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Anaesthesia Dec 2021
Topics: Health Personnel; Humans; Medical Errors; Models, Statistical; Patient Safety; Work Performance; Workload
PubMed: 33858027
DOI: 10.1111/anae.15481 -
Anales de Pediatria Oct 2022
Topics: Delivery of Health Care; Humans; Patient Safety; Quality Improvement
PubMed: 36031551
DOI: 10.1016/j.anpede.2022.08.007 -
The Journal of Medicine and Philosophy Feb 2023Patient safety is a central aspect of healthcare quality, focusing on preventable, iatrogenic harm. Harm, in this context, is typically assumed to mean physical injury...
Patient safety is a central aspect of healthcare quality, focusing on preventable, iatrogenic harm. Harm, in this context, is typically assumed to mean physical injury to patients, often caused by technical error. However, some contributions to the patient safety literature have argued that disrespectful behavior towards patients can cause harm, even when it does not lead to physical injury. This paper investigates the nature of such dignitary harms and explores whether they should be included within the scope of patient safety as a field of practice. We argue that dignitary harms in health care are-at least sometimes-preventable, iatrogenic harms. While we caution against including dignitary harms within the scope of patient safety just because they are relevantly similar to other iatrogenic harms, we suggest that thinking about dignitary harms can help to elucidate the value of patient safety, and to illuminate the evolving relationship between safety and quality.
Topics: Humans; Patient Safety; Quality of Health Care; Iatrogenic Disease
PubMed: 36592336
DOI: 10.1093/jmp/jhac035 -
British Journal of Anaesthesia Apr 2023The March issue contains a laboratory study of auditory perception, which is an unusual topic for this journal. A perspective is provided on how the study relates to...
The March issue contains a laboratory study of auditory perception, which is an unusual topic for this journal. A perspective is provided on how the study relates to recent research on clinical auditory alarms and displays. Techniques used in the study are explored and explained, such as enrolment of non-clinician volunteer participants, use of coordinate response measure phrase stimuli, presentation of sound loudness levels using the decibel scale, and analysis using signal detection theory. Such efforts to improve the safety, efficacy, and tolerability of modern medical device alarms are critical for improved patient safety.
Topics: Humans; Sound; Auditory Perception; Patient Safety
PubMed: 36792387
DOI: 10.1016/j.bja.2023.01.014 -
BMJ Open Quality Sep 2020In the USA over 30% of medication errors occur at the point of administration. Among non-surgical patients in US hospitals exposed to opioids, 0.6% experience a severe...
INTRODUCTION
In the USA over 30% of medication errors occur at the point of administration. Among non-surgical patients in US hospitals exposed to opioids, 0.6% experience a severe opioid-related adverse event. In September 2018, Sierra View Medical Center identified two areas of opportunity for quality improvement: bedside bar code medication administration (BCMA) and pain reassessments. At baseline (April 2018 to September 2018) only 81% of medications were scanned prior to administration with pain reassessments completed only 41% of the time 1 hour postopioid administration.
OBJECTIVE
To improve BCMA scanning rates (goal ≥95%) and pain reassessments within 1 hour postopioid administration (goal ≥90%).
METHODS
Implementation methods included data transparency, weekly dashboards, education and plan-do-study-act (PDSA) cycles informed by feedback from key stakeholders.
RESULTS
Following a series of PDSA cycle implementations, barcode medication administration (BCMA) scanning rates improved by 14% (from 81% to 95%) and pain reassessments improved by 50% (from 41% to 91%), sustained 17 months postproject implementation (October 2018 to February 2019). The number of adverse drug events (ADEs) related to administration errors decreased by 17% (estimated annual cost savings of $120 750-239 725 per year) and opioid-related ADEs decreased by 2.6% (estimated annual cost savings of $72 855-80 928 per year).
CONCLUSION
Adopting John Kotter's model for change, developing performance dashboards and sustaining engagement among stakeholders on a weekly basis improved bar code medication scanning rates and pain reassessment compliance. The stakeholders created momentum for change in both practice and culture resulting in improved patient safety with a favourable financial impact.
Topics: Electronic Data Processing; Hospitals, Community; Humans; Medication Errors; Medication Systems; Medication Systems, Hospital; Pain Measurement; Patient Safety
PubMed: 32958472
DOI: 10.1136/bmjoq-2020-000987 -
Revista Brasileira de Enfermagem 2021to analyze the contents on patient safety in the training of nursing technicians.
