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Revista Brasileira de Enfermagem 2020to report the development and implementation of a digital tool developed by a group of nurses and information technology professionals working in healthcare quality...
OBJECTIVES
to report the development and implementation of a digital tool developed by a group of nurses and information technology professionals working in healthcare quality management.
METHODS
an experience report regarding the development of the Safety Huddle digital model, using the agile Scrum methodology.
RESULTS
the first stage was the development of the model proposed by the team of nurses and IT professionals, based on the demand of quality and patient safety leaders in Brazil, and the second phase was the software implementation.
FINAL CONSIDERATIONS
the development and implementation of the Safety Huddle contributed to expedite the detection and distribution of actions, in addition to promoting integration among teams, accountability, and empowerment of professionals to foresee and identify issues related to patient safety and face them through action plans.
Topics: Brazil; Humans; Patient Care Team; Patient Safety; Software
PubMed: 33338149
DOI: 10.1590/0034-7167-2019-0788 -
The Journal of Extra-corporeal... Dec 2016
Topics: Humans; Patient Safety
PubMed: 27994263
DOI: No ID Found -
International Journal of Medical... Aug 2020Various healthcare stakeholders define quality of care in different ways. Public policy could advocate all these concerns. This study was conducted to identify the main... (Observational Study)
Observational Study
OBJECTIVES
Various healthcare stakeholders define quality of care in different ways. Public policy could advocate all these concerns. This study was conducted to identify the main themes on patient safety of stakeholders expressed before and after the Patient Safety Act was enacted in Korea in 2015.
DESIGN
Longitudinal observational study of the interests of healthcare stakeholders generated between January 2014 and September 2018.
MATERIALS AND METHODS
Text data were collected from 2,487 documents on 18 websites that were identified as representative healthcare stakeholder groups of consumers, providers, government, and researchers. A Korean natural language processing (NLP) package, manual review, and synonym dictionary were used for data preprocessing, and we adopted the unsupervised NLP method of probabilistic topic modeling and latent Dirichlet allocation. A linear trend analysis over time, a qualitative step involving two external experts, and original text reviews were performed to validate the identified topics.
RESULTS
Forty-one topics were identified, and the most common concerns of stakeholders were institutional infection control as triggered by the Middle East respiratory syndrome outbreak in early 2015, and infusion-related infection from late 2017 until the middle of 2018. The other top-three concerns of the stakeholder groups were highly similar, while research topics were limited to the perceptions of providers and the activities and culture of hospitals. Five topics showed statistically significant increasing trends over time, while another five showed decreasing trends (both P < 0.05). In the qualitative step, we confirmed 35 themes and revised the other 6.
CONCLUSIONS
A common concern among stakeholders was hospital infection control, ranging from nosocomial infections to those brought in by family visiting patients. Government policies and systemic approaches to patient safety were highlighted by different stakeholders. Researchers were focused on hospital sociocultural factors at both the organizational and clinician levels. These identified concerns all should be advocated by the public health policy.
Topics: Government; Health Services; Hospitals; Humans; Internet; Longitudinal Studies; Natural Language Processing; Patient Safety; Quality Improvement; Republic of Korea; Research Design
PubMed: 32416430
DOI: 10.1016/j.ijmedinf.2020.104162 -
Journal of the Royal Society of Medicine Dec 2021Six per cent of hospital patients experience a patient safety incident, of which 12% result in severe/fatal outcomes. Acutely sick patients are at heightened risk. Our...
OBJECTIVE
Six per cent of hospital patients experience a patient safety incident, of which 12% result in severe/fatal outcomes. Acutely sick patients are at heightened risk. Our aim was to identify the most frequently reported incidents in acute medical units and their characteristics.
DESIGN
Retrospective mixed methods methodology: (1) an a priori coding process, applying a multi-axial coding framework to incident reports; and, (2) a thematic interpretative analysis of reports.
SETTING
Patient safety incident reports (10 years, 2005-2015) collected from the National Reporting and Learning System, which receives reports from hospitals and other care settings across England and Wales.
PARTICIPANTS
Reports describing severe harm/death in acute medical unit were identified.
MAIN OUTCOME MEASURES
Incident type, contributory factors, outcomes and level of harm were identified in the included reports. During thematic analysis, themes and metathemes were synthesised to inform priorities for quality improvement.
RESULTS
A total of 377 reports of severe harm or death were confirmed. The most common incident types were diagnostic errors ( = 79), medication-related errors ( = 61), and failures monitoring patients ( = 57). Incidents commonly stemmed from lack of active decision-making during patient admissions and communication failures between teams. Patients were at heightened risk of unsafe care during handovers and transfers of care. Metathemes included the necessity of patient self-advocacy and a lack of care coordination.
CONCLUSION
This 10-year national analysis of incident reports provides recommendations to improve patient safety including: introduction of electronic prescribing and monitoring systems; forcing checklists to reduce diagnostic errors; and increased senior presence overnight and at weekends.
