-
Annals of the Royal College of Surgeons... Feb 2024
Topics: Humans; Patient Safety; Operating Rooms; Patient Care Team
PubMed: 38295841
DOI: 10.1308/rcsann.2024.0007 -
Journal of Patient Safety Sep 2021The increase in patient safety reporting systems has led to the challenge of effectively analyzing these data to identify and mitigate safety hazards. Patient safety...
OBJECTIVES
The increase in patient safety reporting systems has led to the challenge of effectively analyzing these data to identify and mitigate safety hazards. Patient safety analysts, who manage reports, may be ill-equipped to make sense of report data. We sought to understand the cognitive needs of patient safety analysts as they work to leverage patient safety reports to mitigate risk and improve patient care.
METHODS
Semistructured interviews were conducted with 21 analysts, from 11 hospitals across 3 healthcare systems. Data were parsed into utterances and coded to extract major themes.
RESULTS
From 21 interviews, 516 unique utterances were identified and categorized into the following 4 stages of data analysis: input (15.1% of utterances), transformation (14.1%), extrapolation (30%), and output (14%). Input utterances centered on the source (35.9% of inputs) and preprocessing of data. Transformation utterances centered on recategorizing patient safety events (57.5% of transformations) or integrating external data sources (42.5% of transformations). The focus of interviews was on extrapolation and trending data (56.1% of extrapolations); alarmingly, 16.1% of trend utterances explicitly mentioned a reliance on memory. The output was either a report (56.9% of outputs) or an action (43.1% of outputs).
CONCLUSIONS
Major gaps in the analysis of patient safety report data were identified. Despite software to support reporting, many reports come from other sources. Transforming data are burdensome because of recategorization of events and integration with other data sources, processes that can be automated. Surprisingly, trend identification was mostly based on patient analyst memory, highlighting a need for new tools that better support analysts.
Topics: Delivery of Health Care; Hospitals; Humans; Patient Safety
PubMed: 28787397
DOI: 10.1097/PTS.0000000000000400 -
British Journal of Anaesthesia Jul 2020Capnography is universally accepted as an essential patient safety monitor in high-income countries (HICs) yet is often unavailable in low and middle-income countries... (Review)
Review
BACKGROUND
Capnography is universally accepted as an essential patient safety monitor in high-income countries (HICs) yet is often unavailable in low and middle-income countries (LMICs). Increasing capnography availability has been proposed as one of many potential approaches to improving perioperative outcomes in LMICs. This scoping review summarises the existing literature on the effect of capnography on patient outcomes to help prioritise interventions and guide expansion of capnography in LMICs.
METHODS
We searched MEDLINE and EMBASE databases for articles published between 1980 and March 2019. Studies that assessed the impact of capnography on morbidity, mortality, or the use of airway interventions both inside and outside the operating room were included.
RESULTS
The search resulted in 7445 unique papers, and 31 were included for analysis. Retrospective and non-randomised data suggest capnography use may improve outcomes in the operating room, ICU, and emergency department, and during resuscitation. Prospective data on capnography use for procedural sedation suggest earlier detection of hypoventilation and a reduction in haemoglobin desaturation events. No randomised studies exist that assess the impact of capnography on patient outcomes.
CONCLUSION
Despite widespread endorsement of capnography as a mandatory perioperative monitor, rigorous data demonstrating its impact on patient outcomes are limited, especially in LMICs. The association between capnography use and a reduction in serious airway complications suggests that closing the capnography gap in LMICs may represent a significant opportunity to improve patient safety. Additional data are needed to quantify the global capnography gap and better understand the barriers to capnography scale-up in LMICs.
