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JAMA Dec 2020
Topics: Anesthesia; Anesthesiology; History, 19th Century; History, 20th Century; History, 21st Century; Humans; Patient Safety
PubMed: 33351053
DOI: 10.1001/jama.2020.23205 -
Enfermeria Clinica (English Edition) 2019
Topics: Humans; Nursing; Patient Safety; Quality Improvement
PubMed: 30366657
DOI: 10.1016/j.enfcli.2018.09.005 -
Practical Radiation Oncology Nov 2019Ensuring safety within RT is of paramount importance. To further support and augment patient safety efforts, the purpose of this research was to test and refine a robust... (Review)
Review
PURPOSE
Ensuring safety within RT is of paramount importance. To further support and augment patient safety efforts, the purpose of this research was to test and refine a robust methodology for analyzing human errors that defeat individual controls within RT quality assurance (QA) programs.
METHODS
The method proposed for performing Bowtie Analysis (BTA) was based on training and recommendations from practitioners in the field of Human Factors and Ergonomics practice. Multidisciplinary meetings to iteratively develop BTA focused on incorrect site setup instructions was conducted.
RESULTS
From November 2015 to February 2017, we had 12 reported incidents related to site setup notes that could have led to site setup errors. Based on this data, we conducted five BTA analyses related to incorrect site setup instructions. None of the individual controls within our QA program designed to check for potential errors with site setup instructions met the level of robustness to be classified as key safeguards or barriers.
CONCLUSIONS
The relatively low number of incidents causing patient harm has led us to typically assume that we have sufficient and effective controls in place to prevent serious human errors from leading to severe patient consequences. Based on our BTA, we question how well we truly understand the details of our individual controls. To meet the level of safety achieved by high reliability organizations (HROs), we need to better ensure that our controls are as reliable and robust as we assume.
Topics: Humans; Patient Safety; Radiation Oncology
PubMed: 31323384
DOI: 10.1016/j.prro.2019.06.022 -
The Surgical Clinics of North America Feb 2021"The focus on patient safety offers a new framework not only for delivering health care but also for training physicians. Medical school and surgical graduate medical... (Review)
Review
"The focus on patient safety offers a new framework not only for delivering health care but also for training physicians. Medical school and surgical graduate medical education must transition to a more holistic approach by teaching technical and nontechnical skills. Formalized safety curricula can be developed by adopting recommended guidelines and content from national and international organizations, existing validated practices of training programs, frequent simulation exercises, and objective evaluation tools."
Topics: Humans; Internship and Residency; Patient Safety; Surgical Procedures, Operative
PubMed: 33212075
DOI: 10.1016/j.suc.2020.09.007 -
Western Journal of Nursing Research Feb 2019Studies that suggest an increased number of bachelor's prepared nurses (BSNs) at the bedside improves patient safety do not stratify their samples into traditional...
Studies that suggest an increased number of bachelor's prepared nurses (BSNs) at the bedside improves patient safety do not stratify their samples into traditional bachelor's and associates (ADN) to BSN graduates. This qualitative study investigated potential differences in patient safety meaning among BSNs and ADN to BSN graduates. Guided by the theory of Language Convergence/Meaning Divergence, interview data from eight BSN and eight ADN to BSN graduates were analyzed. Findings indicate there are two meaning levels or systems, the local level and the systemic level. At the local level, the meaning of patient safety is focused at the patient's bedside and regulated by the nurse. The systemic level included the notion that health system factors such as policies and staffing are paramount to keeping patients safe. More frequently, ADN to BSN graduates' meaning of patient safety was at the local level, while BSNs' meaning centered at the systemic level.
