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British Journal of Nursing (Mark Allen... Apr 2020
Topics: Evidence-Based Nursing; Humans; Patient Safety
PubMed: 32324458
DOI: 10.12968/bjon.2020.29.8.S3 -
Journal of Patient Safety Mar 2022This article reviews several key aspects of the Theory of Active and Latent Failures, typically referred to as the Swiss cheese model of human error and accident... (Review)
Review
This article reviews several key aspects of the Theory of Active and Latent Failures, typically referred to as the Swiss cheese model of human error and accident causation. Although the Swiss cheese model has become well known in most safety circles, there are several aspects of its underlying theory that are often misunderstood. Some authors have dismissed the Swiss cheese model as an oversimplification of how accidents occur, whereas others have attempted to modify the model to make it better equipped to deal with the complexity of human error in health care. This narrative review aims to provide readers with a better understanding and greater appreciation of the Theory of Active and Latent Failures upon which the Swiss cheese model is based. The goal is to help patient safety professionals fully leverage the model and its associated tools when performing a root cause analysis as well as other patient safety activities.
Topics: Delivery of Health Care; Humans; Patient Safety; Root Cause Analysis
PubMed: 33852542
DOI: 10.1097/PTS.0000000000000810 -
Revista Brasileira de Enfermagem 2020to identify the patient safety challenges described by health professionals in Primary Health Care. (Review)
Review
OBJECTIVES
to identify the patient safety challenges described by health professionals in Primary Health Care.
METHODS
a scoping review was conducted on the LILACS, MEDLINE, IBECS, BDENF, and CINAHL databases, and on the Cochrane, SciELO, Pubmed, and Web of Science libraries in January 2019. Original articles on patient safety in the context of Primary Health Care by health professionals were included.
RESULTS
the review included 26 studies published between 2002 and 2019. Four categories resulted from the analysis: challenges of health professionals, administration challenges of health services, challenges with the patient and family, and the potential enhancing resources for patient safety.
CONCLUSIONS
patient safety challenges for Primary Care professionals are multiple and complex. This study provides insight into resources to improve patient safety for health care professionals, patients, administrators, policy makers, educators, and researchers.
Topics: Humans; Patient Safety; Primary Health Care; Safety Management
PubMed: 32638932
DOI: 10.1590/0034-7167-2019-0209 -
Journal of Nursing Care Quality 2019A strong patient safety culture (PSC) may be associated with improved patient outcomes in hospitals. The mechanism that explains this relationship is underexplored;...
BACKGROUND
A strong patient safety culture (PSC) may be associated with improved patient outcomes in hospitals. The mechanism that explains this relationship is underexplored; missed nursing care may be an important link.
PURPOSE
The purpose of this study was to describe relationships among PSC, missed nursing care, and 4 types of adverse patient events.
METHODS
This cross-sectional study employed primary survey data from 311 nurses from 29 units in 5 hospitals and secondary adverse event data from those same units. Analyses include analysis of variance and regression models.
RESULTS
Missed nursing care was reported to occur at an occasional level (M = 3.44, SD = 0.24) across all 29 units. The PSC dimensions explained up to 30% of the variance in missed nursing care, 26% of quality of care concerns, and 15% of vascular access device events. Missed care was associated with falls (P < .05).
CONCLUSIONS
Prioritized actions to enhance PSC should be taken to reduce missed nursing care and adverse patient outcomes.
Topics: Cross-Sectional Studies; Hospitals; Humans; Medical Errors; Nursing Staff, Hospital; Patient Safety; Quality of Health Care; Safety Management; Surveys and Questionnaires
PubMed: 30550496
DOI: 10.1097/NCQ.0000000000000378 -
Revista Latino-americana de Enfermagem Apr 2017to identify the relationship between the workload of the nursing team and the occurrence of patient safety incidents linked to nursing care in a public hospital in Chile.
OBJECTIVE
to identify the relationship between the workload of the nursing team and the occurrence of patient safety incidents linked to nursing care in a public hospital in Chile.