Topics: Capnography; Developed Countries; Developing Countries; Humans; Patient Safety; Poverty
PubMed: 32416994
DOI: 10.1016/j.bja.2020.04.057 -
JAMA Pediatrics Sep 2022
Topics: Child; Humans; Patient Safety
PubMed: 35877110
DOI: 10.1001/jamapediatrics.2022.2500 -
American Journal of Medical Quality :... 2020
Topics: Communicable Disease Control; Humans; Leadership; Masks; Patient Safety; Public Health
PubMed: 32672470
DOI: 10.1177/1062860620940290 -
Studies in Health Technology and... May 2022With the start of the 21st century, patient safety as a topic of special interest has attracted increasing attention in both academia and clinical practice. As... (Review)
Review
With the start of the 21st century, patient safety as a topic of special interest has attracted increasing attention in both academia and clinical practice. As technology has continued to develop since then, questions and focal points surrounding the topic have also shifted. In particular, questions regarding the impact of digitalization on patient safety and its measurement are now of high interest. This work aims to develop a maturity assessment instrument in the form of a criteria set for measuring structural requirements for digital patient safety in hospitals. Based on the results of a literature review and a derivation of maturity objects (MO) from known maturity models, 64 criteria across 11 categories were developed. Written comments of two digital patient safety experts as well as subsequent interviews were used to evaluate and refine the criteria catalog. The resulting catalog offers hospitals guidance for detecting possible areas of structural improvements in their information systems with regard to patient safety and represents a unique instrument for assessing digital maturity in this particular area.
Topics: Hospitals; Humans; Information Systems; Patient Safety
PubMed: 35612236
DOI: 10.3233/SHTI220618 -
BMJ Quality & Safety Feb 2024
Topics: Humans; Patient Safety
PubMed: 38050114
DOI: 10.1136/bmjqs-2023-016652 -
British Journal of Nursing (Mark Allen... Mar 2021
Topics: Humans; Patient Safety
PubMed: 33769882
DOI: 10.12968/bjon.2021.30.6.378 -
Korean Journal of Anesthesiology Feb 2024
Topics: Humans; Patient Safety; Practice Guidelines as Topic
PubMed: 38228394
DOI: 10.4097/kja.24033 -
Nurse Education in Practice Jul 2021Patient safety in hospitals is a key priority. Clinical coaches who educate, support and coach staff to deliver safe, high quality care, are ideally placed to positively...
UNLABELLED
Patient safety in hospitals is a key priority. Clinical coaches who educate, support and coach staff to deliver safe, high quality care, are ideally placed to positively influence patient safety.
AIM
This study aimed to understand how clinical coaches in an education role, manage risk and support patient safety at the point of care.
BACKGROUND
Patient safety has developed from a find and fix reactive model towards an approach which focuses on human performance, aiming to understand how individuals adapt and respond in complex systems to ensure 'things go right'. Clinical coaches working as educators at the point of care, are uniquely placed to ensure 'things go right', supporting staff to anticipate and proactively respond to emerging issues, particularly when complex practice situations change unexpectedly. Clinical coach experiences of intervening 'just in time' to prevent errors incidents or omissions occurring at the point of care is unknown.
DESIGN
This was a descriptive exploratory study conducted with registered nurses working in the role of clinical coach (n = 29).
METHODS
Study data were collected through a purposefully designed survey.
RESULTS
Clinical coaches intervened 'just in time' across a variety of clinical situations including medication errors, clinical procedures, documentation, assessment skills and clinical handover. Lower skill mix, higher patient acuity and the commencement of new staff influenced clinical coach 'just in time' interventions. Most of the clinical coaches had intervened with both junior and senior members of staff. Overall, clinical coaches spent up to 3-4 h every day proactively managing risk across a variety of clinical situations and staff.
CONCLUSIONS
Clinical coaches play an important role in ensuring patient safety by regularly intervening 'just in time' to prevent errors, omissions, or incidents from occurring at the point of care. The clinical coach role, which educates and supports staff to deliver safe, high quality care, makes a valuable contribution towards patient safety.
Topics: Humans; Patient Safety; Surveys and Questionnaires
PubMed: 34256213
DOI: 10.1016/j.nepr.2021.103134