported that patient participation in their own safety varied, and did not always meet national standards. Management of patient safety incidents differed between organizations. Experts also suggested that patient safety training should be increased in both basic and continuing education programmes for healthcare professionals. Patient participation in patient safety is still lacking in clinical practice and systematic actions are needed to create a safety culture in which patients are seen as equal partners in the promotion of high-quality and safe care. © 2016 John Wiley & Sons Australia, Ltd.
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Improving patient safety in radiotherapy through error reporting and analysis
International Nuclear Information System (INIS)
Findlay, Ú.; Best, H.; Ottrey, M.
2016-01-01
Aim: To improve patient safety in radiotherapy (RT) through the analysis and publication of radiotherapy errors and near misses (RTE). Materials and methods: RTE are submitted on a voluntary basis by NHS RT departments throughout the UK to the National Reporting and Learning System (NRLS) or directly to Public Health England (PHE). RTE are analysed by PHE staff using frequency trend analysis based on the classification and pathway coding from Towards Safer Radiotherapy (TSRT). PHE in conjunction with the Patient Safety in Radiotherapy Steering Group publish learning from these events, on a triannual and summarised on a biennial basis, so their occurrence might be mitigated. Results: Since the introduction of this initiative in 2010, over 30,000 (RTE) reports have been submitted. The number of RTE reported in each biennial cycle has grown, ranging from 680 (2010) to 12,691 (2016) RTE. The vast majority of the RTE reported are lower level events, thus not affecting the outcome of patient care. Of the level 1 and 2 incidents reported, it is known the majority of them affected only one fraction of a course of treatment. This means that corrective action could be taken over the remaining treatment fractions so the incident did not have a significant impact on the patient or the outcome of their treatment. Analysis of the RTE reports demonstrates that generation of error is not confined to one professional group or to any particular point in the pathway. It also indicates that the pattern of errors is replicated across service providers in the UK. Conclusion: Use of the terminology, classification and coding of TSRT, together with implementation of the national voluntary reporting system described within this report, allows clinical departments to compare their local analysis to the national picture. Further opportunities to improve learning from this dataset must be exploited through development of the analysis and development of proactive risk management strategies
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Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database
DEFF Research Database (Denmark)
Andersen, Peter Oluf; Maaløe, Rikke; Andersen, Henning Boje
2010-01-01
Background Critical incident reports can identify areas for improvement in resuscitation practice. The Danish Patient Safety Database is a mandatory reporting system and receives critical incident reports submitted by hospital personnel. The aim of this study is to identify, analyse and categorize...... critical incidents related to cardiac arrests reported to the Danish Patient Safety Database. Methods The search terms “cardiac arrest” and “resuscitation” were used to identify reports in the Danish Patient Safety Database. Identified critical incidents were then classified into categories. Results One...
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Schneider, Eric C; Ridgely, M Susan; Quigley, Denise D; Hunter, Lauren E; Leuschner, Kristin J; Weingart, Saul N; Weissman, Joel S; Zimmer, Karen P; Giannini, Robert C
2017-06-01
This article describes the design, development, and testing of the Health Care Safety Hotline, a prototype consumer reporting system for patient safety events. The prototype was designed and developed with ongoing review by a technical expert panel and feedback obtained during a public comment period. Two health care delivery organizations in one metropolitan area collaborated with the researchers to demonstrate and evaluate the system. The prototype was deployed and elicited information from patients, family members, and caregivers through a website or an 800 phone number. The reports were considered useful and had little overlap with information received by the health care organizations through their usual risk management, customer service, and patient safety monitoring systems. However, the frequency of reporting was lower than anticipated, suggesting that further refinements, including efforts to raise awareness by actively soliciting reports from subjects, might be necessary to substantially increase the volume of useful reports. It is possible that a single technology platform could be built to meet a variety of different patient safety objectives, but it may not be possible to achieve several objectives simultaneously through a single consumer reporting system while also establishing trust with patients, caregivers, and providers.
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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.
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Implementation and evaluation of a prototype consumer reporting system for patient safety events.
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
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Patient safety event reporting in critical care: a study of three intensive care units.
Harris, Carolyn B; Krauss, Melissa J; Coopersmith, Craig M; Avidan, Michael; Nast, Patricia A; Kollef, Marin H; Dunagan, W Claiborne; Fraser, Victoria J
2007-04-01
To increase patient safety event reporting in three intensive care units (ICUs) using a new voluntary card-based event reporting system and to compare and evaluate observed differences in reporting among healthcare workers across ICUs. Prospective, single-center, interventional study. A medical ICU (19 beds), surgical ICU (24 beds), and cardiothoracic ICU (17 beds) at a 1,371-bed urban teaching hospital. Adult patients admitted to these three study ICUs. Use of a new, internally designed, card-based reporting program to solicit voluntary anonymous reporting of medical errors and patient safety concerns. During a 14-month period, 714 patient safety events were reported using a new card-based reporting system, reflecting a significant increase in reporting compared with pre-intervention Web-based reporting (20.4 reported events/1,000 patient days pre-intervention to 41.7 reported events/1,000 patient days postintervention; rate ratio, 2.05; 95% confidence interval, 1.79-2.34). Nurses submitted the majority of reports (nurses, 67.1%; physicians, 23.1%; other reporters, 9.5%); however, physicians experienced the greatest increase in reporting among their group (physicians, 43-fold; nurses, 1.7-fold; other reporters, 4.3-fold) relative to pre-intervention rates. There were significant differences in the reporting of harm by job description: 31.1% of reports from nurses, 36.2% from other staff, and 17.0% from physicians described events that did not reach/affect the patient (p = .001); and 33.9% of reports from physicians, 27.2% from nurses, and 13.0% from other staff described events that caused harm (p = .005). Overall reported patient safety events per 1,000 patient days differed by ICU (medical ICU = 55.5, cardiothoracic ICU = 25.3, surgical ICU = 40.2; p reporting system increased reporting significantly compared with pre-intervention Web-based reporting and revealed significant differences in reporting by healthcare worker and ICU. These differences may reveal
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Yoo, Moon Sook; Kim, Kyoung Ja
2017-09-01
The aim of this study was to explore the influence of nurse work environments and patient safety culture on attitudes toward incident reporting. Patient safety culture had been known as a factor of incident reporting by nurses. Positive work environment could be an important influencing factor for the safety behavior of nurses. A cross-sectional survey design was used. The structured questionnaire was administered to 191 nurses working at a tertiary university hospital in South Korea. Nurses' perception of work environment and patient safety culture were positively correlated with attitudes toward incident reporting. A regression model with clinical career, work area and nurse work environment, and patient safety culture against attitudes toward incident reporting was statistically significant. The model explained approximately 50.7% of attitudes toward incident reporting. Improving nurses' attitudes toward incident reporting can be achieved with a broad approach that includes improvements in work environment and patient safety culture.
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Using a quantitative risk register to promote learning from a patient safety reporting system.
Mansfield, James G; Caplan, Robert A; Campos, John S; Dreis, David F; Furman, Cathie
2015-02-01
Patient safety reporting systems are now used in most health care delivery organizations. These systems, such as the one in use at Virginia Mason (Seattle) since 2002, can provide valuable reports of risk and harm from the front lines of patient care. In response to the challenge of how to quantify and prioritize safety opportunities, a risk register system was developed and implemented. Basic risk register concepts were refined to provide a systematic way to understand risks reported by staff. The risk register uses a comprehensive taxonomy of patient risk and algorithmically assigns each patient safety report to 1 of 27 risk categories in three major domains (Evaluation, Treatment, and Critical Interactions). For each category, a composite score was calculated on the basis of event rate, harm, and cost. The composite scores were used to identify the "top five" risk categories, and patient safety reports in these categories were analyzed in greater depth to find recurrent patterns of risk and associated opportunities for improvement. The top five categories of risk were easy to identify and had distinctive "profiles" of rate, harm, and cost. The ability to categorize and rank risks across multiple dimensions yielded insights not previously available. These results were shared with leadership and served as input for planning quality and safety initiatives. This approach provided actionable input for the strategic planning process, while at the same time strengthening the Virginia Mason culture of safety. The quantitative patient safety risk register serves as one solution to the challenge of extracting valuable safety lessons from large numbers of incident reports and could profitably be adopted by other organizations.
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Identification of quality improvement areas in pediatric MRI from analysis of patient safety reports
International Nuclear Information System (INIS)
Jaimes, Camilo; Murcia, Diana J.; Miguel, Karen; DeFuria, Cathryn; Sagar, Pallavi; Gee, Michael S.
2018-01-01
Analysis of safety reports has been utilized to guide practice improvement efforts in adult magnetic resonance imaging (MRI). Data specific to pediatric MRI could help target areas of improvement in this population. To estimate the incidence of safety reports in pediatric MRI and to determine associated risk factors. In a retrospective HIPAA-compliant, institutional review board-approved study, a single-institution Radiology Information System was queried to identify MRI studies performed in pediatric patients (0-18 years old) from 1/1/2010 to 12/31/2015. The safety report database was queried for events matching the same demographic and dates. Data on patient age, gender, location (inpatient, outpatient, emergency room [ER]), and the use of sedation/general anesthesia were recorded. Safety reports were grouped into categories based on the cause and their severity. Descriptive statistics were used to summarize continuous variables. Chi-square analyses were performed for univariate determination of statistical significance of variables associated with safety report rates. A multivariate logistic regression was used to control for possible confounding effects. A total of 16,749 pediatric MRI studies and 88 safety reports were analyzed, yielding a rate of 0.52%. There were significant differences in the rate of safety reports between patients younger than 6 years (0.89%) and those older (0.41%) (P<0.01), sedated (0.8%) and awake children (0.45%) (P<0.01), and inpatients (1.1%) and outpatients (0.4%) (P<0.01). The use of sedation/general anesthesia is an independent risk factor for a safety report (P=0.02). The most common causes for safety reports were service coordination (34%), drug reactions (19%), and diagnostic test and ordering errors (11%). The overall rate of safety reports in pediatric MRI is 0.52%. Interventions should focus on vulnerable populations, such as younger patients, those requiring sedation, and those in need of acute medical attention. (orig.)
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Identification of quality improvement areas in pediatric MRI from analysis of patient safety reports
Energy Technology Data Exchange (ETDEWEB)
Jaimes, Camilo [Massachusetts General Hospital, Harvard Medical School, Division of Neuroradiology, Department of Radiology, Boston, MA (United States); Murcia, Diana J. [Massachusetts General Hospital, Harvard Medical School, Division of Abdominal Imaging, Department of Radiology, Boston, MA (United States); Miguel, Karen; DeFuria, Cathryn [Massachusetts General Hospital, Harvard Medical School, Quality and Safety Office, Department of Radiology, Boston, MA (United States); Sagar, Pallavi; Gee, Michael S. [Massachusetts General Hospital for Children, Harvard Medical School, Division of Pediatric Imaging, Department of Radiology, Boston, MA (United States)
2018-01-15
Analysis of safety reports has been utilized to guide practice improvement efforts in adult magnetic resonance imaging (MRI). Data specific to pediatric MRI could help target areas of improvement in this population. To estimate the incidence of safety reports in pediatric MRI and to determine associated risk factors. In a retrospective HIPAA-compliant, institutional review board-approved study, a single-institution Radiology Information System was queried to identify MRI studies performed in pediatric patients (0-18 years old) from 1/1/2010 to 12/31/2015. The safety report database was queried for events matching the same demographic and dates. Data on patient age, gender, location (inpatient, outpatient, emergency room [ER]), and the use of sedation/general anesthesia were recorded. Safety reports were grouped into categories based on the cause and their severity. Descriptive statistics were used to summarize continuous variables. Chi-square analyses were performed for univariate determination of statistical significance of variables associated with safety report rates. A multivariate logistic regression was used to control for possible confounding effects. A total of 16,749 pediatric MRI studies and 88 safety reports were analyzed, yielding a rate of 0.52%. There were significant differences in the rate of safety reports between patients younger than 6 years (0.89%) and those older (0.41%) (P<0.01), sedated (0.8%) and awake children (0.45%) (P<0.01), and inpatients (1.1%) and outpatients (0.4%) (P<0.01). The use of sedation/general anesthesia is an independent risk factor for a safety report (P=0.02). The most common causes for safety reports were service coordination (34%), drug reactions (19%), and diagnostic test and ordering errors (11%). The overall rate of safety reports in pediatric MRI is 0.52%. Interventions should focus on vulnerable populations, such as younger patients, those requiring sedation, and those in need of acute medical attention. (orig.)
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Howell, Ann-Marie; Burns, Elaine M; Bouras, George; Donaldson, Liam J; Athanasiou, Thanos; Darzi, Ara
2015-01-01
The National Reporting and Learning System (NRLS) collects reports about patient safety incidents in England. Government regulators use NRLS data to assess the safety of hospitals. This study aims to examine whether annual hospital incident reporting rates can be used as a surrogate indicator of individual hospital safety. Secondly assesses which hospital characteristics are correlated with high incident reporting rates and whether a high reporting hospital is safer than those lower reporting hospitals. Finally, it assesses which health-care professionals report more incidents of patient harm, which report more near miss incidents and what hospital factors encourage reporting. These findings may suggest methods for increasing the utility of reporting systems. This study used a mix methods approach for assessing NRLS data. The data were investigated using Pareto analysis and regression models to establish which patients are most vulnerable to reported harm. Hospital factors were correlated with institutional reporting rates over one year to examine what factors influenced reporting. Staff survey findings regarding hospital safety culture were correlated with reported rates of incidents causing harm; no harm and death to understand what barriers influence error disclosure. 5,879,954 incident reports were collected from acute hospitals over the decade. 70.3% of incidents produced no harm to the patient and 0.9% were judged by the reporter to have caused severe harm or death. Obstetrics and Gynaecology reported the most no harm events [OR 1.61(95%CI: 1.12 to 2.27), p<0.01] and pharmacy was the hospital location where most near-misses were captured [OR 3.03(95%CI: 2.04 to 4.55), p<0.01]. Clinicians were significantly more likely to report death than other staff [OR 3.04(95%CI: 2.43 to 3.80) p<0.01]. A higher ratio of clinicians to beds correlated with reduced rate of harm reported [RR = -1.78(95%Cl: -3.33 to -0.23), p = 0.03]. Litigation claims per bed were
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Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database.
Cooper, Jennifer; Edwards, Adrian; Williams, Huw; Sheikh, Aziz; Parry, Gareth; Hibbert, Peter; Butlin, Amy; Donaldson, Liam; Carson-Stevens, Andrew
2017-09-01
A culture of blame and fear of retribution are recognized barriers to reporting patient safety incidents. The extent of blame attribution in safety incident reports, which may reflect the underlying safety culture of health care systems, is unknown. This study set out to explore the nature of blame in family practice safety incident reports. We characterized a random sample of family practice patient safety incident reports from the England and Wales National Reporting and Learning System. Reports were analyzed according to prespecified classification systems to describe the incident type, contributory factors, outcomes, and severity of harm. We developed a taxonomy of blame attribution, and we then used descriptive statistical analyses to identify the proportions of blame types and to explore associations between incident characteristics and one type of blame. Health care professionals making family practice incident reports attributed blame to a person in 45% of cases (n = 975 of 2,148; 95% CI, 43%-47%). In 36% of cases, those who reported the incidents attributed fault to another person, whereas 2% of those reporting acknowledged personal responsibility. Blame was commonly associated with incidents where a complaint was anticipated. The high frequency of blame in these safety, incident reports may reflect a health care culture that leads to blame and retribution, rather than to identifying areas for learning and improvement, and a failure to appreciate the contribution of system factors in others' behavior. Successful improvement in patient safety through the analysis of incident reports is unlikely without achieving a blame-free culture. © 2017 Annals of Family Medicine, Inc.
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Gholson, J Joseph; Lin, Albert; McGlaston, Timothy; DeAngelis, Joseph; Ramappa, Arun
2015-01-01
This survey investigated patients' return to driving after rotator cuff surgery, to determine whether pain, weakness, sling use, and narcotics correlate with self-assessed safety and maneuvering. Fifty-four patients (80.6% of those eligible) were surveyed 4 months after surgery. Return to driving ranged widely from same day to 4 months, with two not driving at 4 months; 12% reported narcotics use and 33% reported sling use. Drivers reporting weakness were more likely to feel unsafe (p = .02) and more likely to report difficulty maneuvering (p driving does not correspond to perceived safety; pain and weakness correspond with feeling unsafe and difficulty maneuvering. Although subjective, clinicians may find these self-assessments predictive when counseling patients on return to driving.
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Developing patient safety in dentistry.
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.
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Integrated care: an Information Model for Patient Safety and Vigilance Reporting Systems.
Rodrigues, Jean-Marie; Schulz, Stefan; Souvignet, Julien
2015-01-01
Quality management information systems for safety as a whole or for specific vigilances share the same information types but are not interoperable. An international initiative tries to develop an integrated information model for patient safety and vigilance reporting to support a global approach of heath care quality.
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OʼConnell, Karen J; Shaw, Kathy N; Ruddy, Richard M; Mahajan, Prashant V; Lichenstein, Richard; Olsen, Cody S; Funai, Tomohiko; Blumberg, Stephen; Chamberlain, James M
2018-04-01
Medical errors threaten patient safety, especially in the pediatric emergency department (ED) where overcrowding, multiple handoffs, and workflow interruptions are common. Errors related to process variance involve situations that are not consistent with standard ED operations or routine patient care. We performed a planned subanalysis of the Pediatric Emergency Care Applied Research Network incident reporting data classified as process variance events. Confidential deidentified incident reports (IRs) were collected and classified by 2 independent investigators. Events categorized as process variance were then subtyped for severity and contributing factors. Data were analyzed using descriptive statistics. The study intention was to describe and measure reported medical errors related to process variance in 17 EDs in the Pediatric Emergency Care Applied Research Network from 2007 to 2008. Between July 2007 and June 2008, 2906 eligible reports were reviewed. Process variance events were identified in 15.4% (447/2906). The majority were related to patient flow (35.4%), handoff communication (17.2%), and patient identification errors (15.9%). Most staff involved included nurses (47.9%) and physicians (28%); trainees were infrequently reported. The majority of events did not result in harm (65.7%); 17.9% (80/447) of cases were classified as unsafe conditions but did not reach the patient. Temporary harm requiring further treatment or hospitalization was reported in 5.6% (25/447). No events resulted in permanent harm, near death, or death. Contributing factors included human factors (92.1%), in particular handoff communication, interpersonal skills, and compliance with established procedures, and system-level errors (18.1%), including unclear or unavailable policies and inadequate staffing levels. Although process variance events accounted for approximately 1 in 6 reported safety events, very few led to patient harm. Because human and system-level factors contributed to
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Lawton, Rebecca; O'Hara, Jane Kathryn; Sheard, Laura; Armitage, Gerry; Cocks, Kim; Buckley, Hannah; Corbacho, Belen; Reynolds, Caroline; Marsh, Claire; Moore, Sally; Watt, Ian; Wright, John
2017-08-01
To evaluate the efficacy of the Patient Reporting and Action for a Safe Environment intervention. A multicentre cluster randomised controlled trial. Clusters were 33 hospital wards within five hospitals in the UK. All patients able to give informed consent were eligible to take part. Wards were allocated to the intervention or control condition. The ward-level intervention comprised two tools: (1) a questionnaire that asked patients about factors contributing to safety (patient measure of safety (PMOS)) and (2) a proforma for patients to report both safety concerns and positive experiences (patient incident reporting tool). Feedback was considered in multidisciplinary action planning meetings. Primary outcomes were routinely collected ward-level harm-free care (HFC) scores and patient-level feedback on safety (PMOS). Intervention uptake and retention of wards was 100% and patient participation was high (86%). We found no significant effect of the intervention on any outcomes at 6 or 12 months. However, for new harms (ie, those for which the wards were directly accountable) intervention wards did show greater, though non-significant, improvement compared with control wards. Analyses also indicated that improvements were largest for wards that showed the greatest compliance with the intervention. Adherence to the intervention, particularly the implementation of action plans, was poor. Patient safety outcomes may represent too blunt a measure. Patients are willing to provide feedback about the safety of their care. However, we were unable to demonstrate any overall effect of this intervention on either measure of patient safety and therefore cannot recommend this intervention for wider uptake. Findings indicate promise for increasing HFC where wards implement ≥75% of the intervention components. ISRCTN07689702; pre-results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.
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Kim, Myoungsoo
2010-04-01
The purpose of this study was to examine the impact of strategies to promote reporting of errors on nurses' attitude to reporting errors, organizational culture related to patient safety, intention to report and reporting rate in hospital nurses. A nonequivalent control group non-synchronized design was used for this study. The program was developed and then administered to the experimental group for 12 weeks. Data were analyzed using descriptive analysis, X(2)-test, t-test, and ANCOVA with the SPSS 12.0 program. After the intervention, the experimental group showed significantly higher scores for nurses' attitude to reporting errors (experimental: 20.73 vs control: 20.52, F=5.483, p=.021) and reporting rate (experimental: 3.40 vs control: 1.33, F=1998.083, porganizational culture and intention to report. The study findings indicate that strategies that promote reporting of errors play an important role in producing positive attitudes to reporting errors and improving behavior of reporting. Further advanced strategies for reporting errors that can lead to improved patient safety should be developed and applied in a broad range of hospitals.
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Pohlman, Katherine A; Carroll, Linda; Hartling, Lisa; Tsuyuki, Ross T; Vohra, Sunita
2016-04-01
A reporting and learning system is a method of monitoring the occurrence of incidents that affect patient safety. This cross-sectional survey asked pediatric chiropractors about factors that may limit their participation in such a system. The list of potential barriers for participation was developed using a systematic approach. All members of the 2 pediatric councils associated with US national chiropractic organizations were invited to complete the survey (N = 400). The cross-sectional survey was created using an online survey tool (REDCap) and sent directly to member emails addressed by the respective executive committees. Of the 400 potential respondents, 81 responded (20.3%). The most common limitations to participating were identified as time pressure (96%) and patient concerns (81%). Reporting and learning systems have been utilized to increase safety awareness in many high-risk industries. To be successful, future patient safety studies with pediatric chiropractors need to ensure these barriers are understood and addressed. © The Author(s) 2015.
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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...
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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...
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Elfering, A; Semmer, N K; Grebner, S
This study investigates the link between workplace stress and the 'non-singularity' of patient safety-related incidents in the hospital setting. Over a period of 2 working weeks 23 young nurses from 19 hospitals in Switzerland documented 314 daily stressful events using a self-observation method (pocket diaries); 62 events were related to patient safety. Familiarity of safety-related events and probability of recurrence, as indicators of non-singularity, were the dependent variables in multilevel regression analyses. Predictor variables were both situational (self-reported situational control, safety compliance) and chronic variables (job stressors such as time pressure, or concentration demands and job control). Chronic work characteristics were rated by trained observers. The most frequent safety-related stressful events included incomplete or incorrect documentation (40.3%), medication errors (near misses 21%), delays in delivery of patient care (9.7%), and violent patients (9.7%). Familiarity of events and probability of recurrence were significantly predicted by chronic job stressors and low job control in multilevel regression analyses. Job stressors and low job control were shown to be risk factors for patient safety. The results suggest that job redesign to enhance job control and decrease job stressors may be an important intervention to increase patient safety.
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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
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Patients' evaluations of patient safety in English general practices: a cross-sectional study.
Ricci-Cabello, Ignacio; Marsden, Kate S; Avery, Anthony J; Bell, Brian G; Kadam, Umesh T; Reeves, David; Slight, Sarah P; Perryman, Katherine; Barnett, Jane; Litchfield, Ian; Thomas, Sally; Campbell, Stephen M; Doos, Lucy; Esmail, Aneez; Valderas, Jose M
2017-07-01
Description of safety problems and harm in general practices has previously relied on information from health professionals, with scarce attention paid to experiences of patients. To examine patient-reported experiences and outcomes of patient safety in primary care. Cross-sectional study in 45 general practices across five regions in the north, centre, and south of England. A version of the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire was sent to a random sample of 6736 patients. Main outcome measures included 'practice activation' (what a practice does to create a safe environment); 'patient activation' (how proactive are patients in ensuring safe healthcare delivery); 'experiences of safety events' (safety errors); 'outcomes of safety' (harm); and 'overall perception of safety' (how safe patients rate their practice). Questionnaires were returned by 1244 patients (18.4%). Scores were high for 'practice activation' (mean [standard error] = 80.4 out of 100 [2.0]) and low for 'patient activation' (26.3 out of 100 [2.6]). Of the patients, 45% reported experiencing at least one safety problem in the previous 12 months, mostly related to appointments (33%), diagnosis (17%), patient provider communication (15%), and coordination between providers (14%). Twenty-three per cent of the responders reported some degree of harm in the previous 12 months. The overall assessment of level of safety of practices was generally high (86.0 out of 100 [16.8]). Priority areas for patient safety improvement in general practices in England include appointments, diagnosis, communication, coordination, and patient activation. © British Journal of General Practice 2017.
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Tvedt, Christine; Sjetne, Ingeborg Strømseng; Helgeland, Jon; Bukholm, Geir
2012-01-01
Objectives The purpose of this study was to identify organisational processes and structures that are associated with nurse-reported patient safety and quality of nursing. Design This is an observational cross-sectional study using survey methods. Setting Respondents from 31 Norwegian hospitals with more than 85 beds were included in the survey. Participants All registered nurses working in direct patient care in a position of 20% or more were invited to answer the survey. In this study, 3618 nurses from surgical and medical wards responded (response rate 58.9). Nurses' practice environment was defined as organisational processes and measured by the Nursing Work Index Revised and items from Hospital Survey on Patient Safety Culture. Outcome measures Nurses' assessments of patient safety, quality of nursing, confidence in how their patients manage after discharge and frequency of adverse events were used as outcome measures. Results Quality system, nurse–physician relation, patient safety management and staff adequacy were process measures associated with nurse-reported work-related and patient-related outcomes, but we found no associations with nurse participation, education and career and ward leadership. Most organisational structures were non-significant in the multilevel model except for nurses’ affiliations to medical department and hospital type. Conclusions Organisational structures may have minor impact on how nurses perceive work-related and patient-related outcomes, but the findings in this study indicate that there is a considerable potential to address organisational design in improvement of patient safety and quality of care. PMID:23263021
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Ko, YuKyung; Yu, Soyoung
2017-09-01
This study was undertaken to explore the correlations among nurses' perceptions of patient safety culture, their intention to report errors, and leader coaching behaviors. The participants (N = 289) were nurses from 5 Korean hospitals with approximately 300 to 500 beds each. Sociodemographic variables, patient safety culture, intention to report errors, and coaching behavior were measured using self-report instruments. Data were analyzed using descriptive statistics, Pearson correlation coefficient, the t test, and the Mann-Whitney U test. Nurses' perceptions of patient safety culture and their intention to report errors showed significant differences between groups of nurses who rated their leaders as high-performing or low-performing coaches. Perceived coaching behavior showed a significant, positive correlation with patient safety culture and intention to report errors, i.e., as nurses' perceptions of coaching behaviors increased, so did their ratings of patient safety culture and error reporting. There is a need in health care settings for coaching by nurse managers to provide quality nursing care and thus improve patient safety. Programs that are systematically developed and implemented to enhance the coaching behaviors of nurse managers are crucial to the improvement of patient safety and nursing care. Moreover, a systematic analysis of the causes of malpractice, as opposed to a focus on the punitive consequences of errors, could increase error reporting and therefore promote a culture in which a higher level of patient safety can thrive.
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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
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Patient safety: Safety culture and patient safety ethics
DEFF Research Database (Denmark)
Madsen, Marlene Dyrløv
2006-01-01
,demonstrating significant, consistent and sometimes large differences in terms of safety culture factors across the units participating in the survey. Paper 5 is the results of a study of the relation between safety culture, occupational health andpatient safety using a safety culture questionnaire survey......Patient safety - the prevention of medical error and adverse events - and the initiative of developing safety cultures to assure patients from harm have become one of the central concerns in quality improvement in healthcare both nationally andinternationally. This subject raises numerous...... challenging issues of systemic, organisational, cultural and ethical relevance, which this dissertation seeks to address through the application of different disciplinary approaches. The main focus of researchis safety culture; through empirical and theoretical studies to comprehend the phenomenon, address...
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Verbakel, Natasha J.; Langelaan, Maaike; Verheij, Theo J M; Wagner, Cordula; Zwart, Dorien L M
2015-01-01
Background: A constructive safety culture is essential for the successful implementation of patient safety improvements. Aim: To assess the effect of two patient safety culture interventions on incident reporting as a proxy of safety culture. Design and setting: A three-arm cluster randomised trial
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Patient safety culture among nurses.
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
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Pietrobon, Ricardo; Lima, Raquel; Shah, Anand; Jacobs, Danny O; Harker, Matthew; McCready, Mariana; Martins, Henrique; Richardson, William
2007-05-01
Studies have shown that 4% of hospitalized patients suffer from an adverse event caused by the medical treatment administered. Some institutions have created systems to encourage medical workers to report these adverse events. However, these systems often prove to be inadequate and/or ineffective for reviewing the data collected and improving the outcomes in patient safety. To describe the Web-application Duke Surgery Patient Safety, designed for the anonymous reporting of adverse and near-miss events as well as scheduled reporting to surgeons and hospital administration. SOFTWARE ARCHITECTURE: DSPS was developed primarily using Java language running on a Tomcat server and with MySQL database as its backend. Formal and field usability tests were used to aid in development of DSPS. Extensive experience with DSPS at our institution indicate that DSPS is easy to learn and use, has good speed, provides needed functionality, and is well received by both adverse-event reporters and administrators. This is the first description of an open-source application for reporting patient safety, which allows the distribution of the application to other institutions in addition for its ability to adapt to the needs of different departments. DSPS provides a mechanism for anonymous reporting of adverse events and helps to administer Patient Safety initiatives. The modifiable framework of DSPS allows adherence to evolving national data standards. The open-source design of DSPS permits surgical departments with existing reporting mechanisms to integrate them with DSPS. The DSPS application is distributed under the GNU General Public License.
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Laboratory test requesting appropriateness and patient safety
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.
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75 FR 16140 - Common Formats for Patient Safety Data Collection and Event Reporting
2010-03-31
... FR 45457-45458. Definition of Common Formats The term ``Common Formats'' is used to describe clinical... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Common Formats for Patient Safety Data Collection and Event Reporting AGENCY: Agency for Healthcare Research and...
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Acute care patients discuss the patient role in patient safety.
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.
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Ricci-Cabello, Ignacio; Saletti-Cuesta, Lorena; Slight, Sarah P; Valderas, Jose M
2017-10-01
There is a growing interest in identifying strategies to achieve safer primary health-care provision. However, most of the research conducted so far in this area relies on information supplied by health-care providers, and limited attention has been paid to patients' perspectives. To explore patients' experiences and perceptions of patient safety in English general practices with the aim of eliciting patient-centred recommendations for improving patient safety. The Patient Reported Experiences and Outcomes of Safety in Primary Care questionnaire was sent to a random sample of 6736 primary care users registered in 45 English practices. We conducted a qualitative content analysis of responses to seven open-ended items addressing patients' experiences of safety problems, lessons learnt as a result of such experiences and recommendations for safer health care. A total of 1244 (18.4%) participants returned completed questionnaires. Of those, 678 (54.5%) responded to at least one open-ended question. Two main themes emerged as follows: (i) experiences of safety problems and (ii) good practices and recommendations to improve patient safety in primary care. Most frequent experiences of safety problems were related to appointments, coordination between providers, tests, medication and diagnosis. Patients' responses to these problems included increased patient activation (eg speaking up about concerns with their health care) and avoidance of unnecessary health care. Recommendations for safer health care included improvements in patient-centred communication, continuity of care, timely appointments, technical quality of care, active monitoring, teamwork, health records and practice environment. This study identified a number of patient-centred recommendations for improving patient safety in English general practices. © 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd.
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Patient safety problem identification and solution sharing among rural community pharmacists.
Galt, Kimberly A; Fuji, Kevin T; Faber, Jennifer
2013-01-01
To implement a communication network for safety problem identification and solution sharing among rural community pharmacists and to report participating pharmacists' perceived value and impact of the network on patient safety after 1 year of implementation. Action research study. Rural community pharmacies in Nebraska from January 2010 to April 2011. Rural community pharmacists who voluntarily agreed to join the Pharmacists for Patient Safety Network in Nebraska. Pharmacists reported errors, near misses, and safety concerns through Web-based event reporting. A rapid feedback process was used to provide patient safety solutions to consider implementing across the network. Qualitative interviews were conducted 1 year after program implementation with participating pharmacists to assess use of the reporting system, value of the disseminated safety solutions, and perceived impact on patient safety in pharmacies. 30 of 38 pharmacists participating in the project completed the interviews. The communication network improved pharmacist awareness, promoted open discussion and knowledge sharing, contributed to practice vigilance, and led to incorporation of proactive safety prevention practices. Despite low participation in error and near-miss reporting, a dynamic communication network designed to rapidly disseminate evidence-based patient safety strategies to reduce risk was valued and effective at improving patient safety practices in rural community pharmacies.
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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.
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Managing patient safety through NPSGs and employee performance.
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.
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Survey of factors associated with nurses' perception of patient safety.
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.
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Patient Safety Learning Systems: A Systematic Review and Qualitative Synthesis.
2017-01-01
A patient safety learning system (sometimes called a critical incident reporting system) refers to structured reporting, collation, and analysis of critical incidents. To inform a provincial working group's recommendations for an Ontario Patient Safety Event Learning System, a systematic review was undertaken to determine design features that would optimize its adoption into the health care system and would inform implementation strategies. The objective of this review was to address two research questions: (a) what are the barriers to and facilitators of successful adoption of a patient safety learning system reported by health professionals and (b) what design components maximize successful adoption and implementation? To answer the first question, we used a published systematic review. To answer the second question, we used scoping study methodology. Common barriers reported in the literature by health care professionals included fear of blame, legal penalties, the perception that incident reporting does not improve patient safety, lack of organizational support, inadequate feedback, lack of knowledge about incident reporting systems, and lack of understanding about what constitutes an error. Common facilitators included a non-accusatory environment, the perception that incident reporting improves safety, clarification of the route of reporting and of how the system uses reports, enhanced feedback, role models (such as managers) using and promoting reporting, legislated protection of those who report, ability to report anonymously, education and training opportunities, and clear guidelines on what to report. Components of a patient safety learning system that increased successful adoption and implementation were emphasis on a blame-free culture that encourages reporting and learning, clear guidelines on how and what to report, making sure the system is user-friendly, organizational development support for data analysis to generate meaningful learning outcomes
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[Cardiac safety of electroconvulsive therapy in an elderly patient--a case report].
Karakuła-Juchnowicz, Hanna; Próchnicki, Michał; Kiciński, Paweł; Olajossy, Marcin; Pelczarska-Jamroga, Agnieszka; Dzikowski, Michał; Jaroszyński, Andrzej
2015-10-01
Since electroconvulsive therapy (ECT) was introduced as treatment for psychiatric disorders in 1938, it has remained one of the most effective therapeutic methods. ECT is often used as a "treatment of last resort" when other methods fail, and a life-saving procedure in acute clinical states when a rapid therapeutic effect is needed. Mortality associated with ECT is lower, compared to the treatment with tricyclic antidepressants, and comparable to that observed in so-called minor surgery. In the literature, cases of effective and safe electroconvulsive therapy have been described in patients of advanced age, with a burden of many somatic disorders. However, cases of acute cardiac episodes have also been reported during ECT. The qualification of patients for ECT and the selection of a group of patients at the highest risk of cardiovascular complications remains a serious clinical problem. An assessment of the predictive value of parameters of standard electrocardiogram (ECG), which is a simple, cheap and easily available procedure, deserves special attention. This paper reports a case of a 74-year-old male patient treated with ECT for a severe depressive episode, in the context of cardiologic safety. Both every single ECT session and the full course were assessed to examine their impact on levels of troponin T, which is a basic marker of cardiac damage, and selected ECG parameters (QTc, QRS). In the presented case ECT demonstrated its high general and cardiac safety with no negative effect on cardiac troponin (TnT) levels, corrected QT interval (QTc) duration, or other measured ECG parameters despite initially increased troponin levels, the patient's advanced age, the burden of a severe somatic disease and its treatment (anticancer therapy). © 2015 MEDPRESS.
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Vallejo-Gutiérrez, Paula; Bañeres-Amella, Joaquim; Sierra, Eduardo; Casal, Jesús; Agra, Yolanda
2014-01-01
To describe the development process and characteristics of a patient safety incidents reporting system to be implemented in the Spanish National Health System, based on the context and the needs of the different stakeholders. Literature review and analysis of most relevant reporting systems, identification of more than 100 stakeholder's (patients, professionals, regional governments representatives) expectations and requirements, analysis of the legal context, consensus of taxonomy, development of the software and pilot test. Patient Safety Events Reporting and Learning system (Sistema de Notificación y Aprendizajepara la Seguridad del Paciente, SiNASP) is a generic reporting system for all types of incidents related to patient safety, voluntary, confidential, non punitive, anonymous or nominative with anonimization, system oriented, with local analysis of cases and based on the WHO International Classification for Patient Safety. The electronic program has an on-line form for reporting, a software to manage the incidents and improvement plans, and a scoreboard with process indicators to monitor the system. The reporting system has been designed to respond to the needs and expectations identified by the stakeholders, taking into account the lessons learned from the previous notification systems, the characteristics of the National Health System and the existing legal context. The development process presented and the characteristics of the system provide a comprehensive framework that can be used for future deployments of similar patient safety systems. Copyright © 2013 SECA. Published by Elsevier Espana. All rights reserved.
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Mohr, David C; Eaton, Jennifer Lipkowitz; McPhaul, Kathleen M; Hodgson, Michael J
2015-04-22
We examined relationships between employee safety climate and patient safety culture. Because employee safety may be a precondition for the development of patient safety, we hypothesized that employee safety culture would be strongly and positively related to patient safety culture. An employee safety climate survey was administered in 2010 and assessed employees' views and experiences of safety for employees. The patient safety survey administered in 2011 assessed the safety culture for patients. We performed Pearson correlations and multiple regression analysis to examine the relationships between a composite measure of employee safety with subdimensions of patient safety culture. The regression models controlled for size, geographic characteristics, and teaching affiliation. Analyses were conducted at the group level using data from 132 medical centers. Higher employee safety climate composite scores were positively associated with all 9 patient safety culture measures examined. Standardized multivariate regression coefficients ranged from 0.44 to 0.64. Medical facilities where staff have more positive perceptions of health care workplace safety climate tended to have more positive assessments of patient safety culture. This suggests that patient safety culture and employee safety climate could be mutually reinforcing, such that investments and improvements in one domain positively impacts the other. Further research is needed to better understand the nexus between health care employee and patient safety to generalize and act upon findings.
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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.
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Patient safety culture assessment in oman.
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.
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Patient Safety Culture Assessment in Oman
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
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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...
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Castleden, C M; Pickles, H
1988-01-01
1. Spontaneous reports of suspected adverse drug reactions (ADRs) reported to the Committee on Safety of Medicines (CSM) have been studied in relation to patient age. 2. The proportion of reports received for the elderly increased between 1965 and 1983. 3. There was a correlation between the use of drugs and the number of ADR reports. Thus age-related prescription figures for two non-steroidal anti-inflammatory drugs (NSAI) and co-trimoxazole matched ADR reports for each drug in each age grou...
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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...
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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...
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76 FR 67456 - Common Formats for Patient Safety Data Collection and Event Reporting
2011-11-01
... information regarding the quality and safety of health care delivery. The Patient Safety Act (at 42 U.S.C... Formats in order to facilitate standardized data collection and improve the safety and quality of health... conjunction with an interagency Federal Patient Safety Work Group (PSWG), revises and refines the Common...
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Feedback from incident reporting: information and action to improve patient safety.
Benn, J; Koutantji, M; Wallace, L; Spurgeon, P; Rejman, M; Healey, A; Vincent, C
2009-02-01
Effective feedback from incident reporting systems in healthcare is essential if organisations are to learn from failures in the delivery of care. Despite the wide-scale development and implementation of incident reporting in healthcare, studies in the UK suggest that information concerning system vulnerabilities could be better applied to improve operational safety within organisations. In this article, the findings and implications of research to identify forms of effective feedback from incident reporting are discussed, to promote best practices in this area. The research comprised a mixed methods review to investigate mechanisms of effective feedback for healthcare, drawing upon experience within established reporting programmes in high-risk industry and transport domains. Systematic searches of published literature were undertaken, and 23 case studies describing incident reporting programmes with feedback were identified for analysis from the international healthcare literature. Semistructured interviews were undertaken with 19 subject matter experts across a range of domains, including: civil aviation, maritime, energy, rail, offshore production and healthcare. In analysis, qualitative information from several sources was synthesised into practical requirements for developing effective feedback in healthcare. Both action and information feedback mechanisms were identified, serving safety awareness, improvement and motivational functions. The provision of actionable feedback that visibly improved systems was highlighted as important in promoting future reporting. Fifteen requirements for the design of effective feedback systems were identified, concerning: the role of leadership, the credibility and content of information, effective dissemination channels, the capacity for rapid action and the need for feedback at all levels of the organisation, among others. Above all, the safety-feedback cycle must be closed by ensuring that reporting, analysis and
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Mitchell, Imogen; Schuster, Anne; Smith, Katherine; Pronovost, Peter; Wu, Albert
2016-02-01
One of the key recommendations of the Institute of Medicine's (IOM) report, To Err is Human, 15 years ago was for greater attention to incident reporting in healthcare, analogous to the role it has played in aviation and other high-risk industries. With the passage of time and maturation of the patient safety field, we conducted semistructured interviews with 11 international patient safety experts with knowledge of the US healthcare and meeting at least one of the following criteria: (1) involved in the development of the IOM's recommendations, (2) responsible for the design and/or implementation of national or regional incident reporting systems, (3) conducted research on patient safety/incident reporting at a national level. Five key challenges emerged to explain why incident reporting has not reached its potential: poor processing of incident reports (triaging, analysis, recommendations), inadequate engagement of doctors, insufficient subsequent visible action, inadequate funding and institutional support of incident reporting systems and inadequate usage of evolving health information technology. Leading patient safety experts acknowledge the current challenges of incident reports. The future of incident reporting lies in targeted incident reporting, effective triaging and robust analysis of the incident reports and meaningful engagement of doctors. Incident reporting must be coupled with visible, sustainable action and linkage of incident reports to the electronic health record. If the healthcare industry wants to learn from its mistakes, miss or near miss events, it will need to take incident reporting as seriously as the health budget. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
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Howell, Ann-Marie; Burns, Elaine M; Hull, Louise; Mayer, Erik; Sevdalis, Nick; Darzi, Ara
2017-02-01
Patient safety incident reporting systems (PSRS) have been established for over a decade, but uncertainty remains regarding the role that they can and ought to play in quantifying healthcare-related harm and improving care. To establish international, expert consensus on the purpose of PSRS regarding monitoring and learning from incidents and developing recommendations for their future role. After a scoping review of the literature, semi-structured interviews with experts in PSRS were conducted. Based on these findings, a survey-based questionnaire was developed and subsequently completed by a larger expert panel. Using a Delphi approach, consensus was reached regarding the ideal role of PSRSs. Recommendations for best practice were devised. Forty recommendations emerged from the Delphi procedure on the role and use of PSRS. Experts agreed reporting system should not be used as an epidemiological tool to monitor the rate of harm over time or to appraise the relative safety of hospitals. They agreed reporting is a valuable mechanism for identifying organisational safety needs. The benefit of a national system was clear with respect to medication error, device failures, hospital-acquired infections and never events as these problems often require solutions at a national level. Experts recommended training for senior healthcare professionals in incident investigation. Consensus recommendation was for hospitals to take responsibility for creating safety solutions locally that could be shared nationally. We obtained reasonable consensus among experts on aims and specifications of PSRS. This information can be used to reflect on existing and future PSRS, and their role within the wider patient safety landscape. The role of PSRS as instruments for learning needs to be elaborated and developed further internationally. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.
