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Uramatsu M, Kimura N, Kojima T, Fujisawa Y, Oto T, Barach P. Frontline nursing staff's perceptions of intravenous medication administration: the first step toward safer infusion processes-a qualitative study. BMJ Open Qual 2024; 13:e002809. [PMID: 38942437 PMCID: PMC11216072 DOI: 10.1136/bmjoq-2024-002809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/30/2024] [Indexed: 06/30/2024] Open
Abstract
OBJECTIVES Intravenous medication errors continue to significantly impact patient safety and outcomes. This study sought to clarify the complexity and risks of the intravenous administration process. DESIGN A qualitative focus group interview study. SETTING Focused interviews were conducted using process mapping with frontline nurses responsible for medication administration in September 2020. PARTICIPANTS Front line experiened nurses from a Japanese tertiary teaching hospital. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measure was to identify the mental models frontline nurses used during intravenous medication administration, which influence their interactions with patients, and secondarily, to examine the medication process gaps between the mental models nurses perceive and the actual defined medication administration process. RESULTS We found gaps between the perceived clinical administration process and the real process challenges with an emphasis on the importance of verifying to see if the drug was ordered for the patient immediately before its administration. CONCLUSIONS This novel and applied improvement approach can help nurses and managers better understand the process vulnerability of the infusion process and develop a deeper understanding of the administration steps useful for reliably improving the safety of intravenous medications.
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Affiliation(s)
| | - Naoko Kimura
- Tokyo Medical University Hospital, Shinjuku-ku, Japan
| | | | - Yoshikazu Fujisawa
- Department of Quality and Patient Safety, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Tomoko Oto
- Tokyo Medical University, Shinjuku-ku, Japan
| | - Paul Barach
- Jefferson College of Population Health, Philadelphia, Pennsylvania, USA
- School of Medicine, Sigmund Freud University, Vienna, Austria
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Koch A, Schlenker B, Becker A, Weigl M. Operating room team strategies to reduce flow disruptions in high-risk task episodes: resilience in robot-assisted surgery. ERGONOMICS 2022:1-14. [PMID: 36285451 DOI: 10.1080/00140139.2022.2136406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 10/10/2022] [Indexed: 06/16/2023]
Abstract
In healthcare work settings, flow disruptions (FDs) pose a potential threat to patient safety. Resilience research suggests that adaptive behavioural strategies contribute to preventing cognitive overload through FDs at crucial moments. We aimed to explore the nature and efficacy of operating room (OR) team strategies to prevent FDs in robot-assisted surgery. Within a mixed-methods design, we first asked surgical professionals, which strategies they apply, and secondly, identified behavioural strategies through direct observations. Findings were analysed using content analysis. Additionally, FDs were assessed through live observations in the OR. The sample included four interviewed experts and 15 observed surgical cases. Sixty originally received strategies were synthesised into 17 final OR team strategies. Overall, 658 FDs were observed with external FDs being the most frequent. During high-risk episodes, FDs were significantly reduced (p < 0.0001). The identified strategies reveal how OR teams deliberatively and dynamically manage and mitigate FDs during critical tasks. Our findings contribute to a nuanced understanding of adaptive strategies to safeguard performance in robot surgery services. Practitioner Summary: Flow disruptions (FDs) in surgical work may become a severe safety threat during high-risk situations. With interviews and observations, we explored team strategies applied to prevent FDs in critical moments. We obtained a comprehensive list of behavioural strategies and found that FDs were significantly reduced during a specific high-risk surgical task. Our findings emphasise the role of providers' and teams' adaptive capabilities to manage workflow in high-technology care environments.
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Affiliation(s)
- Amelie Koch
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU, Munich, Germany
- Institute for Patient Safety, University Hospital, University of Bonn, Bonn, Germany
| | - Boris Schlenker
- Department of Urology, University Hospital, LMU, Munich, Germany
| | - Armin Becker
- Department of Urology, University Hospital, LMU, Munich, Germany
| | - Matthias Weigl
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU, Munich, Germany
- Institute for Patient Safety, University Hospital, University of Bonn, Bonn, Germany
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Application of the Structure Function in the Evaluation of the Human Factor in Healthcare. Symmetry (Basel) 2020. [DOI: 10.3390/sym12010093] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
A structure function is one of the possible mathematical models of systems in reliability engineering. A structure function maps sets of component states into system performance levels. Methods of system reliability evaluation based on structure function representation are well established. A structure function can be formed based on completely specified data about system behavior. Such data for most real-world systems are incomplete and uncertain. The typical example is analysis and evaluation of the human factor. Therefore, the structure function is not used in human reliability analysis (HRA) typically. In this paper, a method for structure function construction is proposed based on incomplete and uncertain data in HRA. The proposed method application is considered for healthcare to evaluate medical error. This method is developed using a fuzzy decision tree (FDT), which allows all possible component states to be classified into classes of system performance levels. The structure function is constructed based on the decision table, which is formed according to the FDT. A case study for this method is considered by evaluating the human factor in healthcare: complications in the familiarization and exploitation of a new device in a hospital department are analyzed and evaluated. This evaluation shows the decreasing of medical errors in diagnosis after one year of device exploitation and a slight decrease in quality of diagnosis after two months of device exploitation. Numerical values of probabilities of medical error are calculated based on the proposed approach.