Topics: Acute Disease; Diagnostic Errors; England; Hospitals; Humans; Medication Errors; Monitoring, Physiologic; Patient Harm; Patient Safety; Patient Transfer; Quality Improvement; Retrospective Studies; Safety Management; Wales
PubMed: 34348052
DOI: 10.1177/01410768211032589 -
Annals of Internal Medicine Mar 2013Missed, delayed, or incorrect diagnosis can lead to inappropriate patient care, poor patient outcomes, and increased cost. This systematic review analyzed evaluations of... (Review)
Review
Missed, delayed, or incorrect diagnosis can lead to inappropriate patient care, poor patient outcomes, and increased cost. This systematic review analyzed evaluations of interventions to prevent diagnostic errors. Searches used MEDLINE (1966 to October 2012), the Agency for Healthcare Research and Quality's Patient Safety Network, bibliographies, and prior systematic reviews. Studies that evaluated any intervention to decrease diagnostic errors in any clinical setting and with any study design were eligible, provided that they addressed a patient-related outcome. Two independent reviewers extracted study data and rated study quality. There were 109 studies that addressed 1 or more intervention categories: personnel changes (n = 6), educational interventions (n = 11), technique (n = 23), structured process changes (n = 27), technology-based systems interventions (n = 32), and review methods (n = 38). Of 14 randomized trials, which were rated as having mostly low to moderate risk of bias, 11 reported interventions that reduced diagnostic errors. Evidence seemed strongest for technology-based systems (for example, text message alerting) and specific techniques (for example, testing equipment adaptations). Studies provided no information on harms, cost, or contextual application of interventions. Overall, the review showed a growing field of diagnostic error research and categorized and identified promising interventions that warrant evaluation in large studies across diverse settings.
Topics: Costs and Cost Analysis; Diagnostic Errors; Health Facility Administration; Humans; Organizational Objectives; Outcome Assessment, Health Care; Patient Safety; Randomized Controlled Trials as Topic; Safety Management; Text Messaging
PubMed: 23460094
DOI: 10.7326/0003-4819-158-5-201303051-00004 -
The Permanente Journal 2016The patient safety movement has been deeply affected by the stories patients have shared that have identified numerous opportunities for improvements in safety. These...
The patient safety movement has been deeply affected by the stories patients have shared that have identified numerous opportunities for improvements in safety. These stories have identified system and/or human inefficiencies or dysfunctions, possibly even failures, often resulting in patient harm. Although patients' stories tell us much, less commonly heard are the stories of clinicians and how their personal observations regarding the environments they work in and the circumstances and pressures under which they work may degrade patient safety and lead to harm.If the health care industry is to function like a high-reliability industry, to improve its processes and achieve the outcomes that patients rightly deserve, then leaders and managers must seek and value input from those on the front lines-both clinicians and patients. Stories from clinicians provided in this article address themes that include incident identification, disclosure and transparency, just culture, the impact of clinical workload pressures, human factors liabilities, clinicians as secondary victims, the impact of disruptive and punitive behaviors, factors affecting professional morale, and personal failings.
Topics: Anecdotes as Topic; Humans; Patient Participation; Patient Safety; Quality Improvement
PubMed: 26580146
DOI: 10.7812/TPP/15-039 -
GMS Journal For Medical Education 2019In final-year clerkships, such as the Practical Year in Germany, students' workplace learning has to be balanced with the ensuring of patient safety. In this...
In final-year clerkships, such as the Practical Year in Germany, students' workplace learning has to be balanced with the ensuring of patient safety. In this qualitative study, we investigated problems concerning patient safety as perceived from the perspective of supervising physicians, and whether and to what extent Entrustable Professional Activities (EPAs) can lead to an improvement in patient safety. Data was collected through focus groups. Participants were specialist physicians with experience of final-year clerkship training (n=11). The analysis of problems influencing patient safety was carried out deductively with an existing system of categories (error factors in the clinic). To identify potential improvements through EPAs, an inductively developed category system on the influence of EPAs in final-year clerkships was used. Supervising physicians perceive a variety of problems which affect patient safety. These can be found in the categories organization and management, individual factors, task factors and work environment. The physicians feel that EPAs may lead to an improvement in training and subsequently in patient safety. Their comments can be collated to the categories improvement in training, performance levels and supporting learning processes, transparency and minimizing uncertainty. Statements by supervising physicians indicate a variety of problems in patient safety during the training of final-year clerkship students, for instance the lack of structure to the training. In their view, the implementation of EPAs can substantially reduce such risks, as they provide better content and organizational structure to the final-year clerkship.
Topics: Clinical Clerkship; Clinical Competence; Focus Groups; Germany; Humans; Medical Errors; Patient Safety; Qualitative Research
PubMed: 30993176
DOI: 10.3205/zma001226 -
BMJ Open Quality May 2024Patient safety and healthcare quality are considered integral parts of the healthcare system that are driven by a dynamic combination of human and non-human factors.... (Review)
Review
BACKGROUND
Patient safety and healthcare quality are considered integral parts of the healthcare system that are driven by a dynamic combination of human and non-human factors. This review article provides an insight into the two major human factors that impact patient safety and quality including compassion and leadership. It also discusses how compassion is different from empathy and explores the impact of both compassion and leadership on patient safety and healthcare quality. In addition, this review also provides strategies for the improvement of patient safety and healthcare quality through compassion and effective leadership.