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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.
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Sivanandy, Palanisamy; Maharajan, Mari Kannan; Rajiah, Kingston; Wei, Tan Tyng; Loon, Tan Wee; Yee, Lim Chong
2016-01-01
Background Patient safety is a major public health issue, and the knowledge, skills, and experience of health professionals are very much essential for improving patient safety. Patient safety and medication error are very much associated. Pharmacists play a significant role in patient safety. The function of pharmacists in the medication use process is very different from medical and nursing colleagues. Medication dispensing accuracy is a vital element to ensure the safety and quality of medication use. Objective To evaluate the attitude and perception of the pharmacist toward patient safety in retail pharmacies setup in Malaysia. Methods A Pharmacy Survey on Patient Safety Culture questionnaire was used to assess patient safety culture, developed by the Agency for Healthcare Research and Quality, and the convenience sampling method was adopted. Results The overall positive response rate ranged from 31.20% to 87.43%, and the average positive response rate was found to be 67%. Among all the eleven domains pertaining to patient safety culture, the scores of “staff training and skills” were less. Communication openness, and patient counseling are common, but not practiced regularly in the Malaysian retail pharmacy setup compared with those in USA. The overall perception of patient safety of an acceptable level in the current retail pharmacy setup. Conclusion The study revealed that staff training, skills, communication in patient counseling, and communication across shifts and about mistakes are less in current retail pharmacy setup. The overall perception of patient safety should be improved by educating the pharmacists about the significance and essential of patient safety. PMID:27524887
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Sivanandy, Palanisamy; Maharajan, Mari Kannan; Rajiah, Kingston; Wei, Tan Tyng; Loon, Tan Wee; Yee, Lim Chong
2016-01-01
Patient safety is a major public health issue, and the knowledge, skills, and experience of health professionals are very much essential for improving patient safety. Patient safety and medication error are very much associated. Pharmacists play a significant role in patient safety. The function of pharmacists in the medication use process is very different from medical and nursing colleagues. Medication dispensing accuracy is a vital element to ensure the safety and quality of medication use. To evaluate the attitude and perception of the pharmacist toward patient safety in retail pharmacies setup in Malaysia. A Pharmacy Survey on Patient Safety Culture questionnaire was used to assess patient safety culture, developed by the Agency for Healthcare Research and Quality, and the convenience sampling method was adopted. The overall positive response rate ranged from 31.20% to 87.43%, and the average positive response rate was found to be 67%. Among all the eleven domains pertaining to patient safety culture, the scores of "staff training and skills" were less. Communication openness, and patient counseling are common, but not practiced regularly in the Malaysian retail pharmacy setup compared with those in USA. The overall perception of patient safety of an acceptable level in the current retail pharmacy setup. The study revealed that staff training, skills, communication in patient counseling, and communication across shifts and about mistakes are less in current retail pharmacy setup. The overall perception of patient safety should be improved by educating the pharmacists about the significance and essential of patient safety.
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Patient safety in otolaryngology: a descriptive review.
Danino, Julian; Muzaffar, Jameel; Metcalfe, Chris; Coulson, Chris
2017-03-01
Human evaluation and judgement may include errors that can have disastrous results. Within medicine and healthcare there has been slow progress towards major changes in safety. Healthcare lags behind other specialised industries, such as aviation and nuclear power, where there have been significant improvements in overall safety, especially in reducing risk of errors. Following several high profile cases in the USA during the 1990s, a report titled "To Err Is Human: Building a Safer Health System" was published. The report extrapolated that in the USA approximately 50,000 to 100,000 patients may die each year as a result of medical errors. Traditionally otolaryngology has always been regarded as a "safe specialty". A study in the USA in 2004 inferred that there may be 2600 cases of major morbidity and 165 deaths within the specialty. MEDLINE via PubMed interface was searched for English language articles published between 2000 and 2012. Each combined two or three of the keywords noted earlier. Limitations are related to several generic topics within patient safety in otolaryngology. Other areas covered have been current relevant topics due to recent interest or new advances in technology. There has been a heightened awareness within the healthcare community of patient safety; it has become a major priority. Focus has shifted from apportioning blame to prevention of the errors and implementation of patient safety mechanisms in healthcare delivery. Type of Errors can be divided into errors due to action and errors due to knowledge or planning. In healthcare there are several factors that may influence adverse events and patient safety. Although technology may improve patient safety, it also introduces new sources of error. The ability to work with people allows for the increase in safety netting. Team working has been shown to have a beneficial effect on patient safety. Any field of work involving human decision-making will always have a risk of error. Within
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77 FR 42736 - Common Formats for Patient Safety Data Collection and Event Reporting
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...
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Lukewich, Julia; Edge, Dana S; Tranmer, Joan; Raymond, June; Miron, Jennifer; Ginsburg, Liane; VanDenKerkhof, Elizabeth
2015-05-01
Given the increasing incidence of adverse events and medication errors in healthcare settings, a greater emphasis is being placed on the integration of patient safety competencies into health professional education. Nurses play an important role in preventing and minimizing harm in the healthcare setting. Although patient safety concepts are generally incorporated within many undergraduate nursing programs, the level of students' confidence in learning about patient safety remains unclear. Self-reported patient safety competence has been operationalized as confidence in learning about various dimensions of patient safety. The present study explores nursing students' self-reported confidence in learning about patient safety during their undergraduate baccalaureate nursing program. Cross-sectional study with a nested cohort component conducted annually from 2010 to 2013. Participants were recruited from one Canadian university with a four-year baccalaureate of nursing science program. All students enrolled in the program were eligible to participate. The Health Professional Education in Patient Safety Survey was administered annually. The Health Professional Education in Patient Safety Survey captures how the six dimensions of the Canadian Patient Safety Institute Safety Competencies Framework and broader patient safety issues are addressed in health professional education, as well as respondents' self-reported comfort in speaking up about patient safety issues. In general, nursing students were relatively confident in what they were learning about the clinical dimensions of patient safety, but they were less confident about the sociocultural aspects of patient safety. Confidence in what they were learning in the clinical setting about working in teams, managing adverse events and responding to adverse events declined in upper years. The majority of students did not feel comfortable speaking up about patient safety issues. The nested cohort analysis confirmed these
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Healthcare professionals’ views of feedback on patient safety culture assessment.
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...
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Directory of Open Access Journals (Sweden)
Sivanandy P
2016-07-01
Full Text Available Palanisamy Sivanandy,1 Mari Kannan Maharajan,1 Kingston Rajiah,1 Tan Tyng Wei,2 Tan Wee Loon,2 Lim Chong Yee2 1Department of Pharmacy Practice, School of Pharmacy, 2School of Pharmacy, International Medical University, Wilayah Persekutuan Kuala Lumpur, Malaysia Background: Patient safety is a major public health issue, and the knowledge, skills, and experience of health professionals are very much essential for improving patient safety. Patient safety and medication error are very much associated. Pharmacists play a significant role in patient safety. The function of pharmacists in the medication use process is very different from medical and nursing colleagues. Medication dispensing accuracy is a vital element to ensure the safety and quality of medication use.Objective: To evaluate the attitude and perception of the pharmacist toward patient safety in retail pharmacies setup in Malaysia.Methods: A Pharmacy Survey on Patient Safety Culture questionnaire was used to assess patient safety culture, developed by the Agency for Healthcare Research and Quality, and the convenience sampling method was adopted.Results: The overall positive response rate ranged from 31.20% to 87.43%, and the average positive response rate was found to be 67%. Among all the eleven domains pertaining to patient safety culture, the scores of “staff training and skills” were less. Communication openness, and patient counseling are common, but not practiced regularly in the Malaysian retail pharmacy setup compared with those in USA. The overall perception of patient safety of an acceptable level in the current retail pharmacy setup.Conclusion: The study revealed that staff training, skills, communication in patient counseling, and communication across shifts and about mistakes are less in current retail pharmacy setup. The overall perception of patient safety should be improved by educating the pharmacists about the significance and essential of patient safety. Keywords
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Using Active Learning to Identify Health Information Technology Related Patient Safety Events.
Fong, Allan; Howe, Jessica L; Adams, Katharine T; Ratwani, Raj M
2017-01-18
The widespread adoption of health information technology (HIT) has led to new patient safety hazards that are often difficult to identify. Patient safety event reports, which are self-reported descriptions of safety hazards, provide one view of potential HIT-related safety events. However, identifying HIT-related reports can be challenging as they are often categorized under other more predominate clinical categories. This challenge of identifying HIT-related reports is exacerbated by the increasing number and complexity of reports which pose challenges to human annotators that must manually review reports. In this paper, we apply active learning techniques to support classification of patient safety event reports as HIT-related. We evaluated different strategies and demonstrated a 30% increase in average precision of a confirmatory sampling strategy over a baseline no active learning approach after 10 learning iterations.
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76 FR 60495 - Patient Safety Organizations: Voluntary Relinquishment From the Patient Safety Group
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...
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Yang, Shu-Hui; Jerng, Jih-Shuin; Chen, Li-Chin; Li, Yu-Tsu; Huang, Hsiao-Fang; Wu, Chao-Ling; Chan, Jing-Yuan; Huang, Szu-Fen; Liang, Huey-Wen; Sun, Jui-Sheng
2017-11-03
Intra-hospital transportation (IHT) might compromise patient safety because of different care settings and higher demand on the human operation. Reports regarding the incidence of IHT-related patient safety events and human failures remain limited. To perform a retrospective analysis of IHT-related events, human failures and unsafe acts. A hospital-wide process for the IHT and database from the incident reporting system in a medical centre in Taiwan. All eligible IHT-related patient safety events between January 2010 to December 2015 were included. Incidence rate of IHT-related patient safety events, human failure modes, and types of unsafe acts. There were 206 patient safety events in 2 009 013 IHT sessions (102.5 per 1 000 000 sessions). Most events (n=148, 71.8%) did not involve patient harm, and process events (n=146, 70.9%) were most common. Events at the location of arrival (n=101, 49.0%) were most frequent; this location accounted for 61.0% and 44.2% of events with patient harm and those without harm, respectively (pprocess step was the preparation of the transportation team (n=91, 48.9%). Contributing unsafe acts included perceptual errors (n=14, 7.5%), decision errors (n=56, 30.1%), skill-based errors (n=48, 25.8%), and non-compliance (n=68, 36.6%). Multivariate analysis showed that human failure found in the arrival and hand-off sub-process (OR 4.84, pprocess at the location of arrival and prevent errors other than omissions. Long-term monitoring of IHT-related events is also warranted. © 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.
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Castleden, C M; Pickles, H
1988-10-01
1. Spontaneous reports of suspected adverse drug reactions (ADRs) reported to the Committee on Safety of Medicines (CSM) have been studied in relation to patient age. 2. The proportion of reports received for the elderly increased between 1965 and 1983. 3. There was a correlation between the use of drugs and the number of ADR reports. Thus age-related prescription figures for two non-steroidal anti-inflammatory drugs (NSAI) and co-trimoxazole matched ADR reports for each drug in each age group. 4. The reported ADR was more likely to be serious or fatal in the elderly. 5. The commonest ADRs reported for the elderly affected the gastrointestinal (GIT) and haemopoietic systems, where more reports were received than would be expected from prescription figures. 6. The drug suspected of causing a GIT reaction was a NSAI in 75% of the reports. 7. Ninety-one per cent of fatal reports of GIT bleeds and perforations associated with NSAI drugs were in patients over 60 years of age.
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Zaheer, Shahram; Ginsburg, Liane; Chuang, You-Ta; Grace, Sherry L
2015-01-01
Increased awareness regarding the importance of patient safety issues has led to the proliferation of theoretical conceptualizations, frameworks, and articles that apply safety experiences from high-reliability industries to medical settings. However, empirical research on patient safety and patient safety climate in medical settings still lags far behind the theoretical literature on these topics. The broader organizational literature suggests that ease of reporting, unit norms of openness, and participative leadership might be important variables for improving patient safety. The aim of this empirical study is to examine in detail how these three variables influence frontline staff perceptions of patient safety climate within health care organizations. A cross-sectional study design was used. Data were collected using a questionnaire composed of previously validated scales. The results of the study show that ease of reporting, unit norms of openness, and participative leadership are positively related to staff perceptions of patient safety climate. Health care management needs to involve frontline staff during the development and implementation stages of an error reporting system to ensure staff perceive error reporting to be easy and efficient. Senior and supervisory leaders at health care organizations must be provided with learning opportunities to improve their participative leadership skills so they can better integrate frontline staff ideas and concerns while making safety-related decisions. Finally, health care management must ensure that frontline staff are able to freely communicate safety concerns without fear of being punished or ridiculed by others.
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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.)
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Organising a manuscript reporting quality improvement or patient safety research.
Holzmueller, Christine G; Pronovost, Peter J
2013-09-01
Peer-reviewed publication plays important roles in disseminating research findings, developing generalisable knowledge and garnering recognition for authors and institutions. Nonetheless, many bemoan the whole manuscript writing process, intimidated by the arbitrary and somewhat opaque conventions. This paper offers practical advice about organising and writing a manuscript reporting quality improvement or patient safety research for submission to a peer-reviewed journal. Each section of the paper discusses a specific manuscript component-from title, abstract and each section of the manuscript body, through to reference list and tables and figures-explaining key principles, offering content organisation tips and providing an example of how this section may read. The paper also offers a checklist of common mistakes to avoid in a manuscript.
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Measurable improvement in patient safety culture: A departmental experience with incident learning.
Kusano, Aaron S; Nyflot, Matthew J; Zeng, Jing; Sponseller, Patricia A; Ermoian, Ralph; Jordan, Loucille; Carlson, Joshua; Novak, Avrey; Kane, Gabrielle; Ford, Eric C
2015-01-01
Rigorous use of departmental incident learning is integral to improving patient safety and quality of care. The goal of this study was to quantify the impact of a high-volume, departmental incident learning system on patient safety culture. A prospective, voluntary, electronic incident learning system was implemented in February 2012 with the intent of tracking near-miss/no-harm incidents. All incident reports were reviewed weekly by a multiprofessional team with regular department-wide feedback. Patient safety culture was measured at baseline with validated patient safety culture survey questions. A repeat survey was conducted after 1 and 2 years of departmental incident learning. Proportional changes were compared by χ(2) or Fisher exact test, where appropriate. Between 2012 and 2014, a total of 1897 error/near-miss incidents were reported, representing an average of 1 near-miss report per patient treated. Reports were filed by a cross section of staff, with the majority of incidents reported by therapists, dosimetrists, and physicists. Survey response rates at baseline and 1 and 2 years were 78%, 80%, and 80%, respectively. Statistically significant and sustained improvements were noted in several safety metrics, including belief that the department was openly discussing ways to improve safety, the sense that reports were being used for safety improvement, and the sense that changes were being evaluated for effectiveness. None of the surveyed dimensions of patient safety culture worsened. Fewer punitive concerns were noted, with statistically significant decreases in the worry of embarrassment in front of colleagues and fear of getting colleagues in trouble. A comprehensive incident learning system can identify many areas for improvement and is associated with significant and sustained improvements in patient safety culture. These data provide valuable guidance as incident learning systems become more widely used in radiation oncology. Copyright © 2015
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Evaluation of Patient and Family Engagement Strategies to Improve Medication Safety.
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
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Patient safety culture among medical students in Singapore and Hong Kong.
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.
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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...
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Implementation of patient safety strategies in European hospitals.
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.
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Healthcare professionals? views on feedback of a patient safety culture assessment
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...
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Are long physician working hours harmful to patient safety?
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.
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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
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Fleischut, Peter M; Evans, Adam S; Nugent, William C; Faggiani, Susan L; Lazar, Eliot J; Liebowitz, Richard S; Forese, Laura L; Kerr, Gregory E
2011-01-01
Ten years after the 1999 Institute of Medicine report, it is clear that despite significant progress, much remains to be done to improve quality and patient safety (QPS). Recognizing the critical role of postgraduate trainees, an innovative approach was developed at New York-Presbyterian Hospital, Weill Cornell Medical Center to engage residents in QPS by creating a Housestaff Quality Council (HQC). HQC leaders and representatives from each clinical department communicate and partner regularly with hospital administration and other key departments to address interdisciplinary quality improvement (QI). In support of the mission to improve patient care and safety, QI initiatives included attaining greater than 90% compliance with medication reconciliation and reduction in the use of paper laboratory orders by more than 70%. A patient safety awareness campaign is expected to evolve into a transparent environment where house staff can openly discuss patient safety issues to improve the quality of care.
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An analysis of electronic health record-related patient safety incidents.
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.
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MedWatch, the FDA Safety Information and Adverse Event Reporting Program
... Reporting Program MedWatch: The FDA Safety Information and Adverse Event Reporting Program Share Tweet Linkedin Pin it ... approved information that can help patients avoid serious adverse events. Potential Signals of Serious Risks/New Safety ...
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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...
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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...
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76 FR 7853 - Patient Safety Organizations: Voluntary Delisting From Oregon Patient Safety Commission
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...
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The effect of organisational culture on patient safety.
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.
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Usher, Kim; Woods, Cindy; Parmenter, Glenda; Hutchinson, Marie; Mannix, Judy; Power, Tamara; Chaboyer, Wendy; Latimer, Sharon; Mills, Jane; Siegloff, Lesley; Jackson, Debra
2017-06-01
, Understanding that reporting adverse events and close calls can lead to change and can reduce recurrence of events, was rated significantly higher by third year students than first and second year students. In order are to achieve meaningful improvements in patient safety, and create harm free environments for patients, it is crucial that nursing students develop confidence communicating with others to improve patient safety, particularly in the areas of challenging poor practice, and recognising, responding to and disclosing adverse events, including errors and near misses. Copyright © 2017 Elsevier Ltd. All rights reserved.
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The impact of health information technology on patient safety.
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.
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Organizational safety culture and medical error reporting by Israeli nurses.
Kagan, Ilya; Barnoy, Sivia
2013-09-01
To investigate the association between patient safety culture (PSC) and the incidence and reporting rate of medical errors by Israeli nurses. Self-administered structured questionnaires were distributed to a convenience sample of 247 registered nurses enrolled in training programs at Tel Aviv University (response rate = 91%). The questionnaire's three sections examined the incidence of medication mistakes in clinical practice, the reporting rate for these errors, and the participants' views and perceptions of the safety culture in their workplace at three levels (organizational, departmental, and individual performance). Pearson correlation coefficients, t tests, and multiple regression analysis were used to analyze the data. Most nurses encountered medical errors from a daily to a weekly basis. Six percent of the sample never reported their own errors, while half reported their own errors "rarely or sometimes." The level of PSC was positively and significantly correlated with the error reporting rate. PSC, place of birth, error incidence, and not having an academic nursing degree were significant predictors of error reporting, together explaining 28% of variance. This study confirms the influence of an organizational safety climate on readiness to report errors. Senior healthcare executives and managers can make a major impact on safety culture development by creating and promoting a vision and strategy for quality and safety and fostering their employees' motivation to implement improvement programs at the departmental and individual level. A positive, carefully designed organizational safety culture can encourage error reporting by staff and so improve patient safety. © 2013 Sigma Theta Tau International.
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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.
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Culture matters: indigenizing patient safety in Bhutan.
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
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Shimada, Yutaka; Fujimoto, Makoto; Nogami, Tatsuya; Watari, Hidetoshi; Kitahara, Hideyuki; Misawa, Hiroki; Kimbara, Yoshiyuki
2017-12-21
Kampo medicine is traditional Japanese medicine, which originated in ancient traditional Chinese medicine, but was introduced and developed uniquely in Japan. Today, Kampo medicines are integrated into the Japanese national health care system. Incident reporting systems are currently being widely used to collect information about patient safety incidents that occur in hospitals. However, no investigations have been conducted regarding patient safety incident reports related to Kampo medicines. The aim of this study was to survey and analyse incident reports related to Kampo medicines in a Japanese university hospital to improve future patient safety. We selected incident reports related to Kampo medicines filed in Toyama University Hospital from May 2007 to April 2017, and investigated them in terms of medication errors and adverse drug events. Out of 21,324 total incident reports filed in the 10-year survey period, we discovered 108 Kampo medicine-related incident reports. However, five cases were redundantly reported; thus, the number of actual incidents was 103. Of those, 99 incidents were classified as medication errors (77 administration errors, 15 dispensing errors, and 7 prescribing errors), and four were adverse drug events, namely Kampo medicine-induced interstitial pneumonia. The Kampo medicine (crude drug) that was thought to induce interstitial pneumonia in all four cases was Scutellariae Radix, which is consistent with past reports. According to the incident severity classification system recommended by the National University Hospital Council of Japan, of the 99 medication errors, 10 incidents were classified as level 0 (an error occurred, but the patient was not affected) and 89 incidents were level 1 (an error occurred that affected the patient, but did not cause harm). Of the four adverse drug events, two incidents were classified as level 2 (patient was transiently harmed, but required no treatment), and two incidents were level 3b (patient was
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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...
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Nurses' perceptions of patient safety culture in Jordanian hospitals.
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
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Patient safety challenges in a case study hospital--of relevance for transfusion processes?
Aase, Karina; Høyland, Sindre; Olsen, Espen; Wiig, Siri; Nilsen, Stein Tore
2008-10-01
The paper reports results from a research project with the objective of studying patient safety, and relates the finding to safety issues within transfusion medicine. The background is an increased focus on undesired events related to diagnosis, medication, and patient treatment in general in the healthcare sector. The study is designed as a case study within a regional Norwegian hospital conducting specialised health care services. The study includes multiple methods such as interviews, document analysis, analysis of error reports, and a questionnaire survey. Results show that the challenges for improved patient safety, based on employees' perceptions, are hospital management support, reporting of accidents/incidents, and collaboration across hospital units. Several of these generic safety challenges are also found to be of relevance for a hospital's transfusion service. Positive patient safety factors are identified as teamwork within hospital units, a non-punitive response to errors, and unit manager's actions promoting safety.
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Schwappach, David L B; Meyer Massetti, Carla; Gehring, Katrin
2012-10-01
Foreign-language (FL) patients are at increased risk for adverse drug events. Evidence regarding communication barriers and the safety of pharmaceutical care of FL patients in European countries is scarce despite large migrant populations. To investigate Swiss public pharmacists' experiences and current practices in counselling FL patients with a focus on patient safety. In a cross-sectional study heads of public pharmacies in Switzerland were surveyed using an electronic questionnaire. The survey assessed the frequency of communication barriers encountered in medication counselling of FL patients, perceptions of risks for adverse drug events, satisfaction with the quality of counselling provided to FL patients, current strategies to reduce risks, and preferences towards tools to improve safety for FL patients. 498 pharmacists completed the survey (43 % response rate). More than every second pharmacist reported at least weekly encounters at which they cannot provide good medication counselling to FL patients in the regional Swiss language. Ad-hoc interpreting by minors is also common at a considerable number of pharmacies (26.5 % reported at least one weekly occurrence). Approximately 10 % of pharmacies reported that they fail at least weekly to explain the essentials of drug therapy (e.g. dosing of children's medications) to FL patients. 79.8 % perceived the risk of FL patients for adverse drug events to be somewhat or much higher compared to other patients. 22.5 % of pharmacists reported being concerned at least monthly about medication safety when FL patients leave their pharmacy. However, the majority of pharmacists were satisfied with the quality of care provided to FL patients in their pharmacy [78.6 % (very) satisfied]. The main strategy used to improve counselling for FL patients was the employment of multilingual staff. Participants would use software for printing foreign-language labels (41.2 %) and multilingual package inserts (42.0 %) if these were
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HRET patient safety leadership fellowship: the role of "community" in patient safety.
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.
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Implementation of patient safety and patient-centeredness strategies in Iranian hospitals.
Directory of Open Access Journals (Sweden)
Asgar Aghaei Hashjin
Full Text Available OBJECTIVE: To examine the extent of implementation for patient safety (PS and patient-centeredness (PC strategies and their association with hospital characteristics (type, ownership, teaching status, annual evaluation grade in Iran. METHODS: A cross-sectional study through an adapted version of the MARQuIS questionnaire, eliciting information from hospital and nursing managers in 84 Iranian hospitals on the implementation of PS and PC strategies in 2009-2010. RESULTS: The majority of hospitals reported to have implemented 84% of the PS and 72% of the PC strategies. In general, implementation of PS strategies was unrelated to the type of hospital, with the exception of health promotion reports, which were more common in the Social Security Organization (SSO, and MRSA testing, which was reported more often in nonprofit hospitals. MRSA testing was also more common among teaching hospitals compared to non-teaching hospitals. The higher grade hospitals reported PS strategies significantly more frequently than lower grade hospitals. Overall, there was no significant difference in the reported implementation of PC strategies across general and specialized hospitals; except for the provision of information in different languages and recording of patient's diet which were reported significantly more often by general than specialized hospitals. Moreover, patient hotel services were more common in private compared to public hospitals. CONCLUSIONS: Despite substantial reporting of PS and PC strategies, there is still room for strengthening standard setting on safety, patient services and patient-centered information strategies in Iranian hospitals. To assure effective implementation of PS and PC strategies, enforcing standards, creating a PS and PC culture, increasing organizational responsiveness, and partnering with patients and their families need more attention.
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Implementation of patient safety and patient-centeredness strategies in Iranian hospitals.
Aghaei Hashjin, Asgar; Kringos, Dionne S; Manoochehri, Jila; Ravaghi, Hamid; Klazinga, Niek S
2014-01-01
To examine the extent of implementation for patient safety (PS) and patient-centeredness (PC) strategies and their association with hospital characteristics (type, ownership, teaching status, annual evaluation grade) in Iran. A cross-sectional study through an adapted version of the MARQuIS questionnaire, eliciting information from hospital and nursing managers in 84 Iranian hospitals on the implementation of PS and PC strategies in 2009-2010. The majority of hospitals reported to have implemented 84% of the PS and 72% of the PC strategies. In general, implementation of PS strategies was unrelated to the type of hospital, with the exception of health promotion reports, which were more common in the Social Security Organization (SSO), and MRSA testing, which was reported more often in nonprofit hospitals. MRSA testing was also more common among teaching hospitals compared to non-teaching hospitals. The higher grade hospitals reported PS strategies significantly more frequently than lower grade hospitals. Overall, there was no significant difference in the reported implementation of PC strategies across general and specialized hospitals; except for the provision of information in different languages and recording of patient's diet which were reported significantly more often by general than specialized hospitals. Moreover, patient hotel services were more common in private compared to public hospitals. Despite substantial reporting of PS and PC strategies, there is still room for strengthening standard setting on safety, patient services and patient-centered information strategies in Iranian hospitals. To assure effective implementation of PS and PC strategies, enforcing standards, creating a PS and PC culture, increasing organizational responsiveness, and partnering with patients and their families need more attention.
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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.
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Doyle, Patricia; VanDenKerkhof, Elizabeth G; Edge, Dana S; Ginsburg, Liane; Goldstein, David H
2015-02-01
Quality and patient safety (PS) are critical components of medical education. This study reports on the self-reported PS competence of medical students and postgraduate trainees. The Health Professional Education in Patient Safety Survey was administered to medical students and postgraduate trainees in January 2012. PS dimension scores were compared across learning settings (classroom and clinical) and year in programme. Sixty-three percent (255/406) of medical students and 32% (141/436) of postgraduate trainees responded. In general, both groups were most confident in their learning of clinical safety skills (eg, hand hygiene) and least confident in learning about sociocultural aspects of safety (eg, understanding human factors). Medical students' confidence in most aspects of safety improved with years of training. For some of the more intangible dimensions (teamwork and culture), medical students in their final year had lower scores than students in earlier years. Thirty-eight percent of medical students felt they could approach someone engaging in unsafe practice, and the majority of medical students (85%) and postgraduate trainees (78%) agreed it was difficult to question authority. Our results suggest the need to improve the overall content, structure and integration of PS concepts in both classroom and clinical learning environments. Decreased confidence in sociocultural aspects of PS among medical students in the final year of training may indicate that culture in clinical settings negatively affects students' perceived PS competence. Alternatively, as medical students spend more time in the clinical setting, they may develop a clearer sense of what they do not know. 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.
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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...
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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...
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Smith, Meredith Y; Benattia, Isma
2016-09-01
Patient-centeredness has become an acknowledged hallmark of not only high-quality health care but also high-quality drug development. Biopharmaceutical companies are actively seeking to be more patient-centric in drug research and development by involving patients in identifying target disease conditions, participating in the design of, and recruitment for, clinical trials, and disseminating study results. Drug safety departments within the biopharmaceutical industry are at a similar inflection point. Rising rates of per capita prescription drug use underscore the importance of having robust pharmacovigilance systems in place to detect and assess adverse drug reactions (ADRs). At the same time, the practice of pharmacovigilance is being transformed by a host of recent regulatory guidances and related initiatives which emphasize the importance of the patient's perspective in drug safety. Collectively, these initiatives impact the full range of activities that fall within the remit of pharmacovigilance, including ADR reporting, signal detection and evaluation, risk management, medication error assessment, benefit-risk assessment and risk communication. Examples include the fact that manufacturing authorization holders are now expected to monitor all digital sources under their control for potential reports of ADRs, and the emergence of new methods for collecting, analysing and reporting patient-generated ADR reports for signal detection and evaluation purposes. A drug safety department's ability to transition successfully into a more patient-centric organization will depend on three defining attributes: (1) a patient-centered culture; (2) deployment of a framework to guide patient engagement activities; and (3) demonstrated proficiency in patient-centered competencies, including patient engagement, risk communication and patient preference assessment. Whether, and to what extent, drug safety departments embrace the new patient-centric imperative, and the methods and
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Yassi, Annalee; Hancock, Tina
2005-01-01
Patient safety within the Canadian healthcare system is currently a high national priority, which merits a comprehensive understanding of the underlying causes of adverse events. Not least among these is worker health and safety, which is linked to patient outcomes. Healthcare workers have a high risk of workplace injuries and more mental health problems than most other occupational groups. Many healthcare professionals feel fatigued, stressed, in pain, or at risk of illness or injury-factors they feel impede their ability to provide consistent quality care. With this background, the Occupational Health and Safety Agency for Healthcare (OHSAH) in British Columbia, jointly governed by healthcare unions and healthcare employers, launched several major initiatives to improve the healthcare workplace. These included the promotion of safe patient handling, adaptive clothing, scheduled toileting, stroke management training, measures to improve management of aggressive behaviour and, of course, infection control-all intended to improve the safety of workers, but also to improve patient safety and quality of care. Other projects also explicitly promoting physical and mental health at work, as well as patient safety are also underway. Results of the projects are at various stages of completion, but ample evidence has already been obtained to indicate that looking after the well-being of healthcare workers results in safer and better quality patient care. While more research is needed, our work to date suggests that a comprehensive systems approach to promoting a climate of safety, which includes taking into account workplace organizational factors and physical and psychological hazards for workers, is the best way to improve the healthcare workplace and thereby patient safety.
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Implementation of Patient Safety and Patient-Centeredness Strategies in Iranian Hospitals
Aghaei Hashjin, Asgar; Kringos, Dionne S.; Manoochehri, Jila; Ravaghi, Hamid; Klazinga, Niek S.
2014-01-01
Objective To examine the extent of implementation for patient safety (PS) and patient-centeredness (PC) strategies and their association with hospital characteristics (type, ownership, teaching status, annual evaluation grade) in Iran. Methods A cross-sectional study through an adapted version of the MARQuIS questionnaire, eliciting information from hospital and nursing managers in 84 Iranian hospitals on the implementation of PS and PC strategies in 2009–2010. Results The majority of hospitals reported to have implemented 84% of the PS and 72% of the PC strategies. In general, implementation of PS strategies was unrelated to the type of hospital, with the exception of health promotion reports, which were more common in the Social Security Organization (SSO), and MRSA testing, which was reported more often in nonprofit hospitals. MRSA testing was also more common among teaching hospitals compared to non-teaching hospitals. The higher grade hospitals reported PS strategies significantly more frequently than lower grade hospitals. Overall, there was no significant difference in the reported implementation of PC strategies across general and specialized hospitals; except for the provision of information in different languages and recording of patient’s diet which were reported significantly more often by general than specialized hospitals. Moreover, patient hotel services were more common in private compared to public hospitals. Conclusions Despite substantial reporting of PS and PC strategies, there is still room for strengthening standard setting on safety, patient services and patient-centered information strategies in Iranian hospitals. To assure effective implementation of PS and PC strategies, enforcing standards, creating a PS and PC culture, increasing organizational responsiveness, and partnering with patients and their families need more attention. PMID:25268797
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Assessing the relationship between patient safety culture and EHR strategy.
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.
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[Innovative training for enhancing patient safety. Safety culture and integrated concepts].
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.
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An analysis of electronic health record-related patient safety concerns
Meeks, Derek W; Smith, Michael W; Taylor, Lesley; Sittig, Dean F; Scott, Jean M; Singh, Hardeep
2014-01-01
Objective A recent Institute of Medicine report called for attention to safety issues related to electronic health records (EHRs). We analyzed EHR-related safety concerns reported within a large, integrated healthcare system. Methods The Informatics Patient Safety Office of the Veterans Health Administration (VA) maintains a non-punitive, voluntary reporting system to collect and investigate EHR-related safety concerns (ie, adverse events, potential events, and near misses). We analyzed completed investigations using an eight-dimension sociotechnical conceptual model that accounted for both technical and non-technical dimensions of safety. Using the framework analysis approach to qualitative data, we identified emergent and recurring safety concerns common to multiple reports. Results We extracted 100 consecutive, unique, closed investigations between August 2009 and May 2013 from 344 reported incidents. Seventy-four involved unsafe technology and 25 involved unsafe use of technology. A majority (70%) involved two or more model dimensions. Most often, non-technical dimensions such as workflow, policies, and personnel interacted in a complex fashion with technical dimensions such as software/hardware, content, and user interface to produce safety concerns. Most (94%) safety concerns related to either unmet data-display needs in the EHR (ie, displayed information available to the end user failed to reduce uncertainty or led to increased potential for patient harm), software upgrades or modifications, data transmission between components of the EHR, or ‘hidden dependencies’ within the EHR. Discussion EHR-related safety concerns involving both unsafe technology and unsafe use of technology persist long after ‘go-live’ and despite the sophisticated EHR infrastructure represented in our data source. Currently, few healthcare institutions have reporting and analysis capabilities similar to the VA. Conclusions Because EHR-related safety concerns have complex
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Patient safety education at Japanese medical schools: results of a nationwide survey.
Maeda, Shoichi; Kamishiraki, Etsuko; Starkey, Jay
2012-05-10
Patient safety education, including error prevention strategies and management of adverse events, has become a topic of worldwide concern. The importance of the patient safety is also recognized in Japan following two serious medical accidents in 1999. Furthermore, educational curriculum guideline revisions in 2008 by relevant the Ministry of Education includes patient safety as part of the core medical curriculum. However, little is known about the patient safety education in Japanese medical schools partly because a comprehensive study has not yet been conducted in this field. Therefore, we have conducted a nationwide survey in order to clarify the current status of patient safety education at medical schools in Japan. Response rate was 60.0% (n = 48/80). Ninety-eight-percent of respondents (n = 47/48) reported integration of patient safety education into their curricula. Thirty-nine percent reported devoting less than five hours to the topic. All schools that teach patient safety reported use of lecture based teaching methods while few used alternative methods, such as role-playing or in-hospital training. Topics related to medical error theory and legal ramifications of error are widely taught while practical topics related to error analysis such as root cause analysis are less often covered. Based on responses to our survey, most Japanese medical schools have incorporated the topic of patient safety into their curricula. However, the number of hours devoted to the patient safety education is far from the sufficient level with forty percent of medical schools that devote five hours or less to it. In addition, most medical schools employ only the lecture based learning, lacking diversity in teaching methods. Although most medical schools cover basic error theory, error analysis is taught at fewer schools. We still need to make improvements to our medical safety curricula. We believe that this study has the implications for the rest of the world as a
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Patient safety education at Japanese medical schools: results of a nationwide survey
Directory of Open Access Journals (Sweden)
Maeda Shoichi
2012-05-01
Full Text Available Abstract Background Patient safety education, including error prevention strategies and management of adverse events, has become a topic of worldwide concern. The importance of the patient safety is also recognized in Japan following two serious medical accidents in 1999. Furthermore, educational curriculum guideline revisions in 2008 by relevant the Ministry of Education includes patient safety as part of the core medical curriculum. However, little is known about the patient safety education in Japanese medical schools partly because a comprehensive study has not yet been conducted in this field. Therefore, we have conducted a nationwide survey in order to clarify the current status of patient safety education at medical schools in Japan. Results Response rate was 60.0% (n = 48/80. Ninety-eight-percent of respondents (n = 47/48 reported integration of patient safety education into their curricula. Thirty-nine percent reported devoting less than five hours to the topic. All schools that teach patient safety reported use of lecture based teaching methods while few used alternative methods, such as role-playing or in-hospital training. Topics related to medical error theory and legal ramifications of error are widely taught while practical topics related to error analysis such as root cause analysis are less often covered. Conclusions Based on responses to our survey, most Japanese medical schools have incorporated the topic of patient safety into their curricula. However, the number of hours devoted to the patient safety education is far from the sufficient level with forty percent of medical schools that devote five hours or less to it. In addition, most medical schools employ only the lecture based learning, lacking diversity in teaching methods. Although most medical schools cover basic error theory, error analysis is taught at fewer schools. We still need to make improvements to our medical safety curricula. We believe that this
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Safety Incident Management Team Report for NIMLT Case 50796
LENUS (Irish Health Repository)
2017-01-17
This is a report on the management of a patient safety incident involving BowelScreen and symptomatic colonoscopy services at Wexford General Hospital (WGH). The patient safety incident relates to the work of a Consultant Endoscopist (referred to as Clinician Y) employed by WGH who undertook screening colonoscopies on behalf of the BowelScreen Programme since the commencement of the screening programme in WGH in March 2013. Clinician Y also performed non-screening colonoscopies for the diagnosis of symptomatic patients as part of routine surgical service provision at WGH.\\r\
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Effects of an educational patient safety campaign on patients' safety behaviours and adverse events.
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
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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.
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International Nuclear Information System (INIS)
Maglinte, Dean D.T.; Applegate, Kimberly E.; Rajesh, Arumugam; Jennings, S. Gregory; Ford, Jason M.; Savabi, Mojgan Sarah; Lappas, John C.
2009-01-01
Objective: To compare the safety and patient-reported effectiveness of two regimens for conscious sedation during enteroclysis. Materials and methods: We surveyed two groups of outpatients and retrospectively reviewed procedure records for conscious sedation and complications. Patients were divided into Group One (received sedative/amnesic diazepam), and Group Two, (received amnesic/sedative, midazolam and analgesic fentanyl). Results: All enteroclyses were successfully completed; there were no hospital admissions due to complications. In Group One (n = 106), mean dose of diazepam was 12.7 mg. 25% had oxygen desaturation (n = 25), and post-procedure vomiting without aspiration (n = 1). 56% of outpatients completed phone surveys, and 68% recalled procedural discomfort. In Group Two (n = 45), mean doses were 3.9 mg midazolam and 108 mcg fentanyl. 31% had desaturation (n = 13), and post-procedure vomiting without aspiration (n = 1). 87% had only a vague recall of the procedure or of any discomfort. Conclusion: A combination of amnesic and fentanyl prevented the recall of discomfort of nasoenteric intubation and infusion in most patients who had enteroclysis compared to diazepam. Most of the patients would undergo the procedure again, if needed.
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Energy Technology Data Exchange (ETDEWEB)
Maglinte, Dean D.T. [Department of Radiology, Indiana University Medical Center, 550 N, University Boulevard, University Hospital Room 0279, Indianapolis, IN 46202-5253 (United States)], E-mail: dmaglint@iupui.edu; Applegate, Kimberly E.; Rajesh, Arumugam; Jennings, S. Gregory; Ford, Jason M. [Department of Radiology, Indiana University Medical Center, 550 N, University Boulevard, University Hospital Room 0279, Indianapolis, IN 46202-5253 (United States); Savabi, Mojgan Sarah [Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, 550 N, University Boulevard, Indianapolis, IN 46202-5253 (United States); Lappas, John C. [Department of Radiology, Indiana University Medical Center, 550 N, University Boulevard, University Hospital Room 0279, Indianapolis, IN 46202-5253 (United States)
2009-06-15
Objective: To compare the safety and patient-reported effectiveness of two regimens for conscious sedation during enteroclysis. Materials and methods: We surveyed two groups of outpatients and retrospectively reviewed procedure records for conscious sedation and complications. Patients were divided into Group One (received sedative/amnesic diazepam), and Group Two, (received amnesic/sedative, midazolam and analgesic fentanyl). Results: All enteroclyses were successfully completed; there were no hospital admissions due to complications. In Group One (n = 106), mean dose of diazepam was 12.7 mg. 25% had oxygen desaturation (n = 25), and post-procedure vomiting without aspiration (n = 1). 56% of outpatients completed phone surveys, and 68% recalled procedural discomfort. In Group Two (n = 45), mean doses were 3.9 mg midazolam and 108 mcg fentanyl. 31% had desaturation (n = 13), and post-procedure vomiting without aspiration (n = 1). 87% had only a vague recall of the procedure or of any discomfort. Conclusion: A combination of amnesic and fentanyl prevented the recall of discomfort of nasoenteric intubation and infusion in most patients who had enteroclysis compared to diazepam. Most of the patients would undergo the procedure again, if needed.
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Patient safety climate and worker safety behaviours in acute hospitals in Scotland.
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.
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De Brún, Aoife; Heavey, Emily; Waring, Justin; Dawson, Pamela; Scott, Jason
2017-08-01
The importance of involving patients in reporting on safety is increasingly recognized. Whilst studies have identified barriers to clinician incident reporting, few have explored barriers and facilitators to patient reporting of safety experiences. This paper explores patient perspectives on providing feedback on safety experiences. Patients (n=28) were invited to take part in semi-structured interviews when given a survey about their experiences of safety following hospital discharge. Transcripts were thematically analysed using NVivo10. Patients were recruited from four hospitals in the UK. Three themes were identified as barriers and facilitators to patient involvement in providing feedback on their safety experiences. The first, cognitive-cultural, found that whilst safety was a priority for most, some felt the term was not relevant to them because safety was the "default" position, and/or because safety could not be disentangled from the overall experience of care. The structural-procedural theme indicated that reporting was facilitated when patients saw the process as straightforward, but that disinclination or perceived inability to provide feedback was a barrier. Finally, learning and change illustrated that perception of the impact of feedback could facilitate or inhibit reporting. When collecting patient feedback on experiences of safety, it is important to consider what may help or hinder this process, beyond the process alone. We present a staged model of prerequisite barriers and facilitators and hypothesize that each stage needs to be achieved for patients to provide feedback on safety experiences. Implications for collecting meaningful data on patients' safety experiences are considered. © 2016 The Authors. Health Expectations Published by John Wiley & Sons Ltd.