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Abuosi AA, Akologo A, Anaba EA. Determinants of patient safety culture among healthcare providers in the Upper East Region of Ghana. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2019. [DOI: 10.1177/2516043519876756] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Aaron A Abuosi
- Department of Public Administration and Health Services Management, University of Ghana Business School, Accra, Ghana
| | - Alexander Akologo
- Department of Public Administration and Health Services Management, University of Ghana Business School, Accra, Ghana
| | - Emmanuel A Anaba
- Department of Public Administration and Health Services Management, University of Ghana Business School, Accra, Ghana
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Akologo A, Abuosi AA, Anaba EA. A cross-sectional survey on patient safety culture among healthcare providers in the Upper East region of Ghana. PLoS One 2019; 14:e0221208. [PMID: 31430303 PMCID: PMC6701748 DOI: 10.1371/journal.pone.0221208] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 08/01/2019] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Adverse events pose a serious threat to quality patient care. Promoting a culture of safety is essential for reducing adverse events. This study aims to assess healthcare providers' perceptions of patient safety culture in three selected hospitals in the Upper East region of Ghana. METHODS The English version of the Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire was administered to 406 clinical staff. Statistical Package for Social Science (SPSS) software, version 23, was used to analyze the data. The results were presented using descriptive statistics, Pearson Correlation Analysis and One-way Analysis of Variance (ANOVA). RESULTS It was found that two out of twelve patient safety culture dimensions recorded high positive response rates (≥ 70%). These include teamwork within units (81.5%) and organizational learning (73.1%). Three patient safety culture dimensions (i.e. staffing, non-punitive response to error and frequency of events reported) recorded low positive response rates (≤ 50%). The overall perception of patient safety correlated significantly with all patient safety culture dimensions, except staffing. There was no statistically significant difference in the overall perception of patient safety among the three hospitals. CONCLUSION Generally, healthcare providers in this study perceived patient safety culture in their units as quite good. Some of the respondents perceived punitive response to errors. Going forward, healthcare policy-makers and managers should make patient safety culture a top priority. The managers should consider creating a 'blame-free' environment to promote adverse event reporting in the hospitals.
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Affiliation(s)
- Alexander Akologo
- Department of Public Administration and Health Services Management, University of Ghana Business School, Legon, Accra, Ghana
| | - Aaron Asibi Abuosi
- Department of Public Administration and Health Services Management, University of Ghana Business School, Legon, Accra, Ghana
| | - Emmanuel Anongeba Anaba
- Department of Public Administration and Health Services Management, University of Ghana Business School, Legon, Accra, Ghana
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Keller S, Tschan F, Semmer NK, Holzer E, Candinas D, Brink M, Beldi G. Noise in the Operating Room Distracts Members of the Surgical Team. An Observational Study. World J Surg 2018; 42:3880-3887. [DOI: 10.1007/s00268-018-4730-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Measuring and improving comprehensive pediatric cardiac care: Learning from continuous quality improvement methods and tools. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Horwitz SK, Horwitz IB. The effects of organizational commitment and structural empowerment on patient safety culture. J Health Organ Manag 2017; 31:10-27. [PMID: 28260410 DOI: 10.1108/jhom-07-2016-0150] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The purpose of this paper is to investigate the relationship between patient safety culture and two attitudinal constructs: affective organizational commitment and structural empowerment. In doing so, the main and interaction effects of the two constructs on the perception of patient safety culture were assessed using a cohort of physicians. Design/methodology/approach Affective commitment was measured with the Organizational Commitment Questionnaire, whereas structural empowerment was assessed with the Conditions of Work Effectiveness Questionnaire-II. The abbreviated versions of these surveys were administered to a cohort of 71 post-doctoral medical residents. For the data analysis, hierarchical regression analyses were performed for the main and interaction effects of affective commitment and structural empowerment on the perception of patient safety culture. Findings A total of 63 surveys were analyzed. The results revealed that both affective commitment and structural empowerment were positively related to patient safety culture. A potential interaction effect of the two attitudinal constructs on patient safety culture was tested but no such effect was detected. Research limitations/implications This study suggests that there are potential benefits of promoting affective commitment and structural empowerment for patient safety culture in health care organizations. By identifying the positive associations between the two constructs and patient safety culture, this study provides additional empirical support for Kanter's theoretical tenet that structural and organizational support together helps to shape the perceptions of patient safety culture. Originality/value Despite the wide recognition of employee empowerment and commitment in organizational research, there has still been a paucity of empirical studies specifically assessing their effects on patient safety culture in health care organizations. To the authors' knowledge, this study is the first empirical study to examine the relationship between structural empowerment as proposed by Kanter and the culture of patient safety using physicians.