OBJECTIVES
to analyze the contents on patient safety in the training of nursing technicians.
METHODS
a documentary study, conducted in three technical nursing courses at a public university in northeastern Brazil, based on the Multi-Professional Patient Safety Curriculum Guide, published by the World Health Organization.
RESULTS
we found that, of the 26 subjects in each course, the tracking terms were found in 22 subjects in the A/C courses, 23 in the B course. The topics of the guide with the highest number of terms were the improvement in medication safety, with 85 terms (22.6%), and Infection prevention and control, with 75 terms (20%). The contents do not express the comprehensiveness of patient safety education; some subjects had this focus, while others did not.
CONCLUSIONS
the documents revealed gaps in the contents related to patient safety and demonstrated that they are addressed only in the course syllabus and discipline plans.
Topics: Brazil; Curriculum; Educational Measurement; Humans; Patient Safety; Universities
PubMed: 34586199
DOI: 10.1590/0034-7167-2020-1364 -
Journal of the American Medical... Jul 2021
Topics: Humans; Medical Informatics; Patient Safety; Quality of Health Care
PubMed: 34329435
DOI: 10.1093/jamia/ocab141 -
Frontiers in Public Health 2022
Topics: Humans; Malpractice; Patient Safety; Risk Management
PubMed: 36133929
DOI: 10.3389/fpubh.2022.970258 -
Perspectives on Medical Education Dec 2021Theory plays an important role in education programming and research. However, its use in quality improvement and patient safety education has yet to be fully... (Review)
Review
INTRODUCTION
Theory plays an important role in education programming and research. However, its use in quality improvement and patient safety education has yet to be fully characterized. The authors undertook a scoping review to examine the use of theory in quality improvement and patient safety education.
METHODS
Eligible articles used theory to inform the design or study of a quality improvement or patient safety curriculum. The authors followed scoping review methodology and searched articles referenced in 20 systematic reviews of quality improvement and patient safety education, or articles citing one of these reviews, and hand searched eligible article references. Data analysis involved descriptive and interpretive summaries of theories used and the perspectives the theories offered.
RESULTS
Eligibility criteria were met by 28 articles, and 102 articles made superficial mention of theory. Eligible articles varied in professional group, learning stage and journal type. Theories fell into two broad categories: learning theories (n = 20) and social science theories (n = 11). Theory was used in the design (n = 12) or study (n = 17) of quality improvement and patient safety education. The range of theories shows the opportunity afforded by using more than one type of theory.
DISCUSSION
Theory can guide decisions regarding quality improvement and patient safety education practices or play a role in selecting a methodology or lens through which to study educational processes and outcomes. Educators and researchers should make deliberate choices around the use of theory that relates to aspects of an educational program that they seek to illuminate.
Topics: Curriculum; Humans; Learning; Patient Safety; Quality Improvement
PubMed: 34609733
DOI: 10.1007/s40037-021-00686-5 -
Studies in Health Technology and... Jun 2022Intensive Care Units (ICUs) are recognized as a susceptible area to potential errors resulting in adverse outcomes. Healthcare professionals are multi-tasking,...
Intensive Care Units (ICUs) are recognized as a susceptible area to potential errors resulting in adverse outcomes. Healthcare professionals are multi-tasking, information-overloaded, and often with an interruptive workflow in ICUs. Such a stressful work environment poses challenges to reach a shared mental model in clinical practice, which leads to ineffective communication and reduces their awareness of potential safety risks. Despite data sources or materials supporting patient safety and team training being available, little research has been conducted to measure teamwork in clinical practice and to detect inefficient communication factors. The advent of telehealth provides an opportunity for remote video watchers to observe the entire process of patient care and related team activities. The potential application of video analyzing algorithms to video recordings can detect safety risks retrospectively. This article presents major teamwork and patient safety challenges in ICUs, and the opportunities of utilizing available data and telehealth including video recordings in future patient safety and teamwork research.
Topics: Health Personnel; Humans; Intensive Care Units; Patient Care Team; Patient Safety; Retrospective Studies
PubMed: 35673059
DOI: 10.3233/SHTI220120