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Language barriers and patient safety risks in hospital care. A mixed methods study.
van Rosse, Floor; de Bruijne, Martine; Suurmond, Jeanine; Essink-Bot, Marie-Louise; Wagner, Cordula
2016-02-01
A language barrier has been shown to be a threat for quality of hospital care. International studies highlighted a lack of adequate noticing, reporting, and bridging of a language barrier. However, studies on the link between language proficiency and patient safety are scarce, especially in Europe. The present study investigates patient safety risks due to language barriers during hospitalization, and the way language barriers are detected, reported, and bridged in Dutch hospital care. We combined quantitative and qualitative methods in a sample of 576 ethnic minority patients who were hospitalized on 30 wards within four urban hospitals. The nursing and medical records of 17 hospital admissions of patients with language barriers were qualitatively analyzed, and complemented by 12 in-depth interviews with care providers and patients and/or their relatives to identify patient safety risks during hospitalization. The medical records of all 576 patients were screened for language barrier reports. The results were compared to patients' self-reported Dutch language proficiency. The policies of wards regarding bridging language barriers were compared with the reported use of interpreters in the medical records. Situations in hospital care where a language barrier threatened patient safety included daily nursing tasks (i.e. medication administration, pain management, fluid balance management) and patient-physician interaction concerning diagnosis, risk communication and acute situations. In 30% of the patients that reported a low Dutch proficiency, no language barrier was documented in the patient record. Relatives of patients often functioned as interpreter for them and professional interpreters were hardly used. The present study showed a wide variety of risky situations in hospital care for patients with language barriers. These risks can be reduced by adequately bridging the language barrier, which, in the first place, demands adequate detecting and reporting of a
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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...
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Saito, Hitoshi; Kakihata, Hiroyuki; Nishida, Yosuke; Yatomi, Sawako; Nihojima, Shigeru; Kobayashi, Yumiko; Tabata, Hidehiro; Nomura, Makoto
2017-07-01
This large-scale post-marketing surveillance study was conducted to assess the safety and effectiveness of eldecalcitol treatment in patients with osteoporosis in a Japanese clinical setting. A total of 3567 patients with osteoporosis were enrolled and received eldecalcitol 0.75 μg/day for 12 months. For this interim report, 3285 patients were eligible for analysis. Mean age was 74.9 ± 8.7 years; 86.8 % (2854/3285) were women. There were 142 reported adverse drug reactions (ADRs) in 129 patients (3.92 % of the total 3285 patients): the most common were hypercalcemia and increased blood calcium (0.88 %), renal impairment (0.27 %), abdominal discomfort (0.24 %), constipation (0.24 %), and pruritus (0.24 %). The incidence of ADRs was 5.10 % in men and 3.74 % in women. Although 10 serious ADRs were reported in 9 patients (0.27 %), no clinically significant safety issues were identified. Incidence of hypercalcemia or increased blood calcium was 8.47 % in patients with renal impairment and only 0.74 % in patients without renal impairment. At last observation, the incidence of new vertebral and nonvertebral fractures was 2.44 % and 1.70 %, respectively. There was a significant increase in bone mineral density at the lumbar spine and distal radius. The bone turnover markers BAP, serum NTX, urinary NTX, and TRACP-5b were suppressed by eldecalcitol treatment in both sexes. In conclusion, consistent with the findings of the phase III pivotal clinical trial, eldecalcitol was shown to have a favorable safety profile and effectiveness in Japanese patients with osteoporosis. However, periodic measurements of serum calcium were required to prevent occurrence of hypercalcemia during eldecalcitol treatment, especially in patients with renal impairment.
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Safety analysis reports. Current status (third key report)
International Nuclear Information System (INIS)
1999-01-01
A review of Ukrainian regulations and laws concerned with Nuclear power and radiation safety is presented with an overview of the requirements for the Safety Analysis Report Contents. Status of Safety Analysis Reports (SAR) is listed for each particular Ukrainian NPP including SAR development schedules. Organisational scheme of SAR development works includes: general technical co-ordination on Safety Analysis Report development; list of leading organisations and utilization of technical support within international projects
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Patient safety in primary care: a survey of general practitioners in The Netherlands.
Gaal, S.; Verstappen, W.H.J.M.; Wensing, M.J.P.
2010-01-01
BACKGROUND: Primary care encompasses many different clinical domains and patient groups, which means that patient safety in primary care may be equally broad. Previous research on safety in primary care has focused on medication safety and incident reporting. In this study, the views of general
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77 FR 25179 - Patient Safety Organizations: Voluntary Relinquishment From Surgical Safety Institute
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...
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National Patient Safety Foundation
... 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 ...
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Safety for all: bringing together patient and employee safety.
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.
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Challenging patient safety culture: survey results
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
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National Nuclear Safety Report 2001. Convention on Nuclear Safety
International Nuclear Information System (INIS)
2001-01-01
The First National Nuclear Safety Report was presented at the first review meeting of the Nuclear Safety Convention. At that time it was concluded that Argentina met the obligations of the Convention. This second National Nuclear Safety Report is an updated report which includes all safety aspects of the Argentinian nuclear power plants and the measures taken to enhance the safety of the plants. The present report also takes into account the observations and discussions maintained during the first review meeting. The conclusion made in the first review meeting about the compliance by Argentina of the obligations of the Convention are included as Annex 1. In general, the information contained in this Report has been updated since March 31, 1998 to March 31, 2001. Those aspects that remain unchanged were not addressed in this second report with the objective of avoiding repetitions and in order to carry out a detailed analysis considering article by article. As a result of the above mentioned detailed analysis of all the Articles, it can be stated that the country fulfils all the obligations imposed by the Nuclear Safety Convention
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National nuclear safety report 2004. Convention on nuclear safety
International Nuclear Information System (INIS)
2004-01-01
The second National Nuclear Safety Report was presented at the second review meeting of the Nuclear Safety Convention. At that time it was concluded that Argentina met the obligations of the Convention. This third National Nuclear Safety Report is an updated report which includes all safety aspects of the Argentinian nuclear power plants and the measures taken to enhance the safety of the plants. The present report also takes into account the observations and discussions maintained during the second review meeting. The conclusion made in the first review meeting about the compliance by Argentina of the obligations of the Convention are included as Annex I and those belonging to the second review meeting are included as Annex II. In general, the information contained in this Report has been updated since March 31, 2001 to April 30, 2004. Those aspects that remain unchanged were not addressed in this third report. As a result of the detailed analysis of all the Articles, it can be stated that the country fulfils all the obligations imposed by the Nuclear Safety Convention. The questions and answers originated at the Second Review Meeting are included as Annex III
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Researchers' Roles in Patient Safety Improvement.
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.
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International Nuclear Information System (INIS)
1982-09-01
A safety report from Section K (Nuclear Physics) of the Dutch National Institute for Nuclear and High Energy Physics is presented for 1981. The report begins with general matters concerning safety policy at NIKHEF, licences and expenditure. Works accidents (none of them radiological) are detailed and accident prevention considered. The measurement programme for neutron radiation in the vicinity of the accelerator is described and the results are discussed. The means and results of personnel dosimetry are also presented. The report is concluded with a list of publications concerning safety aspects at NIKHEF. (C.F.)
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Anesthesia Quality and Patient Safety in China: A Survey.
Zhu, Bin; Gao, Huan; Zhou, Xiangyong; Huang, Jeffrey
There has been no nationwide investigation into anesthesia quality and patient safety in China. The authors surveyed Chinese anesthesiologists about anesthesia quality by sending a survey to all anesthesiologist members of the New Youth Anesthesia Forum via WeChat. The respondents could choose to use a mobile device or desktop to complete the survey. The overall response rate was 43%. Intraoperative monitoring: 77.9% of respondents reported that electrocardiogram monitoring was routinely applied for all patients; only 55% of the respondents reported that they routinely used end-tidal carbon dioxide monitoring for their patients under general anesthesia. 10.3% of respondents admitted that they had at least one wrong medicine administration in the past 3 months; 12.4% reported that they had at least one case of cardiac arrest in the past year. This is the first anesthesia quality survey in China. The findings revealed potential anesthesia safety issues in China.
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76 FR 12358 - Common Formats for Patient Safety Data Collection and Event Reporting
2011-03-07
... DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality Common Formats... information regarding the quality and safety of healthcare delivery. The Patient Safety Act (at 42 U.S.C. 299b...: Device or Supply, including Health Information Technology; Fall; Healthcare-Associated Infection...
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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
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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
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Modeling patient safety incidents knowledge with the Categorial Structure method.
Souvignet, Julien; Bousquet, Cédric; Lewalle, Pierre; Trombert-Paviot, Béatrice; Rodrigues, Jean Marie
2011-01-01
Following the WHO initiative named World Alliance for Patient Safety (PS) launched in 2004 a conceptual framework developed by PS national reporting experts has summarized the knowledge available. As a second step, the Department of Public Health of the University of Saint Etienne team elaborated a Categorial Structure (a semi formal structure not related to an upper level ontology) identifying the elements of the semantic structure underpinning the broad concepts contained in the framework for patient safety. This knowledge engineering method has been developed to enable modeling patient safety information as a prerequisite for subsequent full ontology development. The present article describes the semantic dissection of the concepts, the elicitation of the ontology requirements and the domain constraints of the conceptual framework. This ontology includes 134 concepts and 25 distinct relations and will serve as basis for an Information Model for Patient Safety.
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Laboratory safety and the WHO World Alliance for Patient Safety.
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.
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Safety evaluation status report for the prototype license application safety analysis report
International Nuclear Information System (INIS)
1989-07-01
The US Nuclear Regulatory Commission (NRC) staff and consultants reviewed a Prototype License Application Safety Analysis Report (PLASAR) submitted by the US Department of Energy (DOE) for the earth-mounded concrete bunker (EMCB) alternative method of low-level radioactive waste disposal. The NRC reviewers relied extensively on the Standard Review Plan (SRP), Rev.1 (NUREG-1200), to evaluate the acceptability of the information provided in the EMCB PLASAR. The NRC staff selected certain review areas in the PLASAR for development of safety evaluation report input to provide examples of safety assessments that are necessary as part of a licensing review. Because of the fictitious nature of the assumed disposal site, and the decision to limit the review to essentially first-round review status, the NRC staff report is labeled a ''Safety Evaluation Status Report'' (SESR). Appendix A comprises the NRC review comments and questions on the information that DOE submitted in the PLASAR. The NRC concentrated its review on the design and operations-related portions of the EMCB PLASAR
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NASA Aviation Safety Reporting System (ASRS)
Connell, Linda J.
2017-01-01
The NASA Aviation Safety Reporting System (ASRS) collects, analyzes, and distributes de-identified safety information provided through confidentially submitted reports from frontline aviation personnel. Since its inception in 1976, the ASRS has collected over 1.4 million reports and has never breached the identity of the people sharing their information about events or safety issues. From this volume of data, the ASRS has released over 6,000 aviation safety alerts concerning potential hazards and safety concerns. The ASRS processes these reports, evaluates the information, and provides selected de-identified report information through the online ASRS Database at http:asrs.arc.nasa.gov. The NASA ASRS is also a founding member of the International Confidential Aviation Safety Systems (ICASS) group which is a collection of other national aviation reporting systems throughout the world. The ASRS model has also been replicated for application to improving safety in railroad, medical, fire fighting, and other domains. This presentation will discuss confidential, voluntary, and non-punitive reporting systems and their advantages in providing information for safety improvements.
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Patient participation in patient safety and nursing input - a systematic review.
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
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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.
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Patient Safety and Healthcare Quality
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...
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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.)
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Patient safety is not elective: a debate at the NPSF Patient Safety Congress.
McTiernan, Patricia; Wachter, Robert M; Meyer, Gregg S; Gandhi, Tejal K
2015-02-01
The opening keynote session of the 16th Annual National Patient Safety Foundation Patient Safety Congress, held 14-16 May 2014, featured a debate addressing the merits and challenges of accountability with respect to key issues in patient safety. The specific resolution debated was: Certain safety practices should be inviolable, and transgressions should result in penalties, potentially including fines, suspensions, and firing. The themes discussed in the debate are issues that healthcare professionals and leaders commonly struggle with in their day-to-day work. How do we draw a line between systems problems and personal failings? When should clinicians and staff be penalised for failing to follow a known safety protocol? The majority of those who listened to the live debate agreed that it is time to begin holding health professionals accountable when they wilfully or repeatedly violate policies or protocols put in place by their institutions to protect the safety of patients. This article summarises the debate as well as the questions and discussion generated by each side. A video of the original debate can be found at http://bit.ly/Npsf_debate. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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Patient Safety in Spine Surgery: Regarding the Wrong-Site Surgery
Lee, Seung-Hwan; Kim, Ji-Sup; Jeong, Yoo-Chul; Kwak, Dae-Kyung; Chun, Ja-Hae; Lee, Hwan-Mo
2013-01-01
Patient safety regarding wrong site surgery has been one of the priority issues in surgical fields including that of spine care. Since the wrong-side surgery in the DM foot patient was reported on a public mass media in 1996, the wrong-site surgery issue has attracted wide public interest as regarding patient safety. Despite the many wrong-site surgery prevention campaigns in spine care such as the operate through your initial program by the Canadian Orthopaedic Association, the sign your sit...
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Psychological safety and error reporting within Veterans Health Administration hospitals.
Derickson, Ryan; Fishman, Jonathan; Osatuke, Katerine; Teclaw, Robert; Ramsel, Dee
2015-03-01
In psychologically safe workplaces, employees feel comfortable taking interpersonal risks, such as pointing out errors. Previous research suggested that psychologically safe climate optimizes organizational outcomes. We evaluated psychological safety levels in Veterans Health Administration (VHA) hospitals and assessed their relationship to employee willingness of reporting medical errors. We conducted an ANOVA on psychological safety scores from a VHA employees census survey (n = 185,879), assessing variability of means across racial and supervisory levels. We examined organizational climate assessment interviews (n = 374) evaluating how many employees asserted willingness to report errors (or not) and their stated reasons. Finally, based on survey data, we identified 2 (psychologically safe versus unsafe) hospitals and compared their number of employees who would be willing/unwilling to report an error. Psychological safety increased with supervisory level (P hospital (71% would report, 13% would not) were less willing to report an error than at the psychologically safe hospital (91% would, 0% would not). A substantial minority would not report an error and were willing to admit so in a private interview setting. Their stated reasons as well as higher psychological safety means for supervisory employees both suggest power as an important determinant. Intentions to report were associated with psychological safety, strongly suggesting this climate aspect as instrumental to improving patient safety and reducing costs.
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A 2-year study of patient safety competency assessment in 29 clinical laboratories.
Reed, Robyn C; Kim, Sara; Farquharson, Kara; Astion, Michael L
2008-06-01
Competency assessment is critical for laboratory operations and is mandated by the Clinical Laboratory Improvement Amendments of 1988. However, no previous reports describe methods for assessing competency in patient safety. We developed and implemented a Web-based tool to assess performance of 875 laboratory staff from 29 laboratories in patient safety. Question categories included workplace culture, categorizing error, prioritization of patient safety interventions, strength of specific interventions, and general patient safety concepts. The mean score was 85.0%, with individual scores ranging from 56% to 100% and scores by category from 81.3% to 88.6%. Of the most difficult questions (laboratory technologists. Computer-based competency assessments help laboratories identify topics for continuing education in patient safety.
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Why is patient safety so hard? A selective review of ethnographic studies.
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.
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Patient portal readiness among postpartum patients in a safety net setting.
Wieland, Daryl; Gibeau, Anne; Dewey, Caitlin; Roshto, Melanie; Frankel, Hilary
2017-07-05
Maternity patients interact with the healthcare system over an approximately ten-month interval, requiring multiple visits, acquiring pregnancy-specific education, and sharing health information among providers. Many features of a web-based patient portal could help pregnant women manage their interactions with the healthcare system; however, it is unclear whether pregnant women in safety-net settings have the resources, skills or interest required for portal adoption. In this study of postpartum patients in a safety net hospital, we aimed to: (1) determine if patients have the technical resources and skills to access a portal, (2) gain insight into their interest in health information, and (3) identify the perceived utility of portal features and potential barriers to adoption. We developed a structured questionnaire to collect demographics from postpartum patients and measure use of technology and the internet, self-reported literacy, interest in health information, awareness of portal functions, and perceived barriers to use. The questionnaire was administered in person to women in an inpatient setting. Of the 100 participants surveyed, 95% reported routine internet use and 56% used it to search for health information. Most participants had never heard of a patient portal, yet 92% believed that the portal functions were important. The two most appealing functions were to check results and manage appointments. Most participants in this study have the required resources such as a device and familiarity with the internet to access a patient portal including an interest in interacting with a healthcare institution via electronic means. Pregnancy is a critical episode of care where active engagement with the healthcare system can influence outcomes. Healthcare systems and portal developers should consider ways to tailor a portal to address the specific health needs of a maternity population including those in a safety net setting.
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Patients' and healthcare workers' perceptions of a patient safety advisory.
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.
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Patient-Reported Safety Information : A Renaissance of Pharmacovigilance?
Härmark, Linda; Raine, June; Leufkens, Bert|info:eu-repo/dai/nl/075255049; Edwards, I Ralph; Moretti, Ugo; Sarinic, Viola Macolic; Kant, Agnes
2016-01-01
The role of patients as key contributors in pharmacovigilance was acknowledged in the new EU pharmacovigilance legislation. This contains several efforts to increase the involvement of the general public, including making patient adverse drug reaction (ADR) reporting systems mandatory. Three years
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Assessment of patient safety culture in private and public hospitals in Peru.
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.
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Nurses' Perceptions of Patient Safety Culture in Three Hospitals in Saudi Arabia.
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.
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Lee, Eunjoo
2016-09-01
This study compared registered nurses' perceptions of safety climate and attitude toward medication error reporting before and after completing a hospital accreditation program. Medication errors are the most prevalent adverse events threatening patient safety; reducing underreporting of medication errors significantly improves patient safety. Safety climate in hospitals may affect medication error reporting. This study employed a longitudinal, descriptive design. Data were collected using questionnaires. A tertiary acute hospital in South Korea undergoing a hospital accreditation program. Nurses, pre- and post-accreditation (217 and 373); response rate: 58% and 87%, respectively. Hospital accreditation program. Perceived safety climate and attitude toward medication error reporting. The level of safety climate and attitude toward medication error reporting increased significantly following accreditation; however, measures of institutional leadership and management did not improve significantly. Participants' perception of safety climate was positively correlated with their attitude toward medication error reporting; this correlation strengthened following completion of the program. Improving hospitals' safety climate increased nurses' medication error reporting; interventions that help hospital administration and managers to provide more supportive leadership may facilitate safety climate improvement. Hospitals and their units should develop more friendly and intimate working environments that remove nurses' fear of penalties. Administration and managers should support nurses who report their own errors. © The Author 2016. 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.
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Vyas, Deepti; McCulloh, Russell; Dyer, Carla; Gregory, Gretchen; Higbee, Dena
2012-05-10
To assess the effectiveness of human patient simulation to teach patient safety, team-building skills, and the value of interprofessional collaboration to pharmacy students. Five scenarios simulating semi-urgent situations that required interprofessional collaboration were developed. Groups of 10 to 12 health professions students that included 1 to 2 pharmacy students evaluated patients while addressing patient safety hazards. Pharmacy students' scores on 8 of 30 items on a post-simulation survey of knowledge, skills, and attitudes improved over pre-simulation scores. Students' scores on 3 of 10 items on a team building and interprofessional communications survey also improved after participating in the simulation exercise. Over 90% of students reported that simulation increased their understanding of professional roles and the importance of interprofessional communication. Simulation training provided an opportunity to improve pharmacy students' ability to recognize and react to patient safety concerns and enhanced their interprofessional collaboration and communication skills.
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International Nuclear Information System (INIS)
1986-10-01
This report includes information on a) tritium handling and safety; b) activation product generation and release; c) lithium safety; d) superconducting magnet safety; e) operational safety and shielding; f) environmental impact; g) recycling, decommissioning and waste management; and h) accident analysis. Recommendations for high priority research and development are presented, as well as the current status in each area
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Aviation and healthcare: a comparative review with implications for patient safety.
Kapur, Narinder; Parand, Anam; Soukup, Tayana; Reader, Tom; Sevdalis, Nick
2016-01-01
Safety in aviation has often been compared with safety in healthcare. Following a recent article in this journal, the UK government set up an Independent Patient Safety Investigation Service, to emulate a similar well-established body in aviation. On the basis of a detailed review of relevant publications that examine patient safety in the context of aviation practice, we have drawn up a table of comparative features and a conceptual framework for patient safety. Convergence and divergence of safety-related behaviours across aviation and healthcare were derived and documented. Key safety-related domains that emerged included Checklists, Training, Crew Resource Management, Sterile Cockpit, Investigation and Reporting of Incidents and Organisational Culture. We conclude that whilst healthcare has much to learn from aviation in certain key domains, the transfer of lessons from aviation to healthcare needs to be nuanced, with the specific characteristics and needs of healthcare borne in mind. On the basis of this review, it is recommended that healthcare should emulate aviation in its resourcing of staff who specialise in human factors and related psychological aspects of patient safety and staff wellbeing. Professional and post-qualification staff training could specifically include Cognitive Bias Avoidance Training, as this appears to play a key part in many errors relating to patient safety and staff wellbeing.
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National nuclear safety report 2005. Convention on nuclear safety
International Nuclear Information System (INIS)
2006-01-01
This National Nuclear Safety Report was presented at the 3rd. Review meeting. In general the information contained in the report are: Highlights / Themes; Follow-up from 2nd. Review meeting; Challenges, achievements and good practices; Planned measures to improve safety; Updates to National report to 3rd. Review meeting; Questions from peer review of National Report; and Conclusions
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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
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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.
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Educating future leaders in patient safety
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
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International Nuclear Information System (INIS)
1983-12-01
In this safety report, general information is offered about the safety policy at the NIKHEF-K institute Amsterdam. Costs, prevention, training courses and inspection related to (radiation) safety are briefly discussed. Small accidents are reported. Some measurements have been carried out, but no measurable increase of radiation doses have been found. (Auth.)
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Patient safety culture in primary care
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
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Patient Involvement in Patient Safety: A Qualitative Study of Nursing Staff and Patient Perceptions.
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.
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[An approach to care indicators benchmarking. Learning to improve patient safety].
de Andrés Gimeno, B; Salazar de la Guerra, R M; Ferrer Arnedo, C; Revuelta Zamorano, M; Ayuso Murillo, D; González Soria, J
2014-01-01
Improvements in clinical safety can be achieved by promoting a safety culture, professional training, and learning through benchmarking. The aim of this study was to identify areas for improvement after analysing the safety indicators in two public Hospitals in North-West Madrid Region. Descriptive study performed during 2011 in Hospital Universitario Puerta de Hierro Majadahonda (HUPHM) and Hospital de Guadarrama (HG). The variables under study were 40 indicators on nursing care related to patient safety. Nineteen of them were defined in the SENECA project as care quality standards in order to improve patient safety in the hospitals. The data collected were clinical history, Madrid Health Service assessment reports, care procedures, and direct observation Within the 40 indicators: 22 of them were structured (procedures), HUPHM had 86%, and HG 95% 14 process indicators (training and protocols compliance) with similar results in both hospitals, apart from the care continuity reports and training in hand hygiene. The 4 results indicators (pressure ulcer, falls and pain) showed different results. The analysis of the indicators allowed the following actions to be taken: to identify improvements to be made in each hospital, to develop joint safety recommendations in nursing care protocols in prevention and treatment of chronic wound, to establish systematic pain assessments, and to prepare continuity care reports on all patients transferred from HUPHM to HG. Copyright © 2013 SECA. Published by Elsevier Espana. All rights reserved.
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Patient safety in primary care: a survey of general practitioners in the Netherlands
Directory of Open Access Journals (Sweden)
Wensing Michel
2010-01-01
Full Text Available Abstract Background Primary care encompasses many different clinical domains and patient groups, which means that patient safety in primary care may be equally broad. Previous research on safety in primary care has focused on medication safety and incident reporting. In this study, the views of general practitioners (GPs on patient safety were examined. Methods A web-based survey of a sample of GPs was undertaken. The items were derived from aspects of patient safety issues identified in a prior interview study. The questionnaire used 10 clinical cases and 15 potential risk factors to explore GPs' views on patient safety. Results A total of 68 GPs responded (51.5% response rate. None of the clinical cases was uniformly judged as particularly safe or unsafe by the GPs. Cases judged to be unsafe by a majority of the GPs concerned either the maintenance of medical records or prescription and monitoring of medication. Cases which only a few GPs judged as unsafe concerned hygiene, the diagnostic process, prevention and communication. The risk factors most frequently judged to constitute a threat to patient safety were a poor doctor-patient relationship, insufficient continuing education on the part of the GP and a patient age over 75 years. Language barriers and polypharmacy also scored high. Deviation from evidence-based guidelines and patient privacy in the reception/waiting room were not perceived as risk factors by most of the GPs. Conclusion The views of GPs on safety and risk in primary care did not completely match those presented in published papers and policy documents. The GPs in the present study judged a broader range of factors than in previously published research on patient safety in primary care, including a poor doctor-patient relationship, to pose a potential threat to patient safety. Other risk factors such as infection prevention, deviation from guidelines and incident reporting were judged to be less relevant than by policy
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Patient safety in primary care: a survey of general practitioners in The Netherlands.
Gaal, Sander; Verstappen, Wim; Wensing, Michel
2010-01-21
Primary care encompasses many different clinical domains and patient groups, which means that patient safety in primary care may be equally broad. Previous research on safety in primary care has focused on medication safety and incident reporting. In this study, the views of general practitioners (GPs) on patient safety were examined. A web-based survey of a sample of GPs was undertaken. The items were derived from aspects of patient safety issues identified in a prior interview study. The questionnaire used 10 clinical cases and 15 potential risk factors to explore GPs' views on patient safety. A total of 68 GPs responded (51.5% response rate). None of the clinical cases was uniformly judged as particularly safe or unsafe by the GPs. Cases judged to be unsafe by a majority of the GPs concerned either the maintenance of medical records or prescription and monitoring of medication. Cases which only a few GPs judged as unsafe concerned hygiene, the diagnostic process, prevention and communication. The risk factors most frequently judged to constitute a threat to patient safety were a poor doctor-patient relationship, insufficient continuing education on the part of the GP and a patient age over 75 years. Language barriers and polypharmacy also scored high. Deviation from evidence-based guidelines and patient privacy in the reception/waiting room were not perceived as risk factors by most of the GPs. The views of GPs on safety and risk in primary care did not completely match those presented in published papers and policy documents. The GPs in the present study judged a broader range of factors than in previously published research on patient safety in primary care, including a poor doctor-patient relationship, to pose a potential threat to patient safety. Other risk factors such as infection prevention, deviation from guidelines and incident reporting were judged to be less relevant than by policy makers.
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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.
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Role of effective nurse-patient relationships in enhancing patient safety.
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.
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Haneda, Masakazu; Kadowaki, Takashi; Ito, Hiroshi; Sasaki, Kazuyo; Hiraide, Sonoe; Ishii, Manabu; Matsukawa, Miyuki; Ueno, Makoto
2018-06-01
Teneligliptin is a novel oral dipeptidyl peptidase-4 inhibitor for the treatment of type 2 diabetes mellitus (T2DM). Safety and efficacy of teneligliptin have been demonstrated in clinical studies; however, data supporting its use in patients with moderate or severe renal impairment are limited. This interim analysis of a post-marketing surveillance of teneligliptin, exploRing the long-term efficacy and safety included cardiovascUlar events in patients with type 2 diaBetes treated bY teneligliptin in the real-world (RUBY), aims to verify the long-term safety and efficacy of teneligliptin in Japanese patients with T2DM and impaired renal function. For this analysis, we used the data from case report forms of the RUBY surveillance between May 2013 and June 2017. The patients were classified into G1-G5 stages of chronic kidney disease according to estimated glomerular filtration rate (eGFR) at initiation of teneligliptin treatment. Safety and efficacy were evaluated in these subgroups. Patients on dialysis were also assessed. Safety was assessed from adverse drug reactions (ADRs). Glycemic control was evaluated up to 2 years after teneligliptin initiation. A total of 11,677 patients were enrolled in the surveillance and 11,425 patient case-report forms were collected for the interim analysis. The incidence of ADRs in each subgroup was 2.98-6.98% of patients, with no differences in the ADR profile (including hypoglycemia and renal function ADRs) between subgroups. At 1 and 2 years after starting teneligliptin, the least-squares mean change in HbA1c adjusted to the baseline was - 0.68 to - 0.85% and - 0.71 to - 0.85% across the eGFR groups, respectively. Treatment with teneligliptin in patients on dialysis reduced or tended to reduce glycated albumin levels [- 2.29%, (p < 0.001) after 1 year; - 1.64%, (p = 0.064) after 2 years]. During long-term treatment, teneligliptin was generally well tolerated in patients with any stage of renal impairment from
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RB research reactor safety report
International Nuclear Information System (INIS)
Sotic, O.; Pesic, M.; Vranic, S.
1979-04-01
This new version of the safety report is a revision of the safety report written in 1962 when the RB reactor started operation after reconstruction. The new safety report was needed because reactor systems and components have been improved and the administrative procedures were changed. the most important improvements and changes were concerned with the use of highly enriched fuel (80% enriched), construction of reactor converter outside the reactor vessel, improved control system by two measuring start-up channels, construction of system for heavy water leak detection, new inter phone connection between control room and other reactor rooms. This report includes description of reactor building with installations, rector vessel, reactor core, heavy water system, control system, safety system, dosimetry and alarm systems, experimental channels, neutron converter, reactor operation. Safety aspects contain analyses of accident reasons, method for preventing reactivity insertions, analyses of maximum hypothetical accidents for cores with natural uranium, 2% enriched and 80% enriched fuel elements. Influence of seismic events on the reactor safety and well as coupling between reactor and the converter are parts of this document
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Patient Safety in Pediatrics: a Developing Discipline
C. van der Starre (Cynthia)
2011-01-01
markdownabstract__Abstract__ The publication of the breakthrough report “To Err is Human” by the Institute of Medicine was the launch of patient safety initiatives all over the world. In the intensive care unit (ICU) of the Erasmus MC-Sophia Children’s Hospital this resulted in the institution
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Verbeek-van Noord, I.; Wagner, C.; Dyck, C. van; Twisk, J.W.R.; Bruijne, M.C. de
2014-01-01
Objective: To describe the patient safety culture of Dutch emergency departments (EDs), to examine associations between safety culture dimensions and patient safety grades as reported by ED staff and to compare these associations between nurses and physicians. DESIGN: Cross-sectional survey
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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
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How to Improve Patient Safety Culture in Croatian Hospitals?
Šklebar, Ivan; Mustajbegović, Jadranka; Šklebar, Duška; Cesarik, Marijan; Milošević, Milan; Brborović, Hana; Šporčić, Krunoslav; Petrić, Petar; Husedžinović, Ino
2016-09-01
Patient safety culture (PCS) has a crucial impact on the safety practices of healthcare delivery systems. The purpose of this study was to assess the state of PSC in Croatian hospitals and compare it with hospitals in the United States. The study was conducted in three public general hospitals in Croatia using the Croatian translation of the Hospital Survey of Patient Safety Culture (HSOPSC). A comparison of the results from Croatian and American hospitals was performed using a T-square test. We found statistically significant differences in all 12 PSC dimensions. Croatian responses were more positive in the two dimensions of Handoff s and Transitions and Overall Perceptions of Patient Safety. In the remaining ten dimensions, Croatian responses were less positive than in US hospitals, with the most prominent areas being Nonpunitive Response to Error, Frequency of Events Reported, Communication Openness, Teamwork within Units, Feedback & Communication about Error, Management Support for Patient Safety, and Staffing. Our findings show that PSC is significantly lower in Croatian than in American hospitals, particularly in the areas of Nonpunitive Response to Error, Leadership, Teamwork, Communication Openness and Staffing. This suggests that a more comprehensive system for the improvement of patient safety within the framework of the Croatian healthcare system needs to be developed. Our findings also help confirm that HSOPSC is a useful and appropriate tool for the assessment of PSC. HSOPSC highlights the PSC components in need of improvement and should be considered for use in national and international benchmarking.
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Hull, Louise; Soukup, Tayana; Mayer, Erik; Athanasiou, Thanos; Sevdalis, Nick; Darzi, Ara
2017-01-01
Objectives The development and implementation of incident reporting systems within healthcare continues to be a fundamental strategy to reduce preventable patient harm and improve the quality and safety of healthcare. We sought to identify factors contributing to patient safety incident reporting. Design To facilitate improvements in incident reporting, a theoretical framework, encompassing factors that act as barriers and enablers ofreporting, was developed. Embase, Ovid MEDLINE(R) and PsycINFO were searched to identify relevant articles published between January 1980 and May 2014. A comprehensive search strategy including MeSH terms and keywords was developed to identify relevant articles. Data were extracted by three independent researchers; to ensure the accuracy of data extraction, all studies eligible for inclusion were rescreened by two reviewers. Results The literature search identified 3049 potentially eligible articles; of these, 110 articles, including >29 726 participants, met the inclusion criteria. In total, 748 barriers were identified (frequency count) across the 110 articles. In comparison, 372 facilitators to incident reporting and 118 negative cases were identified. The top two barriers cited were fear of adverse consequences (161, representing 21.52% of barriers) and process and systems of reporting (110, representing 14.71% of barriers). In comparison, the top two facilitators were organisational (97, representing 26.08% of facilitators) and process and systems of reporting (75, representing 20.16% of facilitators). Conclusion A wide range of factors contributing to engagement in incident reporting exist. Efforts that address the current tendency to under-report must consider the full range of factors in order to develop interventions as well as a strategic policy approach for improvement. PMID:29284714
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Snijders, Cathelijne; Kollen, Boudewijn J.; van Lingen, Richard A.; Fetter, Willem P. F.; Molendijk, Harry; Kok, J. H.; te Pas, E.; Pas, H.; van der Starre, C.; Bloemendaal, E.; Lopes Cardozo, R. H.; Molenaar, A. M.; Giezen, A.; van Lingen, R. A.; Maat, H. E.; Molendijk, A.; Snijders, C.; Lavrijssen, S.; Mulder, A. L. M.; de Kleine, M. J. K.; Koolen, A. M. P.; Schellekens, M.; Verlaan, W.; Vrancken, S.; Fetter, W. P. F.; Schotman, L.; van der Zwaan, A.; van der Tuijn, Y.; Tibboel, D.; van der Schaaf, T. W.; Klip, H.; Kollen, B. J.
2009-01-01
OBJECTIVES: Safety culture assessments are increasingly used to evaluate patient-safety programs. However, it is not clear which aspects of safety culture are most relevant in understanding incident reporting behavior, and ultimately improving patient safety. The objective of this study was to
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DEFF Research Database (Denmark)
Kristensen, Solvejg; Mainz, Jan; Bartels, Paul
2009-01-01
such as culture, infections, surgical complications, medication errors, obstetrics, falls and specific diagnostic areas. CONCLUSION: The patient safety indicators recommended present a set of possible measures of patient safety. One of the future perspectives of implementing patient safety indicators...... for systematic monitoring is that it will be possible to continuously estimate the prevalence and incidence of patient safety quality problems. The lesson learnt from quality improvement is that it will pay off in terms of improving patient safety....
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Patients for patient safety in China: a cross sectional study.
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
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Role of a quality management system in improving patient safety - laboratory aspects.
Allen, Lynn C
2013-09-01
The aim of this study is to describe how implementation of a quality management system (QMS) based on ISO 15189 enhances patient safety. A literature review showed that several European hospitals implemented a QMS based on ISO 9001 and assessed the impact on patient safety. An Internet search showed that problems affecting patient safety have occurred in a number of laboratories across Canada. The requirements of a QMS based on ISO 15189 are outlined, and the impact of the implementation of each requirement on patient safety is summarized. The Quality Management Program - Laboratory Services in Ontario is briefly described, and the experience of Ontario laboratories with Ontario Laboratory Accreditation, based on ISO 15189, is outlined. Several hospitals that implemented ISO 9001 reported either a positive impact or no impact on patient safety. Patient safety problems in Canadian laboratories are described. Implementation of each requirement of the QMS can be seen to have a positive effect on patient safety. Average laboratory conformance on Ontario Laboratory Accreditation is very high, and laboratories must address and resolve any nonconformities. Other standards, practices, and quality requirements may also contribute to patient safety. Implementation of a QMS based on ISO 15189 provides a solid foundation for quality in the laboratory and enhances patient safety. It helps to prevent patient safety issues; when such issues do occur, effective processes are in place for investigation and resolution. Patient safety problems in Canadian laboratories might have been prevented had effective QMSs been in place. Ontario Laboratory Accreditation has had a positive impact on quality in Ontario laboratories. Copyright © 2013 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.
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Making Residents Part of the Safety Culture: Improving Error Reporting and Reducing Harms.
Fox, Michael D; Bump, Gregory M; Butler, Gabriella A; Chen, Ling-Wan; Buchert, Andrew R
2017-01-30
Reporting medical errors is a focus of the patient safety movement. As frontline physicians, residents are optimally positioned to recognize errors and flaws in systems of care. Previous work highlights the difficulty of engaging residents in identification and/or reduction of medical errors and in integrating these trainees into their institutions' cultures of safety. The authors describe the implementation of a longitudinal, discipline-based, multifaceted curriculum to enhance the reporting of errors by pediatric residents at Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center. The key elements of this curriculum included providing the necessary education to identify medical errors with an emphasis on systems-based causes, modeling of error reporting by faculty, and integrating error reporting and discussion into the residents' daily activities. The authors tracked monthly error reporting rates by residents and other health care professionals, in addition to serious harm event rates at the institution. The interventions resulted in significant increases in error reports filed by residents, from 3.6 to 37.8 per month over 4 years (P error reporting correlated with a decline in serious harm events, from 15.0 to 8.1 per month over 4 years (P = 0.01). Integrating patient safety into the everyday resident responsibilities encourages frequent reporting and discussion of medical errors and leads to improvements in patient care. Multiple simultaneous interventions are essential to making residents part of the safety culture of their training hospitals.
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Perspective of Nurses toward the Patient Safety Culture in Neonatal Intensive Care Units
Directory of Open Access Journals (Sweden)
Saba Farzi
2017-12-01
Conclusion: According to the results, adherence to the dimensions of the patient safety culture was poor in the studied hospitals. Therefore, the patient safety culture requires special attention by providing proper facilities, adequate staff, developing checklists for handoffs and transitions, and surveillance and continuous monitoring by healthcare centers. Furthermore, a system-based approach should be implemented to deal with errors, while a persuasive reporting approach is needed to promote the patient safety culture in the NICUs of these hospitals.
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Hospital nurses' working conditions in relation to motivation and patient safety.
Toode, Kristi; Routasalo, Pirkko; Helminen, Mika; Suominen, Tarja
2015-03-01
There is a lack of empirical knowledge about nurses' perceptions of their workplace characteristics and conditions, such as level of autonomy and decision authority, work climate, teamwork, skill exploitation and learning opportunities, and their work motivation in relation to practice outputs such as patient safety. Such knowledge is needed particularly in countries, such as Estonia, where hospital systems for preventing errors and improving patient safety are in the early stages of development. This article reports the findings from a cross-sectional survey of hospital nurses in Estonia that was aimed at determining their perceptions of workplace characteristics, working conditions, work motivation and patient safety, and at exploring the relationship between these. Results suggest that perceptions of personal control over their work can affect nurses' motivation, and that perceptions of work satisfaction might be relevant to patient safety improvement work.
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Fong, Allan; Harriott, Nicole; Walters, Donna M; Foley, Hanan; Morrissey, Richard; Ratwani, Raj R
2017-08-01
Many healthcare providers have implemented patient safety event reporting systems to better understand and improve patient safety. Reviewing and analyzing these reports is often time consuming and resource intensive because of both the quantity of reports and length of free-text descriptions in the reports. Natural language processing (NLP) experts collaborated with clinical experts on a patient safety committee to assist in the identification and analysis of medication related patient safety events. Different NLP algorithmic approaches were developed to identify four types of medication related patient safety events and the models were compared. Well performing NLP models were generated to categorize medication related events into pharmacy delivery delays, dispensing errors, Pyxis discrepancies, and prescriber errors with receiver operating characteristic areas under the curve of 0.96, 0.87, 0.96, and 0.81 respectively. We also found that modeling the brief without the resolution text generally improved model performance. These models were integrated into a dashboard visualization to support the patient safety committee review process. We demonstrate the capabilities of various NLP models and the use of two text inclusion strategies at categorizing medication related patient safety events. The NLP models and visualization could be used to improve the efficiency of patient safety event data review and analysis. Copyright © 2017 Elsevier B.V. All rights reserved.
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Safe patient care - safety culture and risk management in otorhinolaryngology.
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
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[Safe patient care: safety culture and risk management in otorhinolaryngology].
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
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Pitts, Samantha I; Maruthur, Nisa M; Luu, Ngoc-Phuong; Curreri, Kimberly; Grimes, Renee; Nigrin, Candace; Sateia, Heather F; Sawyer, Melinda D; Pronovost, Peter J; Clark, Jeanne M; Peairs, Kimberly S
2017-11-01
While there is growing awareness of the risk of harm in ambulatory health care, most patient safety efforts have focused on the inpatient setting. The Comprehensive Unit-based Safety Program (CUSP) has been an integral part of highly successful safety efforts in inpatient settings. In 2014 CUSP was implemented in an academic primary care practice. As part of CUSP implementation, staff and clinicians underwent training on the science of safety and completed a two-question safety assessment survey to identify safety concerns in the practice. The concerns identified by team members were used to select two initial safety priorities. The impact of CUSP on safety climate and teamwork was assessed through a pre-post comparison of results on the validated Safety Attitudes Questionnaire. Ninety-six percent of staff completed science of safety training as part of CUSP implementation, and 100% of staff completed the two-question safety assessment. The most frequently identified safety concerns were related to medications (n = 11, 28.2), diagnostic testing (n = 9, 25), and communication (n = 5, 14). The CUSP team initially prioritized communication and infection control, which led to standardization of work flows within the practice. Six months following CUSP implementation, large but nonstatistically significant increases were found for the percentage of survey respondents who reported knowledge of the proper channels for questions about patient safety, felt encouraged to report safety concerns, and believed that the work setting made it easy to learn from the errors of others. CUSP is a promising tool to improve safety climate and to identify and address safety concerns within ambulatory health care. Copyright © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved.
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2011 NASA Range Safety Annual Report
Dumont, Alan G.
2012-01-01
Welcome to the 2011 edition of the NASA Range Safety Annual Report. Funded by NASA Headquarters, this report provides a NASA Range Safety overview for current and potential range users. As is typical with odd year editions, this is an abbreviated Range Safety Annual Report providing updates and links to full articles from the previous year's report. It also provides more complete articles covering new subject areas, summaries of various NASA Range Safety Program activities conducted during the past year, and information on several projects that may have a profound impact on the way business will be done in the future. Specific topics discussed and updated in the 2011 NASA Range Safety Annual Report include a program overview and 2011 highlights; Range Safety Training; Range Safety Policy revision; Independent Assessments; Support to Program Operations at all ranges conducting NASA launch/flight operations; a continuing overview of emerging range safety-related technologies; and status reports from all of the NASA Centers that have Range Safety responsibilities. Every effort has been made to include the most current information available. We recommend this report be used only for guidance and that the validity and accuracy of all articles be verified for updates. Once again the web-based format was used to present the annual report. We continually receive positive feedback on the web-based edition and hope you enjoy this year's product as well. As is the case each year, contributors to this report are too numerous to mention, but we thank individuals from the NASA Centers, the Department of Defense, and civilian organizations for their contributions. In conclusion, it has been a busy and productive year. I'd like to extend a personal Thank You to everyone who contributed to make this year a successful one, and I look forward to working with all of you in the upcoming year.