METHODS
This narrative review explores the existing literature on compassion and leadership and their combined impact on patient safety and healthcare quality. The literature for this purpose was gathered from published research articles, reports, recommendations and guidelines.
RESULTS
The findings from the literature suggest that both compassion and transformational leadership can create a positive culture where healthcare professionals (HCPs) prioritise patient safety and quality. Leaders who exhibit compassion are more likely to inspire their teams to deliver patient-centred care and focus on error prevention.
CONCLUSION
Compassion can become an antidote for the burnout of HCPs. Compassion is a behaviour that is not only inherited but can also be learnt. Both compassionate care and transformational leadership improve organisational culture, patient experience, patient engagement, outcomes and overall healthcare excellence. We propose that transformational leadership that reinforces compassion remarkably improves patient safety, patient engagement and quality.
Topics: Humans; Leadership; Empathy; Patient Safety; Quality of Health Care; Organizational Culture; Delivery of Health Care
PubMed: 38719520
DOI: 10.1136/bmjoq-2023-002651 -
BMJ Open Feb 2017To explore the status of patient safety culture in Arab countries based on the findings of the Hospital Survey on Patient Safety Culture (HSPSC). (Review)
Review
OBJECTIVES
To explore the status of patient safety culture in Arab countries based on the findings of the Hospital Survey on Patient Safety Culture (HSPSC).
DESIGN
Systematic review.
METHODS
We performed electronic searches of the MEDLINE, EMBASE, CINAHL, ProQuest and PsychINFO, Google Scholar and PubMed databases, with manual searches of bibliographies of included articles and key journals. We included studies that were conducted in the Arab countries that were focused on patient safety culture. 2 reviewers independently verified that the studies met the inclusion criteria and critically assessed the quality of the studies.
RESULTS
18 studies met our inclusion criteria. The review identified that non-punitive response to error is seen as a serious issue which needs to be improved. Healthcare professionals in the Arab countries tend to think that a 'culture of blame' still exists that prevents them from reporting incidents. We found an overall similarity between the reported composite score for dimension of teamwork within units in all of the reviewed studies. Teamwork within units was found to be better than teamwork across hospital units. All of the reviewed studies reported that organisational learning and continuous improvement was satisfactory as the average score of this dimension for all studies was 73.2%. Moreover, the review found that communication openness seems to be a concerning issue for healthcare professionals in the Arab countries.
CONCLUSIONS
There is a need to promote patient safety culture as a strategy for improving the patient safety in the Arab world. Improving patient safety culture should include all stakeholders, like policymakers, healthcare providers and those responsible for medical education. This review was limited only to English language publications. The varied settings in which the HSPSC was used may have influenced the areas of strengths and weaknesses as healthcare workers' perception of safety culture may differ.
Topics: Attitude of Health Personnel; Communication; Humans; Middle East; Organizational Culture; Patient Safety; Quality Improvement; Stakeholder Participation
PubMed: 28237956
DOI: 10.1136/bmjopen-2016-013487 -
JMIR MHealth and UHealth Apr 2019Patient verification by unique identification is an important procedure in health care settings. Risks to patient safety occur throughout health care settings by failure...
BACKGROUND
Patient verification by unique identification is an important procedure in health care settings. Risks to patient safety occur throughout health care settings by failure to correctly identify patients, resulting in the incorrect patient, incorrect site procedure, incorrect medication, and other errors. To avoid medical malpractice, radio-frequency identification (RFID), fingerprint scanners, iris scanners, and other technologies have been implemented in care settings. The drawbacks of these technologies include the possibility to lose the RFID bracelet, infection transmission, and impracticality when the patient is unconscious.
OBJECTIVE
The purpose of this study was to develop a mobile health app for patient identification to overcome the limitations of current patient identification alternatives. The development of this app is expected to provide an easy-to-use alternative method for patient identification.
METHODS
We have developed a facial recognition mobile app for improved patient verification. As an evaluation purpose, a total of 62 pediatric patients, including both outpatient and inpatient, were registered for the facial recognition test and tracked throughout the facilities for patient verification purpose.
RESULTS
The app was developed to contain 5 main parts: registration, medical records, examinations, prescriptions, and appointments. Among 62 patients, 30 were outpatients visiting plastic surgery department and 32 were inpatients reserved for surgery. Whether patients were under anesthesia or unconscious, facial recognition verified all patients with 99% accuracy even after a surgery.
CONCLUSIONS
It is possible to correctly identify both outpatients and inpatients and also reduce the unnecessary cost of patient verification by using the mobile facial recognition app with great accuracy. Our mobile app can provide valuable aid to patient verification, including when the patient is unconscious, as an alternative identification method.
Topics: Adolescent; Biometric Identification; Child; Child, Preschool; Facial Recognition; Female; Humans; Infant; Male; Mobile Applications; Patient Safety; Validation Studies as Topic; Young Adult
PubMed: 30958275
DOI: 10.2196/11472