-
Revista Da Escola de Enfermagem Da U S P 2024To identify whether safety huddle implementation enabled a change in patient safety culture.
OBJECTIVE
To identify whether safety huddle implementation enabled a change in patient safety culture.
METHOD
Quasi-experimental research that assessed patient safety culture before and after safety huddle implementation.
RESULTS.
The study revealed that 53.98% completed the two safety culture assessments, with 60.1% adherence from the nursing team, with a statistically significant difference in the second assessment regarding perception of patient safety and adverse events notified (p < 0.00). Regarding good practice indicators, a statistically significant difference (p < 0.00) was observed in item 43 and improvement in almost all dimensions in the second safety culture assessment. The huddles totaled 105 days, with 100% adherence from the nursing team. Regarding checklist items, all presented satisfactory responses (above 50%).
CONCLUSION
Safety huddles proved to be an effective tool for communication between healthcare professionals and managers, demonstrating positive impacts on good practice indicators and most safety culture dimensions.
Topics: Humans; Patient Care Team; Safety Management; Communication; Nursing, Team; Patient Safety
PubMed: 38358114
DOI: 10.1590/1980-220X-REEUSP-2023-0270en -
Journal of Health Organization and... Aug 2019The purpose of this paper is to systematically describe the types of non-clinical rounds implemented in hospital settings. (Review)
Review
PURPOSE
The purpose of this paper is to systematically describe the types of non-clinical rounds implemented in hospital settings.
DESIGN/METHODOLOGY/APPROACH
This scoping review was conducted and reported in accordance with the PRISMA. The review followed the four stages of conducting scoping review as defined by Arskey and O'Malley (2005).
FINDINGS
Initially, 978 articles were identified through database search from which only 24 studies were considered relevant and included in the final review. Overall, eight types of non-clinical rounds were identified (death rounds, grand rounds, morbidity and mortality conferences, multidisciplinary rounds, patient safety rounds, patient safety huddles, walkarounds and Schwartz rounds) that independently of their format, goal, participants and type of outcomes aimed to enhance patient safety and improve quality of healthcare delivery in hospital settings, either by focusing on physician, patient or organizational system.
ORIGINALITY/VALUE
To the authors' knowledge this is the first review that aims to provide a comprehensive summary to the types of non-clinical rounds that has been applied in clinical settings.
Topics: Hospitals; Patient Safety; Teaching Rounds
PubMed: 31483207
DOI: 10.1108/JHOM-09-2018-0244 -
Journal of the American Medical... Oct 2021This study investigated how well-suited the International Classification of Diseases, 11th Revision, for Mortality and Morbidity Statistics, (ICD-11 MMS) is for 2...
OBJECTIVE
This study investigated how well-suited the International Classification of Diseases, 11th Revision, for Mortality and Morbidity Statistics, (ICD-11 MMS) is for 2 morbidity use cases, patient safety and quality, examining the level of detail captured, and evaluating the necessity for the development of a US clinical modification (CM).
MATERIALS AND METHODS
Utilizing the 5 NCVHS-specified perspectives plus the consumer perspective, a framework was created of International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) use cases. Analysis yielded candidate source criteria for use in case evaluation. Patient safety and quality were chosen because they are relevant across all perspectives.Granularity differences and content coverage of ICD-11 MMS entities were assessed pre- and post-coordination to determine suitability for the 2 use cases. Pressure ulcers, a common condition across 3 patient safety applications, became the focus for comparing ICD-10-CM codes to ICD-11 MMS codes. For 3 electronic clinical quality measures (eCQMs), the evaluation centered on specified value sets for ischemic stroke, hypertension, and diabetes.
RESULTS
For pressure ulcers, the ICD-11 MMS was found to exceed ICD-10-CM capabilities via post-coordinated extension codes. For the 3 eCQM value sets explored, the ICD-11 MMS fully represented the disease concepts when post-coordinated code clusters were used.
CONCLUSIONS
The examples from the patient safety and quality use cases evaluated in this study are appropriate for ICD-11 MMS. It captures greater detail than ICD-10-CM, and ICD-11 MMS specificity would benefit both use cases. The authors believe this preliminary study indicates the US should invest resources to explore adopting the WHO ICD-11 MMS and tooling and guidelines to implement post-coordination.