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Colorectal Cancer Safety Net: Is It Catching Patients Appropriately?
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
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International Nuclear Information System (INIS)
R.J. Garrett
2002-01-01
As part of the internal Integrated Safety Management Assessment verification process, it was determined that there was a lack of documentation that summarizes the safety basis of the current Yucca Mountain Project (YMP) site characterization activities. It was noted that a safety basis would make it possible to establish a technically justifiable graded approach to the implementation of the requirements identified in the Standards/Requirements Identification Document. The Standards/Requirements Identification Documents commit a facility to compliance with specific requirements and, together with the hazard baseline documentation, provide a technical basis for ensuring that the public and workers are protected. This Safety Basis Report has been developed to establish and document the safety basis of the current site characterization activities, establish and document the hazard baseline, and provide the technical basis for identifying structures, systems, and components (SSCs) that perform functions necessary to protect the public, the worker, and the environment from hazards unique to the YMP site characterization activities. This technical basis for identifying SSCs serves as a grading process for the implementation of programs such as Conduct of Operations (DOE Order 5480.19) and the Suspect/Counterfeit Items Program. In addition, this report provides a consolidated summary of the hazards analyses processes developed to support the design, construction, and operation of the YMP site characterization facilities and, therefore, provides a tool for evaluating the safety impacts of changes to the design and operation of the YMP site characterization activities
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Energy Technology Data Exchange (ETDEWEB)
R.J. Garrett
2002-01-14
As part of the internal Integrated Safety Management Assessment verification process, it was determined that there was a lack of documentation that summarizes the safety basis of the current Yucca Mountain Project (YMP) site characterization activities. It was noted that a safety basis would make it possible to establish a technically justifiable graded approach to the implementation of the requirements identified in the Standards/Requirements Identification Document. The Standards/Requirements Identification Documents commit a facility to compliance with specific requirements and, together with the hazard baseline documentation, provide a technical basis for ensuring that the public and workers are protected. This Safety Basis Report has been developed to establish and document the safety basis of the current site characterization activities, establish and document the hazard baseline, and provide the technical basis for identifying structures, systems, and components (SSCs) that perform functions necessary to protect the public, the worker, and the environment from hazards unique to the YMP site characterization activities. This technical basis for identifying SSCs serves as a grading process for the implementation of programs such as Conduct of Operations (DOE Order 5480.19) and the Suspect/Counterfeit Items Program. In addition, this report provides a consolidated summary of the hazards analyses processes developed to support the design, construction, and operation of the YMP site characterization facilities and, therefore, provides a tool for evaluating the safety impacts of changes to the design and operation of the YMP site characterization activities.
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Patient safety culture in Norwegian nursing homes.
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
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RB research reactor Safety Report
International Nuclear Information System (INIS)
Sotic, O.; Pesic, M.; Vranic, S.
1979-04-01
This RB reactor safety report is a revised and improved version of the Safety report written in 1962. It contains descriptions of: reactor building, reactor hall, control room, laboratories, reactor components, reactor control system, heavy water loop, neutron source, safety system, dosimetry system, alarm system, neutron converter, experimental channels. Safety aspects of the reactor operation include analyses of accident causes, errors during operation, measures for preventing uncontrolled activity changes, analysis of the maximum possible accident in case of different core configurations with natural uranium, slightly and highly enriched fuel; influence of possible seismic events
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Patient safety competency and educational needs of nursing educators in South Korea
2017-01-01
Background Nursing educators must be qualified to teach patient safety to nursing students to ensure patient safety in the clinical field. The purpose of this study was to assess nursing educators’ competencies and educational needs for patient safety in hospitals and nursing schools. Method A mixed-methods sequential explanatory design employed a survey and focus group interview with nursing educators (school clinical instructors and hospital nurse preceptors). Thirty-eight questionnaires filled out by clinical instructors from six four-year nursing universities and 106 questionnaires from nurse preceptors from three high-level general hospitals in the Seoul metropolitan area were analyzed to obtain quantitative data. Focus group interviews were conducted among six clinical instructors from one nursing school and four nurse preceptors from one high-level general hospital in Seoul. Results Nursing educators had higher levels of attitude compared with relatively lower levels of skill and knowledge regarding patient safety. They reported educational needs of “medication” and “infection prevention” as being higher and “human factors” and “complexity of systems” as being lower. Nursing educators desired different types of education for patient safety. Conclusion It is necessary to enhance nursing educators’ patient safety skills and knowledge by developing and providing an integrated program of patient safety, with various teaching methods to meet their educational needs. The findings of this study provide the basic information needed to reform patient safety education programs appropriately to fit nursing educators' needs and their patient safety competencies in both clinical practice and academia. Furthermore, the findings have revealed the importance of effective communication between clinical and academic settings in making patient safety education seamless. PMID:28873099
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Patient safety competency and educational needs of nursing educators in South Korea.
Directory of Open Access Journals (Sweden)
Haena Jang
Full Text Available Nursing educators must be qualified to teach patient safety to nursing students to ensure patient safety in the clinical field. The purpose of this study was to assess nursing educators' competencies and educational needs for patient safety in hospitals and nursing schools.A mixed-methods sequential explanatory design employed a survey and focus group interview with nursing educators (school clinical instructors and hospital nurse preceptors. Thirty-eight questionnaires filled out by clinical instructors from six four-year nursing universities and 106 questionnaires from nurse preceptors from three high-level general hospitals in the Seoul metropolitan area were analyzed to obtain quantitative data. Focus group interviews were conducted among six clinical instructors from one nursing school and four nurse preceptors from one high-level general hospital in Seoul.Nursing educators had higher levels of attitude compared with relatively lower levels of skill and knowledge regarding patient safety. They reported educational needs of "medication" and "infection prevention" as being higher and "human factors" and "complexity of systems" as being lower. Nursing educators desired different types of education for patient safety.It is necessary to enhance nursing educators' patient safety skills and knowledge by developing and providing an integrated program of patient safety, with various teaching methods to meet their educational needs. The findings of this study provide the basic information needed to reform patient safety education programs appropriately to fit nursing educators' needs and their patient safety competencies in both clinical practice and academia. Furthermore, the findings have revealed the importance of effective communication between clinical and academic settings in making patient safety education seamless.
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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 ...
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Zhu, Junya
2018-06-11
Self-report instruments have been widely used to better understand variations in patient safety climate between physicians and nurses. Research is needed to determine whether differences in patient safety climate reflect true differences in the underlying concepts. This is known as measurement equivalence, which is a prerequisite for meaningful group comparisons. This study aims to examine the degree of measurement equivalence of the responses to a patient safety climate survey of Chinese hospitals and to demonstrate how the measurement equivalence method can be applied to self-report climate surveys for patient safety research. Using data from the Chinese Hospital Survey of Patient Safety Climate from six Chinese hospitals in 2011, we constructed two groups: physicians and nurses (346 per group). We used multiple-group confirmatory factor analyses to examine progressively more stringent restrictions for measurement equivalence. We identified weak factorial equivalence across the two groups. Strong factorial equivalence was found for Organizational Learning, Unit Management Support for Safety, Adequacy of Safety Arrangements, Institutional Commitment to Safety, Error Reporting and Teamwork. Strong factorial equivalence, however, was not found for Safety System, Communication and Peer Support and Staffing. Nevertheless, further analyses suggested that nonequivalence did not meaningfully affect the conclusions regarding physician-nurse differences in patient safety climate. Our results provide evidence of at least partial equivalence of the survey responses between nurses and physicians, supporting mean comparisons of its constructs between the two groups. The measurement equivalence approach is essential to ensure that conclusions about group differences are valid.
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Archer, Stephanie; Hull, Louise; Soukup, Tayana; Mayer, Erik; Athanasiou, Thanos; Sevdalis, Nick; Darzi, Ara
2017-12-27
The development and implementation of incident reporting systems within healthcare continues to be a fundamental strategy to reduce preventable patient harm and improve the quality and safety of healthcare. We sought to identify factors contributing to patient safety incident reporting. To facilitate improvements in incident reporting, a theoretical framework, encompassing factors that act as barriers and enablers ofreporting, was developed. Embase, Ovid MEDLINE(R) and PsycINFO were searched to identify relevant articles published between January 1980 and May 2014. A comprehensive search strategy including MeSH terms and keywords was developed to identify relevant articles. Data were extracted by three independent researchers; to ensure the accuracy of data extraction, all studies eligible for inclusion were rescreened by two reviewers. The literature search identified 3049 potentially eligible articles; of these, 110 articles, including >29 726 participants, met the inclusion criteria. In total, 748 barriers were identified (frequency count) across the 110 articles. In comparison, 372 facilitators to incident reporting and 118 negative cases were identified. The top two barriers cited were fear of adverse consequences (161, representing 21.52% of barriers) and process and systems of reporting (110, representing 14.71% of barriers). In comparison, the top two facilitators were organisational (97, representing 26.08% of facilitators) and process and systems of reporting (75, representing 20.16% of facilitators). A wide range of factors contributing to engagement in incident reporting exist. Efforts that address the current tendency to under-report must consider the full range of factors in order to develop interventions as well as a strategic policy approach for improvement. © 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.
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An international review of patient safety measures in radiotherapy practice
International Nuclear Information System (INIS)
Shafiq, Jesmin; Barton, Michael; Noble, Douglas; Lemer, Claire; Donaldson, Liam J.
2009-01-01
Errors from radiotherapy machine or software malfunction usually are well documented as they affect hundreds of patients, whereas random errors affecting individual patients are more difficult to be discovered and prevented. Although major clinical radiotherapy incidents have been reported, many more have remained unrecognised or have not been reported. The literature in this field is limited as it is mostly published as a result of investigation of major errors. We present a review of radiotherapy incidents internationally with the aim of identifying the domains where most errors occur through extensive review and synthesis of published reports, unpublished 'Grey literature' and departmental incident data. Our review of radiotherapy-related events in the last three decades (1976-2007) identified more than seven thousand (N = 7741) incidents and near misses. Three thousand one hundred and twenty-five incidents reported patient harm of variable intensity ranging from underdose increasing the risk of recurrence, to overdose causing toxicity, and even death for 1% (N = 38); 4616 events were near misses with no recognisable patient harm. Based on our review, a radiotherapy risk profile has been published by the WHO World Alliance for Patient Safety that highlights the role of communication, training and strict adherence to guidelines/protocols in improving the safety of radiotherapy process.
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Assessing Patient Activation among High-Need, High-Cost Patients in Urban Safety Net Care Settings.
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
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National nuclear safety report 1998. Convention on nuclear safety
International Nuclear Information System (INIS)
1998-01-01
The Argentine Republic subscribed the Convention on Nuclear Safety, approved by a Diplomatic Conference in Vienna, Austria, in June 17th, 1994. According to the provisions in Section 5th of the Convention, each Contracting Party shall submit for its examination a National Nuclear Safety Report about the measures adopted to comply with the corresponding obligations. This Report describes the actions that the Argentine Republic is carrying on since the beginning of its nuclear activities, showing that it complies with the obligations derived from the Convention, in accordance with the provisions of its Article 4. The analysis of the compliance with such obligations is based on the legislation in force, the applicable regulatory standards and procedures, the issued licenses, and other regulatory decisions. The corresponding information is described in the analysis of each of the Convention Articles constituting this Report. The present National Report has been performed in order to comply with Article 5 of the Convention on Nuclear Safety, and has been prepared as much as possible following the Guidelines Regarding National Reports under the Convention on Nuclear Safety, approved in the Preparatory Meeting of the Contracting Parties, held in Vienna in April 1997. This means that the Report has been ordered according to the Articles of the Convention on Nuclear Safety and the contents indicated in the guidelines. The information contained in the articles, which are part of the Report shows the compliance of the Argentine Republic, as a contracting party of such Convention, with the obligations assumed
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Annual report on occupational safety 1985
International Nuclear Information System (INIS)
1986-09-01
This report presents information on occupational safety relating to the Company's employees for the year 1985, and compares data with figures for the previous year. The following headings are listed: principle activities of BNFL, general policy and organisation, radiological safety, including whole body, skin and extremity, and internal organ doses, non-radiological safety, incidents reportable to the health and safety executive. (U.K.)
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Evaluation of the patient safety Leadership Walkabout programme of a hospital in Singapore.
Lim, Raymond Boon Tar; Ng, Benjamin Boon Lui; Ng, Kok Mun
2014-02-01
The Patient Safety Leadership Walkabout (PSLWA) programme is a commonly employed tool in the West, in which senior leaders visit sites within the hospital that are involved in patient care to talk to healthcare staff about patient safety issues. As there is a lack of perspective regarding PSLWA in Asia, we carried out an evaluation of its effectiveness in improving the patient safety culture in Tan Tock Seng Hospital, Singapore. A mixed methods analysis approach was used to review and evaluate all documents, protocols, meeting minutes, post-walkabout surveys, action plans and verbal feedback pertaining to the walkabouts conducted from January 2005 to October 2012. A total of 321 patient safety issues were identified during the study period. Of these, 308 (96.0%) issues were resolved as of November 2012. Among the various categories of issues raised, issues related to work environment were the most common (45.2%). Of all the issues raised during the walkabouts, 72.9% were not identified through other conventional methods of error detection. With respect to the hospital's patient safety culture, 94.8% of the participants reported an increased awareness in patient safety and 90.2% expressed comfort in openly and honestly discussing patient safety issues. PSLWA serves as a good tool to uncover latent errors before actual harm reaches the patient. If properly implemented, it is an effective method for engaging leadership, identifying patient safety issues, and supporting a culture of patient safety in the hospital setting.
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Whitehurst, Julie M; Schroder, John; Leonard, Dave; Horvath, Monica M; Cozart, Heidi; Ferranti, Jeffrey
2012-05-18
Transfusion and clinical laboratory services are high-volume activities involving complicated workflows across both ambulatory and inpatient environments. As a result, there are many opportunities for safety lapses, leading to patient harm and increased costs. Organizational techniques such as voluntary safety event reporting are commonly used to identify and prioritize risk areas across care settings. Creation of functional, standardized safety data structures that facilitate effective exploratory examination is therefore essential to drive quality improvement interventions. Unfortunately, voluntarily reported adverse event data can often be unstructured or ambiguously defined. To address this problem, we sought to create a "best-of-breed" patient safety classification for data contained in the Duke University Health System Safety Reporting System (SRS). Our approach was to implement the internationally recognized World Health Organization International Classification for Patient Safety Framework, supplemented with additional data points relevant to our organization. Data selection and integration into the hierarchical framework is discussed, as well as placement of the classification into the SRS. We evaluated the impact of the new SRS classification on system usage through comparisons of monthly average report rates and completion times before and after implementation. Monthly average inpatient transfusion reports decreased from 102.1 ± 14.3 to 91.6 ± 11.2, with the proportion of transfusion reports in our system remaining consistent before and after implementation. Monthly average transfusion report rates in the outpatient and homecare environments were not significantly different. Significant increases in clinical lab report rates were present across inpatient and outpatient environments, with the proportion of lab reports increasing after implementation. Report completion times increased modestly but not significantly from a practical standpoint. A
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Lee, Hoo-Yeon; Hahm, Myung-Il; Lee, Sang Gyu
2018-04-04
The purpose of this study was to examine undergraduate medical students' perceptions and intentions regarding patient safety during clinical clerkships. Cross-sectional study administered in face-to-face interviews using modified the Medical Student Safety Attitudes and Professionalism Survey (MSSAPS) from three colleges of medicine in Korea. We assessed medical students' perceptions of the cultures ('safety', 'teamwork', and 'error disclosure'), 'behavioural intentions' concerning patient safety issues and 'overall patient safety'. Confirmatory factor analysis and Spearman's correlation analyses was performed. In total, 194(91.9%) of the 211 third-year undergraduate students participated. 78% of medical students reported that the quality of care received by patients was impacted by teamwork during clinical rotations. Regarding error disclosure, positive scores ranged from 10% to 74%. Except for one question asking whether the disclosure of medical errors was an important component of patient safety (74%), the percentages of positive scores for all the other questions were below 20%. 41.2% of medical students have intention to disclose it when they saw a medical error committed by another team member. Many students had difficulty speaking up about medical errors. Error disclosure guidelines and educational efforts aimed at developing sophisticated communication skills are needed. This study may serve as a reference for other institutions planning patient safety education in their curricula. Assessing student perceptions of safety culture can provide clerkship directors and clinical service chiefs with information that enhances the educational environment and promotes patient safety.
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Directory of Open Access Journals (Sweden)
Farahnaz Abdolahzadeh
2012-11-01
Full Text Available Introduction: Safety culture is considered as an important factor in improving patient safety. Therefore, identifying individual and organizational factors affecting safety culture is crucial. This study was carried out to determine individual and organizational factors associated with nurses' perception of patient safety culture. Methods: The present descriptive study included 940 nurses working in four training hospitals affiliated with Urmia University of Medical Sciences (Iran. Data was collected through the self-report questionnaire of patient safety culture. Descriptive (number, percent, mean, and standard deviation and inferential (t-test and analysis of variance statistics were used to analyze the data in SPSS. Results: Nurses' perception of patient safety culture was significantly correlated with marital status, workplace, and overtime hours. Conclusion: The results of this study revealed that some individual and organizational factors can impact on nurses' perception of patient safety culture. Nursing authorities should thus pay more attention to factors which promote patient safety culture and ultimately the safety of provided services.
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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
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Naessens, James M; Culbertson, Richard A; Lefante, John J; Campbell, Claudia R
2007-01-01
Attempts to provide information to consumers about patient safety on specific hospitals have conflicted with organization self-perceptions and led to confusion among the general public. This article presents organizational theory framework and criteria to classify organizations as single versus multiple reporting entities. Operational definitions are presented. A case study comparing institutions both within and across state boundaries in the Mayo Clinic Health System is used to demonstrate their utility. The study includes analysis of an employee survey on employee satisfaction and patient safety climate in 2004 among nurses and physicians at the 2 Mayo Clinic hospitals in Rochester, Minn. The criteria for a single organization are more strongly supported for the Mayo Clinic hospitals located in the same city than for hospitals in the same system but separated geographically. Although there is debate about the measurement of organizational culture, employee surveys provide some evidence of a commonality across hospitals in the same city. The case study comparing institutions both within and across state boundaries in the Mayo Clinic Health System demonstrate the utility of the proposed criteria.
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Alswat, Khalid; Abdalla, Rawia Ahmad Mustafa; Titi, Maher Abdelraheim; Bakash, Maram; Mehmood, Faiza; Zubairi, Beena; Jamal, Diana; El-Jardali, Fadi
2017-08-02
Measuring patient safety culture can provide insight into areas for improvement and help monitor changes over time. This study details the findings of a re-assessment of patient safety culture in a multi-site Medical City in Riyadh, Kingdom of Saudi Arabia (KSA). Results were compared to an earlier assessment conducted in 2012 and benchmarked with regional and international studies. Such assessments can provide hospital leadership with insight on how their hospital is performing on patient safety culture composites as a result of quality improvement plans. This paper also explored the association between patient safety culture predictors and patient safety grade, perception of patient safety, frequency of events reported and number of events reported. We utilized a customized version of the patient safety culture survey developed by the Agency for Healthcare Research and Quality. The Medical City is a tertiary care teaching facility composed of two sites (total capacity of 904 beds). Data was analyzed using SPSS 24 at a significance level of 0.05. A t-Test was used to compare results from the 2012 survey to that conducted in 2015. Two adopted Generalized Estimating Equations in addition to two linear models were used to assess the association between composites and patient safety culture outcomes. Results were also benchmarked against similar initiatives in Lebanon, Palestine and USA. Areas of strength in 2015 included Teamwork within units, and Organizational Learning-Continuous Improvement; areas requiring improvement included Non-Punitive Response to Error, and Staffing. Comparing results to the 2012 survey revealed improvement on some areas but non-punitive response to error and Staffing remained the lowest scoring composites in 2015. Regression highlighted significant association between managerial support, organizational learning and feedback and improved survey outcomes. Comparison to international benchmarks revealed that the hospital is performing at or
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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...
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Pai, Sarayu A; Kshirsagar, Nilima A
2016-11-01
With pioglitazone ban and subsequent revoking in India along with varying regulatory decisions in other countries, it was decided to carry out a systematic review on its safety, efficacy and drug utilization in patients with type 2 diabetes mellitus (T2DM) in India and compare with the data from the European Medicines Agency Assessment Report (EMA-AR). Systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching Medline/PubMed, Google Scholar and Science Direct databases using 'pioglitazone AND India AND human' and 'pioglitazone AND India AND human AND patient' and compared with EMA-AR. Spontaneous reports in World Health Organization VigiBase from India were compared with VigiBase data from other countries. Sixty six publications, 26 (efficacy), 32 (drug utilization) and eight (safety), were retrieved. In India, pioglitazone was used at 15-30 mg/day mostly with metformin and sulphonylurea, being prescribed to 26.7 and 8.4 per cent patients in north and south, respectively. The efficacy in clinical trials (CTs) was similar to those in EMA-AR. Incidence of bladder cancer in pioglitazone exposed and non-exposed patients was not significantly different in an Indian retrospective cohort study. There were two cases and a series of eight cases of bladder cancer published but none reported in VigiBase. In India, probably due to lower dose, lower background incidence of bladder cancer and smaller sample size in epidemiological studies, association of bladder cancer with pioglitazone was not found to be significant. Reporting of CTs and adverse drug reactions to Clinical Trials Registry of India and Pharmacovigilance Programme of India, respectively, along with compliance studies with warning given in package insert and epidemiological studies with larger sample size are needed.
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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.
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Bernalte-Martí, Vicente; Orts-Cortés, María Isabel; Maciá-Soler, Loreto
2015-01-01
To assess nursing professionals and health care assistants' perceptions, opinions and behaviours on patient safety culture in the operating room of a public hospital of the Spanish National Health Service. To describe strengths and weaknesses or opportunities for improvement according to the Agency for Healthcare Research and Quality criteria, as well as to determine the number of events reported. A descriptive, cross-sectional study was conducted using the Spanish version of the questionnaire Hospital Survey on Patient Safety Culture. The sample consisted of nursing professionals, who agreed to participate voluntarily in this study and met the selection criteria. A descriptive and inferential analysis was performed depending on the nature of the variables and the application conditions of statistical tests. Significance if p < .05. In total, 74 nursing professionals responded (63.2%). No strengths were found in the operating theatre, and improvements are needed concerning staffing (64.0%), and hospital management support for patient safety (52.9%). A total of 52.3% (n = 65) gave patient safety a score from 7 to 8.99 (on a 10 point scale); 79.7% (n = 72) reported no events last year. The total variance explained by the regression model was 0.56 for "Frequency of incident reporting" and 0.26 for "Overall perception of safety". There was a more positive perception of patient safety culture at unit level. Weaknesses have been identified, and they can be used to design specific intervention activities to improve patient safety culture in other nearby operating theatres. Copyright © 2014 Elsevier España, S.L.U. All rights reserved.
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The effects of power, leadership and psychological safety on resident event reporting.
Appelbaum, Nital P; Dow, Alan; Mazmanian, Paul E; Jundt, Dustin K; Appelbaum, Eric N
2016-03-01
Although the reporting of adverse events is a necessary first step in identifying and addressing lapses in patient safety, such events are under-reported, especially by frontline providers such as resident physicians. This study describes and tests relationships between power distance and leader inclusiveness on psychological safety and the willingness of residents to report adverse events. A total of 106 resident physicians from the departments of neurosurgery, orthopaedic surgery, emergency medicine, otolaryngology, neurology, obstetrics and gynaecology, paediatrics and general surgery in a mid-Atlantic teaching hospital were asked to complete a survey on psychological safety, perceived power distance, leader inclusiveness and intention to report adverse events. Perceived power distance (β = -0.26, standard error [SE] 0.06, 95% confidence interval [CI] -0.37 to 0.15; p leadership practices build psychological safety and minimise power distance between low- and high-status members in order to support greater reporting of adverse events. © 2016 John Wiley & Sons Ltd.
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Aviation Safety Reporting System: Process and Procedures
Connell, Linda J.
1997-01-01
The Aviation Safety Reporting System (ASRS) was established in 1976 under an agreement between the Federal Aviation Administration (FAA) and the National Aeronautics and Space Administration (NASA). This cooperative safety program invites pilots, air traffic controllers, flight attendants, maintenance personnel, and others to voluntarily report to NASA any aviation incident or safety hazard. The FAA provides most of the program funding. NASA administers the program, sets its policies in consultation with the FAA and aviation community, and receives the reports submitted to the program. The FAA offers those who use the ASRS program two important reporting guarantees: confidentiality and limited immunity. Reports sent to ASRS are held in strict confidence. More than 350,000 reports have been submitted since the program's beginning without a single reporter's identity being revealed. ASRS removes all personal names and other potentially identifying information before entering reports into its database. This system is a very successful, proof-of-concept for gathering safety data in order to provide timely information about safety issues. The ASRS information is crucial to aviation safety efforts both nationally and internationally. It can be utilized as the first step in safety by providing the direction and content to informed policies, procedures, and research, especially human factors. The ASRS process and procedures will be presented as one model of safety reporting feedback systems.
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Economic evaluation in patient safety: a literature review of methods.
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.
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En Route Patient Safety: A Mixed-Methods Study
2014-03-01
Army, Navy, volunteers, and civilians who meet the planes lack proper safety training First-names-only rule • MCD often refuses to give report...record; EMED = emergency medical; GPMRC = Global Patient Movement Requirements Center; MCD = medical crew director; MDG = Medical Group; OI...crews voiced concerns that “the biggest issue as far as taking report from the MCD is it’s always second hand.” However, several nurses who filled
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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
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Wu, Yinghui; Fujita, Shigeru; Seto, Kanako; Ito, Shinya; Matsumoto, Kunichika; Huang, Chiu-Chin; Hasegawa, Tomonori
2013-10-07
A positive patient safety culture (PSC) is one of the most critical components to improve healthcare quality and safety. The Hospital Survey on Patient Safety Culture (HSOPS), developed by the US Agency for Healthcare Research and Quality, has been used to assess PSC in 31 countries. However, little is known about the impact of nurse working hours on PSC. We hypothesized that long nurse working hours would deteriorate PSC, and that the deterioration patterns would vary between countries. Moreover, the common trends observed in Japan, the US and Chinese Taiwan may be useful to improve PSC in other countries. The purpose of this study was to clarify the impact of long nurse working hours on PSC in Japan, the US, and Chinese Taiwan using HSOPS. The HSOPS questionnaire measures 12 sub-dimensions of PSC, with higher scores indicating a more positive PSC. Odds ratios (ORs) were calculated using a generalized linear mixed model to evaluate the impact of working hours on PSC outcome measures (patient safety grade and number of events reported). Tukey's test and Cohen's d values were used to verify the relationships between nurse working hours and the 12 sub-dimensions of PSC. Nurses working ≥60 h/week in Japan and the US had a significantly lower OR for patient safety grade than those working working ≥40 h/week had a significantly higher OR for the number of events reported. The mean score on 'staffing' was significantly lower in the ≥60-h group than in the Japan and Chinese Taiwan. Patient safety grade deteriorated and the number of events reported increased with long working hours. Among the 12 sub-dimensions of PSC, long working hours had an impact on 'staffing' and 'teamwork within units' in Japan, the US and Chinese Taiwan.
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The perceptions of patient safety culture: A difference between physicians and nurses in Taiwan.
Huang, Chih-Hsuan; Wu, Hsin-Hung; Lee, Yii-Ching
2018-04-01
In order to pursue a better patient safety culture and provide a superior medical service for patients, this study aims to respectively investigate the perceptions of patient safety from the viewpoints of physicians and nurses in Taiwan. Little knowledge has clearly identified the difference of perceptions between physicians and nurses in patient safety culture. Understanding physicians and nurses' attitudes toward patient safety is a critical issue for healthcare organizations to improve medical quality. Confirmatory factor analysis (CFA) is used to verify the structure of data (e.g. reliability and validity), and Pearson's correlation analysis is conducted to demonstrate the relationships among seven patient safety culture dimensions. Research results illustrate that more teamwork is exhibited among team members, the more safety of a patient is committed. Perceptions of management and emotional exhaustion are important components that contribute to a better patient safety. More importantly, working conditions and stress recognition are found to be negatively related from the perceptions of nurses. Compared to physicians, nurses reported higher stress and challenges which result from multi-task working conditions in the hospital. This study focused on the contribution of a better patient safety culture from different viewpoints of physicians and nurses for healthcare organizations in Taiwan. A different attitudes toward patient safety is found between physicians and nurses. The results enable the hospital management to realize and design appropriate implications for hospital staffs to establish a better patient safety culture. Copyright © 2017. Published by Elsevier Inc.
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Implementing Patient Safety Initiatives in Rural Hospitals
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…
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International Nuclear Information System (INIS)
1997-02-01
DOE 5480.23, Nuclear Safety Analysis Reports, requires that the US Department of Energy conduct an independent, defensible, review in order to approve a Safety Analysis Report (SAR). That review and the SAR approval basis is documented in this formal Safety Evaluation Report (SER). This SER documents the DOE's review of the Waste Isolation Pilot Plant SAR and provides the Carlsbad Area Office Manager, the WIPP SAR approval authority, with the basis for approving the safety document. It concludes that the safety basis documented in the WIPP SAR is comprehensive, correct, and commensurate with hazards associated with planned waste disposal operations
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Annual report on reactor safety research projects. Reporting period 2011. Progress report
International Nuclear Information System (INIS)
2011-01-01
Within its competence for energy research the Federal Ministry of Economics and Technology (BMWi) sponsors research projects on the safety of nuclear power plants currently in operation. The objective of these projects is to provide fundamental knowledge, procedures and methods to contribute to realistic safety assessments of nuclear installations, to the further development of safety technology and to make use of the potential of innovative safety-related approaches. The Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS)mbH, by order of the BMWi, continuously issues information on the status of such research projects by publishing semi-annual and annual progress reports within the series of GRSF- Fortschrittsberichte (GRS-F-Progress Reports). Each progress report represents a compilation of individual reports about the objectives, work performed, results achieved, next steps of the work etc. The individual reports are prepared in a standard form by the research organisations themselves as documentation of their progress in work. The progress reports are published by the Project Management Agency/Authority Support Division of GRS. The reports as of the year 2000 are available in the Internet-based information system on results and data of reactor safety research (http://www.grs-fbw.de). The compilation of the reports is classified according to the classification system ''Joint Safety Research Index (JSRI)''. The reports are arranged in sequence of their project numbers. It has to be pointed out that the authors of the reports are responsible for the contents of this compilation. The BMWi does not take any responsibility for the correctness, exactness and completeness of the information nor for the observance of private claims of third parties. (orig.)
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Annual report on reactor safety research projects. Reporting period 2014. Progress report
Energy Technology Data Exchange (ETDEWEB)
NONE
2014-07-01
Within its competence for energy research the Federal Ministry for Economic Affairs and Energy (BMWi) sponsors research projects on the safety of nuclear power plants currently in operation. The objective of these projects is to provide fundamental knowledge, procedures and methods to contribute to realistic safety assessments of nuclear installations, to the further development of safety technology and to make use of the potential of innovative safety-related approaches. The Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS) gGmbH, by order of the BMWi, continuously issues information on the status of such research projects by publishing semi-annual and annual progress reports within the series of GRS-F-Fortschrittsberichte (GRS-F-Progress Reports). Each progress report represents a compilation of individual reports about the objectives, work performed, results achieved, next steps of the work etc. The individual reports are prepared in a standard form by the research organisations themselves as documentation of their progress in work. The progress reports are published by the Project Management Agency/Authority Support Division of GRS. The reports as of the year 2000 are available in the lnternet-based information system on results and data of reactor safety research (http://www.grs-fbw.de). The compilation of the reports is classified according to the classification system ''Joint Safety Research Index (JSRI)''. The reports are arranged in sequence of their project numbers. lt has to be pointed out that the authors of the reports are responsible for the contents of this compilation. The BMWi does not take any responsibility for the correctness, exactness and completeness of the information nor for the observance of private claims of third parties.
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Annual report on reactor safety research projects. Reporting period 2013. Progress report
International Nuclear Information System (INIS)
2013-01-01
Within its competence for energy research the Federal Ministry of Economics and Technology (BMWi) sponsors research projects on the safety of nuclear power plants currently in operation. The objective of these projects is to provide fundamental knowledge, procedures and methods to contribute to realistic safety assessments of nuclear installations, to the further development of safety technology and to make use of the potential of innovative safety-related approaches. The Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS)mbH, by order of the BMWi, continuously issues information on the status of such research projects by publishing semi-annual and annual progress reports within the series of GRSF- Fortschrittsberichte (GRS-F-Progress Reports). Each progress report represents a compilation of individual reports about the objectives, work performed, results achieved, next steps of the work etc. The individual reports are prepared in a standard form by the research organisations themselves as documentation of their progress in work. The progress reports are published by the Project Management Agency/Authority Support Division of GRS. The reports as of the year 2000 are available in the Internet-based information system on results and data of reactor safety research (http://www.grs-fbw.de). The compilation of the reports is classified according to the classification system ''Joint Safety Research Index (JSRI)''. The reports are arranged in sequence of their project numbers. It has to be pointed out that the authors of the reports are responsible for the contents of this compilation. The BMWi does not take any responsibility for the correctness, exactness and completeness of the information nor for the observance of private claims of third parties. (orig.)
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Annual report on reactor safety research projects. Reporting period 2015. Progress report
International Nuclear Information System (INIS)
2015-01-01
Within its competence for energy research the Federal Ministry for Economic Affairs and Energy (BMWi) sponsors research projects on the safety of nuclear power plants currently in operation. The objective of these projects is to provide fundamental knowledge, procedures and methods to contribute to realistic safety assessments of nuclear installations, to the further development of safety technology and to make use of the potential of innovative safety-related approaches. The Gesellschaft tor Anlagen- und Reaktorsicherheit (GRS) gGmbH, by order of the BMWi, continuously issues information on the status of such research projects by publishing semi-annual and annual progress reports within the series of GRS-F-Fortschrittsberichte (GRS-F-Progress Reports). Each progress report represents a compilation of individual reports about the objectives, work performed, results achieved, next steps of the work etc. The individual reports are ·' prepared in a standard form by the research organisations themselves as documentation of their progress in work. The progress reports are published by the Project Management Agency/Authority Support Division of GRS. The reports as of the year 2000 are available in the lnternet-based information system on results and data of reactor safety research (http://www.grs-fbw.de). The compilation of the reports is classified according to the classification system ''Joint Safety Research Index (JSRI)''. The reports are arranged in sequence of their project numbers. it has to be pointed out that the authors of the reports are responsible for the contents of this compilation. The BMWi does not take any responsibility for the correctness, exactness and completeness of the information nor for the observance of private claims of third parties.
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Patient safety culture in China: a case study in an outpatient setting in Beijing.
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.
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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.
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Systems engineered health and safety criteria for safety analysis reports
International Nuclear Information System (INIS)
Beitel, G.A.; Morcos, N.
1993-01-01
The world of safety analysis is filled with ambiguous words: codes and standards, consequences and risks, hazard and accident, and health and safety. These words have been subject to disparate interpretations by safety analysis report (SAR) writers, readers, and users. open-quotes Principal health and safety criteriaclose quotes has been one of the most frequently misused phrases; rarely is it used consistently or effectively. This paper offers an easily understood definition for open-quotes principal health and safety criteriaclose quotes and uses systems engineering to convert an otherwise mysterious topic into the primary means of producing an integrated SAR. This paper is based on SARs being written for environmental restoration and waste management activities for the U.S. Department of Energy (DOE). Requirements for these SARs are prescribed in DOE Order 5480-23, open-quotes Nuclear Safety Analysis Reports.close quotes
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In-Office Endoscopic Laryngeal Laser Procedures: A Patient Safety Initiative.
Anderson, Jennifer; Bensoussan, Yael; Townsley, Richard; Kell, Erika
2018-05-01
Objective To review complications of in-office endoscopic laryngeal laser procedures after implementation of standardized safety protocol. Methods A retrospective review was conducted of the first 2 years of in-office laser procedures at St Michaels Hospital after the introduction of a standardized safety protocol. The protocol included patient screening, procedure checklist with standardized reporting of processes, medications, and complications. Primary outcomes measured were complication rates of in-office laryngeal laser procedures. Secondary outcomes included hemodynamic changes, local anesthetic dose, laser settings, total laser/procedure time, and incidence of sedation. Results A total of 145 in-office KTP procedures performed on 65 patients were reviewed. In 98% of cases, the safety protocol was fully implemented. The overall complication rate was 4.8%. No major complications were encountered. Minor complications included vasovagal episodes and patient intolerance. The rate of patient intolerance resulting early termination of anticipated procedure was 13.1%. Total local anesthetic dose averaged 172.9 mg lidocaine per procedure. The mean amount of laser energy dispersed was 261.2 J, with mean total procedure time of 48.3 minutes. Sixteen percent of patients had preprocedure sedation. Vital signs were found to vary modestly. Systolic blood pressure was lower postprocedure in 13.8% and symptomatic in 4.1%. Discussion The review of our standardized safety protocol has revealed that in-office laser treatment for laryngeal pathology has extremely low complication rates with safe patient outcomes. Implications for Practice The trend of shifting procedures out of the operating room into the office/clinic setting requires new processes designed to promote patient safety.
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The aviation safety reporting system
Reynard, W. D.
1984-01-01
The aviation safety reporting system, an accident reporting system, is presented. The system identifies deficiencies and discrepancies and the data it provides are used for long term identification of problems. Data for planning and policy making are provided. The system offers training in safety education to pilots. Data and information are drawn from the available data bases.
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The association between EMS workplace safety culture and safety outcomes.
Weaver, Matthew D; Wang, Henry E; Fairbanks, Rollin J; Patterson, Daniel
2012-01-01
Prior studies have highlighted wide variation in emergency medical services (EMS) workplace safety culture across agencies. To determine the association between EMS workplace safety culture scores and patient or provider safety outcomes. We administered a cross-sectional survey to EMS workers affiliated with a convenience sample of agencies. We recruited these agencies from a national EMS management organization. We used the EMS Safety Attitudes Questionnaire (EMS-SAQ) to measure workplace safety culture and the EMS Safety Inventory (EMS-SI), a tool developed to capture self-reported safety outcomes from EMS workers. The EMS-SAQ provides reliable and valid measures of six domains: safety climate, teamwork climate, perceptions of management, working conditions, stress recognition, and job satisfaction. A panel of medical directors, emergency medical technicians and paramedics, and occupational epidemiologists developed the EMS-SI to measure self-reported injury, medical errors and adverse events, and safety-compromising behaviors. We used hierarchical linear models to evaluate the association between EMS-SAQ scores and EMS-SI safety outcome measures. Sixteen percent of all respondents reported experiencing an injury in the past three months, four of every 10 respondents reported an error or adverse event (AE), and 89% reported safety-compromising behaviors. Respondents reporting injury scored lower on five of the six domains of safety culture. Respondents reporting an error or AE scored lower for four of the six domains, while respondents reporting safety-compromising behavior had lower safety culture scores for five of the six domains. Individual EMS worker perceptions of workplace safety culture are associated with composite measures of patient and provider safety outcomes. This study is preliminary evidence of the association between safety culture and patient or provider safety outcomes.
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McFadden, Kathleen L; Stock, Gregory N; Gowen, Charles R
2014-10-01
Successful amelioration of medical errors represents a significant problem in the health care industry. There is a need for greater understanding of the factors that lead to improved process quality and patient safety outcomes in hospitals. We present a research model that shows how transformational leadership, safety climate, and continuous quality improvement (CQI) initiatives are related to objective quality and patient safety outcome measures. The proposed framework is tested using structural equation modeling, based on data collected for 204 hospitals, and supplemented with objective outcome data from the Centers for Medicare and Medicaid Services. The results provide empirical evidence that a safety climate, which is connected to the chief executive officer's transformational leadership style, is related to CQI initiatives, which are linked to improved process quality. A unique finding of this study is that, although CQI initiatives are positively associated with improved process quality, they are also associated with higher hospital-acquired condition rates, a measure of patient safety. Likewise, safety climate is directly related to improved patient safety outcomes. The notion that patient safety climate and CQI initiatives are not interchangeable or universally beneficial is an important contribution to the literature. The results confirm the importance of using CQI to effectively enhance process quality in hospitals, and patient safety climate to improve patient safety outcomes. The overall pattern of findings suggests that simultaneous implementation of CQI initiatives and patient safety climate produces greater combined benefits.
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Yardley, Iain; Yardley, Sarah; Williams, Huw; Carson-Stevens, Andrew; Donaldson, Liam J
2018-06-01
Patients receiving palliative care are vulnerable to patient safety incidents but little is known about the extent of harm caused or the origins of unsafe care in this population. To quantify and qualitatively analyse serious incident reports in order to understand the causes and impact of unsafe care in a population receiving palliative care. A mixed-methods approach was used. Following quantification of type of incidents and their location, a qualitative analysis using a modified framework method was used to interpret themes in reports to examine the underlying causes and the nature of resultant harms. Reports to a national database of 'serious incidents requiring investigation' involving patients receiving palliative care in the National Health Service (NHS) in England during the 12-year period, April 2002 to March 2014. A total of 475 reports were identified: 266 related to pressure ulcers, 91 to medication errors, 46 to falls, 21 to healthcare-associated infections (HCAIs), 18 were other instances of disturbed dying, 14 were allegations against health professions, 8 transfer incidents, 6 suicides and 5 other concerns. The frequency of report types differed according to the care setting. Underlying causes included lack of palliative care experience, under-resourcing and poor service coordination. Resultant harms included worsened symptoms, disrupted dying, serious injury and hastened death. Unsafe care presents a risk of significant harm to patients receiving palliative care. Improvements in the coordination of care delivery alongside wider availability of specialist palliative care support may reduce this risk.