Topics: Adult; Communication; Educational Status; Female; Humans; Interprofessional Relations; Interviews as Topic; Nurses; Patient Safety; Qualitative Research; Surveys and Questionnaires
PubMed: 29243561
DOI: 10.1177/0193945917747600 -
BMJ Quality & Safety Jun 2012Patient safety practices, targeting organisational changes for improving patient safety, are implemented worldwide but their costs are rarely evaluated. This paper... (Review)
Review
Patient safety practices, targeting organisational changes for improving patient safety, are implemented worldwide but their costs are rarely evaluated. This paper provides a review of the methods used in economic evaluation of such practices. International medical and economics databases were searched for peer-reviewed publications on economic evaluations of patient safety between 2000 and 2010 in English and French. This was complemented by a manual search of the reference lists of relevant papers. Grey literature was excluded. Studies were described using a standardised template and assessed independently by two researchers according to six quality criteria. 33 articles were reviewed that were representative of different patient safety domains, data types and evaluation methods. 18 estimated the economic burden of adverse events, 3 measured the costs of patient safety practices and 12 provided complete economic evaluations. Healthcare-associated infections were the most common subject of evaluation, followed by medication-related errors and all types of adverse events. Of these, 10 were selected that had adequately fulfilled one or several key quality criteria for illustration. This review shows that full cost-benefit/utility evaluations are rarely completed as they are resource intensive and often require unavailable data; some overcome these difficulties by performing stochastic modelling and by using secondary sources. Low methodological transparency can be a problem for building evidence from available economic evaluations. Investing in the economic design and reporting of studies with more emphasis on defining study perspectives, data collection and methodological choices could be helpful for strengthening our knowledge base on practices for improving patient safety.
Topics: Costs and Cost Analysis; Humans; Patient Safety
PubMed: 22396602
DOI: 10.1136/bmjqs-2011-000191 -
The New England Journal of Medicine Jan 2023
Topics: Humans; Patient Safety
PubMed: 36630628
DOI: 10.1056/NEJMe2213567 -
Health Affairs (Project Hope) Feb 2019
Topics: Health Priorities; Humans; Medical Overuse; Patient Safety
PubMed: 30715994
DOI: 10.1377/hlthaff.2018.05349 -
Journal of Patient Safety Sep 2019For 8.5 consecutive years, all patient safety articles of a journal underwent statistical review before publication. We sought to establish the prevalence of statistical... (Review)
Review
OBJECTIVES
For 8.5 consecutive years, all patient safety articles of a journal underwent statistical review before publication. We sought to establish the prevalence of statistical themes in the statistical reviews, consideration of contemporary statistical methods, and their associations with time to journal receipt of authors' revision.
METHODS
An initial set of statistical themes was created using the statistical editor's notes. For example, for the statistical theme of "CONSORT checklist," the search term needed was "CONSORT." A complete (exhaustive) list of additional themes was obtained inductively.
RESULTS
Among the 273 subsequent reviews for manuscripts that were ultimately accepted, the number of paragraphs that included a theme of a statistical method was only weakly associated with longer revision times (Kendall τ = 0.139 ± 0.039, P = 0.0004). Among the total 3274 paragraphs of statistical reviews, 72.2% did not include a theme of a statistical method (e.g., the editor instead asked the authors to clarify what statistical method had been used) (95% confidence interval [CI] = 70.6%-73.7%, P < 0.0001 versus 50%).Among the 207 manuscripts with a review that included a statistical method, 47.3% included a contemporary topic (e.g., generalized pivotal methods) (95% CI = 40.4%-54.4%). However, among the 911 corresponding paragraphs of statistical review comments, only 16.0% included a contemporary theme (95% CI = 13.7%-18.6%).
CONCLUSIONS
The revised versions of patient safety articles, which are eventually to be accepted for publication, have many statistical limitations especially in the reporting (writing) of basic statistical methods and results. The results suggest a need for education of patient safety investigators to include statistical writing.
Topics: Evaluation Studies as Topic; Humans; Patient Safety; Periodicals as Topic
PubMed: 28590949
DOI: 10.1097/PTS.0000000000000391 -
Journal of Nursing Management Oct 2014
Topics: Humans; Patient Care; Patient Safety; Treatment Outcome
PubMed: 25298048
DOI: 10.1111/jonm.12263