METHOD
quantitative, analytical, cross-sectional research through review of medical records. The estimation of workload in Intensive Care Units (ICUs) was performed using the Therapeutic Interventions Scoring System (TISS-28) and for the other services, we used the nurse/patient and nursing assistant/patient ratios. Descriptive univariate and multivariate analysis were performed. For the multivariate analysis we used principal component analysis and Pearson correlation.
RESULTS
879 post-discharge clinical records and the workload of 85 nurses and 157 nursing assistants were analyzed. The overall incident rate was 71.1%. It was found a high positive correlation between variables workload (r = 0.9611 to r = 0.9919) and rate of falls (r = 0.8770). The medication error rates, mechanical containment incidents and self-removal of invasive devices were not correlated with the workload.
CONCLUSIONS
the workload was high in all units except the intermediate care unit. Only the rate of falls was associated with the workload.
Topics: Cross-Sectional Studies; Humans; Nursing; Patient Safety; Workload
PubMed: 28403334
DOI: 10.1590/1518-8345.1280.2841 -
Applied Ergonomics Apr 2020The Systems Engineering Initiative for Patient Safety (SEIPS) and SEIPS 2.0 models provide a framework for integrating Human Factors and Ergonomics (HFE) in health care...
The Systems Engineering Initiative for Patient Safety (SEIPS) and SEIPS 2.0 models provide a framework for integrating Human Factors and Ergonomics (HFE) in health care quality and patient safety improvement. As care becomes increasingly distributed over space and time, the "process" component of the SEIPS model needs to evolve and represent this additional complexity. In this paper, we review different ways that the process component of the SEIPS models have been described and applied. We then propose the SEIPS 3.0 model, which expands the process component, using the concept of the patient journey to describe the spatio-temporal distribution of patients' interactions with multiple care settings over time. This new SEIPS 3.0 sociotechnical systems approach to the patient journey and patient safety poses several conceptual and methodological challenges to HFE researchers and professionals, including the need to consider multiple perspectives, issues with genuine participation, and HFE work at the boundaries.
Topics: Ergonomics; Humans; Medical Errors; Models, Theoretical; Patient Safety; Quality Improvement; Quality of Health Care; Safety Management; Systems Analysis; Task Performance and Analysis
PubMed: 31987516
DOI: 10.1016/j.apergo.2019.103033 -
Saudi Medical Journal Dec 2017Since the original Institute of Medicine (IOM) report was published there has been an accelerated development and adoption of health information technology with varying... (Review)
Review
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.
Topics: Humans; Medical Informatics; National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division; Patient Safety; United States
PubMed: 29209664
DOI: 10.15537/smj.2017.12.20631 -
BMJ Open Dec 2019Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (eg, self-harm), and the measures taken to address these (eg, restraint), may result in further risks to patient safety. The objective of this review is to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology.
DESIGN
Systematic review and meta-synthesis. Embase, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science were systematically searched from 1999 to 2019. Search terms were related to 'mental health', 'patient safety', 'inpatient setting' and 'research'. Study quality was assessed using the Hawker checklist. Data were extracted and grouped based on study focus and outcome. Safety incidents were meta-analysed where possible using a random-effects model.
RESULTS
Of the 57 637 article titles and abstracts, 364 met inclusion criteria. Included publications came from 31 countries and included data from over 150 000 participants. Study quality varied and statistical heterogeneity was high. Ten research categories were identified: interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorised leave, clinical decision making, falls and infection prevention and control.
CONCLUSIONS
Patient safety in inpatient mental health settings is under-researched in comparison to other non-mental health inpatient settings. Findings demonstrate that inpatient mental health settings pose unique challenges for patient safety, which require investment in research, policy development, and translation into clinical practice.
PROSPERO REGISTRATION NUMBER
CRD42016034057.