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Mazur, Lukasz; Chera, Bhishamjit; Mosaly, Prithima; Taylor, Kinley; Tracton, Gregg; Johnson, Kendra; Comitz, Elizabeth; Adams, Robert; Pooya, Pegah; Ivy, Julie; Rockwell, John; Marks, Lawrence B
2015-01-01
To present our approach and results from our quality and safety program and to report their possible impact on our culture of patient safety. We created an event learning system (termed a "good catch" program) and encouraged staff to report any quality or safety concerns in real time. Events were analyzed to assess the utility of safety barriers. A formal continuous quality improvement program was created to address these reported events and make improvements. Data on perceptions of the culture of patient safety were collected using the Agency for Health Care Research and Quality survey administered before, during, and after the initiatives. Of 560 good catches reported, 367 could be ascribed to a specific step on our process map. The calculated utility of safety barriers was highest for those embedded into the pretreatment quality assurance checks performed by physicists and dosimetrists (utility score 0.53; 93 of 174) and routine checks done by therapists on the initial day of therapy. Therapists and physicists reported the highest number of good catches (24% each). Sixty-four percent of events were caused by performance issues (eg, not following standardized processes, including suboptimal communications). Of 31 initiated formal improvement events, 26 were successfully implemented and sustained, 4 were discontinued, and 1 was not implemented. Most of the continuous quality improvement program was conducted by nurses (14) and therapists (7). Percentages of positive responses in the patient safety culture survey appear to have increased on all dimensions (p continuous quality improvement programs can be successfully implemented and that there are contemporaneous improvements in the culture of safety. Copyright © 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
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Collier, Aileen; Sorensen, Ros; Iedema, Rick
2016-02-01
The aim of this study was to investigate patients' and families' perspectives of safety and quality in the setting of a life-limiting illness. Data reported here were generated from a qualitative study using video-reflexive ethnographic methodology. Data were collected over 18 months and generated through participant observation, shadowing of clinicians, field-interviews and semi-structured interviews with patients and families. The study was conducted at two hospital sites in Sydney, Australia and in patients' homes. Patients with an advanced life-limiting illness (n = 29) ranging in age between 27 and 89 years and family members (n = 5) participated in the study. Patient safety remains important to dying patients and families. For dying people, iatrogenic harm is not regarded as 'one off' incidents. Rather, harm is experienced as a result of an unfolding series of negative events. Critically, iatrogenic harm is emotional, social and spiritual and not solely technical-clinical misadventure and is inextricably linked with feeling unsafe. Thus, patient safety extends beyond narrowly defined technical-clinical parameters to include interpersonal safety. Current approaches to patient safety do not address fully the needs of dying patients and their families. Patients and their families regard poor communication with and by health professionals to be harmful in and of itself. © The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.
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Tella, Susanna; Smith, Nancy-Jane; Partanen, Pirjo; Turunen, Hannele
2015-06-01
Globalization of health care demands nursing education programs that equip students with evidence-based patient safety competences in the global context. Nursing students' entrance into clinical placements requires professional readiness. Thus, evidence-based learning activities about patient safety must be provided in academic settings prior to students' clinical placements. To explore and compare Finnish and British nursing students' perceptions of learning about patient safety in academic settings to inform nursing educators about designing future education curriculum. A purpose-designed instrument, Patient Safety in Nursing Education Questionnaire (PaSNEQ) was used to examine the perceptions of Finnish (n = 195) and British (n = 158) nursing students prior to their final year of registration. Data were collected in two Finnish and two English nursing schools in 2012. Logistic regressions were used to analyze the differences. British students reported more inclusion (p motivation" related to patient safety in their programs. Both student groups considered patient safety education to be more valuable for their own learning than what their programs had provided. Training patient safety skills in the academic settings were the strongest predictors for differences (odds ratio [OR] = 34.69, 95% confidence interval [CI] 7.39-162.83), along with work experience in the healthcare sector (OR = 3.02, 95% CI 1.39-6.58). To prepare nursing students for practical work, training related to clear communication, reporting errors, systems-based approaches, interprofessional teamwork, and use of simulation in academic settings requires comprehensive attention, especially in Finland. Overall, designing patient safety-affirming nursing curricula in collaboration with students may enhance their positive experiences on teaching and learning about patient safety. An international collaboration between educators could help to develop and harmonize patient safety education and to better
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The impact of nursing leadership on patient safety in a developing country.
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.
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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...
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Assessment of Patient Safety Culture in an Adult Oncology Department in Saudi Arabia
Directory of Open Access Journals (Sweden)
Waleed Alharbi
2018-05-01
Full Text Available Objectives: We sought to evaluate patient safety culture across different healthcare professionals from different countries of origin working in an adult oncology department in a medical facility in Saudi Arabia. Methods: This cross-sectional survey of 130 healthcare staff (doctors, pharmacists, nurses was conducted in February 2017. We used the Hospital Survey of Patient Safety Culture (HSOPSC to examine healthcare staff perceptions of safety culture. Results: A total of 127 questionnaires were returned, yielding a response rate of 97.7%. Eight out of 12 HSOPSC composites were considered areas for improvement (percent positivity < 50.0%. Significantly different mean scores were observed across the three professional groups in all 12 HSOPSC composites. Doctors tended to rate patient safety culture significantly more positively than nurses or pharmacists. Nurses scored significantly lower than pharmacists in the majority of HSOPSC composites. No significant differences in patient safety culture composite scores were observed between Saudi/Gulf Cooperation Council (GCC and non-Saudi/GCC groups. Regression analysis showed that the frequency of reported events is predicted by feedback and communication about errors, and teamwork across units. Perception of patient safety is associated with respondents’ profession and teamwork across units. Conclusions: This study brings to the fore the assumption that all healthcare professionals have a shared understanding of patient safety. We urge healthcare leaders and policy makers to look at patient safety culture at this granular level in their contexts and use this information to develop strategies and training to improve patient safety culture.
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Injury & Safety Report - Legacy
National Oceanic and Atmospheric Administration, Department of Commerce — The Injury & Safety Report is a mandatory post trip legal document observers fill out to report any injuries they have incurred, illnesses they have had, or...
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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
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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.
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Engaging Employees: The Importance of High-Performance Work Systems for Patient Safety.
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.
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Applying importance-performance analysis to patient safety culture.
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.
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Emotional influences in patient safety.
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.
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[Operating Room Nurses' Experiences of Securing for Patient Safety].
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.
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Annual report on occupational safety 1987
International Nuclear Information System (INIS)
1988-01-01
This report presents detailed information on occupational safety relating to the Company's employees for 1987. Data are quoted in tables and text, together with data from the previous year for comparison where available. The report is presented under the following headings: radiological and non-radiological safety, incidents, appendices (statutory dose limits, nuclear incident criteria for reporting to ministers). (author)
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Using Smart Pumps to Understand and Evaluate Clinician Practice Patterns to Ensure Patient Safety
Mansfield, Jennifer; Jarrett, Steven
2013-01-01
Background: Safety software installed on intravenous (IV) infusion pumps has been shown to positively impact the quality of patient care through avoidance of medication errors. The data derived from the use of smart pumps are often overlooked, although these data provide helpful insight into the delivery of quality patient care. Objective: The objectives of this report are to describe the value of implementing IV infusion safety software and analyzing the data and reports generated by this system. Case study: Based on experience at the Carolinas HealthCare System (CHS), executive score cards provide an aggregate view of compliance rate, number of alerts, overrides, and edits. The report of serious errors averted (ie, critical catches) supplies the location, date, and time of the critical catch, thereby enabling management to pinpoint the end-user for educational purposes. By examining the number of critical catches, a return on investment may be calculated. Assuming 3,328 of these events each year, an estimated cost avoidance would be $29,120,000 per year for CHS. Other reports allow benchmarking between institutions. Conclusion: A review of the data about medication safety across CHS has helped garner support for a medication safety officer position with the goal of ultimately creating a safer environment for the patient. PMID:24474836
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Directory of Open Access Journals (Sweden)
Schwappach David LB
2008-03-01
Full Text Available Abstract Background Involvement of patients in the detection and prevention of safety related events and medical errors have been widely recommended. However, it has also been questioned whether patients at large are willing and able to identify safety-related events in their care. The aim of this study was to develop and pilot test a brief patient safety survey applicable to inpatient care in Swiss hospitals. Methods A survey instrument was developed in an iterative procedure. The instrument asks patients to report whether they have experienced specific undesirable events during their hospital stay. The preliminary version was developed together with experts and tested in focus groups with patients. The adapted survey instrument was pilot-tested in random samples of patients of two Swiss hospitals (n = 400. Responders to the survey that had reported experience of any incident were sampled for qualitative interviews (n = 18. Based on the interview, the researcher classified the reported incidents as confirmed or discarded. Results The survey was generally well accepted in the focus groups and interviews. In the quantitative pilot test, 125 patients returned the survey (response rate: 31%. The mean age of responders was 55 years (range 17–91, SD 18 years and 62.5% were female. The 125 participating patients reported 94 "definitive" and 34 "uncertain" events. 14% of the patients rated any of the experienced events as "serious". The definitive and uncertain events reported with highest frequency were phlebitis, missing hand hygiene, allergic drug reaction, unavailability of documents, and infection. 23% of patients reported some or serious concerns about their safety. The qualitative interviews indicate that both, the extent of patients' uncertainty in the classification of events and the likelihood of confirmation by the interviewer vary very much by type of incident. Unexpectedly, many patients reported problems and incidents related to food
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Medical error disclosure and patient safety: legal aspects
Directory of Open Access Journals (Sweden)
Olivier Guillod
2013-12-01
Full Text Available Reducing the number of preventable adverse events has become a public health issue. The paper discusses in which ways the law can contribute to that goal, especially by encouraging a culture of safety among healthcare professionals. It assesses the need or the usefulness to pass so-called disclosure laws and apology laws, to adopt mandatory but strictly confidential Critical Incidents Reporting Systems in hospitals, to change the fault-based system of medical liability or to amend the rules on criminal liability. The paper eventually calls for adding the law to the present agenda of patient safety.
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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...
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Program nuclear safety research: report 2000
International Nuclear Information System (INIS)
Muehl, B.
2001-09-01
The reactor safety R and D work of forschungszentrum karlsruhe (FZK) had been part of the nuclear safety research project (PSF) since 1990. In 2000, a new organisational structure was introduced and the Nuclear Safety Research Project was transferred into the nuclear safety research programme (NUKLEAR). In addition to the three traditional main topics - Light Water Reactor safety, Innovative systems, Studies related to the transmutation of actinides -, the new Programme NUKLEAR also covers Safety research related to final waste storage and Immobilisation of HAW. These new topics, however, will only be dealt with in the next annual report. Some tasks related to the traditional topics have been concluded and do no longer appear in the annual report; other tasks are new and are described for the first time. Numerous institutes of the research centre contribute to the work programme, as well as several external partners. The tasks are coordinated in agreement with internal and external working groups. The contributions to this report, which are either written in German or in English, correspond to the status of early/mid 2001. (orig.)
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Donn, Steven M; McDonnell, William M
2012-01-01
The Institute of Medicine has recommended a change in culture from "name and blame" to patient safety. This will require system redesign to identify and address errors, establish performance standards, and set safety expectations. This approach, however, is at odds with the present medical malpractice (tort) system. The current system is outcomes-based, meaning that health care providers and institutions are often sued despite providing appropriate care. Nevertheless, the focus should remain to provide the safest patient care. Effective peer review may be hindered by the present tort system. Reporting of medical errors is a key piece of peer review and education, and both anonymous reporting and confidential reporting of errors have potential disadvantages. Diagnostic and treatment errors continue to be the leading sources of allegations of malpractice in pediatrics, and the neonatal intensive care unit is uniquely vulnerable. Most errors result from systems failures rather than human error. Risk management can be an effective process to identify, evaluate, and address problems that may injure patients, lead to malpractice claims, and result in financial losses. Risk management identifies risk or potential risk, calculates the probability of an adverse event arising from a risk, estimates the impact of the adverse event, and attempts to control the risk. Implementation of a successful risk management program requires a positive attitude, sufficient knowledge base, and a commitment to improvement. Transparency in the disclosure of medical errors and a strategy of prospective risk management in dealing with medical errors may result in a substantial reduction in medical malpractice lawsuits, lower litigation costs, and a more safety-conscious environment. Thieme Medical Publishers, Inc.
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Pfeiffer, Yvonne; Schwappach, David
2016-01-01
National safety alert systems publish relevant information to improve patient safety in hospitals. However, the information has to be transformed into local action to have an effect on patient safety. We studied three research questions: How do Swiss healthcare quality and risk managers (qm/rm(1)) see their own role in learning from safety alerts issued by the Swiss national voluntary reporting and analysis system? What are their attitudes towards and evaluations of the alerts, and which types of improvement actions were fostered by the safety alerts? A survey was developed and applied to Swiss healthcare risk and quality managers, with a response rate of 39 % (n=116). Descriptive statistics are presented. The qm/rm disseminate and communicate with a broad variety of professional groups about the alerts. While most respondents felt that they should know the alerts and their contents, only a part of them felt responsible for driving organizational change based on the recommendations. However, most respondents used safety alerts to back up their own patient safety goals. The alerts were evaluated positively on various dimensions such as usefulness and were considered as standards of good practice by the majority of the respondents. A range of organizational responses was applied, with disseminating information being the most common. An active role is related to using safety alerts for backing up own patient safety goals. To support an active role of qm/rm in their hospital's learning from safety alerts, appropriate organizational structures should be developed. Furthermore, they could be given special information or training to act as an information hub on the issues discussed in the alerts. Copyright © 2016. Published by Elsevier GmbH.
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Mill, Deanna; Dawson, Jessica; Johnson, Jacinta Lee
2018-05-01
Lactose intolerance is exceedingly common, reportedly affecting up to 70% of the world's population, leading to both abdominal and systemic symptoms. Current treatment focuses predominantly on restricting dietary consumption of lactose. Given lactose is one of the most commonly used excipients in the pharmaceutical industry, consideration must be given to the lactose content and therefore safety of pharmaceutical preparations prescribed for patients with lactose intolerance. This article summarizes the current literature examining the likelihood of inducing adverse effects through the administration of lactose-containing pharmaceutical preparations in patients reporting lactose intolerance, describes how to assess this risk on an individual patient basis and reviews suitable analgesic options for this population. A case study is presented detailing a patient reporting lactose intolerance who insists on treatment with the lactose-free product codeine/ibuprofen (Nurofen Plus) rather than other codeine-free analgesics. It is important to assess the likelihood of lactose as an excipient inducing symptoms in this scenario, as reluctance to cease codeine could suggest codeine dependence, an issue that is becoming increasingly common in countries such as Australia and Canada. Given codeine dependence is associated with serious sequelae including hospitalization and death, the patient must either be reassured the lactose component in their prescribed analgesics will not induce symptoms or an alternative treatment strategy must be confirmed. General recommendations applying theory from the literature to the management of acute pain in lactose-intolerant patients are discussed and specific treatment options are outlined. Although large inter-individual variability is reported, most lactose-intolerant patients can tolerate the small quantities of lactose found in pharmaceutical preparations. Cumulative lactose exposure can be assessed in patients taking multiple medications
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Effects of patient safety auditing in hospital care: results of a mixed-method evaluation (part 1).
Hanskamp-Sebregts, Mirelle; Zegers, Marieke; Westert, Gert P; Boeijen, Wilma; Teerenstra, Steven; van Gurp, Petra J; Wollersheim, Hub
2018-06-15
To evaluate the effectiveness of internal auditing in hospital care focussed on improving patient safety. A before-and-after mixed-method evaluation study was carried out in eight departments of a university medical center in the Netherlands. Internal auditing and feedback focussed on improving patient safety. The effect of internal auditing was assessed 15 months after the audit, using linear mixed models, on the patient, professional, team and departmental levels. The measurement methods were patient record review on adverse events (AEs), surveys regarding patient experiences, safety culture and team climate, analysis of administrative hospital data (standardized mortality rate, SMR) and safety walk rounds (SWRs) to observe frontline care processes on safety. The AE rate decreased from 36.1% to 31.3% and the preventable AE rate from 5.5% to 3.6%; however, the differences before and after auditing were not statistically significant. The patient-reported experience measures regarding patient safety improved slightly over time (P audit. The SWRs showed that medication safety and information security were improved (P auditing was associated with improved patient experiences and observed safety on wards. No effects were found on adverse outcomes, safety culture and team climate 15 months after the internal audit.
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Reichsman, Ann; Werner, James; Cella, Peggi; Bobiak, Sarah; Stange, Kurt C
2009-01-01
To identify barriers and opportunities for quality diabetes care in safety net practices. In 3 federally qualified health centers and 1 free clinic, 19 primary care clinicians profiled patient and visit characteristics and quality of care measures for 181 consecutive visits by adult type 2 diabetic patients. Open-ended questions assessed patient and clinician perception of barriers to diabetes care and patient report of enabling factors. A multidisciplinary team identified themes from open-ended responses. Logistic regression analyses assessed the association of the identified barriers/enablers with 2 measures of quality care: glycosylated hemoglobin and prophylactic aspirin use. Ranked barriers noted by patients included adherence (40%), financial/insurance (23%), and psychosocial (13%) factors. Clinicians ranked systemic factors, including financial/ insurance (32%) and cultural/psychosocial (29%) factors, as important to adherence (29%) in determining quality diabetes care. Patients reported dietary and medical adherence (37%) and family/health care worker support (17%) as helpful factors. Among 175 patients with available data, glycosylated hemoglobin levels were associated with patient report of financial/insurance factors both as a barrier when visits and medications were unaffordable and as an opportunity when free or low-cost medications and services were provided. Patients' adherence with aspirin prophylaxis was strongly associated with African American race, prior prescription of aspirin and distribution of aspirin at the practice site (p<.001). Patients were less likely than clinicians to identify systemic and contextual factors contributing to poor diabetes care. From the front line's perspective, enabling patient self-management and systemic support is a target for improving diabetes care in safety net practices.
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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...
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Stomski, Norman; Gluyas, Heather; Andrus, Prue; Williams, Anne; Hopkins, Martin; Walters, Jennifer; Sandy, Martinique; Morrison, Paul
2018-04-01
Several studies report that patient safety skills, especially non-technical skills, receive scant attention in nursing curricula. Hence, there is a compelling reason to incorporate material that enhances non-technical skills, such as situation awareness, in nursing curricula in order to assist in the reduction of healthcare related adverse events. The objectives of this study were to: 1) understand final year nursing students' confidence in their patient safety skills; and 2) examine the impact of situation awareness training on final year nursing students' confidence in their patient safety skills. Participants were enrolled from a convenience sample comprising final year nursing students at a Western Australia university. Self-reported confidence in patient safety skills was assessed with the Health Professional in Patient Safety Survey before and after the delivery of a situation awareness educational intervention. Pre/post educational intervention differences were examined by repeated measures ANOVA. No significant differences in confidence about patient safety skills were identified within settings (class/clinical). However, confidence in patient safety skills significantly decreased between settings i.e. nursing students lost confidence after clinical placements. The educational intervention delivered in this study did not seem to improve confidence in patient safety skills, but substantial ceiling effects may have confounded the identification of such improvement. Further studies are required to establish whether the findings of this study can be generalised to other university nursing cohorts. Copyright © 2018 Elsevier Ltd. All rights reserved.
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75 FR 57281 - Patient Safety Organizations: Voluntary delisting
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...
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Laboratory errors and patient safety.
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
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Safety of Magnetic Resonance Imaging in Patients with Cardiac Devices.
Nazarian, Saman; Hansford, Rozann; Rahsepar, Amir A; Weltin, Valeria; McVeigh, Diana; Gucuk Ipek, Esra; Kwan, Alan; Berger, Ronald D; Calkins, Hugh; Lardo, Albert C; Kraut, Michael A; Kamel, Ihab R; Zimmerman, Stefan L; Halperin, Henry R
2017-12-28
Patients who have pacemakers or defibrillators are often denied the opportunity to undergo magnetic resonance imaging (MRI) because of safety concerns, unless the devices meet certain criteria specified by the Food and Drug Administration (termed "MRI-conditional" devices). We performed a prospective, nonrandomized study to assess the safety of MRI at a magnetic field strength of 1.5 Tesla in 1509 patients who had a pacemaker (58%) or an implantable cardioverter-defibrillator (42%) that was not considered to be MRI-conditional (termed a "legacy" device). Overall, the patients underwent 2103 thoracic and nonthoracic MRI examinations that were deemed to be clinically necessary. The pacing mode was changed to asynchronous mode for pacing-dependent patients and to demand mode for other patients. Tachyarrhythmia functions were disabled. Outcome assessments included adverse events and changes in the variables that indicate lead and generator function and interaction with surrounding tissue (device parameters). No long-term clinically significant adverse events were reported. In nine MRI examinations (0.4%; 95% confidence interval, 0.2 to 0.7), the patient's device reset to a backup mode. The reset was transient in eight of the nine examinations. In one case, a pacemaker with less than 1 month left of battery life reset to ventricular inhibited pacing and could not be reprogrammed; the device was subsequently replaced. The most common notable change in device parameters (>50% change from baseline) immediately after MRI was a decrease in P-wave amplitude, which occurred in 1% of the patients. At long-term follow-up (results of which were available for 63% of the patients), the most common notable changes from baseline were decreases in P-wave amplitude (in 4% of the patients), increases in atrial capture threshold (4%), increases in right ventricular capture threshold (4%), and increases in left ventricular capture threshold (3%). The observed changes in lead parameters
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Enhancing nuclear safety. Annual report 2014. Financial report 2014
International Nuclear Information System (INIS)
2015-01-01
After some introductory texts proposed by several IRSN head managers, and a brief presentation of some key data illustrating the activity, the annual report presents the main strategic orientations, notably in the field of knowledge management, and of information and communication. After some images illustrating the past year, activities are presented. They first deal with safety: Reactor safety (operating experience feedback), From decommissioning old reactors to designing those of the future, Safety of laboratories and plants, Safety regarding risks due to infrastructure near nuclear facilities, Reactor aging, Fuel: research on corrosion and deformation, Research and assessments for improved understanding of accident situations, Earthquakes: research and assessments, About defense, Geological disposal of radioactive waste. They secondly deal with security and non-proliferation (nuclear security, nuclear non-proliferation, chemical weapon ban), thirdly with radiation protection for human and environment health (environment monitoring, radionuclide transfer in the environment, radon and polluted sites, human exposure, radiation protection in the workplace, effects of low-dose chronic exposures, Organization of radiation protection at the European level, protection in health care), and fourthly with emergency and post-accident situations (emergency and post-accident preparedness and response, Emergency response tools). The next part of the activity report addresses issues related to efficiency: Real estate program (construction projects get started), Hygiene, safety, social responsibility, Human resources, Organization chart, Board of directors, Steering committee for the nuclear defense expertise Division - CODEND, Scientific council, Ethics commission composition, Nuclear safety and radiation protection Research policy committee - COR. The financial report proposes a management report, financial statements with an appendix to annual accounts, and an auditor
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Template for safety reports with descriptive example
International Nuclear Information System (INIS)
1995-12-01
This report provides a template for future safety reports on long-term safety in support of important decisions and permit applications in connection with the construction of a deep repository system. The template aims at providing a uniform structure for describing long-term safety, after the repository has been closed and sealed. The availability of such a structure will simplify both preparation and review of the safety reports, and make it possible to follow how safety assessments are influenced by the progressively more detailed body of data that emerges. A separate section containing 'descriptive examples' has been appended to the template. This section illustrates what the different chapters of the template should contain. 279 refs
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Template for safety reports with descriptive example
Energy Technology Data Exchange (ETDEWEB)
NONE
1995-12-01
This report provides a template for future safety reports on long-term safety in support of important decisions and permit applications in connection with the construction of a deep repository system. The template aims at providing a uniform structure for describing long-term safety, after the repository has been closed and sealed. The availability of such a structure will simplify both preparation and review of the safety reports, and make it possible to follow how safety assessments are influenced by the progressively more detailed body of data that emerges. A separate section containing `descriptive examples` has been appended to the template. This section illustrates what the different chapters of the template should contain. 279 refs.
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Swary, Jillian Havey; Stratman, Erik J
2014-07-01
Curriculum and role modeling adjustments are necessary to address patient safety gaps occurring during dermatology residency. To identify the source of clinical practices among dermatology residents that affect patient safety and determine the best approach for overcoming gaps in knowledge and practice patterns that contribute to these practices. A survey-based study, performed at a national medical dermatology meeting in Itasca, Illinois, in 2012, included 142 dermatology residents from 44 residency programs in the United States and Canada. Self-reported rates of dermatology residents committing errors, identifying local systems errors, and identifying poor patient safety role modeling. Of surveyed dermatology residents, 45.2% have failed to report needle-stick injuries incurred during procedures, 82.8% reported cutting and pasting a previous author's patient history information into a medical record without confirming its validity, 96.7% reported right-left body part mislabeling during examination or biopsy, and 29.4% reported not incorporating clinical photographs of lesions sampled for biopsy in the medical record at their institution. Residents variably perform a purposeful pause ("time-out") when indicated to confirm patient, procedure, and site before biopsy, with 20.0% always doing so. In addition, 59.7% of residents work with at least 1 attending physician who intimidates the residents, reducing the likelihood of reporting safety issues they witness. Finally, 78.3% have witnessed attending physicians purposefully disregarding required safety steps. Our data reinforce the need for modified curricula, systems, and teacher development to reduce injuries, improve communication with patients and between physicians, residents, and other members of the health care team, and create an environment free of intimidation.
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42 CFR 3.212 - Nonidentification of patient safety work product.
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...
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Assessment of Patient Safety Culture in Primary Health Care Settings in Kuwait
Directory of Open Access Journals (Sweden)
Maha Mohamed Ghobashi
2014-01-01
Full Text Available Background Patient safety is critical component of health care quality. We aimed to assess the awareness of primary healthcare staff members about patient safety culture and explore the areas of deficiency and opportunities for improvement concerning this issue.Methods: This descriptive cross sectional study surveyed 369 staff members in four primary healthcare centers in Kuwait using self-administered “Hospital Survey on Patient Safety Culture” adopted questionnaire. The total number of respondents was 276 participants (response rate = 74.79%.Results: Five safety dimensions with lowest positivity (less than 50% were identified and these are; the non – punitive response to errors, frequency of event reporting, staffing, communication openness, center handoffs and transitions with the following percentages of positivity 24%, 32%, 41%, 45% and 47% respectively. The dimensions of highest positivity were teamwork within the center’s units (82% and organizational learning (75%.Conclusion: Patient safety culture in primary healthcare settings in Kuwait is not as strong as improvements for the provision of safe health care. Well-designed patient safety initiatives are needed to be integrated with organizational policies, particularly the pressing need to address the bioethical component of medical errors and their disclosure, communication openness and emotional issues related to them and investing the bright areas of skillful organizational learning and strong team working attitudes.
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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.
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42 CFR 3.204 - Privilege of patient safety work product.
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...
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Escher, Cecilia; Creutzfeldt, Johan; Meurling, Lisbet; Hedman, Leif; Kjellin, Ann; Felländer-Tsai, Li
2017-02-10
Patient safety education, as well as the safety climate at clinical rotations, has an impact on students' attitudes. We explored medical students' self-reported motivation to participate in simulation-based teamwork training (SBTT), with the hypothesis that high scores in patient safety attitudes would promote motivation to SBTT and that intrinsic motivation would increase after training. In a prospective cohort study we explored Swedish medical students' attitudes to patient safety, their motivation to participate in SBTT and how motivation was affected by the training. The setting was an integrated SBTT course during the surgical semester that focused on non-technical skills and safe treatment of surgical emergencies. Data was collected using the Situational Motivation Scale (SIMS) and the Attitudes to Patient Safety Questionnaire (APSQ). We found a positive correlation between students' individual patient safety attitudes and self-reported motivation (identified regulation) to participate in SBTT. We also found that intrinsic motivation increased after training. Female students in our study scored higher than males regarding some of the APSQ sub-scores and the entire group scored higher or on par with comparable international samples. In order to enable safe practice and professionalism in healthcare, students' engagement in patient safety education is important. Our finding that students' patient safety attitudes show a positive correlation to motivation and that intrinsic motivation increases after training underpins patient safety climate and integrated teaching of patient safety issues at medical schools in order to help students develop the knowledge, skills and attitudes required for safe practice.
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Safety and health annual report 1996
International Nuclear Information System (INIS)
1997-01-01
The 1996 report on the Health and Safety performance of the nuclear fuel cycle company BNFL at its sites in the United Kingdom demonstrates a continuing improvement. The site locations and developments are briefly described and international developments in subsidiary organisations noted. Other sections of the report cover health and safety policy, radiological and industrial safety, emergency planning, incidents, occupational health services, compensation scheme developments, transport, putting radiation in perspective, and safety and health research. Data are provided on: radioactive discharges; industrial safety of BNFL and contractors' employees; radiation dose summaries for BNFL and contractors' employees. There is evidence of the expected plateauing out of doses to BNFL employees at a level less than or similar to background radiation. (UK)
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Improving Patient Safety: Improving Communication.
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.
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2009 VHA Facility Quality and Safety Report - Patient Satisfaction
Department of Veterans Affairs — The 2008 Hospital Report Card was mandated by the FY08 Appropriations Act, and focused on Congressionally-mandated metrics applicable to general patient populations....
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Chiang, Hui-Ying; Lin, Shu-Yuan; Hsiao, Ya-Chu; Chang, Yuanmay
2012-01-01
This study explored the effects of incident reporting culture and willingness of incident reporting on behavioral involvement in patient safety (BIPS) by surveying 1049 hospital nurses in Taiwan. The highest areas of BIPS were handoff communication and discussion on error prevention. Yet, sharing information about human factors toward safety awareness was less frequent. Results indicated that the reporting culture, willingness to report, tenure of work, and reporting rate contributed positively to BIPS.
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Nydahl, Peter; Sricharoenchai, Thiti; Chandra, Saurabh; Kundt, Firuzan Sari; Huang, Minxuan; Fischill, Magdalena; Needham, Dale M
2017-05-01
Early mobilization and rehabilitation of patients in intensive care units (ICUs) may improve physical function, and reduce the duration of delirium, mechanical ventilation, and ICU length of stay. However, safety concerns are an important barrier to widespread implementation. To synthesize safety data regarding patient mobilization and rehabilitation in the ICU, including falls, removal of endotracheal tubes, removal or dysfunction of intravascular catheters, removal of other catheters/tubes, cardiac arrest, hemodynamic changes, and desaturation. Systematic literature review, including searches of five databases. Eligible studies evaluated patients who received mobilization-related interventions in the ICU. Exclusion criteria included: (1) case series with fewer than 10 patients; (2) majority of patients under 18 years of age; and (3) data not reported to permit calculation of incidence of safety events. Number of patients, mobilization/rehabilitation sessions, potential safety events, and events with negative consequences (e.g., requiring intervention or additional therapy). Heterogeneity was assessed by I 2 statistics, and bias assessed by the Newcastle-Ottawa Scale and Cochrane risk of bias assessment. The literature search identified 20,660 titles. There were 48 eligible publications evaluating 7,546 patients, with 583 potential safety events occurring in 22,351 mobilization/rehabilitation sessions. There was a total of 583 (2.6%) potential safety events with heterogeneity in the definitions for these events. For the safety event types that could be meta-analyzed, pooled incidences per 1,000 mobilization/rehabilitation sessions (95% confidence interval), were: hemodynamic changes, 3.8 (1.3-11.4), and desaturation, 1.9 (0.9-4.3). A total of 24 studies of 3,404 patients reported on any consequences of potential safety events (e.g., needing to increase dose of vasopressor due to mobility-related hypotension), with a frequency of 0.6% in 14,398 mobilization
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Davis, Rachel E; Joshi, Devavrata; Patel, Krishan; Briggs, M; Vincent, Charles A
2013-10-01
In recent years, factors that affect patients' willingness and ability to participate in safety-relevant behaviours have been investigated. However, how trained healthcare professionals or medical students would feel participating in safety-relevant behaviours as a patient in hospital remains largely unexplored. To investigate medical students' willingness to participate in behaviours related to the quality and safety of their health care. A cross-sectional exploratory study using a survey that addressed willingness to participate in different behaviours recommended by current patient safety initiatives. Three types of interactional behaviours (asking factual or challenging questions, notifying doctors or nurses of errors/problems) and three non-interactional behaviours (choosing a hospital based on the safety record, bringing medicines and a list of allergies into hospital, and reporting an error to a national reporting system) were assessed. One hundred and seventy-nine medical students from an inner city London teaching hospital participated in the study. Students' willingness to participate was affected (P interactional behaviours) whether the patient was engaging in the specific action with a doctor or nurse. Students were least willing to ask 'challenging' questions to doctors and nurses and to report errors to a national reporting system. Doctors' and nurses' encouragement appeared to increase self-reported willingness to participate in behaviours where baseline willingness was low. Similar to research on lay patient populations; medical students do not view involvement in safety-related behaviours equally. Interventions should be tailored at encouraging students to participate in behaviours they are less inclined to take on an active role in. Future research is required to examine students' motivations for participation in this important but heavily under-researched area. © 2012 John Wiley & Sons Ltd.
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Culture, language, and patient safety: Making the link.
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.
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Directory of Open Access Journals (Sweden)
Khalil Alimohammadzadeh
2017-04-01
Full Text Available Introduction: Patient safety and its requirements fulfillment are today one of the useful valuation indicators in healthcare organizations. Thus, patient safety culture and its promotion are referred to as one of the most important issues raised in the country. The present study aims to examine the effective factors (personal and organizational in patient safety culture from the point of view of nursing staff in Bahman and Parsian private hospitals. Method: The study has an analytical cross-sectional design and is an applied research. HSOPSC (with Cronbach’s alpha coefficient was 0.82 and researcher-devised questionnaires (with Cronbach’s Alpha equal to 0.912 were the only data collection tools. Statistical population includes nursing staff of Bahman and Parsian private hospitals in north-west Tehran. A sample consisting of 150 nurse shift supervisors and head nurses was selected from the population. Necessary data for completing questionnaires were collected by interview. Data were analyzed using SPSS16 software. Given the levels of measurement for the variables, valid measures of central tendency (mean, standard deviation, correlation tests, Chi-square, t- test, and ANOVA were used. Results: The findings showed us that such factors as organizational commitment, error reporting system, management support, reward system, and employee empowerment equipment distribution have important roles in patient safety. Their P-values are reported <0.001 for all of them. Patient safety was not significantly associated with age (P=0.964, educational level (P=0.154, and work experience (P=0.888 There is no low awareness about safety culture in any hospital and their mean awareness about patient safety culture was equal to 3.13 ±0.478 and 3.68 ±0.587 in Parsian and Bahman hospitals, respectively (P<0.001. Conclusion: Error reporting system and organizational commitment respectively have the most and the least effect on promoting patient safety culture
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[Patient safety and errors in medicine: development, prevention and analyses of incidents].
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
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Wagar, Elizabeth A; Tamashiro, Lorraine; Yasin, Bushra; Hilborne, Lee; Bruckner, David A
2006-11-01
Patient safety is an increasingly visible and important mission for clinical laboratories. Attention to improving processes related to patient identification and specimen labeling is being paid by accreditation and regulatory organizations because errors in these areas that jeopardize patient safety are common and avoidable through improvement in the total testing process. To assess patient identification and specimen labeling improvement after multiple implementation projects using longitudinal statistical tools. Specimen errors were categorized by a multidisciplinary health care team. Patient identification errors were grouped into 3 categories: (1) specimen/requisition mismatch, (2) unlabeled specimens, and (3) mislabeled specimens. Specimens with these types of identification errors were compared preimplementation and postimplementation for 3 patient safety projects: (1) reorganization of phlebotomy (4 months); (2) introduction of an electronic event reporting system (10 months); and (3) activation of an automated processing system (14 months) for a 24-month period, using trend analysis and Student t test statistics. Of 16,632 total specimen errors, mislabeled specimens, requisition mismatches, and unlabeled specimens represented 1.0%, 6.3%, and 4.6% of errors, respectively. Student t test showed a significant decrease in the most serious error, mislabeled specimens (P patient safety projects. Trend analysis demonstrated decreases in all 3 error types for 26 months. Applying performance-improvement strategies that focus longitudinally on specimen labeling errors can significantly reduce errors, therefore improving patient safety. This is an important area in which laboratory professionals, working in interdisciplinary teams, can improve safety and outcomes of care.
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Sensemaking and the co-production of safety: a qualitative study of primary medical care patients.
Rhodes, Penny; McDonald, Ruth; Campbell, Stephen; Daker-White, Gavin; Sanders, Caroline
2016-02-01
This study explores the ways in which patients make sense of 'safety' in the context of primary medical care. Drawing on qualitative interviews with primary care patients, we reveal patients' conceptualisation of safety as fluid, contingent, multi-dimensional, and negotiated. Participant accounts drew attention to a largely invisible and inaccessible (but taken for granted) architecture of safety, the importance of psycho-social as well as physical dimensions and the interactions between them, informal strategies for negotiating safety, and the moral dimension of safety. Participants reported being proactive in taking action to protect themselves from potential harm. The somewhat routinised and predictable nature of the primary medical care consultation, which is very different from 'one off' inpatient spells, meant that patients were not passive recipients of care. Instead they had a stock of accumulated knowledge and experience to inform their actions. In addition to highlighting the differences and similarities between hospital and primary care settings, the study suggests that a broad conceptualisation of patient safety is required, which encompasses the safety concerns of patients in primary care settings. © 2015 The Authors. Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL.
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Martín Delgado, M C; Merino de Cos, P; Sirgo Rodríguez, G; Álvarez Rodríguez, J; Gutiérrez Cía, I; Obón Azuara, B; Alonso Ovies, Á
2015-01-01
To explore contributing factors (CF) associated to related critical patients safety incidents. SYREC study pos hoc analysis. A total of 79 Intensive Care Departments were involved. The study sample consisted of 1.017 patients; 591 were affected by one or more incidents. The CF were categorized according to a proposed model by the National Patient Safety Agency from United Kingdom that was modified. Type, class and severity of the incidents was analyzed. A total 2,965 CF were reported (1,729 were associated to near miss and 1,236 to adverse events). The CF group more frequently reported were related patients factors. Individual factors were reported more frequently in near miss and task related CF in adverse events. CF were reported in all classes of incidents. The majority of CF were reported in the incidents classified such as less serious, even thought CF patients factors were associated to serious incidents. Individual factors were considered like avoidable and patients factors as unavoidable. The CF group more frequently reported were patient factors and was associated to more severe and unavoidable incidents. By contrast, individual factors were associated to less severe and avoidable incidents. In general, CF most frequently reported were associated to near miss. Copyright © 2014 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.
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Safety culture in design. Final report
International Nuclear Information System (INIS)
Macchi, L.; Pietikaeinen, E.; Liinasuo, M.; Savioja, P.; Reiman, T.; Wahlstroem, M.; Kahlbom, U.; Rollenhagen, C.
2013-04-01
In this report we approach design from a safety culture approach As this research area is new and understudied, we take a wide scope on the issue. Different theoretical perspectives that can be taken when improving safety of the design process are considered in this report. We suggest that in the design context the concept of safety culture should be expanded from an organizational level to the level of the network of organizations involved in the design activity. The implication of approaching the design process from a safety culture perspective are discussed and the results of the empirical part of the research are presented. In the interview study in Finland and Sweden we identified challenges and opportunities in the design process from safety culture perspective. Also, a small part of the interview study concentrated on state of the art human factors engineering (HFE) practices in Finland and the results relating to that are presented. This report provide a basis for future development of systematic good design practices and for providing guidelines that can lead to safe and robust technical solutions. (Author)
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Safety culture in design. Final report
Energy Technology Data Exchange (ETDEWEB)
Macchi, L.; Pietikaeinen, E.; Liinasuo, M.; Savioja, P.; Reiman, T.; Wahlstroem, M. [VTT Technical Research Centre of Finland, Espoo (Finland); Kahlbom, U. [Risk Pilot AB, Stockholm (Sweden); Rollenhagen, C. [Vattenfall, Stockholm, (Sweden)
2013-04-15
In this report we approach design from a safety culture approach As this research area is new and understudied, we take a wide scope on the issue. Different theoretical perspectives that can be taken when improving safety of the design process are considered in this report. We suggest that in the design context the concept of safety culture should be expanded from an organizational level to the level of the network of organizations involved in the design activity. The implication of approaching the design process from a safety culture perspective are discussed and the results of the empirical part of the research are presented. In the interview study in Finland and Sweden we identified challenges and opportunities in the design process from safety culture perspective. Also, a small part of the interview study concentrated on state of the art human factors engineering (HFE) practices in Finland and the results relating to that are presented. This report provide a basis for future development of systematic good design practices and for providing guidelines that can lead to safe and robust technical solutions. (Author)
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Spence Laschinger, Heather K; Leiter, Michael P
2006-05-01
To test a theoretical model of professional nurse work environments linking conditions for professional nursing practice to burnout and, subsequently, patient safety outcomes. The 2004 Institute of Medicine report raised serious concerns about the impact of hospital restructuring on nursing work environments and patient safety outcomes. Few studies have used a theoretical framework to study the nature of the relationships between nursing work environments and patient safety outcomes. Hospital-based nurses in Canada (N = 8,597) completed measures of worklife (Practice Environment Scale of the Nursing Work Index), burnout (Maslach Burnout Inventory-Human Service Scale), and their report of frequency of adverse patient events. Structural equation modeling analysis supported an extension of Leiter and Laschinger's Nursing Worklife Model. Nursing leadership played a fundamental role in the quality of worklife regarding policy involvement, staffing levels, support for a nursing model of care (vs medical), and nurse/physician relationships. Staffing adequacy directly affected emotional exhaustion, and use of a nursing model of care had a direct effect on nurses' personal accomplishment. Both directly affected patient safety outcomes. The results suggest that patient safety outcomes are related to the quality of the nursing practice work environment and nursing leadership's role in changing the work environment to decrease nurse burnout.
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Ethnic inequalities in patient safety in Dutch hospital care
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
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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.
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Effects of auditing patient safety in hospital care: design of a mixed-method evaluation.
Hanskamp-Sebregts, Mirelle; Zegers, Marieke; Boeijen, Wilma; Westert, Gert P; van Gurp, Petra J; Wollersheim, Hub
2013-06-22
Auditing of patient safety aims at early detection of risks of adverse events and is intended to encourage the continuous improvement of patient safety. The auditing should be an independent, objective assurance and consulting system. Auditing helps an organisation accomplish its objectives by bringing a systematic, disciplined approach to evaluating and improving the effectiveness of risk management, control, and governance. Audits are broadly conducted in hospitals, but little is known about their effects on the behaviour of healthcare professionals and patient safety outcomes. This study was initiated to evaluate the effects of patient safety auditing in hospital care and to explore the processes and mechanisms underlying these effects. Our study aims to evaluate an audit system to monitor and improve patient safety in a hospital setting. We are using a mixed-method evaluation with a before-and-after study design in eight departments of one university hospital in the period October 2011-July 2014. We measure several outcomes 3 months before the audit and 15 months after the audit. The primary outcomes are adverse events and complications. The secondary outcomes are experiences of patients, the standardised mortality ratio, prolonged hospital stay, patient safety culture, and team climate. We use medical record reviews, questionnaires, hospital administrative data, and observations to assess the outcomes. A process evaluation will be used to find out which components of internal auditing determine the effects. We report a study protocol of an effect and process evaluation to determine whether auditing improves patient safety in hospital care. Because auditing is a complex intervention targeted on several levels, we are using a combination of methods to collect qualitative and quantitative data about patient safety at the patient, professional, and department levels. This study is relevant for hospitals that want to early detect unsafe care and improve patient
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Vandewalle, Joeri; Malfait, Simon; Eeckloo, Kristof; Colman, Roos; Beeckman, Dimitri; Verhaeghe, Sofie; Van Hecke, Ann
2018-04-01
The World Health Organization highlights the need for more patient participation in patient safety. In mental health care, psychiatric nurses are in a frontline position to support this evolution. The aim of the present study was to investigate the demographic and contextual factors that influence the willingness of psychiatric nurses to share power and responsibility with patients concerning patient safety. The patient participation culture tool for inpatient psychiatric wards was completed by 705 nurses employed in 173 psychiatric wards within 37 hospitals. Multilevel modelling was used to analyse the self-reported data. The acceptance of a role wherein nurses share power and responsibility with patients concerning patient safety is influenced by the nurses' sex, age, perceived competence, perceived support, and type of ward. To support nurses in fulfilling their role in patient participation, patient participation-specific basic and continuing education should be provided. Managers and supervisors should recognize and fulfil their facilitating role in patient participation by offering support to nurses. Special attention is needed for young nurses and nurses on closed psychiatric wards, because these particular groups report being less willing to accept a new role. Ward characteristics that restrict patient participation should be challenged so that these become more patient participation stimulating. More research is needed to explore the willingness and ability of psychiatric nurses to engage in collaborative safety management with patients who have specific conditions, such as suicidal ideation and emotional harm. © 2017 Australian College of Mental Health Nurses Inc.
