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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 -
Archivos Argentinos de Pediatria Dec 2021An essential characteristic of health care facilities is teamwork, and this implies an organizational philosophy where collective talent, with common goals in clearly...
An essential characteristic of health care facilities is teamwork, and this implies an organizational philosophy where collective talent, with common goals in clearly identified directions, allows to obtain better results. Communication is at the core of this model, understood as an interaction process, not just an activity aimed at conveying information. Medical errors and conflict in the institutional setting are usually caused by failures in effective communication. Like in other areas of health, communicational aspects of teamwork advance with learning. The acquisition of such competences, the development of active listening, and an interaction among disciplines favor professional training and patient safety. Actually, together with other factors, these aspects necessary for communication underscore the quality of health care.
Topics: Communication; Humans; Medical Errors; Patient Care Team; Patient Safety
PubMed: 34813238
DOI: 10.5546/aap.2021.eng.e589 -
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 -
Health Informatics Journal Mar 2020We identify and describe nine key, short-term, challenges to help healthcare organizations, health information technology developers, researchers, policymakers, and...
We identify and describe nine key, short-term, challenges to help healthcare organizations, health information technology developers, researchers, policymakers, and funders focus their efforts on health information technology-related patient safety. Categorized according to the stage of the health information technology lifecycle where they appear, these challenges relate to (1) developing models, methods, and tools to enable risk assessment; (2) developing standard user interface design features and functions; (3) ensuring the safety of software in an interfaced, network-enabled clinical environment; (4) implementing a method for unambiguous patient identification (1-4 Design and Development stage); (5) developing and implementing decision support which improves safety; (6) identifying practices to safely manage information technology system transitions (5 and 6 Implementation and Use stage); (7) developing real-time methods to enable automated surveillance and monitoring of system performance and safety; (8) establishing the cultural and legal framework/safe harbor to allow sharing information about hazards and adverse events; and (9) developing models and methods for consumers/patients to improve health information technology safety (7-9 Monitoring, Evaluation, and Optimization stage). These challenges represent key "to-do's" that must be completed before we can expect to have safe, reliable, and efficient health information technology-based systems required to care for patients.
Topics: Humans; Information Systems; Medical Informatics; Patient Safety
PubMed: 30537881
DOI: 10.1177/1460458218814893 -
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 -
International Journal of Environmental... Nov 2022Adverse events in hospitals are prevented through risk reduction and reliable processes. Highly reliable hospitals are grounded by a robust patient safety culture with... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Adverse events in hospitals are prevented through risk reduction and reliable processes. Highly reliable hospitals are grounded by a robust patient safety culture with effective communication, leadership, teamwork, error reporting, continuous improvement, and organizational learning. Although hospitals regularly measure their patient safety culture for strengths and weaknesses, there have been no systematic reviews with meta-analyses reported from Latin America.
PURPOSE
Our systematic review aims to produce evidence about the status of patient safety culture in Latin American hospitals from studies using the Hospital Survey on Patient Safety Culture (HSOPSC).
METHODS
This systematic review was guided by the JBI guidelines for evidence synthesis. Four databases were systematically searched for studies from 2011 to 2021 originating in Latin America. Studies identified for inclusion were assessed for methodological quality and risk of bias. Descriptive and inferential statistics, including meta-analysis for professional subgroups and meta-regression for subgroup effect, were calculated.
RESULTS
In total, 30 studies from five countries-Argentina (1), Brazil (22), Colombia (3), Mexico (3), and Peru (1)-were included in the review, with 10,915 participants, consisting primarily of nursing staff (93%). The HSOPSC dimensions most positive for patient safety culture were "organizational learning: continuous improvement" and "teamwork within units", while the least positive were "nonpunitive response to error" and "staffing". Overall, there was a low positive perception (48%) of patient safety culture as a global measure (95% CI, 44.53-51.60), and a significant difference was observed for physicians who had a higher positive perception than nurses (59.84; 95% CI, 56.02-63.66).
CONCLUSIONS
Patient safety culture is a relatively unknown or unmeasured concept in most Latin American countries. Health professional programs need to build patient safety content into curriculums with an emphasis on developing skills in communication, leadership, and teamwork. Despite international accreditation penetration in the region, there were surprisingly few studies from countries with accredited hospitals. Patient safety culture needs to be a priority for hospitals in Latin America through health policies requiring annual assessments to identify weaknesses for quality improvement initiatives.
Topics: Humans; Patient Safety; Latin America; Organizational Culture; Safety Management; Hospitals; Surveys and Questionnaires
PubMed: 36361273
DOI: 10.3390/ijerph192114380 -
Frontiers in Public Health 2022To predict the amount of teamwork that takes place throughout a surgery, based on performing a preoperative safety standards (surgical safety checklist and surgical...
OBJECTIVES
To predict the amount of teamwork that takes place throughout a surgery, based on performing a preoperative safety standards (surgical safety checklist and surgical count) and to explore factors affecting patient safety and staff psychological safety during a surgery, based on interprofessional teamwork.
METHODS
This mixed methods study included quantitative and qualitative analyses. Quantitative data included 2,184 direct observations of surgical cases with regard to the performance of safety standards during surgeries in 29 hospitals, analyzed using multivariate binary logistic regressions. Qualitative data were obtained from an analysis of 25 semi-structured interviews with operating room (OR) clinicians and risk managers, using an inductive thematic analysis approach.
RESULTS
Analysis of the OR observations revealed that a lack of teamwork in the preoperative "sign-in" phase doubled the chances of there being a lack of teamwork during surgery [odds ratio = 1.972, 95% confidence interval (CI) 1.741, 2.233, < 0.001] and during the "time-out" phase (odds ratio = 2.142, 95% CI 1.879, 2.441, < 0.001). Consistent presence of staff during surgery significantly increased teamwork, by 21% for physicians and 24% for nurses ( < 0.05), but staff turnover significantly decreased teamwork, by 73% for physicians ( < 0.05). Interview data indicated that patient safety and staff psychological safety are related to a perception of a collaborative team role among OR staff, with mutual commitment and effective interprofessional communication.
CONCLUSIONS
Healthcare organizations should consider the key finding of this study when trying to identify factors that affect teamwork during a surgery. Effective preoperative teamwork positively affects intraoperative teamwork, as does the presence of more clinicians participating in a surgery, with no turnover. Other factors include working in a fixed, designated team, led by a surgeon, which functions with effective interprofessional communication that promotes patient safety and staff psychological safety.
Topics: Humans; Operating Rooms; Patient Safety; Patient Care Team; Hospitals; Physicians
PubMed: 36620282
DOI: 10.3389/fpubh.2022.1060473 -
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