Topics: Humans; International Classification of Diseases; Patient Safety; Stroke
PubMed: 34472597
DOI: 10.1093/jamia/ocab163 -
Atencion Primaria Dec 2021
Topics: Forecasting; Humans; Patient Safety; Primary Health Care
PubMed: 34961583
DOI: 10.1016/j.aprim.2021.102221 -
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 -
International Journal of Environmental... Jul 2021Thinking in patient safety has evolved over time from more simplistic accident causation models to more robust frameworks of work system design. Throughout this... (Review)
Review
Thinking in patient safety has evolved over time from more simplistic accident causation models to more robust frameworks of work system design. Throughout this evolution, less consideration has been given to the role of the built environment in supporting safety. The aim of this paper is to theoretically explore how we think about harm as a systems problem by mitigating the risk of adverse events through proactive healthcare facility design. We review the evolution of thinking in safety as a safety science. Using falls as a case study topic, we use a previously published model (SCOPE: Safety as Complexity of the Organization, People, and Environment) to develop an expanded framework. The resulting theoretical model and matrix, DEEP SCOPE (DEsigning with Ergonomic Principles), provide a way to synthesize design interventions into a systems-based model for healthcare facility design using human factors/ergonomics (HF/E) design principles. The DEEP SCOPE matrix is proposed to highlight the design of safe healthcare facilities as an ergonomic problem of design that fits the environment to the user by understanding built environments that support the "human" factor.
Topics: Accidental Falls; Delivery of Health Care; Ergonomics; Health Facilities; Humans; Patient Safety
PubMed: 34360068
DOI: 10.3390/ijerph18157780 -
Lakartidningen Apr 2022
Topics: Humans; Patient Safety; Quality Assurance, Health Care; Safety Management
PubMed: 35415829
DOI: No ID Found -
Journal of Patient Safety Aug 2021There have been efforts to understand the epidemiology of iatrogenic harm in hospitals and primary care and to improve the safety of care provision. There has in...
BACKGROUND
There have been efforts to understand the epidemiology of iatrogenic harm in hospitals and primary care and to improve the safety of care provision. There has in contrast been very limited progress in relation to the safety of ambulatory dental care.
OBJECTIVES
To provide a comprehensive overview of the range and frequencies of existing evidence on patient safety incidents and adverse events in ambulatory dentistry.
METHODS
We searched MEDLINE and EMBASE for articles reporting events that could have or did result in unnecessary harm in ambulatory dental care. We extracted and synthesized data on the types and frequencies of patient safety incidents and adverse events.
RESULTS
Forty articles were included. We found that the frequencies varied very widely between studies; this reflected differences in definitions, populations studied, and sampling strategies. The main 5 PSIs we identified were errors in diagnosis and examination, treatment planning, communication, procedural errors, and the accidental ingestion or inhalation of foreign objects. However, little attention was paid to wider organizational issues.
CONCLUSIONS
Patient safety research in dentistry is immature because current evidence cannot provide reliable estimates on the frequency of patient safety incidents in ambulatory dental care or the associated disease burden. Well-designed epidemiological investigations are needed that also investigate contributory factors.
Topics: Dental Care; Hospitals; Humans; Medical Errors; Patient Safety; Primary Health Care
PubMed: 27611771
DOI: 10.1097/PTS.0000000000000316 -
Revista Latino-americana de Enfermagem Nov 2021
Topics: Humans; Leadership; Patient Safety; Safety Management
PubMed: 34755772
DOI: 10.1590/1518-8345.0000.3484 -
Canadian Medical Education Journal Apr 2023The Royal College of Physicians and Surgeons of Canada has made Quality Improvement and Patient Safety (QIPS) a priority in residency education, however, implementation...
The Royal College of Physicians and Surgeons of Canada has made Quality Improvement and Patient Safety (QIPS) a priority in residency education, however, implementation is limited by the heterogeneity of previously published curricula. We created a longitudinal resident-led patient safety (PS) curriculum using relatable, real-life PS incidents (PSIs) and an analysis framework.Implementation was feasible, well received by residents and demonstrated significant improvement in residents' PS knowledge,skills, and attitudes. Our curriculum built a culture of PS within a pediatric residency program, promoted engagement in QIPS practices early in training, and filled a gap in the current curriculum teaching.
Topics: Child; Humans; Patient Safety; Curriculum; Canada; Educational Status; Surgeons
PubMed: 37304624
DOI: 10.36834/cmej.74871