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Air Travel Safety in Postoperative Breast Cancer Patients: A Systematic Review.
Co, Michael; Ng, Judy; Kwong, Ava
2018-05-17
Air travel has long been a dilemma in post-breast cancer surgery patients. Anecdotal reports have described adverse outcomes on surgical wound, implants, and lymphedema during air travel. This review aims to evaluate the best evidence from the literature concerning the air travel safety in breast cancer patients. A comprehensive review was performed of the Medline, Embase, CINAHL, and Cochrane databases using a predefined strategy. Retrieved studies were independently screened and rated for relevance. Data were extracted by 2 researchers. We reviewed the best evidence on air travel safety in postoperative breast cancer patients. Evidence was limited in the current literature to suggest adverse effects on postoperative mastectomy wounds and drains by high-altitude travel. Similarly, adverse effects on breast implants were limited to case reports and ex vivo experiments. A systematic review of 12 studies concluded that air travel is not associated with upper limb lymphedema after breast cancer surgery. Deep-vein thrombosis (DVT) is a known complication after air travel; in addition, malignancy itself is a known risk factor for DVT. Evidence of safety to continue tamoxifen during the period of air travel is lacking in the literature. Evidence to support the use of systemic DVT prophylaxis in general postoperative breast cancer patients is also limited. Best evidence from a large retrospective study suggested that mechanical antiembolism devices and early mobilization are the only measures required. Air travel is generally safe in patients after breast cancer surgery. Copyright © 2018. Published by Elsevier Inc.
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Developing a patient-led electronic feedback system for quality and safety within Renal PatientView.
Giles, Sally J; Reynolds, Caroline; Heyhoe, Jane; Armitage, Gerry
2017-03-01
It is increasingly acknowledged that patients can provide direct feedback about the quality and safety of their care through patient reporting systems. The aim of this study was to explore the feasibility of patients, healthcare professionals and researchers working in partnership to develop a patient-led quality and safety feedback system within an existing electronic health record (EHR), known as Renal PatientView (RPV). Phase 1 (inception) involved focus groups (n = 9) and phase 2 (requirements) involved cognitive walkthroughs (n = 34) and 1:1 qualitative interviews (n = 34) with patients and healthcare professionals. A Joint Services Expert Panel (JSP) was convened to review the findings from phase 1 and agree the core principles and components of the system prototype. Phase 1 data were analysed using a thematic approach. Data from phase 1 were used to inform the design of the initial system prototype. Phase 2 data were analysed using the components of heuristic evaluation, resulting in a list of core principles and components for the final system prototype. Phase 1 identified four main barriers and facilitators to patients feeding back on quality and safety concerns. In phase 2, the JSP agreed that the system should be based on seven core principles and components. Stakeholders were able to work together to identify core principles and components for an electronic patient quality and safety feedback system in renal services. Tensions arose due to competing priorities, particularly around anonymity and feedback. Careful consideration should be given to the feasibility of integrating a novel element with differing priorities into an established system with existing functions and objectives. © 2016 European Dialysis and Transplant Nurses Association/European Renal Care Association.
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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
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Improving Patient Safety in Anesthesia: A Success Story?
International Nuclear Information System (INIS)
Botney, Richard
2008-01-01
Anesthesia is necessary for surgery; however, it does not deliver any direct therapeutic benefit. The risks of anesthesia must therefore be as low as possible. Anesthesiology has been identified as a leader in improving patient safety. Anesthetic mortality has decreased, and in healthy patients can be as low as 1:250,000. Trends in anesthetic morbidity have not been as well defined, but it appears that the risk of injury is decreasing. Studies of error during anesthesia and Closed Claims studies have identified sources of risk and methods to reduce the risks associated with anesthesia. These include changes in technology, such as anesthetic delivery systems and monitors, the application of human factors, the use of simulation, and the establishment of reporting systems. A review of the important events in the past 50 years illustrates the many steps that have contributed to the improvements in anesthesia safety
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Chemical Safety Vulnerability Working Group Report
Energy Technology Data Exchange (ETDEWEB)
1994-09-01
This report marks the culmination of a 4-month review conducted to identify chemical safety vulnerabilities existing at DOE facilities. This review is an integral part of DOE's efforts to raise its commitment to chemical safety to the same level as that for nuclear safety.
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Directory of Open Access Journals (Sweden)
Gianfranco Damiani
2005-12-01
Full Text Available Since the Harvard Medical Practice Study was published in 1991 the growing mass of international literature has demonstrated that medical adverse events can cause iatrogenic illnesses, prolonged hospitalisations and increased costs. In 1999-2001, reports made by the Institute of Medicine (IOM in the USA, the Department of Health (DoH in the UK and the Australian Patient Safety Foundation (APSF stressed the necessity for creating a safer environment and a reporting culture throughout healthcare systems. They also emphasized the need for researchers to investigate means of turning policies into practice. Since their publication a lot of effort has gone into collecting data on adverse events and near misses. As a result, in 2001, the AHRQ published a Health Technology Assessment report on best practices for patient safety. While in Australia national meetings have been dedicated to address important issues across the whole spectrum of healthcare. In the UK the Audit Commission has published a report that is also focused on medication safety: “A spoonful of sugar”. In 2004 the World Health Organisation promoted a Patient Safety Alliance; while in April 2005the Standing Committee of European Doctors organised a Conference in Luxembourg called “Patient safety - Making it happen!”. The issue of patient safety is therefore seen as a priority by EU institutional bodies and by many European health stakeholders.
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Directory of Open Access Journals (Sweden)
Nortvedt Monica W
2010-09-01
Full Text Available Abstract Background How hospital health care personnel perceive safety climate has been assessed in several countries by using the Hospital Survey on Patient Safety (HSOPS. Few studies have examined safety climate factors in surgical departments per se. This study examined the psychometric properties of a Norwegian translation of the HSOPS and also compared safety climate factors from a surgical setting to hospitals in the United States, the Netherlands and Norway. Methods This survey included 575 surgical personnel in Haukeland University Hospital in Bergen, an 1100-bed tertiary hospital in western Norway: surgeons, operating theatre nurses, anaesthesiologists, nurse anaesthetists and ancillary personnel. Of these, 358 returned the HSOPS, resulting in a 62% response rate. We used factor analysis to examine the applicability of the HSOPS factor structure in operating theatre settings. We also performed psychometric analysis for internal consistency and construct validity. In addition, we compared the percent of average positive responds of the patient safety climate factors with results of the US HSOPS 2010 comparative data base report. Results The professions differed in their perception of patient safety climate, with anaesthesia personnel having the highest mean scores. Factor analysis using the original 12-factor model of the HSOPS resulted in low reliability scores (r = 0.6 for two factors: "adequate staffing" and "organizational learning and continuous improvement". For the remaining factors, reliability was ≥ 0.7. Reliability scores improved to r = 0.8 by combining the factors "organizational learning and continuous improvement" and "feedback and communication about error" into one six-item factor, supporting an 11-factor model. The inter-item correlations were found satisfactory. Conclusions The psychometric properties of the questionnaire need further investigations to be regarded as reliable in surgical environments. The operating
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Improving patient safety: lessons from rock climbing.
Robertson, Nic
2012-02-01
How to improve patient safety remains an intractable problem, despite large investment and some successes. Academics have argued that the root of the problem is a lack of a comprehensive 'safety culture' in hospitals. Other safety-critical industries such as commercial aviation invest heavily in staff training to develop such a culture, but comparable programmes are almost entirely absent from the health care sector. In rock climbing and many other dangerous activities, the 'buddy system' is used to ensure that safety systems are adhered to despite adverse circumstances. This system involves two or more people using simple checks and clear communication to prevent problems causing harm. Using this system as an example could provide a simple, original and entertaining way of introducing medical students to the idea that human factors are central to ensuring patient safety. Teaching the buddy system may improve understanding and acceptance of other patient safety initiatives, and could also be used by junior doctors as a tool to improve the safety of their practice. © Blackwell Publishing Ltd 2012.
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76 FR 7854 - Patient Safety Organizations: Voluntary Delisting From Lumetra PSO
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...
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Safety analysis report 231-Z Building
Energy Technology Data Exchange (ETDEWEB)
Powers, C.S.
1989-03-01
This report provides an intensive review of the nuclear safety of the operation of the 231-Z Building. For background information complete descriptions of the floor plan, building services, alarm systems, and glove box systems are included in this report. In addition, references are included to The Plutonium Laboratory Radiation Work Procedures, Safety Guides, 231-Z Operating Procedures Manual and Nuclear Materials accountability Procedures. Engineered and administrative features contribute to the overall safety of personnel, the building, and environs. The consequences of credible incidents were considered and are discussed.
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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.
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Patient safety: break the silence.
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.
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Hot Cell Facility (HCF) Safety Analysis Report
Energy Technology Data Exchange (ETDEWEB)
MITCHELL,GERRY W.; LONGLEY,SUSAN W.; PHILBIN,JEFFREY S.; MAHN,JEFFREY A.; BERRY,DONALD T.; SCHWERS,NORMAN F.; VANDERBEEK,THOMAS E.; NAEGELI,ROBERT E.
2000-11-01
This Safety Analysis Report (SAR) is prepared in compliance with the requirements of DOE Order 5480.23, Nuclear Safety Analysis Reports, and has been written to the format and content guide of DOE-STD-3009-94 Preparation Guide for U. S. Department of Energy Nonreactor Nuclear Safety Analysis Reports. The Hot Cell Facility is a Hazard Category 2 nonreactor nuclear facility, and is operated by Sandia National Laboratories for the Department of Energy. This SAR provides a description of the HCF and its operations, an assessment of the hazards and potential accidents which may occur in the facility. The potential consequences and likelihood of these accidents are analyzed and described. Using the process and criteria described in DOE-STD-3009-94, safety-related structures, systems and components are identified, and the important safety functions of each SSC are described. Additionally, information which describes the safety management programs at SNL are described in ancillary chapters of the SAR.
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Hot Cell Facility (HCF) Safety Analysis Report
International Nuclear Information System (INIS)
MITCHELL, GERRY W.; LONGLEY, SUSAN W.; PHILBIN, JEFFREY S.; MAHN, JEFFREY A.; BERRY, DONALD T.; SCHWERS, NORMAN F.; VANDERBEEK, THOMAS E.; NAEGELI, ROBERT E.
2000-01-01
This Safety Analysis Report (SAR) is prepared in compliance with the requirements of DOE Order 5480.23, Nuclear Safety Analysis Reports, and has been written to the format and content guide of DOE-STD-3009-94 Preparation Guide for U. S. Department of Energy Nonreactor Nuclear Safety Analysis Reports. The Hot Cell Facility is a Hazard Category 2 nonreactor nuclear facility, and is operated by Sandia National Laboratories for the Department of Energy. This SAR provides a description of the HCF and its operations, an assessment of the hazards and potential accidents which may occur in the facility. The potential consequences and likelihood of these accidents are analyzed and described. Using the process and criteria described in DOE-STD-3009-94, safety-related structures, systems and components are identified, and the important safety functions of each SSC are described. Additionally, information which describes the safety management programs at SNL are described in ancillary chapters of the SAR
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Health Information Technology in Healthcare Quality and Patient Safety: Literature Review.
Feldman, Sue S; Buchalter, Scott; Hayes, Leslie W
2018-06-04
The area of healthcare quality and patient safety is starting to use health information technology to prevent reportable events, identify them before they become issues, and act on events that are thought to be unavoidable. As healthcare organizations begin to explore the use of health information technology in this realm, it is often unclear where fiscal and human efforts should be focused. The purpose of this study was to provide a foundation for understanding where to focus health information technology fiscal and human resources as well as expectations for the use of health information technology in healthcare quality and patient safety. A literature review was conducted to identify peer-reviewed publications reporting on the actual use of health information technology in healthcare quality and patient safety. Inductive thematic analysis with open coding was used to categorize a total of 41 studies. Three pre-set categories were used: prevention, identification, and action. Three additional categories were formed through coding: challenges, outcomes, and location. This study identifies five main categories across seven study settings. A majority of the studies used health IT for identification and prevention of healthcare quality and patient safety issues. In this realm, alerts, clinical decision support, and customized health IT solutions were most often implemented. Implementation, interface design, and culture were most often noted as challenges. This study provides valuable information as organizations determine where they stand to get the most "bang for their buck" relative to health IT for quality and patient safety. Knowing what implementations are being effectivity used by other organizations helps with fiscal and human resource planning as well as managing expectations relative to cost, scope, and outcomes. The findings from this scan of the literature suggest that having organizational champion leaders that can shepherd implementation, impact culture
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Patient Safety Threat - Syringe Reuse
... 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 ...
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76 FR 60494 - Patient Safety Organizations: Voluntary Relinquishment From HPI-PSO
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...
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[Learning from aviation - how to increase patient safety in surgery].
Renz, B; Angele, M K; Jauch, K-W; Kasparek, M S; Kreis, M; Müller, M H
2012-04-01
During the last years attempts have been made to draw lessons from aviation to increase patient safety in medicine. In particular similar conditions are present in surgery as pilots and surgeons may have to support high physical and mental pressure. The use of a few safety instruments from aviation is feasible in an attempt to increase safety in surgery. First a "root caused" accident research may be established. This is achievable by morbidity and mortality conferences and critical incident reporting systems (CIRS). Second, standard operating procedures may assure a uniform mental model of team members. Furthermore, crew resource management illustrates a strategy and attitude concept, which is applicable in all situations. Safety instruments from aviation, therefore, seem to have a high potential to increase safety in surgery when properly employed. © Georg Thieme Verlag KG Stuttgart ˙ New York.
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Vogus, Timothy J; Sutcliffe, Kathleen M
2011-01-01
Prior research has found that safety organizing behaviors of registered nurses (RNs) positively impact patient safety. However, little research exists on the joint benefits of safety organizing and other contextual factors that help foster safety. Although we know that organizational practices often have more powerful effects when combined with other mutually reinforcing practices, little research exists on the joint benefits of safety organizing and other contextual factors believed to foster safety. Specifically, we examined the benefits of bundling safety organizing with leadership (trust in manager) and design (use of care pathways) factors on reported medication errors. A total of 1033 RNs and 78 nurse managers in 78 emergency, internal medicine, intensive care, and surgery nursing units in 10 acute-care hospitals in Indiana, Iowa, Maryland, Michigan, and Ohio who completed questionnaires between December 2003 and June 2004. Cross-sectional analysis of medication errors reported to the hospital incident reporting system for the 6 months after the administration of the survey linked to survey data on safety organizing, trust in manager, use of care pathways, and RN characteristics and staffing. Multilevel Poisson regression analyses indicated that the benefits of safety organizing on reported medication errors were amplified when paired with high levels of trust in manager or the use of care pathways. Safety organizing plays a key role in improving patient safety on hospital nursing units especially when bundled with other organizational components of a safety supportive system.
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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.)
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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 ...
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Daker-White, Gavin; Hays, Rebecca; McSharry, Jennifer; Giles, Sally; Cheraghi-Sohi, Sudeh; Rhodes, Penny; Sanders, Caroline
2015-01-01
Objective Studies of patient safety in health care have traditionally focused on hospital medicine. However, recent years have seen more research located in primary care settings which have different features compared to secondary care. This study set out to synthesize published qualitative research concerning patient safety in primary care in order to build a conceptual model. Method Meta-ethnography, an interpretive synthesis method whereby third order interpretations are produced that best describe the groups of findings contained in the reports of primary studies. Results Forty-eight studies were included as 5 discrete subsets where the findings were translated into one another: patients’ perspectives of safety, staff perspectives of safety, medication safety, systems or organisational issues and the primary/secondary care interface. The studies were focused predominantly on issues seen to either improve or compromise patient safety. These issues related to the characteristics or behaviour of patients, staff or clinical systems and interactions between staff, patients and staff, or people and systems. Electronic health records, protocols and guidelines could be seen to both degrade and improve patient safety in different circumstances. A conceptual reading of the studies pointed to patient safety as a subjective feeling or judgement grounded in moral views and with potentially hidden psychological consequences affecting care processes and relationships. The main threats to safety appeared to derive from ‘grand’ systems issues, for example involving service accessibility, resources or working hours which may not be amenable to effective intervention by individual practices or health workers, especially in the context of a public health system. Conclusion Overall, the findings underline the human elements in patient safety primary health care. The key to patient safety lies in effective face-to-face communication between patients and health care staff or
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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
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Dimensions of patient safety culture in family practice.
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.
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Plutonium Finishing Plant safety evaluation report
International Nuclear Information System (INIS)
1995-01-01
The Plutonium Finishing Plant (PFP) previously known as the Plutonium Process and Storage Facility, or Z-Plant, was built and put into operation in 1949. Since 1949 PFP has been used for various processing missions, including plutonium purification, oxide production, metal production, parts fabrication, plutonium recovery, and the recovery of americium (Am-241). The PFP has also been used for receipt and large scale storage of plutonium scrap and product materials. The PFP Final Safety Analysis Report (FSAR) was prepared by WHC to document the hazards associated with the facility, present safety analyses of potential accident scenarios, and demonstrate the adequacy of safety class structures, systems, and components (SSCs) and operational safety requirements (OSRs) necessary to eliminate, control, or mitigate the identified hazards. Documented in this Safety Evaluation Report (SER) is DOE's independent review and evaluation of the PFP FSAR and the basis for approval of the PFP FSAR. The evaluation is presented in a format that parallels the format of the PFP FSAR. As an aid to the reactor, a list of acronyms has been included at the beginning of this report. The DOE review concluded that the risks associated with conducting plutonium handling, processing, and storage operations within PFP facilities, as described in the PFP FSAR, are acceptable, since the accident safety analyses associated with these activities meet the WHC risk acceptance guidelines and DOE safety goals in SEN-35-91
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Takahashi, Tomohiko; Hayata, Satoru; Kobayashi, Akihiro; Onaka, Yuna; Ebihara, Takeshi; Hara, Terufumi
2018-03-01
Pulmonary arterial hypertension (PAH) is an intractable and rare disease and the accumulation of clinical evidence under real-world setting is needed. A post-marketing surveillance for the endothelin receptor antagonist ambrisentan (Volibris tablet) has been conducted by all-case investigation since September 2010. This paper is an interim report on the safety and efficacy of ambrisentan in 702 patients with PAH. PAH patients aged 15 years or older were subjected to the analysis. The safety analysis by overall cases or stratification of patient backgrounds and the efficacy analysis were investigated. Regarding patient characteristics, the 702 patients subjected to safety analysis included 543 (77.4%) women and 546 (77.8%) patients at WHO functional class II/III. The mean observational time was 392.7 days. A total of 324 adverse drug reaction (ADR) occurred in 204 (29.1%) patients. Common ADRs (≥ 2%) included anemia (4.6%), peripheral edema (4.1%), headache (3.6%), edema and face edema (2.6% each), abnormal hepatic function (2.3%), and epistaxis (2.1%). There were 82 serious ADRs occurring in 44 (6.3%) patients (385 serious adverse events in 184 (26.2%) patients). Although 11 (1.6%) interstitial lung disease (ILD) cases were reported, all were observed in patients with disease that may contribute to ILD and therefore it is difficult to assess if ambrisentan was associated with these events. There was no difference in safety in relation to the presence/absence of connective tissue disease-related PAH (CTD-PAH) or combination therapy. Among 677 patients subjected to efficacy analysis, those in whom hemodynamic status was determined before and after treatment showed improvement in the mean pulmonary arterial pressure and pulmonary vascular resistance after treatment. The interim results showed safety consistent with the known profile of ambrisentan in terms of the types and frequencies of ADRs in patients with PAH in real clinical practice, in comparison with
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Preliminary Integrated Safety Analysis Status Report
International Nuclear Information System (INIS)
Gwyn, D.
2001-01-01
This report provides the status of the potential Monitored Geologic Repository (MGR) Integrated Safety Analysis (EA) by identifying the initial work scope scheduled for completion during the ISA development period, the schedules associated with the tasks identified, safety analysis issues encountered, and a summary of accomplishments during the reporting period. This status covers the period from October 1, 2000 through March 30, 2001
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Effects of a team-based assessment and intervention on patient safety culture in general practice
DEFF Research Database (Denmark)
Hoffmann, B; Müller, V; Rochon, J
2014-01-01
Background: The measurement of safety culture in healthcare is generally regarded as a first step towards improvement. Based on a self-assessment of safety culture, the Frankfurt Patient Safety Matrix (FraTrix) aims to enable healthcare teams to improve safety culture in their organisations....... In this study we assessed the effects of FraTrix on safety culture in general practice. Methods: We conducted an open randomised controlled trial in 60 general practices. FraTrix was applied over a period of 9 months during three facilitated team sessions in intervention practices. At baseline and after 12...... months, scores were allocated for safety culture as expressed in practice structure and processes (indicators), in safety climate and in patient safety incident reporting. The primary outcome was the indicator error management. Results: During the team sessions, practice teams reflected on their safety...
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77 FR 22322 - Common Formats for Patient Safety Data Collection and Event Reporting
2012-04-13
... safety reporting systems. This inventory provides an evidence base that informs construction of the Common Formats. The inventory includes many systems from the private sector, including prominent academic... HHS Web site: http://www.PSO.AHRQ.gov/index.html . FOR FURTHER INFORMATION CONTACT: Cathryn Niane...
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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...
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Fusion safety program Annual report, Fiscal year 1995
International Nuclear Information System (INIS)
Longhurst, G.R.; Cadwallader, L.C.; Carmack, W.J.
1995-12-01
This report summarizes the major activities of the Fusion Safety Program in FY-95. The Idaho National Engineering Laboratory (INEL) is the designated lead laboratory, and Lockheed Idaho Technologies Company is the prime contractor for this program. The Fusion Safety Program was initiated in 1979. Activities are conducted at the INEL, at other DOE laboratories, and at other institutions. Among the technical areas covered in this report are tritium safety, beryllium safety, chemical reactions and activation product release, safety aspects of fusion magnet systems, plasma disruptions, risk assessment failure rate database development, and safety code development and application to fusion safety issues. Most of this work has been done in support of the International Thermonuclear Experimental Reactor (ITER). Also included in the report are summaries of the safety and environmental studies performed by the Fusion Safety Program for the Tokamak Physics Experiment and the Tokamak Fusion Test Reactor and the technical support for commercial fusion facility conceptual design studies. A final activity described is work to develop DOE Technical Standards for Safety of Fusion Test Facilities
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Annual safety research report, JFY 2010
International Nuclear Information System (INIS)
2011-09-01
In the safety infrastructure research working group report, 'the effective conducting of nuclear safety infrastructure research', published by METI in March 2010, the roles of regulatory agencies and JNES and their cooperation, and the research road map for nuclear safety regulation researches were summarized. As for the regulatory issues the governments or JNES considered necessary, JNES had compiled' safety research plan' in respective research areas necessary for solving the regulatory issues (safety research needs) and was conducting safety research to obtain the results, etc. Safety research areas, subjects and research projects were as follows: design review of nuclear power plant (4 subjects and each subject having several research projects totaled 19), control management of nuclear power plant (3 subjects and each subject having several research projects totaled 11), nuclear fuel cycle (2 subjects and each subject having several research projects totaled 5), nuclear fuel cycle backend (2 subjects and each subject having several research projects totaled 6), nuclear emergency preparedness and response (3 subjects and each subject having several research projects totaled 5) and bases of nuclear safety technology (3 subjects and each subject having several research projects totaled 7). In JFY 2010, JNES worked on the 53 research projects of 17 subjects in 6 areas as safety researches. This annual safety research report summarized respective achievements and stage of regulatory tools necessary for solving regulatory issues according to the safety research plan, JFY 2010 Edition as well as the situation of the reflection for the safety regulations. (T. Tanaka)
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Patient safety trilogy: perspectives from clinical engineering.
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.
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Model for safety reports including descriptive examples
International Nuclear Information System (INIS)
1995-12-01
Several safety reports will be produced in the process of planning and constructing the system for disposal of high-level radioactive waste in Sweden. The present report gives a model, with detailed examples, of how these reports should be organized and what steps they should include. In the near future safety reports will deal with the encapsulation plant and the repository. Later reports will treat operation of the handling systems and the repository
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Ikuta, Ichiro; Sodickson, Aaron; Wasser, Elliot J; Warden, Graham I; Gerbaudo, Victor H; Khorasani, Ramin
2012-08-01
To develop and validate an open-source informatics toolkit capable of creating a radiation exposure data repository from existing nuclear medicine report archives and to demonstrate potential applications of such data for quality assurance and longitudinal patient-specific radiation dose monitoring. This study was institutional review board approved and HIPAA compliant. Informed consent was waived. An open-source toolkit designed to automate the extraction of data on radiopharmaceuticals and administered activities from nuclear medicine reports was developed. After iterative code training, manual validation was performed on 2359 nuclear medicine reports randomly selected from September 17, 1985, to February 28, 2011. Recall (sensitivity) and precision (positive predictive value) were calculated with 95% binomial confidence intervals. From the resultant institutional data repository, examples of usage in quality assurance efforts and patient-specific longitudinal radiation dose monitoring obtained by calculating organ doses from the administered activity and radiopharmaceutical of each examination were provided. Validation statistics yielded a combined recall of 97.6% ± 0.7 (95% confidence interval) and precision of 98.7% ± 0.5. Histograms of administered activity for fluorine 18 fluorodeoxyglucose and iodine 131 sodium iodide were generated. An organ dose heatmap which displays a sample patient's dose accumulation from multiple nuclear medicine examinations was created. Large-scale repositories of radiation exposure data can be extracted from institutional nuclear medicine report archives with high recall and precision. Such repositories enable new approaches in radiation exposure patient safety initiatives and patient-specific radiation dose monitoring.
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Safety-related LWR research. Annual report 1993
International Nuclear Information System (INIS)
Hueper, R.
1994-06-01
The reactor safety R and D work of the Karlsruhe Nuclear Research Centre (KfK) has been part of the Nuclear Safety Research Project (PSF) since 1990. The present annual report 1993 summarizes the results on LWR safety. The research tasks are coordinated in agreement with internal and external working groups. The contributions to this report correspond to the status at the end of 1993. (orig./HP) [de
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42 CFR 3.208 - Continued protection of patient safety work product.
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...
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VanDenKerkhof, Elizabeth; Sears, Nancy; Edge, Dana S; Tregunno, Deborah; Ginsburg, Liane
2017-04-01
Practical nurses have experienced an increasing scope of practice, including an expectation to care for complex patients and function on interdisciplinary teams. Little is known about the degree to which patient safety principles are addressed in practical nursing education. To examine self-reported patient safety competencies of practical nurses. A cross-sectional online survey (July 2014) and face-to-face interviews (June 2015). Ontario, Canada. Survey participants were practical nurses newly registered with the College of Nurses of Ontario between January 2012 and December 2013. Interview participants were faculty and students in a practical nursing program in Ontario. Survey respondents completed the Health Professional Education in Patient Safety Survey online. Self-reported competencies in various patient safety domains were compared between classroom and clinical settings. Faculty members were interviewed about educational preparation of practical nurses and students were interviewed to provide insight into interpretation of survey questions. The survey response rate was 28.4% (n=1104/3883). Mean domain scores indicated a high level of confidence in patient safety competence (Nurses of Ontario >2years and in those who obtained their education outside of Canada. Faculty believed their approach to teaching and learning instilled a deep understanding of the limits to practical nurse autonomous practice. Practical nurses were confident in what they learned about patient safety in their educational programs. The high degree of patient safety competence may be a true reflection of practical nurses understanding of, and comfort with, the limits of their knowledge and, ultimately, the limits of their individual autonomous practice. Further exploration as to whether the questionnaire requires additional modification for use with practical nurse populations is warranted. However, this study provides the first examination of practical nurses' perspectives and
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A patient safety objective structured clinical examination.
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.
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Annual report on occupational safety 1983
International Nuclear Information System (INIS)
1984-08-01
The 1983 Annual Report on occupational safety at BNFL is presented. Data for whole-body radiation doses and skin and extremity doses are given for BNFL employees together with 1982 data for comparison. Similarly, accidental deaths and major injuries are recorded. Finally information on the frequency of both nuclear and non-nuclear incidents reported to the Health and Safety Executive is given. (U.K.)
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Najjar, Peter; Kachalia, Allen; Sutherland, Tori; Beloff, Jennifer; David-Kasdan, Jo Ann; Bates, David W; Urman, Richard D
2015-01-01
The AHRQ Patient Safety Indicators (PSIs) are used for calculation of risk-adjusted postoperative rates for adverse events. The payers and quality consortiums are increasingly requiring public reporting of hospital performance on these metrics. We discuss processes designed to improve the accuracy and clinical utility of PSI reporting in practice. The study was conducted at a 793-bed tertiary care academic medical center where PSI processes have been aggressively implemented to track patient safety events at discharge. A three-phased approach to improving administrative data quality was implemented. The initiative consisted of clinical review of all PSIs, documentation improvement, and provider outreach including active querying for patient safety events. This multidisciplinary effort to develop a streamlined process for PSI calculation reduced the reporting of miscoded PSIs and increased the clinical utility of PSI monitoring. Over 4 quarters, 4 of 41 (10%) PSI-11 and 9 of 138 (7%) PSI-15 errors were identified on review of clinical documentation and appropriate adjustments were made. A multidisciplinary, phased approach leveraging existing billing infrastructure for robust metric coding, ongoing clinical review, and frontline provider outreach is a novel and effective way to reduce the reporting of false-positive outcomes and improve the clinical utility of PSIs.
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Ock, Minsu; Lim, So Yun; Jo, Min-Woo; Lee, Sang-Il
2017-03-01
We performed a systematic review to assess and aggregate the available evidence on the frequency, expected effects, obstacles, and facilitators of disclosure of patient safety incidents (DPSI). We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for this systematic review and searched PubMed, Scopus, and the Cochrane Library for English articles published between 1990 and 2014. Two authors independently conducted the title screening and abstract review. Ninety-nine articles were selected for full-text reviews. One author extracted the data and another verified them. There was considerable variation in the reported frequency of DPSI among medical professionals. The main expected effects of DPSI were decreased intention of the general public to file medical lawsuits and punish medical professionals, increased credibility of medical professionals, increased intention of patients to revisit and recommend physicians or hospitals, higher ratings of quality of care, and alleviation of feelings of guilt among medical professionals. The obstacles to DPSI were fear of medical lawsuits and punishment, fear of a damaged professional reputation among colleagues and patients, diminished patient trust, the complexity of the situation, and the absence of a patient safety culture. However, the factors facilitating DPSI included the creation of a safe environment for reporting patient safety incidents, as well as guidelines and education for DPSI. The reported frequency of the experience of the general public with DPSI was somewhat lower than the reported frequency of DPSI among medical professionals. Although we identified various expected effects of DPSI, more empirical evidence from real cases is required.
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[Experience feedback committee: a method for patient safety improvement].
François, P; Sellier, E; Imburchia, F; Mallaret, M-R
2013-04-01
An experience feedback committee (CREX, Comité de Retour d'EXpérience) is a method which contributes to the management of safety of care in a medical unit. Originally used for security systems of civil aviation, the method has been adapted to health care facilities and successfully implemented in radiotherapy units and in other specialties. We performed a brief review of the literature for studies reporting data on CREX established in hospitals. The review was performed using the main bibliographic databases and Google search results. The CREX is designed to analyse incidents reported by professionals. The method includes monthly meetings of a multi-professional committee that reviews the reported incidents, chooses a priority incident and designates a "pilot" responsible for investigating the incident. The investigation of the incident involves a systemic analysis method and a written synthesis presented at the next meeting of the committee. The committee agrees on actions for improvement that are suggested by the analysis and follows their implementation. Systems for the management of health care, including reporting systems, are organized into three levels: the medical unit, the hospital and the country as a triple loop learning process. The CREX is located in the base level, short loop of risk management and allows direct involvement of care professionals in patient safety. Safety of care has become a priority of health systems. In this context, the CREX can be a useful vehicle for the implementation of a safety culture in medical units. Copyright © 2013 Elsevier Masson SAS. All rights reserved.
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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...
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[Attitudes towards patient safety culture in a hospital setting and related variables].
Mir-Abellán, Ramon; Falcó-Pegueroles, Anna; de la Puente-Martorell, María Luisa
To describe attitudes towards patient safety culture among workers in a hospital setting and determine the influence of socio-demographic and professional variables. The Hospital Survey on Patient Safety Culture was distributed among a sample of professionals and nursing assistants. A dimension was considered a strength if positive responses exceeded 75% and an opportunity for improvement if more than 50% of responses were negative. 59% (n=123) of respondents rated safety between 7 and 8. 53% (n=103) stated that they had not used the notification system to report any incidents in the previous twelve months. The strength identified was "teamwork in the unit/service" and the opportunity for improvement was "staffing". A more positive attitude was observed in outpatient services and among nursing professionals and part-time staff. This study has allowed us to determine the rating of the hospital in patient safety culture. This is vital for developing improvement strategies. Copyright © 2016 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.
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Ethical issues in patient safety: Implications for nursing management.
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.
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Sheard, Laura; O'Hara, Jane; Armitage, Gerry; Wright, John; Cocks, Kim; McEachan, Rosemary; Watt, Ian; Lawton, Rebecca
2014-10-29
Estimates show that as many as one in 10 patients are harmed while receiving hospital care. Previous strategies to improve safety have focused on developing incident reporting systems and changing systems of care and professional behaviour, with little involvement of patients. The need to engage with patients about the quality and safety of their care has never been more evident with recent high profile reviews of poor hospital care all emphasising the need to develop and support better systems for capturing and responding to the patient perspective on their care. Over the past 3 years, our research team have developed, tested and refined the PRASE (Patient Reporting and Action for a Safe Environment) intervention, which gains patient feedback about quality and safety on hospital wards. A multi-centre, cluster, wait list design, randomised controlled trial with an embedded qualitative process evaluation. The aim is to assess the efficacy of the PRASE intervention, in achieving patient safety improvements over a 12-month period.The trial will take place across 32 hospital wards in three NHS Hospital Trusts in the North of England. The PRASE intervention comprises two tools: (1) a 44-item questionnaire which asks patients about safety concerns and issues; and (2) a proforma for patients to report (a) any specific patient safety incidents they have been involved in or witnessed and (b) any positive experiences. These two tools then provide data which are fed back to wards in a structured feedback report. Using this report, ward staff are asked to hold action planning meetings (APMs) in order to action plan, then implement their plans in line with the issues raised by patients in order to improve patient safety and the patient experience.The trial will be subjected to a rigorous qualitative process evaluation which will enable interpretation of the trial results. fieldworker diaries, ethnographic observation of APMs, structured interviews with APM lead and collection
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Patients' perceptions of safety and quality of maternity clinical handover
Directory of Open Access Journals (Sweden)
Chin Georgiana SM
2011-08-01
Full Text Available Abstract Background Maternity clinical handover serves to address the gaps in knowledge existing when transitions between individuals or groups of clinicians occur throughout the antenatal, intra-partum and postnatal period. There are limited published studies on maternity handover and a paucity of information about patients' perceptions of the same. This paper reports postnatal patients' perceptions of how maternity handover contributes to the quality and safety of maternity care. Methods This paper reports on a mixed-methods study consisting of qualitative interviews and quantitative medical record analysis. Thirty English-speaking postnatal patients who gave birth at an Australian tertiary maternity hospital participated in a semi-structured interview prior to discharge from hospital. Interview data were coded thematically using the constant comparative method and managed via NVivo software; this data set was supplemented by medical record data analysed using STATA. Results Almost half of the women were aware of a handover process. Clinician awareness of patient information was seen as evidence that handover had taken place and was seen as representing positive aspects of teamwork, care and communication by participants, all important factors in the perception of quality health care. Collaborative cross-checking, including the use of cognitive artefacts such as hand held antenatal records and patient-authored birth plans, and the involvement of patients and their support people in handover were behaviours described by participants to be protective mechanisms that enhanced quality and safety of care. These human factors also facilitated team situational awareness (TSA, shared decision making and patient motivation in labour. Conclusions This study illustrates that many patients are aware of handover processes. For some patients, evidence of handover, through clinician awareness of information, represented positive aspects of teamwork, care and
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Influence of workplace demands on nurses' perception of patient safety.
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.
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Effects of auditing patient safety in hospital care: design of a mixed-method evaluation
2013-01-01
Background Auditing of patient safety aims at early detection of risks of adverse events and is intended to encourage the continuous improvement of patient safety. The auditing should be an independent, objective assurance and consulting system. Auditing helps an organisation accomplish its objectives by bringing a systematic, disciplined approach to evaluating and improving the effectiveness of risk management, control, and governance. Audits are broadly conducted in hospitals, but little is known about their effects on the behaviour of healthcare professionals and patient safety outcomes. This study was initiated to evaluate the effects of patient safety auditing in hospital care and to explore the processes and mechanisms underlying these effects. Methods and design Our study aims to evaluate an audit system to monitor and improve patient safety in a hospital setting. We are using a mixed-method evaluation with a before-and-after study design in eight departments of one university hospital in the period October 2011–July 2014. We measure several outcomes 3 months before the audit and 15 months after the audit. The primary outcomes are adverse events and complications. The secondary outcomes are experiences of patients, the standardised mortality ratio, prolonged hospital stay, patient safety culture, and team climate. We use medical record reviews, questionnaires, hospital administrative data, and observations to assess the outcomes. A process evaluation will be used to find out which components of internal auditing determine the effects. Discussion We report a study protocol of an effect and process evaluation to determine whether auditing improves patient safety in hospital care. Because auditing is a complex intervention targeted on several levels, we are using a combination of methods to collect qualitative and quantitative data about patient safety at the patient, professional, and department levels. This study is relevant for hospitals that want to
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Collaborating with nurse leaders to develop patient safety practices.
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.
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TIS General Safety Group Annual Report 2000
Weingarten, W
2001-01-01
This report summarises the main activities of the General Safety (GS) Group of the Technical Inspection and Safety Division (TIS) during the year 2000, and the results obtained. The different topics in which the Group is active are covered: general safety inspections and ergonomy, electrical, chemistry and gas safety, chemical pollution containment and control, industrial hygiene, the safety of civil engineering works and outside contractors, fire prevention and the safety aspects of the LHC experiments.
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Ribeliene, Janina; Blazeviciene, Aurelija; Nadisauskiene, Ruta Jolanta; Tameliene, Rasa; Kudreviciene, Ausrele; Nedzelskiene, Irena; Macijauskiene, Jurate
2018-04-22
Patients treated in health care facilities that provide services in the fields of obstetrics, gynecology, and neonatology are especially vulnerable. Large multidisciplinary teams of physicians, multiple invasive and noninvasive diagnostic and therapeutic procedures, and the use of advanced technologies increase the probability of adverse events. The evaluation of knowledge about patient safety culture among nurses and midwives working in such units and the identification of critical areas at a health care institution would reduce the number of adverse events and improve patient safety. The aim of the study was to evaluate the opinion of nurses and midwives working in clinical departments that provide services in the fields of obstetrics, gynecology, and neonatology about patient safety culture and to explore potential predictors for the overall perception of safety. We used the Hospital Survey on Patient Safety Culture (HSOPSC) to evaluate nurses' and midwives' opinion about patient safety issues. The overall response rate in the survey was 100% (n = 233). The analysis of the dimensions of safety on the unit level showed that the respondents' most positive evaluations were in the Organizational Learning - Continuous Improvement (73.2%) and Feedback and Communication about Error (66.8%) dimensions, and the most negative evaluations in the Non-punitive Response to Error (33.5%) and Staffing (44.6%) dimensions. On the hospital level, the evaluation of the safety dimensions ranged between 41.4 and 56.8%. The percentage of positive responses in the outcome dimensions Frequency of Events Reported was 82.4%. We found a significant association between the outcome dimension Frequency of Events Reported and the Hospital Management Support for Patient Safety and Feedback and Communication about Error Dimensions. On the hospital level, the critical domains in health care facilities that provide services in the fields of obstetrics, gynecology, and neonatology were Teamwork
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IRSN - Annual Report 2013. Financial Report 2013. Enhancing nuclear safety
International Nuclear Information System (INIS)
Schuler, Matthieu; Marchal, Valerie; Albert, Marc-Gerard; Aurelle, Jacques; Bigot, Marie-Pierre; Bruna, Giovanni; Charron, Sylvie; Clavelle, Stephanie; Cousinou, Patrick; Deschamps, Patrice; Delattre, Aleth; Demeillers, Didier; Dumas, Agnes; Franquard, Dominique; Laloi, Patrick; Lorthioir, Stephane; Monti, Pascale; Rollinger, Francois; Rouyer, Veronique; Rutschkovsky, Nathalie; Scott De Martinville, Edouard; Tharaud, Christine; Verpeaux, Jean-Luc; Jaunet, Camille; Hedouin, Jean-Christophe; Pascal-Heuze, Charlotte
2014-03-01
IRSN, a public entity with industrial and commercial activities, is placed under the joint authority of the Ministries of Defense, Environment, Industry, Research, and Health. It is the nation's public service expert in nuclear and radiation risks, and its activities cover all the related scientific and technical issues. Its areas of specialization include the environment and radiological emergency response, human radiation protection in both a medical and professional capacity, and in both normal and post-accident situations, the prevention of major accidents, nuclear reactor safety, as well as safety in nuclear plants and laboratories, transport and waste treatment, and nuclear defense and security expertise. IRSN interacts with all parties concerned by these risks (public authorities, in particular nuclear safety and security authorities, local authorities, companies, research organizations, stakeholders' associations, etc.) to contribute to public policy issues relating to nuclear safety, human and environmental protection against ionizing radiation, and the protection of nuclear materials, facilities, and transport against the risk of malicious acts. This document is the 2013 issue of IRSN's activity report. Content: 1 - Organization, key figures; 2 - Strategy: Progress and main activities in 2013, Transparency and communications policy, Promoting a safety and radiation protection culture; 3 - Activities: Safety (Safety of existing facilities, Studies and researches, About defense, Conducting assessments of future facilities); Nuclear security and non-proliferation (Nuclear security activities, International non-proliferation controls); Radiation protection - environment and human health (Environmental and population exposure, Radiation protection in the workplace, Effects of chronic exposure, Protection in health care); Emergency and post-accident situations efficiency; 4 - Efficiency: Health, safety, environmental, protection and quality, Human resources
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Application of patient safety indicators internationally: a pilot study among seven countries.
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.
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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)
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21 CFR 312.88 - Safeguards for patient safety.
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...
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Teamwork, organizational learning, patient safety and job outcomes.
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.