Topics: Biomedical Research; Humans; Inpatients; Patient Safety; Psychiatric Department, Hospital
PubMed: 31874869
DOI: 10.1136/bmjopen-2019-030230 -
BMC Health Services Research Jul 2018Adverse events (AEs) seriously affect patient safety and quality of care, and remain a pressing global issue. This study had three objectives: (1) to describe the... (Review)
Review
BACKGROUND
Adverse events (AEs) seriously affect patient safety and quality of care, and remain a pressing global issue. This study had three objectives: (1) to describe the proportions of patients affected by in-hospital AEs; (2) to explore the types and consequences of observed AEs; and (3) to estimate the preventability of in-hospital AEs.
METHODS
We applied a scoping review method and concluded a comprehensive literature search in PubMed and CINAHL in May 2017 and in February 2018. Our target was retrospective medical record review studies applying the Harvard method-or similar methods using screening criteria-conducted in acute care hospital settings on adult patients (≥18 years).
RESULTS
We included a total of 25 studies conducted in 27 countries across six continents. Overall, a median of 10% patients were affected by at least one AE (range: 2.9-21.9%), with a median of 7.3% (range: 0.6-30%) of AEs being fatal. Between 34.3 and 83% of AEs were considered preventable (median: 51.2%). The three most common types of AEs reported in the included studies were operative/surgical related, medication or drug/fluid related, and healthcare-associated infections.
CONCLUSIONS
Evidence regarding the occurrence of AEs confirms earlier estimates that a tenth of inpatient stays include adverse events, half of which are preventable. However, the incidence of in-hospital AEs varied considerably across studies, indicating methodological and contextual variations regarding this type of retrospective chart review across health care systems. For the future, automated methods for identifying AE using electronic health records have the potential to overcome various methodological issues and biases related to retrospective medical record review studies and to provide accurate data on their occurrence.
Topics: Cross Infection; Data Accuracy; Data Collection; Electronic Health Records; Hospitalization; Hospitals; Humans; Incidence; Medical Errors; Patient Safety; Retrospective Studies
PubMed: 29973258
DOI: 10.1186/s12913-018-3335-z -
BMJ Open Quality Feb 2020Open communication between leadership and frontline staff at the unit level is vital in promoting safe hospital culture. Our hospital staff culture survey identified the...
BACKGROUND
Open communication between leadership and frontline staff at the unit level is vital in promoting safe hospital culture. Our hospital staff culture survey identified the failure to address safety issues as one of the areas where staff felt unable to express their concerns openly. Thus, this improvement project using the daily safety huddle tool has been developed to enhance teamwork communication and respond effectively to patient safety issues identified in a paediatric intensive care unit.
METHODS
We used the TeamSTEPPS quality approach. TeamSTEPPS is an evidence-based set of teamwork tools developed by the US Agency of Healthcare Research and Quality to enhance teamwork and communication. We applied TeamSTEPPS using a tool called the Daily Safety Huddle, aiming at improving communication and interaction between healthcare workers and building trust by acting immediately when there is any patient safety issue or concern at the unit level.
RESULTS
During the period from April to December 2017, the interaction between frontline staff and unit leadership increased through compliance with the daily safety huddle. Initially, compliance was at 73%, but it increased to 97%, with a total of 340 safety issues addressed. The majority of these safety issues pertained to infection control and medication errors (109; 32.05%), followed by communication (83; 24.41%), documentation (59; 17.35%), other issues (37; 10.88%), procedure (20; 5.88%), patient flow (16; 4.7%) and equipment and supplies (16; 4.7%).
CONCLUSIONS
Systematic use of daily safety huddle is a powerful tool to create an equitable environment where frontline staff can speak up freely about daily patient safety concerns. The huddle leads to a more open and active discussion with unit leadership and to the ability to perform the right action at the right time.
Topics: Communication; Humans; Intensive Care Units, Pediatric; Patient Care Team; Patient Safety; Quality Improvement; State Medicine; Surveys and Questionnaires
PubMed: 32098776
DOI: 10.1136/bmjoq-2019-000753