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Tomazoni, Andréia; Rocha, Patrícia Kuerten; de Souza, Sabrina; Anders, Jane Cristina; de Malfussi, Hamilton Filipe Correia
2014-01-01
OBJECTIVE: to verify the assessment of the patient safety culture according to the function and length of experience of the nursing and medical teams at Neonatal Intensive Care Units. METHOD: quantitative survey undertaken at four Neonatal Intensive Care Units in Florianópolis, Brazil. The sample totaled 141 subjects. The data were collected between February and April 2013 through the application of the Hospital Survey on Patient Safety Culture. For analysis, the Kruskal-Wallis and Chi-Square tests and Cronbach's Alpha coefficient were used. Approval for the research project was obtained from the Ethics Committee, CAAE: 05274612.7.0000.0121. RESULTS: differences in the number of positive answers to the Hospital Survey on Patient Safety Culture, the safety grade and the number of reported events were found according to the professional characteristics. A significant association was found between a shorter Length of work at the hospital and Length of work at the unit and a larger number of positive answers; longer length of experience in the profession represented higher grades and less reported events. The physicians and nursing technicians assessed the patient safety culture more positively. Cronbach's alpha demonstrated the reliability of the instrument. CONCLUSION: the differences found reveal a possible relation between the assessment of the safety culture and the subjects' professional characteristics at the Neonatal Intensive Care Units. PMID:25493670
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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.
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Fusion safety program annual report fiscal year 1997
International Nuclear Information System (INIS)
Longhurst, G.R.; Anderl, R.A.; Cadwallader, L.C.
1998-01-01
This report summarizes the major activities of the Fusion Safety Program in FY 1997. The Idaho National Engineering and Environmental Laboratory (INEEL) is the designated lead laboratory, and Lockheed Martin Idaho Technologies Company is the prime contractor for this program. The Fusion Safety Program was initiated in FY 1979 to perform research and develop data needed to ensure safety in fusion facilities. Activities include experiments, analysis, code development and application, and other forms of research. These activities are conducted at the INEEL, different DOE laboratories, and other institutions. The technical areas covered in this report include chemical reactions and activation product release, tritium safety, risk assessment failure rate database development, and safety code development and application to fusion safety issues. Most of this work has been done in support of the International Thermonuclear Experimental Reactor (ITER) project. Work done for ITER this year has focused on developing the needed information for the Non-site Specific Safety Report (NSSR-2)
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Fusion safety program annual report fiscal year 1997
Energy Technology Data Exchange (ETDEWEB)
Longhurst, G.R.; Anderl, R.A.; Cadwallader, L.C. [and others
1998-01-01
This report summarizes the major activities of the Fusion Safety Program in FY 1997. The Idaho National Engineering and Environmental Laboratory (INEEL) is the designated lead laboratory, and Lockheed Martin Idaho Technologies Company is the prime contractor for this program. The Fusion Safety Program was initiated in FY 1979 to perform research and develop data needed to ensure safety in fusion facilities. Activities include experiments, analysis, code development and application, and other forms of research. These activities are conducted at the INEEL, different DOE laboratories, and other institutions. The technical areas covered in this report include chemical reactions and activation product release, tritium safety, risk assessment failure rate database development, and safety code development and application to fusion safety issues. Most of this work has been done in support of the International Thermonuclear Experimental Reactor (ITER) project. Work done for ITER this year has focused on developing the needed information for the Non-site Specific Safety Report (NSSR-2).
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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.
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Fusion Safety Program Annual Report, Fiscal Year 1996
International Nuclear Information System (INIS)
Longhurst, G.R.; Anderl, R.A.; Cadwallader, L.C.
1996-12-01
This report summarizes the major activities of the Fusion Safety Program in FY 1996. The Idaho National Engineering Laboratory (INEL) is the designated lead laboratory, and Lockheed Martin Idaho Technologies Company is the prime contractor for this program. The Fusion Safety Program was initiated in 1979. The objective is to perform research and develop data needed to ensure safety in fusion facilities. Activities include experiments, analysis, code development and application, and other forms of research. These activities are conducted at the INEL, at other DOE laboratories, and at other institutions. Among the technical areas covered in this report are tritium safety, chemical reactions and activation product release, risk assessment failure rate database development, and safety code development and application to fusion safety issues. Most of this work has been done in support of the International Thermonuclear Experimental Reactor (ITER). Work done for ITER this year has focused on developing the needed information for the Non- Site- Specific Safety Report (NSSR-1). A final area of activity described is development of the new DOE Technical Standards for Safety of Magnetic Fusion Facilities
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Current status of safety analysis report for ANPP
International Nuclear Information System (INIS)
Amirjanyan, A.
1999-01-01
Current situation concerning Armenian NPP safety analysis report is considered within the frame of accepted safety practice. Licensing procedure is being developed. Technical support group was established in the Armenian Nuclear Regulatory Authority (ANRA). The task of the group is to study modern methods of NPP in depth safety analysis for technical assistance for the ANRA, and perform independent safety assessments. ANRA will be obliged to demand assistance from various foreign organisations for preparation of different parts of the Safety Analysis Report like determination though certain parts can be prepared in Armenia
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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
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Central Safety Department. Annual report 1986
International Nuclear Information System (INIS)
Kiefer, H.; Koenig, L.A.
1987-03-01
The Safety Officer and the Security Officer are responsible for radiation protection and technical safety, both conventional and nuclear, for the physical protection as well as the safeguards of nuclear materials and radioactive substances within the Kernforschungszentrum Karlsruhe GmbH (KfK). To fulfill these functions they rely on the assistance of the Central Safety Department. The Central Safety Department is responsible for handling all problems of radiation protection, safety and security of the institutes and departments of the Karlsruhe Nuclear Research Center, for waste water activity measurements and environmental monitoring of the whole area of the Center, and for research and development work mainly focusing on nuclear safety and radiation protection measures. The r+d work concentrates on the following aspects: physical and chemical behavior of biologically particularly active radionuclides, behavior of HT in the air/plant/soil system, biophysics of multicellular systems, improvement in radiation protection measurement and personnel dosimetry. The report gives details of the different duties, indicates the results of 1986 routine tasks and reports about results of investigations and developments of the working groups of the Department. (orig.) [de
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Fusion Safety Program annual report, fiscal year 1994
International Nuclear Information System (INIS)
Longhurst, G.R.; Cadwallader, L.C.; Dolan, T.J.; Herring, J.S.; McCarthy, K.A.; Merrill, B.J.; Motloch, C.G.; Petti, D.A.
1995-03-01
This report summarizes the major activities of the Fusion Safety Program in fiscal year 1994. The Idaho National Engineering Laboratory (INEL) is the designated lead laboratory and Lockheed Idaho Technologies Company is the prime contractor for this program. The Fusion Safety Program was initiated in 1979. Activities are conducted at the INEL, at other DOE laboratories, and at other institutions, including the University of Wisconsin. The technical areas covered in this report include tritium safety, beryllium safety, chemical reactions and activation product release, safety aspects of fusion magnet systems, plasma disruptions, risk assessment failure rate data base development, and thermalhydraulics code development and their application to fusion safety issues. Much of this work has been done in support of the International Thermonuclear Experimental Reactor (ITER). Also included in the report are summaries of the safety and environmental studies performed by the Fusion Safety Program for the Tokamak Physics Experiment and the Tokamak Fusion Test Reactor and of the technical support for commercial fusion facility conceptual design studies. A major activity this year has been work to develop a DOE Technical Standard for the safety of fusion test facilities
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Nuclear Safety Project. Annual report 1983
International Nuclear Information System (INIS)
1984-06-01
The annual report 1983 is a detailed description (in German language) of work within the Nuclear Safety Project performed in 1983 in the nuclear safety field by KfK institutes and departments and by external institutes on behalf of KfK. It includes for each individual research activity short summaries in English language on work performed, results obtained and plans for future work. This report was compiled by the project management. (orig.) [de
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Nuclear safety project. Annual report 1985
International Nuclear Information System (INIS)
1986-07-01
The annual report 1985 is a detailed description (in German language) of work within the nuclear safety project performed in 1985 in the nuclear safety field by KfK institutes and departments and by external institutes on behalf of KfK. It includes for each individual research activity short summaries in English language on work performed, results obtained and plans for future work. This report was compiled by the project management. (orig./HP) [de
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2010-09-29
The Food and Drug Administration (FDA) is amending its regulations governing safety reporting requirements for human drug and biological products subject to an investigational new drug application (IND). The final rule codifies the agency's expectations for timely review, evaluation, and submission of relevant and useful safety information and implements internationally harmonized definitions and reporting standards. The revisions will improve the utility of IND safety reports, reduce the number of reports that do not contribute in a meaningful way to the developing safety profile of the drug, expedite FDA's review of critical safety information, better protect human subjects enrolled in clinical trials, subject bioavailability and bioequivalence studies to safety reporting requirements, promote a consistent approach to safety reporting internationally, and enable the agency to better protect and promote public health.
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Evaluation and Customization of WHO Safety Checklist for Patient Safety in Otorhinolaryngology.
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.
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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...
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Enhancing nuclear safety. Annual report 2015. Financial report 2015
International Nuclear Information System (INIS)
Le Guludec, Dominique; Niel, Jean-Christophe; Mouton, Georges-Henri; Repussard, Jacques; Schuler, Matthieu; Marchal, Valerie; Albert, Marc-Gerard; Bigot, Marie-Pierre; Brisset, Yves; Bruna, Giovanni; Charron, Sylvie; Clavelle, Stephanie; Deschamps, Patrice; Delattre, Aleth; Demeillers, Didier; Laloi, Patrick; Lorthioir, Stephane; Monti, Pascale; Rollinger, Francois; Rouyer, Veronique; Tharaud, Christine; Jaunet, Camille; Pascal-Heuze, Charlotte
2016-01-01
After some introductory texts proposed by several IRSN head managers, and a brief presentation of some key data illustrating the activity, the annual report presents the main strategic orientations, notably in the field of knowledge management, and of information and communication. After some images illustrating the past year, activities are presented. They first deal with safety: safety of civil nuclear facilities, from decommissioning old reactors to designing those of the future, reactor ageing, severe accidents, fuel, criticality and neutronics, fire and containment, safety and radiation protection of defence-related facilities and activities, geological disposal of radioactive wastes. They secondly deal with security and non-proliferation (nuclear security, nuclear non-proliferation, chemical weapon ban), thirdly with radiation protection for human and environment health (environment monitoring, radionuclide transfer in the environment, radon and polluted sites, human exposure, radiation protection in the workplace, effects of chronic exposures, protection in health care), and fourthly with emergency and post-accident situations (emergency and post-accident preparedness and response). The next part of the activity report addresses issues related to efficiency: improved economic and financial management, property, computer security, quality and corporate social responsibility, human resources, organisation chart. The financial report proposes a management report, financial statements with an appendix to annual accounts, and an auditor's report
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Safety climate and self-reported injury: assessing the mediating role of employee safety control.
Huang, Yueng-Hsiang; Ho, Michael; Smith, Gordon S; Chen, Peter Y
2006-05-01
To further reduce injuries in the workplace, companies have begun focusing on organizational factors which may contribute to workplace safety. Safety climate is an organizational factor commonly cited as a predictor of injury occurrence. Characterized by the shared perceptions of employees, safety climate can be viewed as a snapshot of the prevailing state of safety in the organization at a discrete point in time. However, few studies have elaborated plausible mechanisms through which safety climate likely influences injury occurrence. A mediating model is proposed to link safety climate (i.e., management commitment to safety, return-to-work policies, post-injury administration, and safety training) with self-reported injury through employees' perceived control on safety. Factorial evidence substantiated that management commitment to safety, return-to-work policies, post-injury administration, and safety training are important dimensions of safety climate. In addition, the data support that safety climate is a critical factor predicting the history of a self-reported occupational injury, and that employee safety control mediates the relationship between safety climate and occupational injury. These findings highlight the importance of incorporating organizational factors and workers' characteristics in efforts to improve organizational safety performance.
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Directory of Open Access Journals (Sweden)
Minsu Ock
2017-03-01
Full Text Available Objectives We performed a systematic review to assess and aggregate the available evidence on the frequency, expected effects, obstacles, and facilitators of disclosure of patient safety incidents (DPSI. Methods We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA guidelines for this systematic review and searched PubMed, Scopus, and the Cochrane Library for English articles published between 1990 and 2014. Two authors independently conducted the title screening and abstract review. Ninety-nine articles were selected for full-text reviews. One author extracted the data and another verified them. Results There was considerable variation in the reported frequency of DPSI among medical professionals. The main expected effects of DPSI were decreased intention of the general public to file medical lawsuits and punish medical professionals, increased credibility of medical professionals, increased intention of patients to revisit and recommend physicians or hospitals, higher ratings of quality of care, and alleviation of feelings of guilt among medical professionals. The obstacles to DPSI were fear of medical lawsuits and punishment, fear of a damaged professional reputation among colleagues and patients, diminished patient trust, the complexity of the situation, and the absence of a patient safety culture. However, the factors facilitating DPSI included the creation of a safe environment for reporting patient safety incidents, as well as guidelines and education for DPSI. Conclusions The reported frequency of the experience of the general public with DPSI was somewhat lower than the reported frequency of DPSI among medical professionals. Although we identified various expected effects of DPSI, more empirical evidence from real cases is required.
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Hays, Rebecca; Daker-White, Gavin; Esmail, Aneez; Barlow, Wendy; Minor, Brian; Brown, Benjamin; Blakeman, Thomas; Sanders, Caroline; Bower, Peter
2017-11-21
In primary care, older patients with multimorbidity (two or more long-term conditions) are especially likely to experience patient safety incidents. Risks to safety in this setting arise as a result of patient, staff and system factors; particularly where these interact or fail to do so. Recent research and policy highlight the important contribution patients can make to improving safety. Older patients with multimorbidity may have the most to gain from increasing their involvement but before interventions can be developed to support them to improve their patient safety, more needs to be known about how this is threatened and how patients respond to perceived threats. We sought to identify and describe threats to patient safety in primary care among older people with multimorbidity, to provide a better understanding of how these are experienced and to inform the development of interventions to reduce risks to patient safety. Twenty-six older people, aged 65 or over, with multimorbidity were recruited to a longitudinal qualitative study. At baseline, data on their health and healthcare were collected through semi-structured interviews. Data were analysed thematically, using a framework developed from a previous synthesis of qualitative studies of patient safety in primary care. Threats to patient safety were organised into six themes, across three domains of health and care. These encompassed all aspects of the patient journey, from access to everyday management. Across the journey, many issues arose due to poor communication, and uncoordinated care created extra burdens for patients and healthcare staff. Patients' sense of safety and trust in their care providers were especially threatened when they felt their needs were ignored, or when they perceived responses from staff as inappropriate or insensitive. For older patients with multimorbidity, patient safety is intrinsically linked to the challenges people face when managing health conditions, navigating the
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Using safety crosses for patient self-reflection.
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.
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Social capital and knowledge sharing: effects on patient safety.
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.
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Health and safety annual report 1992
International Nuclear Information System (INIS)
1993-01-01
BNFL operates 6 sites in the United Kingdom concerned with the nuclear fuel cycle. The annual report on occupational health and safety gives information on all aspects of health and safety within BNFL with special reference to radiation doses received by the workforce and radiation protection measures taken by the company. BNFL's safety policy is set out. Radiation doses to all workers have remained low. Other industrial accidents are also listed and its safety measures for transport, radioactive effluents and in the event of an incident, are mentioned briefly. (UK)
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Fusion Safety Program annual report, Fiscal Year 1993
International Nuclear Information System (INIS)
Longhurst, G.R.; Cadwallader, L.C.; Dolan, T.J.; Herring, J.S.; McCarthy, K.A.; Merrill, B.J.; Motloch, C.G.; Petti, D.A.
1993-12-01
This report summarizes the major activities of the Fusion Safety Program in Fiscal Year 1993. The Idaho National Engineering Laboratory (INEL) has been designated by DOE as the lead laboratory for fusion safety, and EG ampersand G Idaho, Inc., is the prime contractor for INEL operations. The Fusion Safety Program was initiated in 1979. Activities are conducted at the INEL and in participating organizations, including universities and private companies. Technical areas covered in the report include tritium safety, beryllium safety, activation product release, reactions involving potential plasma-facing materials, safety of fusion magnet systems, plasma disruptions and edge physics modeling, risk assessment failure rates, computer codes for reactor transient analysis, and regulatory support. These areas include work completed in support of the International Thermonuclear Experimental Reactor (ITER). Also included in the report are summaries of the safety and environmental studies performed at the INEL for the Tokamak Physics Experiment and the Tokamak Fusion Test Reactor projects at the Princeton Plasma Physics Laboratory and a summary of the technical support for the ARIES/PULSAR commercial reactor design studies
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77 FR 25179 - Patient Safety Organizations: Expired Listing for Medkinetics, LLC
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...
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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…
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Bell, Sigall K; Mejilla, Roanne; Anselmo, Melissa; Darer, Jonathan D; Elmore, Joann G; Leveille, Suzanne; Ngo, Long; Ralston, James D; Delbanco, Tom; Walker, Jan
2017-04-01
Patient advocates and safety experts encourage adoption of transparent health records, but sceptics worry that shared notes may offend patients, erode trust or promote defensive medicine. As electronic health records disseminate, such disparate views fuel policy debates about risks and benefits of sharing visit notes with patients through portals. Presurveys and postsurveys from 99 volunteer doctors at three US sites who participated in OpenNotes and postsurveys from 4592 patients who read at least one note and submitted a survey. Patients read notes to be better informed and because they were curious; about a third read them to check accuracy. In total, 7% (331) of patients reported contacting their doctor's office about their note. Of these, 29% perceived an error, and 85% were satisfied with its resolution. Nearly all patients reported feeling better (37%) or the same (62%) about their doctor. Patients who were older (>63), male, non-white, had fair/poor self-reported health or had less formal education were more likely to report feeling better about their doctor. Among doctors, 26% anticipated documentation errors, and 44% thought patients would disagree with notes. After a year, 53% believed patient satisfaction increased, and 51% thought patients trusted them more. None reported ordering more tests or referrals. Despite concerns about errors, offending language or defensive practice, transparent notes overall did not harm the patient-doctor relationship. Rather, doctors and patients perceived relational benefits. Traditionally more vulnerable populations-non-white, those with poorer self-reported health and those with fewer years of formal education-may be particularly likely to feel better about their doctor after reading their notes. Further informing debate about OpenNotes, the findings suggest transparent records may improve patient satisfaction, trust and safety. Published by the BMJ Publishing Group Limited. For permission to use (where not already
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Galván Núñez, Pablo; Santander Barrios, María Dolores; Villa Álvarez, María Cristina; Castro Delgado, Rafael; Alonso Lorenzo, Julio C; Arcos González, Pedro
2016-06-01
To describe the reported incidents and adverse events in the emergency medical services of Asturias, Spain, and assess their consequences, delays caused, and preventability. Prospective, observational study of incidents reported by the staff of the emergency medical services of Asturias after implementation of a system devised by the researchers. Incident reports were received for 0.48% (95% CI, 0.41%-0.54%) of the emergencies attended. Patient safety was compromised in 74.7% of the reported incidents. Problems arising in the emergency response coordination center (ERCC) accounted for 37.6% of the incidents, transport problems for 13.4%, vehicular problems for 10.8%, and communication problems for 8.8%. Seventy percent of the reported incidents caused delays in care; 55% of the reported incidents that put patients at risk (according to severity assessment code ratings) corresponded to problems related to human or material resources. A total of 88.1% of the incidents reported were considered avoidable. Some type of intervention was required to attenuate the effects of 46.2% of the adverse events reported. The measures that staff members most often proposed to prevent adverse events were to increase human and material resources (28.3%), establish protocols (14.5%), and comply with quality of care recommendations (9.7%). It is important to promote a culture of safety and incident reporting among health care staff in Asturias given the number of serious adverse events. Reporting is necessary for understanding the errors made and taking steps to prevent them. The ERCC is the point in the system where incidents are particularly likely to appear and be noticed and reported.
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Directory of Open Access Journals (Sweden)
Ahmadreza Izadi
2015-01-01
Full Text Available Introduction: Patient safety improvement requires ongoing culture. This cultural change is the most important challenge that managers are faced with in creation of a safe system. This study aims to show the results of initiatives to improvement in patient safety culture in Fateme Al-zahra hospital. Method: In the quasi-experimental research, patient safety culture was measured using the Persian questionnaire on adaptation of the hospital survey on patient safety culture in 12 dimensions. The research was conducted before (January 2010 and after (September 2012 the improvement initiatives. In this study, all units were determined and no sampling method was used. Reliability of the questionnaire was tested by Alpha Chronbakh (0.83. Data were analyzed using descriptive statistics indices and Independent T-Test by SPSS Software (version 18. Results: 350 questionnaires were distributed in each phaseand overall response rate was 58 and 56 percent, respectively. According to Independent T-test, Management expectations and actions, Organizational learning, Management support, Feedback and communication about error, Communication openness, Overall Perceptions of Safety, Non-punitive Response to Error, Frequency of Event Reporting, and Patient safety culture showed significant differences (P-value0.05. The mean score of Patient safety culture was 2.27 (from 5 and it was increased to 2.46 after initiatives that showed a significant difference (P-value<0.05. Conclusion: Although, improvement in patient safety culture needs teamwork and continuous attempts, the study showed that initiatives implemented in the case hospital had been effective in some dimensions. However, Teamwork within hospital units, Teamwork across units, Hospital handoffs and transitions, and Staffing dimensions were recognized for further intervention. Hospital could improve the patient safety culture with planning and measures in these dimensions.
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Improving patient safety: patient-focused, high-reliability team training.
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.
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Nuclear safety in Slovak Republic. Safety analysis reports for WWER 440 reactors
International Nuclear Information System (INIS)
Rohar, S.
1999-01-01
Implementation of nuclear power program is connected to establishment of regulatory body for safe regulation of siting, construction, operation and decommissioning of nuclear installations. Licensing being one of the most important regulatory surveillance activity is based on independent regulatory review and assessment of information on nuclear safety for particular nuclear facility. Documents required to be submitted to the regulatory body by the licensee in Slovakia for the review and assessment usually named Safety Analysis Report (SAR) are presented in detail in this paper. Current status of Safety Analysis Reports for Bohunice V-1, Bohunice V-2 and Mochovce NPP is shown
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Gu, Yong Hong; Ng, Chui Shan; Cai, Xiao; Xu, Jun; Zhang, Xin Shi; Ke, Dong Ge; Yu, Qian Hui; Chan, Chi Kuen
2018-01-01
Background The World Health Organization highlights that patient safety interventions are not lacking but that the local context affects their successful implementation. Increasing attention is being paid to patient safety in Mainland China, yet few studies focus on patient safety in organizations with mixed cultures. This paper evaluates the current patient safety culture in an experimental Chinese hospital with a Hong Kong hospital management culture, and it aims to explore the application of Hong Kong’s patient safety strategies in the context of Mainland China. Methods A quantitative survey of 307 hospital staff members was conducted using the Hospital Survey on Patient Safety Culture questionnaire. The findings were compared with a similar study on general Chinese hospitals and were appraised with reference to the Manchester Patient Safety Framework. Results Lower scores were observed among participants with the following characteristics: males, doctors, those with more work experience, those with higher education, and those from the general practice and otolaryngology departments. However, the case study hospital achieved better scores in management expectations, actions and support for patient safety, incident reporting and communication, and teamwork within units. Its weaknesses were related to non-punitive responses to errors, teamwork across units, and staffing. Conclusions The case study hospital contributes to a changing patient safety culture in Mainland China, yet its patient safety culture remains mostly bureaucratic. Further efforts could be made to deepen the staff’s patient safety culture mind-set, to realize a “bottom-up” approach to cultural change, to build up a comprehensive and integrated incident management system, and to improve team building and staffing for patient safety. PMID:29750061
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Safety assessment of research reactors and preparation of the safety analysis report
International Nuclear Information System (INIS)
1994-01-01
This Safety Guide presents guidelines, approved by international consensus, for the preparation, review and assessment of safety documentation for research reactors such as the Safety Analysis Report. While the Guide is most applicable to research reactors in the design and construction stage, it is also recommended for use during relicensing or reassessment of existing reactors
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The sociotechnical configuration of the problem of Patient Safety
DEFF Research Database (Denmark)
Danholt, Peter
2010-01-01
Abstract. This paper presents and discusses two approaches to “the sociotechnical”, one coming from the Tavistock tradition and the other from actor network theory. These two differ in important ways and from the latter it follows that what patient safety means must be scrutinized and unpacked....... The paper thus rudimentarily discusses central contributions to the problematization of patient safety. Last it is argued that research that provide data on the processes of medical interventions where events, decisions and entities become transformed through their interactions is needed in order to further...... nuance the problem of patient safety. Keywords. Sociotechnical, patient safety, actor network theory, adverse events....
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Annual report on occupational safety 1989
International Nuclear Information System (INIS)
1990-01-01
This report presents detailed information on occupational safety relating to BNFL's employees for 1989 and data compared with the previous year. Routine monitoring, non-radiological safety and 'incidents' are discussed and 'statutory' whole-body exposures, nuclear incidents, lost-time accidents, and types of injury are tabulated. (author)
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76 FR 60495 - Patient Safety Organizations: Voluntary Relinquishment From Illinois PSO
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...
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Towards an international classification for patient safety : the conceptual framework
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.
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International Nuclear Information System (INIS)
2006-01-01
Nuclear Safety Commission's taskforce on 'Introduction of Safety Regulation Utilizing Risk Information' completed the interim report on its future subjects and directions in December 2005. Although current safety regulatory activities have been based on deterministic approach, this report shows the risk informed approach is expected to be very useful for making nuclear safety regulation and assurance activities reasonable and also for appropriate allocation of regulatory resources. For introduction of risk informed regulation, it also recommends pileups of experiences with gradual introduction and trial of the risk informed approach, improvement of plant maintenance rules and regulatory requirements utilizing risk information, and establishment of framework to assure quality of risk evaluation. (T. Tanaka)
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Implementing Protocols to Improve Patient Safety in the Medical Imaging Department.
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.
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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.
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Sammer, Christine; Hauck, Loran D; Jones, Cason; Zaiback-Aldinger, Julie; Li, Michael; Classen, David
2018-02-07
In 2015, the Institute of Medicine Vital Signs report called for a new patient safety composite measure to lessen the reporting burden of patient harm. Before this report, two patient safety organizations had developed an electronic all-cause harm measurement system leveraging data from the electronic health record, which identified and grouped harms into five broad categories and consolidated them into one all-cause harm outcome measure. The objective of this study was to examine the relationship between this all-cause harm patient safety measure and the following three performance measures important to overall hospital safety performance: safety culture, employee engagement, and patient experience. We studied the relationship between all-cause harm and three performance measures on eight inpatient care units at one hospital for 7 months. The findings demonstrated strong correlations between an all-cause harm measure and patient safety culture, employee engagement, and patient experience at the hospital unit level. Four safety culture domains showed significant negative correlations with all-cause harm at a P value of 0.05 or less. Six employee engagement domains were significantly negatively correlated with all-cause harm at a P value of 0.01 or less, and six of the ten patient experience measures were significantly correlated with all-cause harm at a P value of 0.05 or less. The results show that there is a strong relationship between all-cause harm and these performance measures indicating that when there is a positive patient safety culture, a more engaged employee, and a more satisfying patient experience, there may be less all-cause harm.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the
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Taylor, Jennifer A; Gerwin, Daniel; Morlock, Laura; Miller, Marlene R
2011-12-01
To evaluate the need for triangulating case-finding tools in patient safety surveillance. This study applied four case-finding tools to error-associated patient safety events to identify and characterise the spectrum of events captured by these tools, using puncture or laceration as an example for in-depth analysis. Retrospective hospital discharge data were collected for calendar year 2005 (n=48,418) from a large, urban medical centre in the USA. The study design was cross-sectional and used data linkage to identify the cases captured by each of four case-finding tools. Three case-finding tools (International Classification of Diseases external (E) and nature (N) of injury codes, Patient Safety Indicators (PSI)) were applied to the administrative discharge data to identify potential patient safety events. The fourth tool was Patient Safety Net, a web-based voluntary patient safety event reporting system. The degree of mutual exclusion among detection methods was substantial. For example, when linking puncture or laceration on unique identifiers, out of 447 potential events, 118 were identical between PSI and E-codes, 152 were identical between N-codes and E-codes and 188 were identical between PSI and N-codes. Only 100 events that were identified by PSI, E-codes and N-codes were identical. Triangulation of multiple tools through data linkage captures potential patient safety events most comprehensively. Existing detection tools target patient safety domains differently, and consequently capture different occurrences, necessitating the integration of data from a combination of tools to fully estimate the total burden.
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Explaining Ethnic Disparities in Patient Safety: A Qualitative Analysis
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
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Focus on patient safety all day, every day.
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.
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Non-technical skills training to enhance patient safety.
Gordon, Morris
2013-06-01
Patient safety is an increasingly recognised issue in health care. Systems-based and organisational methods of quality improvement, as well as education focusing on key clinical areas, are common, but there are few reports of educational interventions that focus on non-technical skills to address human factor sources of error. A flexible model for non-technical skills training for health care professionals has been designed based on the best available evidence, and with sound theoretical foundations. Educational sessions to improve non-technical skills in health care have been described before. The descriptions lack the details to allow educators to replicate and innovate further. A non-technical skills training course that can be delivered as either a half- or full-day intervention has been designed and delivered to a number of mixed groups of undergraduate medical students and doctors in postgraduate training. Participant satisfaction has been high and patient safety attitudes have improved post-intervention. This non-technical skills educational intervention has been built on a sound evidence base, and is described so as to facilitate replication and dissemination. With the key themes laid out, clinical educators will be able to build interventions focused on numerous clinical issues that pay attention to human factor contributors to safety. © 2013 John Wiley & Sons Ltd.
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75 FR 57477 - Patient Safety Organizations: Voluntary Delisting
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...
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Supplement to safety analysis report. 306-W building operations safety requirement
International Nuclear Information System (INIS)
Richey, C.R.
1979-08-01
The operations safety requirements (OSRs) presented in this report define the conditions, safe boundaries, and management control needed for safely conducting operations with radioactive materials in the Pacific Northwest Laboratory (PNL) 306-W building. The safety requirements are organized in five sections. Safety limits are safety-related process variables that are observable and measurable. Limiting conditions cover: equipment and technical conditions and characteristics of the facility and operations necessary for continued safe operation. Surveillance requirements prescribe the requirements for checking systems and components that are essential to safety. Equipment design controls require that changes to process equipment and systems be independently checked and approved to assure that the changes will have no adverse effect on safety. Administrative controls describe and discuss the organization and administrative systems and procedures to be used for safe operation of the facility. Details of the implementation of the operations safety requirements are prescribed by internal PNL documents such as criticality safety specifications and radiation work procedures
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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...
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Safety analysis reports - new strategies
International Nuclear Information System (INIS)
Booth, J.A.
1994-01-01
Within the past year there have been many external changes in the requirements of safety analysis reports. Now there is emphasis on open-quotes graded approachesclose quotes depending on the Hazard Classification of the project. The Energy Facility Contractors Group (EFCOG) has a Safety Analysis Working Group. The results of this group for the past year are discussed as well as the implications for EG ampersand G. New strategies include ideas for incorporating the graded approach, auditable safety documents, additional guidance for Hazard Classification per DOE-STD-1027-92. The emphasis in the paper is on those projects whose hazard classification is category three or less
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Fareed, Naleef; Mick, Stephen S
2011-01-01
For almost a decade, public and private organizations have pressured hospitals to improve their patient safety records. Since 2008, the Centers for Medicare & Medicaid Services has no longer been reimbursing hospitals for secondary diagnoses not reported during the point of admission. This ruling has motivated some hospitals to engage in safety-oriented programs to decrease adverse events. This study examined which hospitals may engage in patient safety solutions and whether they create these patient safety solutions within their structures or use suppliers in the market. We used a theoretical model that incorporates the key constructs of resource dependence theory and transaction cost economics theory to predict a hospital's reaction to Centers for Medicare & Medicaid Services "never event" regulations. We present propositions that speculate on how forces conceptualized from the resource dependence theory may affect adoption of patient safety innovations and, when they do, whether the adopting hospitals will do so internally or externally according to the transaction cost economics theory. On the basis of forces identified by the resource dependence theory, we predict that larger, teaching, safety net, horizontally integrated, highly interdependent, and public hospitals in concentrated, high public payer presence, competitive, and resource-rich environments will be more likely to engage in patient safety innovations. Following the logic of the transaction cost economics theory, we predict that of the hospitals that react positively to the never event regulation, most will internalize their innovations in patient safety solutions rather than approach the market, a choice that helps hospitals economize on transaction costs. This study helps hospital managers in their strategic thinking and planning in relation to current and future regulations related to patient safety. For researchers and policy analysts, our propositions provide the basis for empirical testing.
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Patient Education May Improve Perioperative Safety.
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
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[Does simulator-based team training improve patient safety?].
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.
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Identifying organizational cultures that promote patient safety.
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
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Jaeger, Veronika K.; Hoffman, Hal M.; van der Poll, Tom; Tilson, Hugh; Seibert, Julia; Speziale, Antonio; Junge, Guido; Franke, Kristina; Vritzali, Eleni; Hawkins, Philip N.; Kuemmerle-Deschner, Jasmin; Walker, Ulrich A.
2017-01-01
Pneumococcal, tetanus and influenza vaccinations are recommended for patients with cryopyrin-associated periodic syndromes (CAPS) when treated with immunosuppressive medication. The aim of this publication is to report the safety of pneumococcal and other vaccinations in CAPS patients. All CAPS
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Patient safety in dentistry - state of play as revealed by a national database of errors.
Thusu, S; Panesar, S; Bedi, R
2012-08-01
Modern dentistry has become increasingly invasive and sophisticated. Consequently the risk to the patient has increased. The aim of this study is to investigate the types of patient safety incidents (PSIs) that occur in dentistry and the accuracy of the National Patient Safety Agency (NPSA) database in identifying those attributed to dentistry. The database was analysed for all incidents of iatrogenic harm in the speciality of dentistry. A snapshot view using the timeframe January to December 2009 was used. The free text elements from the database were analysed thematically and reclassified according to the nature of the PSI. Descriptive statistics were provided. Two thousand and twelve incident reports were analysed and organised into ten categories. The commonest was due to clerical errors - 36%. Five areas of PSI were further analysed: injury (10%), medical emergency (6%), inhalation/ingestion (4%), adverse reaction (4%) and wrong site extraction (2%). There is generally low reporting of PSIs within the dental specialities. This may be attributed to the voluntary nature of reporting and the reluctance of dental practitioners to disclose incidences for fear of loss of earnings. A significant amount of iatrogenic harm occurs not during treatment but through controllable pre- and post-procedural checks. Incidences of iatrogenic harm to dental patients do occur but their reporting is not widely used. The use of a dental specific reporting system would aid in minimising iatrogenic harm and adhere to the Care Quality Commission (CQC) compliance monitoring system on essential standards of quality and safety in dental practices.
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Directory of Open Access Journals (Sweden)
Panesar SS
2013-03-01
Full Text Available Sukhmeet S Panesar,1 Andrew Carson-Stevens,2 Sarah A Salvilla,1 Bhavesh Patel,3 Saqeb B Mirza,4 Bhupinder Mann51Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK; 2Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK; 3National Patient Safety Agency, London, UK; 4Department of Trauma and Orthopaedic Surgery, University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, Hampshire, UK; 5Buckinghamshire Healthcare NHS Trust, Stoke Mandeville Hospital, Aylesbury, UKBackground: With scientific and technological advances, the practice of orthopedic surgery has transformed the lives of millions worldwide. Such successes however have a downside; not only is the provision of comprehensive orthopedic care becoming a fiscal challenge to policy-makers and funders, concerns are also being raised about the extent of the associated iatrogenic harm. The National Reporting and Learning System (NRLS in England and Wales is an underused resource which collects intelligence from reports about health care error.Methods: Using methods akin to case-control methodology, we have identified a method of prioritizing the areas of a national database of errors that have the greatest propensity for harm. Our findings are presented using odds ratios (ORs and 95% confidence intervals (CIs.Results: The largest proportion of surgical patient safety incidents reported to the NRLS was from the trauma and orthopedics specialty, 48,095/163,595 (29.4%. Of those, 14,482/48,095 (30.1% resulted in iatrogenic harm to the patient and 71/48,095 (0.15% resulted in death. The leading types of errors associated with harm involved the implementation of care and on-going monitoring (OR 5.94, 95% CI 5.53, 6.38; self-harming behavior of patients in hospitals (OR 2.14, 95% CI 1.45, 3.18; and infection control (OR 1.91, 95% CI 1.69, 2.17. We analyze these data to quantify the extent and type of iatrogenic
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75 FR 75471 - Patient Safety Organizations: Voluntary Delisting
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...
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75 FR 57048 - Patient Safety Organizations: Voluntary Delisting
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...
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42 CFR 3.206 - Confidentiality of patient safety work product.
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...
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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.
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[Patient safety culture in Family practice residents of Galicia].
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.
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Fusion Safety Program annual report, fiscal year 1992
International Nuclear Information System (INIS)
Holland, D.F.; Cadwallader, L.C.; Herring, J.S.; Longhurst, G.R.; McCarthy, K.A.; Merrill, B.J.; Piet, S.J.
1993-01-01
This report summarizes the major activities of the Fusion Safety Program in fiscal year 1992. The Idaho National Engineering Laboratory (INEL) is the designated lead laboratory and EG ampersand G Idaho, Inc. is the prime contractor for this program. The Fusion Safety Program was initiated in 1979. Activities are conducted at the INEL and in participating organizations including the Westinghouse Hanford Company at the Hanford Engineering Development Laboratory, the Massachusetts Institute of Technology, and the University of Wisconsin. The technical areas covered in the report include tritium safety, activation product release, reactions involving beryllium, reactions involving lithium breeding materials, safety of fusion magnet systems, plasma disruptions, risk assessment failure rate data base, and computer code development for reactor transients. Also included in the report is a summary of the safety and environmental studies performed by the INEL for the Tokamak Physics Experiments and the Tokamak Fusion Test Reactor, the safety analysis for the International Thermonuclear Experimental Reactor design, and the technical support for the ARIES commercial reactor design study
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Fusion Safety Program annual report: Fiscal year 1987
International Nuclear Information System (INIS)
Holland, D.F.; Herring, J.S.; Longhurst, G.R.; Lyon, R.E.; Merrill, B.J.; Piet, S.J.
1988-02-01
This report summarizes the Fusion Safety Program major activities in fiscal year 1987. The Idaho National Engineering Laboratory (INEL) is the designated lead laboraotry and EG and G Idaho, Inc., is the prime contractor for this program, which was initiated in 1979. Activities are conducted at the INEL and in participating laboratories including the Hanford Engineering Development Laboratory (HEDL), the Massachusetts Institute of Technology (MIT), and the University of Wisconsin. The technical areas covered in the report include tritium safety, activation product release, reactions involving lithium breeding materials, safety of fusion magnet systems, plasma disruptions, risk assessment methodology, computer codes development for reactor transients, and fusion waste management. Also included in the report is a summary of the safety and environmental analysis and conventional facilities design performed by INEL for the Compact Ignition Tokamak design project, the safety analysis and documentation performed for the Tokamak Ignition/Burn Experimental Reactor design, and the technical support provided to the Environmental Safety and Economics Committee (ESECOM). 42 refs., 17 figs., 4 tabs
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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.)
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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.)
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Safety coaches in radiology: decreasing human error and minimizing patient harm.
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.
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Central Safety Department, annual report 1987
International Nuclear Information System (INIS)
Kiefer, H.; Koenig, L.A.
1988-02-01
The Central Safety Department is responsible for handling all problems of radiation protection, safety and security of the institutes and departments of the Karlsruhe Nuclear Research Center, for waste water activity measurements and environmental monitoring of the whole area of the Center, and for research and development work mainly focusing on nuclear safety and radiation protection measures. The r+d work concentrates on the following aspects: physical and chemical behaviour of biologically particularly active radionuclides, behaviour of HT in the air/plan/soil system, biophysics of multicellular systems, improvement in radiation protection measurement and personnel dosimetry. This report gives details of the different duties, indicates the results of 1987 routine tasks and reports about results of investigations and developments of the working groups of the Department. (orig./HP) [de
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[Assessment of the patient-safety culture in a healthcare district].
Pozo Muñoz, F; Padilla Marín, V
2013-01-01
1) To describe the frequency of positive attitudes and behaviours, in terms of patient safety, among the healthcare providers working in a healthcare district; 2) to determine whether the level of safety-related culture differs from other studies; and 3) to analyse negatively valued dimensions, and to establish areas for their improvement. A descriptive, cross-sectional study based on the results of an evaluation of the safety-related culture was conducted on a randomly selected sample of 247 healthcare providers, by using the Spanish adaptation of the Hospital Survey on Patient Safety Culture (HSOPSC) designed by the Agency for Healthcare Research and Quality (AHRQ), as the evaluation tool. Positive and negative responses were analysed, as well as the global score. Results were compared with international and national results. A total of 176 completed survey questionnaires were analysed (response rate: 71.26%); 50% of responders described the safety climate as very good, 37% as acceptable, and 7% as excellent. Strong points were: «Teamwork within the units» (80.82%) and «Supervisor/manager expectations and actions» (80.54%). Dimensions identified for potential improvement included: «Staffing» (37.93%), «Non-punitive response to error» (41.67%), and «Frequency of event reporting» (49.05%). Strong and weak points were identified in the safety-related culture of the healthcare district studied, together with potential improvement areas. Benchmarking at the international level showed that our safety-related culture was within the average of hospitals, while at the national level, our results were above the average of hospitals. Copyright © 2013 SECA. Published by Elsevier Espana. All rights reserved.
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Wang, Manli; Tao, Hongbing
2017-09-26
Objectives : Patient safety culture affects patient safety and the performance of hospitals. The Hospital Survey on Patient Safety Culture (HSOPSC) is generally used to assess the safety culture in hospitals and unit levels. However, only a few studies in China have measured surgical settings compared with other units in county hospitals using the HSOPSC. This study aims to assess the strengths and weaknesses of surgical departments compared with all other departments in county hospitals in China with HSOPSC. Design : This research is a cross-sectional study. Methods : In 2015, a Chinese translation of HSOPSC was administered to 1379 staff from sampled departments from 19 county hospitals in Xiaogan City (Hubei Province, China) using a simple random and cluster sampling method. Outcome Measures : The HSOPSC was completed by 1379 participants. The percent positive ratings (PPRs) of 12 dimensions (i.e., teamwork within units, organizational learning and continuous improvement, staffing, non-punitive response to errors, supervisor/ manager expectations and actions promoting patient safety, feedback and communication about errors, communication openness, hospital handoffs and transitions, teamwork across hospital units, hospital management support for patient safety, overall perception of safety, as well as frequency of events reported) and the positive proportion of outcome variables (patient safety grade and number of events reported) between surgical departments and other departments were compared with t -tests and X² tests, respectively. A multiple regression analysis was conducted, with the outcome dimensions serving as dependent variables and basic characteristics and other dimensions serving as independent variables. Similarly, ordinal logistic regression was used to explore the influencing factors of two categorical outcomes. Results : A total of 56.49% of respondents were from surgical departments. The PPRs for "teamwork within units" and "organizational
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The role of the ward manager in promoting patient safety.
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.
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NPP Temelin safety analysis reports and PSA status
International Nuclear Information System (INIS)
Mlady, O.
1999-01-01
To enhance the safety level of Temelin NPP, recommendations of the international reviews were implemented into the design as well as into organization of the plant construction and preparation for operation. The safety assessment of these design changes has been integrated and reflected in the Safety Analysis Reports, which follow the internationally accepted guidelines. All safety analyses within Safety Analysis Reports were repeated carefully considering technical improvements and replacements to complement preliminary safety documentation. These analyses were performed by advanced western computer codes to the depth and in the structure required by western standards. The Temelin NPP followed a systematic approach in the functional design of the Reactor Protection System and related safety analyses. Modifications of reactor protection system increase defense in depth and facilitate demonstrating that LOCA and radiological limits are met for non-LOCA events. The rigorous safety analysis methodology provides assurance that LOCA and radiological limits are met. Established and accepted safety analysis methodology and accepted criteria were applied to Temelin NPP meeting US NRC and Czech Republic requirements. IAEA guidelines and recommendations
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Safety report content and development for test loop facility on MARIA reactor
International Nuclear Information System (INIS)
Konechko, A.; Shumskij, A.M.; Mikul'ahin, V.E.
1982-01-01
A 600 kW test loop facility for investigatin.o safety problems is realized on MARIA reactor in Poland together with USSR organizations. Safety reports have been developed in two steps at the designstage. The 1st report being essentially a preliminary safety analysis was developed within the scope of the feasibility study. At the engineering design stage the preliminary test loop facility safety report had been prepared considering measures excluding the possibility of the MARIA reactor damage. The test loop facility safety report is fulfilled for normal, transient and emergency operation regimes. Separate safety basing for each group of experiments will be prepared. The report presents the test loop facility safety criteria coordinated by the nuclear safety comission. They contains the preliminary reports on the test loop facility safety. At the final stage of construction and at thecommitioning stage the start-up safety report will be developed which after required correction and adding up the putting into operation data will turn into operation safety report [ru
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Assessing patient safety culture in hospitals across countries
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:
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Assessing patient safety culture in hospitals across countries.
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:
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Assessing patient safety culture in hospitals across countries
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:
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75 FR 63498 - Patient Safety Organizations: Voluntary Delisting
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...
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75 FR 75473 - Patient Safety Organizations: Voluntary Delisting
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...
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75 FR 75472 - Patient Safety Organizations: Voluntary Delisting
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...
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Preliminary report of radiological safety to hydrology 1993 campaign
International Nuclear Information System (INIS)
Badano, A.; Suarez Antola, R.; Dellepere, A.; Barreiro, M.
1993-01-01
This report has been prepared based on the interaction between project managers and division radiological Protection and Nuclear Safety. In seeking to establish a basis for approval from the point of view of radiation safety practices . The idea for the audit has been provided at all times because the interest was the exchange of ideas and the use of common sense to improve the safety of radioactive substances, security of operators and public safety and environment.The above shows that in the planned radiation safety condition described in this report,the practice can be carried out according to the criteria of safety accepted .
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Environment and safety research status report: 1993
International Nuclear Information System (INIS)
1993-03-01
The 1993 status report discusses ongoing and planned research activities in the GRI Environment and Safety Program. The objectives and goals, accomplishments, and strategy along with the basis for each project area are presented for the supply, end use, and gas operations subprograms. Within the context of these subprograms, contract status summaries under their conceptual titles are given for the following project areas: Gas Supply Environmental and Safety Research, Air Quality Research, End Use Equipment Safety Research, Gas Operations Safety Research, Liquefied Natural Gas, Safety Research, and Gas Operations Environmental Research
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Ensuring a proactive, evidence-based, patient safety approach to patient assessment.
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.
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Fusion Safety Program annual report: Fiscal year 1986
International Nuclear Information System (INIS)
Holland, D.F.; Merrill, B.J.; Herring, J.S.; Piet, S.J.; Longhurst, G.R.
1987-06-01
This report summarizes the Fusion Safety Program's (FSP) major activities in fiscal year 1986. The Idaho National Engineering Laboratory (INEL) is the designated lead laboratory, and EG and G Idaho, Inc., is the prime contractor for FSP, which was initiated in 1979. Activities are conducted at the INEL and in participating facilities, including the Hanford Engineering Development Laboratory (HEDL), the Massachusetts Institute of Technology (MIT), and the University of Wisconsin. The technical areas covered in this report include tritium safety, activation product release, reactions involving lithium breeding materials, safety of fusion magnet systems, plasma disruption, risk assessment methodology, and computer code development for reactor transients. Contributions to the Technical Planning Activity (TPA) and the ''white paper'' study by the Environmental, Safety,and Economics Committee (ESECOM) are summarized. The report also includes a summary of the safety and environmental analysis and documentation performed by the INEL for the Compact Ignition Tokamak (CIT) design project
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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...
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Advancing perinatal patient safety through application of safety science principles using health IT.
Webb, Jennifer; Sorensen, Asta; Sommerness, Samantha; Lasater, Beth; Mistry, Kamila; Kahwati, Leila
2017-12-19
The use of health information technology (IT) has been shown to promote patient safety in Labor and Delivery (L&D) units. The use of health IT to apply safety science principles (e.g., standardization) to L&D unit processes may further advance perinatal safety. Semi-structured interviews were conducted with L&D units participating in the Agency for Healthcare Research and Quality's (AHRQ's) Safety Program for Perinatal Care (SPPC) to assess units' experience with program implementation. Analysis of interview transcripts was used to characterize the process and experience of using health IT for applying safety science principles to L&D unit processes. Forty-six L&D units from 10 states completed participation in SPPC program implementation; thirty-two (70%) reported the use of health IT as an enabling strategy for their local implementation. Health IT was used to improve standardization of processes, use of independent checks, and to facilitate learning from defects. L&D units standardized care processes through use of electronic health record (EHR)-based order sets and use of smart pumps and other technology to improve medication safety. Units also standardized EHR documentation, particularly related to electronic fetal monitoring (EFM) and shoulder dystocia. Cognitive aids and tools were integrated into EHR and care workflows to create independent checks such as checklists, risk assessments, and communication handoff tools. Units also used data from EHRs to monitor processes of care to learn from defects. Units experienced several challenges incorporating health IT, including obtaining organization approval, working with their busy IT departments, and retrieving standardized data from health IT systems. Use of health IT played an integral part in the planning and implementation of SPPC for participating L&D units. Use of health IT is an encouraging approach for incorporating safety science principles into care to improve perinatal safety and should be incorporated
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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.
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[Electronic patient record as the tool for better patient safety].
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.
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Health IT for Patient Safety and Improving the Safety of Health IT.
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.
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The General Safety Group Annual Report 2001/2002
Weingarten, W
2003-01-01
This report summarizes the main activities of the General Safety (GS) Group of the Technical Inspection and Safety Division during 2001 and 2002, and the results obtained. The different topics in which the group is active are covered: general safety inspections and ergonomics, electrical, chemical and gas safety, chemical pollution containment and control, industrial hygiene, the safety of civil engineering works and outside contractors, fire prevention and the safety aspects of the LHC experiments.
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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.
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Directory of Open Access Journals (Sweden)
Bradley Nick
2009-09-01
Full Text Available Abstract Background Significant event analysis (SEA is promoted as a team-based approach to enhancing patient safety through reflective learning. Evidence of SEA participation is required for appraisal and contractual purposes in UK general practice. A voluntary educational model in the west of Scotland enables general practitioners (GPs and doctors-in-training to submit SEA reports for feedback from trained peers. We reviewed reports to identify the range of safety issues analysed, learning needs raised and actions taken by GP teams. Method Content analysis of SEA reports submitted in an 18 month period between 2005 and 2007. Results 191 SEA reports were reviewed. 48 described patient harm (25.1%. A further 109 reports (57.1% outlined circumstances that had the potential to cause patient harm. Individual 'error' was cited as the most common reason for event occurrence (32.5%. Learning opportunities were identified in 182 reports (95.3% but were often non-specific professional issues not shared with the wider practice team. 154 SEA reports (80.1% described actions taken to improve practice systems or professional behaviour. However, non-medical staff were less likely to be involved in the changes resulting from event analyses describing patient harm (p Conclusion The study provides some evidence of the potential of SEA to improve healthcare quality and safety. If applied rigorously, GP teams and doctors in training can use the technique to investigate and learn from a wide variety of quality issues including those resulting in patient harm. This leads to reported change but it is unclear if such improvement is sustained.
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Workplace engagement and workers' compensation claims as predictors for patient safety culture.
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.
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The NASA Aviation Safety Reporting System
1983-01-01
This is the fourteenth in a series of reports based on safety-related incidents submitted to the NASA Aviation Safety Reporting System by pilots, controllers, and, occasionally, other participants in the National Aviation System (refs. 1-13). ASRS operates under a memorandum of agreement between the National Aviation and Space Administration and the Federal Aviation Administration. The report contains, first, a special study prepared by the ASRS Office Staff, of pilot- and controller-submitted reports related to the perceived operation of the ATC system since the 1981 walkout of the controllers' labor organization. Next is a research paper analyzing incidents occurring while single-pilot crews were conducting IFR flights. A third section presents a selection of Alert Bulletins issued by ASRS, with the responses they have elicited from FAA and others concerned. Finally, the report contains a list of publications produced by ASRS with instructions for obtaining them.
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Pereira, Luisa Santos; Müller, Vanessa Teixeira; da Mota Gomes, Marleide; Rotenberg, Alexander; Fregni, Felipe
2016-04-01
Approximately one-third of patients with epilepsy remain with pharmacologically intractable seizures. An emerging therapeutic modality for seizure suppression is repetitive transcranial magnetic stimulation (rTMS). Despite being considered a safe technique, rTMS carries the risk of inducing seizures, among other milder adverse events, and thus, its safety in the population with epilepsy should be continuously assessed. We performed an updated systematic review on the safety and tolerability of rTMS in patients with epilepsy, similar to a previous report published in 2007 (Bae EH, Schrader LM, Machii K, Alonso-Alonso M, Riviello JJ, Pascual-Leone A, Rotenberg A. Safety and tolerability of repetitive transcranial magnetic stimulation in patients with epilepsy: a review of the literature. Epilepsy Behav. 2007; 10 (4): 521-8), and estimated the risk of seizures and other adverse events during or shortly after rTMS application. We searched the literature for reports of rTMS being applied on patients with epilepsy, with no time or language restrictions, and obtained studies published from January 1990 to August 2015. A total of 46 publications were identified, of which 16 were new studies published after the previous safety review of 2007. We noted the total number of subjects with epilepsy undergoing rTMS, medication usage, incidence of adverse events, and rTMS protocol parameters: frequency, intensity, total number of stimuli, train duration, intertrain intervals, coil type, and stimulation site. Our main data analysis included separate calculations for crude per subject risk of seizure and other adverse events, as well as risk per 1000 stimuli. We also performed an exploratory, secondary analysis on the risk of seizure and other adverse events according to the type of coil used (figure-of-8 or circular), stimulation frequency (≤ 1 Hz or > 1 Hz), pulse intensity in terms of motor threshold (stimulator output for speech arrest, clinically arising from the region of
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Characterization report for the ferrocyanide safety issue
International Nuclear Information System (INIS)
Pulsipher, B.A.; Burger, L.L.; Liebetrau, A.M.; Scheele, R.D.
1997-06-01
Recently PNNL was tasked by DOE to develop and demonstrate a risk-based strategic approach to characterizing Hanford's Nuclear Waste Tanks. This strategic approach was documented in a report entitled ''A Risk-Based Focused Decision-Management Approach for Justifying Characterization of Hanford Tank Waste''. In support of the general approach, a specific strategy for addressing each of the several safety issues associated with the tanks was developed. This report documents the approach for the Ferrocyanide Safety Issue. The purpose of this report is to describe a structured logic diagram (SLD) for determining the risk associated with the ferrocyanide tank safety issue and provide the supporting information for the SLD. The SLD addresses the resolution of risks resulting from the presence of ferrocyanide layers within the Hanford tanks. The informational requirements for determining risk from any reaction stemming from ferrocyanide are outlined in the SLD. This report will describe the potential paths to a successful resolution of the ferrocyanide safety issue. Complete development of the intervention pathway is outside the scope of this current activity. General descriptions of the approach, key components of the SLD, and conclusions are provided in the body of this report. The complete SLD, descriptions of each box shown in the SLD, a discussion on how to fill data needs, and a list of contributors is provided in the appendices
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EMS helicopter incidents reported to the NASA Aviation Safety Reporting System
Connell, Linda J.; Reynard, William D.
1993-01-01
The objectives of this evaluation were to: Identify the types of safety-related incidents reported to the Aviation Safety Reporting System (ASRS) in Emergency Medical Service (EMS) helicopter operations; Describe the operational conditions surrounding these incidents, such as weather, airspace, flight phase, time of day; and Assess the contribution to these incidents of selected human factors considerations, such as communication, distraction, time pressure, workload, and flight/duty impact.
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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.
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Nuclear-power-safety reporting system: feasibility analysis
International Nuclear Information System (INIS)
Finlayson, F.C.; Ims, J.
1983-04-01
The US Nuclear Regulatory Commission (NRC) is evaluating the possibility of instituting a data gathering system for identifying and quantifying the factors that contribute to the occurrence of significant safety problems involving humans in nuclear power plants. This report presents the results of a brief (6 months) study of the feasibility of developing a voluntary, nonpunitive Nuclear Power Safety Reporting System (NPSRS). Reports collected by the system would be used to create a data base for documenting, analyzing and assessing the significance of the incidents. Results of The Aerospace Corporation study are presented in two volumes. This document, Volume I, contains a summary of an assessment of the Aviation Safety Reporting System (ASRS). The FAA-sponsored, NASA-managed ASRS was found to be successful, relatively low in cost, generally acceptable to all facets of the aviation community, and the source of much useful data and valuable reports on human factor problems in the nation's airways. Several significant ASRS features were found to be pertinent and applicable for adoption into a NPSRS
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Summary report on safety objectives in nuclear power plants
International Nuclear Information System (INIS)
1989-01-01
The special Task Force on Safety Objectives of the Commission of the European Communities (CEC) Working Group on the Safety of Light Water Reactors reported in May 1983 on its review of existing overall safety objectives in nuclear power plants. Since then much relevant worlwide activity has taken place. This report reviews those activities that have taken place since 1983 in European Community Member States, including more recent Members, as well as in Sweden and Finland. The report confines itself to issues related to probabilistic safety objectives, and concludes that significant progress has been made in many areas. Mutual understanding of safety objectives is leading to a convergence of views and approaches, but it is noted that much work remains to be completed
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Directory of Open Access Journals (Sweden)
Xu XP
2018-05-01
Full Text Available Xiao Ping Xu,* Dong Ning Deng,* Yong Hong Gu, Chui Shan Ng, Xiao Cai, Jun Xu, Xin Shi Zhang, Dong Ge Ke, Qian Hui Yu, Chi Kuen Chan Clinical Service Department, The University of Hong Kong - Shenzhen Hospital, Shenzhen, Guangdong, People’s Republic of China *These authors contributed equally to this work Background: The World Health Organization highlights that patient safety interventions are not lacking but that the local context affects their successful implementation. Increasing attention is being paid to patient safety in Mainland China, yet few studies focus on patient safety in organizations with mixed cultures. This paper evaluates the current patient safety culture in an experimental Chinese hospital with a Hong Kong hospital management culture, and it aims to explore the application of Hong Kong’s patient safety strategies in the context of Mainland China. Methods: A quantitative survey of 307 hospital staff members was conducted using the Hospital Survey on Patient Safety Culture questionnaire. The findings were compared with a similar study on general Chinese hospitals and were appraised with reference to the Manchester Patient Safety Framework. Results: Lower scores were observed among participants with the following characteristics: males, doctors, those with more work experience, those with higher education, and those from the general practice and otolaryngology departments. However, the case study hospital achieved better scores in management expectations, actions and support for patient safety, incident reporting and communication, and teamwork within units. Its weaknesses were related to non-punitive responses to errors, teamwork across units, and staffing. Conclusions: The case study hospital contributes to a changing patient safety culture in Mainland China, yet its patient safety culture remains mostly bureaucratic. Further efforts could be made to deepen the staff’s patient safety culture mind-set, to realize a
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Annual safety research report, JFY 2012
International Nuclear Information System (INIS)
2013-08-01
As for the regulatory issues the governments or JNES considered necessary, JNES had compiled 'safety research plan' in respective research areas necessary for solving the regulatory issues (safety research needs) and was conducting safety research to obtain the results, etc. Safety research areas, subjects and research projects were as follows: design review of nuclear power plant (5 subjects and each subject having several research projects totaled 20), control management of nuclear power plant (3 subjects and each subject having several research projects totaled 6), nuclear fuel cycle (2 subjects and each subject having several research projects totaled 4), nuclear fuel cycle backend (2 subjects and each subject having several research projects totaled 6), nuclear emergency preparedness and response (3 subjects and each subject having several research projects totaled 7) and bases of nuclear safety technology (3 subjects and each subject having several research projects totaled 6). In addition to these 49 research projects of 18 subjects in 6 areas, JNES worked on 19 research projects of 7 subjects in added areas (specific research projects on of the disaster at Fukushima Daiichi NPP accident and other challenges JNES considered necessary) in JFY 2012. This annual safety research report summarized respective achievements and state of regulatory tools necessary for solving regulatory issues according to the safety research plan, JFY 2012 Edition as well as the situation of the reflection for the safety regulations, and also described 16 research projects of 4 subjects: examination for new safety regulation (8 research projects), development of newly necessary evaluation methods (one research project), evaluation of the validity for the work for convergence at Fukushima Daiichi NPP accident (4 research project) and horizontal development to other nuclear power plants (3 research projects), and 3 research projects of 3 subjects as other challenges. A list of JNES
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Safety of Monopolar Electrocautery in Patients With Cochlear Implants.
Tien, Duc A; Woodson, Erika A; Anne, Samantha
2016-09-01
The outcomes of 2 patients with cochlear implants (CIs) who underwent adenotonsillectomy (AT) with inadvertent use of monopolar cautery are presented. The safety data regarding monopolar cautery use in CI recipients is also reviewed. This is a retrospective case series of 2 CI recipients that underwent AT with monopolar cautery and literature review of electrocautery safety in the setting of CI. Two patients with CIs underwent AT with use of monopolar cautery inadvertently by surgeons that do not routinely perform cochlear implants as part of his or her clinical practice. Patient 1 was a 9-year-old female who had AT for obstructive sleep apnea (OSA) after undergoing unilateral CI for profound congenital sensorineural hearing loss (SNHL) 8 years ago. Patient 2 was a 7-year-old female who underwent AT for OSA 4 months after undergoing unilateral CI for congenital SNHL. Both patients had no immediate signs of complications with their CI use postoperatively. Both patients demonstrated unchanged postoperative neural response telemetry and behavioral audiometric testing. Patient 1 continues to have no CI-related complications 3.5 years after the procedure. Patient 2 has been followed for at least 3 months by audiometric testing and 10 months by otolaryngologist with no CI-related complications. Although animal and cadaveric studies suggest that monopolar cautery may be safely used in patients with cochlear implants, there have been no in vivo human studies that have evaluated the risk to the patient or implant. This is a report of a small, unintended experience with 2 patients, both of whom exhibit no complications or changes to CI function thus far. © The Author(s) 2016.
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Wang, Ying; Coiera, Enrico; Runciman, William; Magrabi, Farah
2017-06-12
Approximately 10% of admissions to acute-care hospitals are associated with an adverse event. Analysis of incident reports helps to understand how and why incidents occur and can inform policy and practice for safer care. Unfortunately our capacity to monitor and respond to incident reports in a timely manner is limited by the sheer volumes of data collected. In this study, we aim to evaluate the feasibility of using multiclass classification to automate the identification of patient safety incidents in hospitals. Text based classifiers were applied to identify 10 incident types and 4 severity levels. Using the one-versus-one (OvsO) and one-versus-all (OvsA) ensemble strategies, we evaluated regularized logistic regression, linear support vector machine (SVM) and SVM with a radial-basis function (RBF) kernel. Classifiers were trained and tested with "balanced" datasets (n_ Type = 2860, n_ SeverityLevel = 1160) from a state-wide incident reporting system. Testing was also undertaken with imbalanced "stratified" datasets (n_ Type = 6000, n_ SeverityLevel =5950) from the state-wide system and an independent hospital reporting system. Classifier performance was evaluated using a confusion matrix, as well as F-score, precision and recall. The most effective combination was a OvsO ensemble of binary SVM RBF classifiers with binary count feature extraction. For incident type, classifiers performed well on balanced and stratified datasets (F-score: 78.3, 73.9%), but were worse on independent datasets (68.5%). Reports about falls, medications, pressure injury, aggression and blood products were identified with high recall and precision. "Documentation" was the hardest type to identify. For severity level, F-score for severity assessment code (SAC) 1 (extreme risk) was 87.3 and 64% for SAC4 (low risk) on balanced data. With stratified data, high recall was achieved for SAC1 (82.8-84%) but precision was poor (6.8-11.2%). High risk incidents (SAC2) were confused
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Nurse working conditions and patient safety outcomes.
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.
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[Patient safety in education and training of healthcare professionals in Germany].
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.
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Can we improve patient safety?
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.
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Early fluid loading for septic patients: Any safety limit needed?
Gong, Yi-Chun; Liu, Jing-Tao; Ma, Peng-Lin
2018-02-01
Early adequate fluid loading was the corner stone of hemodynamic optimization for sepsis and septic shock. Meanwhile, recent recommended protocol for fluid resuscitation was increasingly debated on hemodynamic stability vs risk of overloading. In recent publications, it was found that a priority was often given to hemodynamic stability rather than organ function alternation in the early fluid resuscitation of sepsis. However, no safety limits were used at all in most of these reports. In this article, the rationality and safety of early aggressive fluid loading for septic patients were discussed. It was concluded that early aggressive fluid loading improved hemodynamics transitorily, but was probably traded off with a follow-up organ function impairment, such as worsening oxygenation by reduction of lung aeration, in a part of septic patients at least. Thus, a safeguard is needed against unnecessary excessive fluids in early aggressive fluid loading for septic patients. Copyright © 2017 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. All rights reserved.
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Walpola, Ramesh L; Fois, Romano A; McLachlan, Andrew J; Chen, Timothy F
2017-02-25
Objective. To evaluate the effectiveness of a face-to-face educational intervention in improving the patient safety attitudes of intern pharmacists. Methods. A patient safety education program was delivered to intern pharmacists undertaking The University of Sydney Intern Training Program in 2014. Their patient safety attitudes were evaluated immediately prior to, immediately after, and three-months post-intervention. Underlying attitudinal factors were identified using exploratory factor analysis. Changes in factor scores were examined using analysis of variance. Results. Of the 120 interns enrolled, 95 (78.7%) completed all three surveys. Four underlying attitudinal factors were identified: attitudes towards addressing errors, questioning behaviors, blaming individuals, and reporting errors. Improvements in all attitudinal factors were evident immediately after the intervention. However, only improvements in attitudes towards blaming individuals involved in errors were sustained at three months post-intervention. Conclusion. The educational intervention was associated with short-term improvements in pharmacist interns' patient safety attitudes. However, other factors likely influenced their attitudes in the longer term.
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Tamura, Kazuo; Hashimoto, Kazue; Nishikawa, Kiyohiro
2018-05-01
We conducted a post-marketing surveillance to evaluate the safety and efficacy of TKN732, approved as "filgrastim biosimilar 2", in Japanese patients who developed neutropenia in the course of cancer chemotherapy or hematopoietic stem cell transplantation. A total of 653 patients were registered during the 2-year enrollment period starting from May 2013, and 627 and 614 patients were eligible for safety and efficacy analyses of the G-CSF biosimilar, respectively. Forty-three adverse drug reactions were reported in 33 patients (5.26%). Back pain was most frequently observed and reported in 20 patients (3.19%), followed by pyrexia (1.28%) and bone pain (0.96%). Risk factors for adverse reactions identified by logistic regression analyses were younger age, presence of past medical history, and lower total dose at the onset of adverse reactions. Among the 576 cancer patients who developed Grade 2-4 neutropenia after chemotherapy, recovery to Grade 1/0 was reported in 553 patients (96%) following filgrastim biosimilar 2 treatment. The median duration of neutrophil counts below 1500/μL was 5 days. In addition, all 11 patients who underwent hematopoietic stem cell transplantation had good responses to filgrastim biosimilar 2. In conclusion, this study showed that filgrastim biosimilar 2 has a similar safety profile and comparable effects to the original G-CSF product in the real world clinical setting. Copyright © 2018 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
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Report on nuclear and radiological safety in 1994
International Nuclear Information System (INIS)
Lovincic, D.
1995-01-01
The Slovenian Nuclear Safety Administration (SNSA) in cooperation with the Health Inspectorate, prepared the Report on Nuclear and Radiological Safety in the Republic of Slovenia for 1994 as part of its regular practice of reporting on its activities to the Government and the Parliament of the Republic of Slovenia. The report is divided into seven thematic chapters covering the activities of the SNSA, the operation of nuclear facilities in Slovenia, the activities of the Agency for Radwaste Management (ARAO), the activities of international safety missions in Slovenia, environmental radioactivity monitoring in Slovenia, ionizing radiation sources control by Slovenian Health Inspectorate and review of the operation of nuclear facilities around the world.
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Patient safety ward round checklist via an electronic app: implications for harm prevention.
Keller, C; Arsenault, S; Lamothe, M; Bostan, S R; O'Donnell, R; Harbison, J; Doherty, C P
2017-11-06
Patient safety is a value at the core of modern healthcare. Though awareness in the medical community is growing, implementing systematic approaches similar to those used in other high reliability industries is proving difficult. The aim of this research was twofold, to establish a baseline for patient safety practices on routine ward rounds and to test the feasibility of implementing an electronic patient safety checklist application. Two research teams were formed; one auditing a medical team to establish a procedural baseline of "usual care" practice and an intervention team concurrently was enforcing the implementation of the checklist. The checklist was comprised of eight standard clinical practice items. The program was conducted over a 2-week period and 1 month later, a retrospective analysis of patient charts was conducted using a global trigger tool to determine variance between the experimental groups. Finally, feedback from the physician participants was considered. The results demonstrated a statistically significant difference on five variables of a total of 16. The auditing team observed low adherence to patient identification (0.0%), hand decontamination (5.5%), and presence of nurse on ward rounds (6.8%). Physician feedback was generally positive. The baseline audit demonstrated significant practice bias on daily ward rounds which tended to omit several key-proven patient safety practices such as prompting hand decontamination and obtaining up to date reports from nursing staff. Results of the intervention arm demonstrate the feasibility of using the Checklist App on daily ward rounds.
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Patient Safety and Workplace Bullying: An Integrative Review.
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.
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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.
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[Safety profile of zolpidem: two studies of 3805 patients by Swiss practitioners].
Ganzoni, E; Gugger, M
1999-06-24
Evaluation and treatment of insomnia are frequent procedures in the physician's everyday practice, since many patients seek medical treatment for this condition. Knowledge of pharmacological therapeutical alternatives is therefore decisive, in order to identify the most efficaceous and safe therapy for the patient among the available hypnotics. The short-acting hypnotic zolpidem has been investigated in Switzerland in two multicenter safety studies in ambulatory practice. In the first study 8.9% (n = 125 of 1,972 treated patients), and in the second 7.2% of the patients (n = 175 of 1,833 treated patients) reported an adverse event. The most frequent events were related to the central nervous system (CNS) (somnolence, headache, confusion, vertigo); gastrointestinal and cutaneous symptoms were the most frequent non CNS-dependent effects. New, unknown or serious adverse events were not found and no specific risk factor or population at risk was identified. The safety profile of zolpidem is consistent with its known pharmacological properties, the results of previous clinical trials and the international experience obtained in large patients groups.
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Ghahramanian, Akram; Rezaei, Tayyebeh; Abdullahzadeh, Farahnaz; Sheikhalipour, Zahra; Dianat, Iman
2017-01-01
Background: This study investigated quality of healthcare services from patients' perspectives and its relationship with patient safety culture and nurse-physician professional communication. Methods: A cross-sectional study was conducted among 300 surgery patients and 101 nurses caring them in a public hospital in Tabriz-Iran. Data were collected using the service quality measurement scale (SERVQUAL), hospital survey on patient safety culture (HSOPSC) and nurse physician professional communication questionnaire. Results: The highest and lowest mean (±SD) scores of the patients' perception on the healthcare services quality belonged to the assurance 13.92 (±3.55) and empathy 6.78 (±1.88) domains,respectively. With regard to the patient safety culture, the mean percentage of positive answers ranged from 45.87% for "non-punitive response to errors" to 68.21% for "organizational continuous learning" domains. The highest and lowest mean (±SD) scores for the nurse physician professional communication were obtained for "cooperation" 3.44 (±0.35) and "non-participative decision-making" 2.84 (±0.34) domains, respectively. The "frequency of reported errors by healthcare professionals" (B=-4.20, 95% CI = -7.14 to -1.27, P<0.01) and "respect and sharing of information" (B=7.69, 95% CI=4.01 to 11.36, P<0.001) predicted the patients'perceptions of the quality of healthcare services. Conclusion: Organizational culture in dealing with medical error should be changed to non-punitive response. Change in safety culture towards reporting of errors, effective communication and teamwork between healthcare professionals are recommended.
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78 FR 70560 - Patient Safety Organizations: Voluntary Relinquishment From GE-PSO
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...
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77 FR 26280 - Patient Safety Organizations: Voluntary Relinquishment From CareRise LLC
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...
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van Dulmen, Simone A; Tacken, Margot A J B; Staal, J Bart; Gaal, Sander; Wensing, Michel; Nijhuis-van der Sanden, Maria W G
2011-12-01
Research on patient safety in allied healthcare is scarce. Our aim was to document patient safety in primary allied healthcare in the Netherlands and to identify factors associated with incidents. DESIGN AND SUBJECT: A retrospective study of 1000 patient records in a representative sample of 20 allied healthcare practices was combined with a prospective incident-reporting study. All records were reviewed by trained researchers to identify patient safety incidents. The incidents were classified and analyzed, using the Prevention and Recovery Information System for Monitoring and Analysis method. Factors associated with incidents were examined in a logistic regression analysis. In 18 out of 1000 (1.8%; 95% confidence interval: 1.0-2.6) records an incident was detected. The main causes of incidents were related to errors in clinical decisions (89%), communication with other healthcare providers (67%), and monitoring (56%). The probability of incidents was higher if more care providers had been involved and if patient records were incomplete (37% of the records). No incidents were reported in the prospective study. The absolute number of incidents was low, which could imply a low risk of harm in Dutch primary allied healthcare. Nevertheless, incompleteness of the patient records and the fact that incidents were mainly caused through human actions suggest that a focus on clinical reasoning and record keeping is needed to further enhance patient safety. Improvements in record keeping will be necessary before accurate incident reporting will be feasible and valid.
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A Real-Time Safety and Quality Reporting System: Assessment of Clinical Data and Staff Participation
International Nuclear Information System (INIS)
Rahn, Douglas A.; Kim, Gwe-Ya; Mundt, Arno J.; Pawlicki, Todd
2014-01-01
Purpose: To report on the use of an incident learning system in a radiation oncology clinic, along with a review of staff participation. Methods and Materials: On September 24, 2010, our department initiated an online real-time voluntary reporting system for safety issues, called the Radiation Oncology Quality Reporting System (ROQRS). We reviewed these reports from the program's inception through January 18, 2013 (2 years, 3 months, 25 days) to assess error reports (defined as both near-misses and incidents of inaccurate treatment). Results: During the study interval, there were 60,168 fractions of external beam radiation therapy and 955 brachytherapy procedures. There were 298 entries in the ROQRS system, among which 108 errors were reported. There were 31 patients with near-misses reported and 27 patients with incidents of inaccurate treatment reported. These incidents of inaccurate treatment occurred in 68 total treatment fractions (0.11% of treatments delivered during the study interval). None of these incidents of inaccurate treatment resulted in deviation from the prescription by 5% or more. A solution to the errors was documented in ROQRS in 65% of the cases. Errors occurred as repeated errors in 22% of the cases. A disproportionate number of the incidents of inaccurate treatment were due to improper patient setup at the linear accelerator (P<.001). Physician participation in ROQRS was nonexistent initially, but improved after an education program. Conclusions: Incident learning systems are a useful and practical means of improving safety and quality in patient care
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A Real-Time Safety and Quality Reporting System: Assessment of Clinical Data and Staff Participation
Energy Technology Data Exchange (ETDEWEB)
Rahn, Douglas A.; Kim, Gwe-Ya; Mundt, Arno J.; Pawlicki, Todd, E-mail: tpawlicki@ucsd.edu
2014-12-01
Purpose: To report on the use of an incident learning system in a radiation oncology clinic, along with a review of staff participation. Methods and Materials: On September 24, 2010, our department initiated an online real-time voluntary reporting system for safety issues, called the Radiation Oncology Quality Reporting System (ROQRS). We reviewed these reports from the program's inception through January 18, 2013 (2 years, 3 months, 25 days) to assess error reports (defined as both near-misses and incidents of inaccurate treatment). Results: During the study interval, there were 60,168 fractions of external beam radiation therapy and 955 brachytherapy procedures. There were 298 entries in the ROQRS system, among which 108 errors were reported. There were 31 patients with near-misses reported and 27 patients with incidents of inaccurate treatment reported. These incidents of inaccurate treatment occurred in 68 total treatment fractions (0.11% of treatments delivered during the study interval). None of these incidents of inaccurate treatment resulted in deviation from the prescription by 5% or more. A solution to the errors was documented in ROQRS in 65% of the cases. Errors occurred as repeated errors in 22% of the cases. A disproportionate number of the incidents of inaccurate treatment were due to improper patient setup at the linear accelerator (P<.001). Physician participation in ROQRS was nonexistent initially, but improved after an education program. Conclusions: Incident learning systems are a useful and practical means of improving safety and quality in patient care.
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Improving the safety of LWR power plants. Final report
International Nuclear Information System (INIS)
1980-04-01
This report documents the results of the Study to identify current, potential research issues and efforts for improving the safety of Light Water Reactor (LWR) power plants. This final report describes the work accomplished, the results obtained, the problem areas, and the recommended solutions. Specifically, for each of the issues identified in this report for improving the safety of LWR power plants, a description is provided in detail of the safety significance, the current status (including information sources, status of technical knowledge, problem solution and current activities), and the suggestions for further research and development. Further, the issues are ranked for action into high, medium, and low priority with respect to primarily (a) improved safety (e.g. potential reduction in public risk and occupational exposure), and secondly (b) reduction in safety-related costs
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Geosphere process report for the safety assessment SR-Site
International Nuclear Information System (INIS)
Skagius, Kristina
2010-11-01
This report documents geosphere processes identified as relevant to the long-term safety of a KBS-3 repository, and forms an important part of the reporting of the safety assessment SR-Site. The detailed assessment methodology, including the role of the process reports in the assessment, is described in the SR-Site Main report /SKB 2011/
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Geosphere process report for the safety assessment SR-Site
Energy Technology Data Exchange (ETDEWEB)
Skagius, Kristina (ed.) (Kemakta Konsult AB, Stockholm (Sweden))
2010-11-15
This report documents geosphere processes identified as relevant to the long-term safety of a KBS-3 repository, and forms an important part of the reporting of the safety assessment SR-Site. The detailed assessment methodology, including the role of the process reports in the assessment, is described in the SR-Site Main report /SKB 2011/
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Improving patient safety in Libya: insights from a British health system perspective.
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.
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Denying a patient's final will: public safety vs. medical confidentiality and patient autonomy.
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.
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Leaving patients to their own devices? Smart technology, safety and therapeutic relationships.
Ho, Anita; Quick, Oliver
2018-03-06
This debate article explores how smart technologies may create a double-edged sword for patient safety and effective therapeutic relationships. Increasing utilization of health monitoring devices by patients will likely become an important aspect of self-care and preventive medicine. It may also help to enhance accurate symptom reports, diagnoses, and prompt referral to specialist care where appropriate. However, the development, marketing, and use of such technology raise significant ethical implications for therapeutic relationships and patient safety. Drawing on lessons learned from other direct-to-consumer health products such as genetic testing, this article explores how smart technology can also pose regulatory challenges and encourage overutilization of healthcare services. In order for smart technology to promote safer care and effective therapeutic encounters, the technology and its utilization must be safe. This article argues for unified regulatory guidelines and better education for both healthcare providers and patients regarding the benefits and risks of these devices.
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Perception is reality: How patients contribute to poor workplace safety perceptions.
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
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Safety Review Committee - Annual Report 1991-1992
International Nuclear Information System (INIS)
1993-01-01
During the year under review. The Safety Review Committee (SRC) assessed the safety of ANSTO's operations. This was done by site visits, examination of documentation and briefing by ANSTO officers responsible for particular operations, and includes HIFAR and Moata reactors, radioisotope production, packing and dispatch, radioactive waste management practices, occupational health and safety activities and ANSTO's arrangements for public health and safety beyond the site. This report describes the activities and findings of the SRC during the year ending 30 June 1992. 8 figs., ills
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McMullan, Kathryn L; Wedner, H James
2013-01-01
Aspirin (ASA) is the drug of choice in patients with coronary artery disease for primary and secondary prevention. This poses a problem for those patients reporting hypersensitivity to this drug or class of drugs. Desensitization to ASA may be carried out safely and effectively in patients with reported ASA or nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity needing ASA for cardiac indications. Our 7-step protocol is one choice for a rapid desensitization protocol. A retrospective chart review was conducted evaluating ASA desensitization in patients with reported ASA or NSAID hypersensitivity and a cardiac indication for ASA. In 160 evaluations over 15 years, 89 desensitizations were performed in both the inpatient and outpatient setting with only 16 reactions (18%). Eleven of these 16 patients (68.7%) were able to take daily ASA. Twenty-six desensitization procedures were performed with our 7-step rapid desensitization protocol in 10 inpatients and 16 outpatients with 3 reactions (18.75% of reactions). Initial reaction to ASA involving angioedema and reacting to ASA within the past year increased the risk of having a reaction to desensitization. Desensitization may be safely performed in patients with reported ASA or NSAID hypersensitivity and a cardiac indication for ASA. Our 7-step rapid protocol may be used in both the inpatient and outpatient setting to desensitize these patients. Patients who had angioedema with ASA ingestion or a reaction to ASA within the past year are at higher risk for reaction during the desensitization protocol. The authors have no funding, financial relationships, or conflicts of interest to disclose. © 2012 Wiley Periodicals, Inc.
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Safety report on WWR-S reactor
International Nuclear Information System (INIS)
Horyna, J.; Kaisler, L.; Listik, E.
1981-04-01
The present Safety Report of the WWR-S reactor summarizes findings obtained during the trial and partially also permanent operation of the reactor after two stages of its reconstruction implemented between 1974 and 1976. Most data are presented necessary for assessing probable risks of possible accident conditions whose consequences pose health hazards to individuals of the population, radiation personnel and the facilities themselves. Attention is devoted to the description of the locality, to components and systems, heat removal from the core, design aspects, the quality of new and old parts of the technological circuits, the systems of protection and control, the emergency core cooling system, the problems of radiation safety, and to the safety analyses of the abnormal states envisaged. The Report was compiled with regard to IAEA and CMEA recommendations concerning safe operation of research reactors and to the recommendations and binding decisions of the Czechoslovak Atomic Energy Commission. (author)
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International Nuclear Information System (INIS)
1987-04-01
The Integrated Safety Assessment Program (ISAP) was initiated in November 1984, by the US Nuclear Regulatory Commission to conduct integrated assessments for operating nuclear power reactors. The integrated assessment is conducted in a plant-specific basis to evaluate all licensing actions, licensee initiated plant improvements and selected unresolved generic/safety issues to establish implementation schedules for each item. In addition, procedures will be established to allow for a periodic updating of the schedules to account for licensing issues that arise in the future. This report documents the review of Millstone Nuclear Power Station, Unit No. 1, operated by Northeast Nuclear Energy Company (located in Waterford, Connecticut). Millstone Nuclear Power Station, Unit No. 1, is one of two plants being reviewed under the pilot program for ISAP. This report indicates how 85 topics selected for review were addressed. This report presents the staff's recommendations regarding the corrective actions to resolve the 85 topics and other actions to enhance plant safety. The report is being issued in draft form to obtain comments from the licensee, nuclear safety experts, and the Advisory Committee for Reactor Safeguards (ACRS). Once those comments have been resolved, the staff will present its positions, along with a long-term implementation schedule from the licensee, in the final version of this report
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[The road to patient safety: facts and desire].
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.
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Bilateral effects of hospital patient-safety procedures on nurses' job satisfaction.
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
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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
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2010-01-01
... 14 Aeronautics and Space 2 2010-01-01 2010-01-01 false Aviation Safety Reporting Program... GENERAL OPERATING AND FLIGHT RULES General § 91.25 Aviation Safety Reporting Program: Prohibition against... to the National Aeronautics and Space Administration under the Aviation Safety Reporting Program (or...
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Fusion Safety Program. Annual report, FY 1982
International Nuclear Information System (INIS)
Crocker, J.G.; Cohen, S.
1983-07-01
The Fusion Safety Program major activities for Fiscal Year 1982 are summarized in this report. The program was started in FY-79, with the Idaho National Engineering Laboratory (INEL) designated as lead laboratory and EG and G Idaho, Inc., named as prime contractor to implement this role. The report contains four sections: EG and G Idaho, Inc., Activities at INEL includes major portions of papers dealing with ongoing work in tritium implantation experiments, tritium risk assessment, transient code development, heat transfer and fluid flow analysis, and high temperature oxidation and mobilization of structural material experiments. The section Outside Contracts includes studies of superconducting magnet safety conducted by Argonne National Laboratory, experiments concerning superconductor safety issues performed by the Francis Bitter Magnet Laboratory of the Massachusetts Institute of Technology (MIT) to verify analytical work, a continuation of safety and environmental studies by MIT, a summary of lithium safety experiments at Hanford Engineering Development Laboratory, and the results of tritium gas conversion to oxide experiments at Oak Ridge National Laboratory. A List of Publications and Proposed FY-83 Activities are also presented
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76 FR 74788 - Patient Safety Organizations: Voluntary Relinquishment From HealthWatch, Inc.
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...
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76 FR 7853 - Patient Safety Organizations: Voluntary Delisting From HealthDataPSO
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...
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Nuclear Safety Research Department annual report 2000
DEFF Research Database (Denmark)
Majborn, B.; Nielsen, Sven Poul; Damkjær, A.
2001-01-01
The report presents a summary of the work of the Nuclear Safety Research Department in 2000. The department's research and development activities were organized in two research programmes: "Radiation Protection and Reactor Safety" and "Radioecology andTracer Studies". In addtion the department...
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Nuclear Safety Research Department annual report 2001
DEFF Research Database (Denmark)
Majborn, B.; Damkjær, A.; Nielsen, Sven Poul
2002-01-01
The report presents a summary of the work of the Nuclear Safety Research Department in 2001. The department's research and development activities were organized in two research programmes: "Radiation Protection and Reactor Safety" and "Radioecology andTracer Studies". In addition the department...
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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.
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The President's Report on Occupational Safety and Health.
Department of Health, Education, and Welfare, Washington, DC.
This report describes what has been done to implement the Occupational Safety and Health Act of 1970 during its first year of operation. The report examines the responsibilities of the Department of Labor for setting safety and health standards and also explores the activities of the Department of Health, Education, and Welfare in research and…
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Nuclear safety research project. Annual report 1995
International Nuclear Information System (INIS)
Hueper, R.
1996-08-01
The reactor safety R and D work of the Karlsruhe Research Centre (FZK) has been part of the Nuclear Safety Research Project (PSF) since 1990. The present annual report 1995 summarizes the R and D results. The research tasks are coordinated in agreement with internal and external working groups. The contributions to this report correspond to the status of early 1996. An abstract in English precedes each of them, whenever the respective article is written in German. (orig.) [de