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Affiliation(s)
- Sujin K Horwitz
- Cameron School of Business, University of St Thomas , Houston, Texas, USA
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Wright J, Lawton R, O’Hara J, Armitage G, Sheard L, Marsh C, Grange A, McEachan RRC, Cocks K, Hrisos S, Thomson R, Jha V, Thorp L, Conway M, Gulab A, Walsh P, Watt I. Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04150] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BackgroundEstimates suggest that, in NHS hospitals, incidents causing harm to patients occur in 10% of admissions, with costs to the NHS of > £2B. About one-third of harmful events are believed to be preventable. Strategies to reduce patient safety incidents (PSIs) have mostly focused on changing systems of care and professional behaviour, with the role that patients can play in enhancing the safety of care being relatively unexplored. However, although the role and effectiveness of patient involvement in safety initiatives is unclear, previous work has identified a general willingness among patients to contribute to initiatives to improve health-care safety.AimOur aim in this programme was to design, develop and evaluate four innovative approaches to engage patients in preventing PSIs: assessing risk, reporting incidents, direct engagement in preventing harm and education and training.Methods and resultsWe developed tools to report PSIs [patient incident reporting tool (PIRT)] and provide feedback on factors that might contribute to PSIs in the future [Patient Measure of Safety (PMOS)]. These were combined into a single instrument and evaluated in the Patient Reporting and Action for a Safe Environment (PRASE) intervention using a randomised design. Although take-up of the intervention by, and retention of, participating hospital wards was 100% and patient participation was high at 86%, compliance with the intervention, particularly the implementation of action plans, was poor. We found no significant effect of the intervention on outcomes at 6 or 12 months. The ThinkSAFE project involved the development and evaluation of an intervention to support patients to directly engage with health-care staff to enhance their safety through strategies such as checking their care and speaking up to staff if they had any concerns. The piloting of ThinkSAFE showed that the approach is feasible and acceptable to users and may have the potential to improve patient safety. We also developed a patient safety training programme for junior doctors based on patients who had experienced PSIs recounting their own stories. This approach was compared with traditional methods of patient safety teaching in a randomised controlled trial. The study showed that delivering patient safety training based on patient narratives is feasible and had an effect on emotional engagement and learning about communication. However, there was no effect on changing general attitudes to safety compared with the control.ConclusionThis research programme has developed a number of novel interventions to engage patients in preventing PSIs and protecting them against unintended harm. In our evaluations of these interventions we have been unable to demonstrate any improvement in patient safety although this conclusion comes with a number of caveats, mainly about the difficulty of measuring patient safety outcomes. Reflecting this difficulty, one of our recommendations for future research is to develop reliable and valid measures to help efficiently evaluate safety improvement interventions. The programme found patients to be willing to codesign, coproduce and participate in initiatives to prevent PSIs and the approaches used were feasible and acceptable. These factors together with recent calls to strengthen the patient voice in health care could suggest that the tools and interventions from this programme would benefit from further development and evaluation.Trial registrationCurrent Controlled Trials ISRCTN07689702.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- John Wright
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Rebecca Lawton
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
- School of Psychology, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Jane O’Hara
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
- Leeds Institute of Medical Education, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Gerry Armitage
- Faculty of Health Studies, University of Bradford, Bradford, UK
| | - Laura Sheard
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Claire Marsh
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Angela Grange
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Rosemary RC McEachan
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Kim Cocks
- York Trials Unit, University of York, York, UK
| | - Susan Hrisos
- Institute of Health & Society, University of Newcastle, Newcastle, UK
| | - Richard Thomson
- Institute of Health & Society, University of Newcastle, Newcastle, UK
| | - Vikram Jha
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Liz Thorp
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | | | - Peter Walsh
- Action against Medical Accidents, Croydon, UK
| | - Ian Watt
- Department of Health Sciences, University of York, York, UK
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Abstract
A research agenda for investigating the impact of team-work training on patient safety in the perioperative environment is presented. The current status of teamwork training is reviewed briefly, and conclusions based on existing research are presented. We present a roadmap for future research on how teamwork training should be structured, delivered, and evaluated to optimize patient safety in the operating room. For teamwork skills to be assessed and have credibility, team performance measures must be grounded in team theory, account for individual and team-level performance, capture team process and outcomes, adhere to standards for reliability and validity, and address real or perceived barriers to measurement. The interdisciplinary nature of work in the perioperative environment and the necessity of cooperation among team members play an important role in enabling patient safety and avoiding errors. Teams make fewer mistakes than do individuals, especially when each team member knows his or her responsibilities, as well as those of other team members. However, simply installing a team structure without addressing the organizational context of care—the culture—does not automatically ensure it will operate effectively. Factors associated with the design of teamwork training, measures of training effectiveness, and the assessment process that should be explored in near-term work (1 to 2 years) are addressed. We also address the impact of the organizational environment, including the role of institutional support and culture, that need to be explored in longer term research (3 to 5 years).
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Patient Safety Science in Cardiothoracic Surgery: An Overview. Ann Thorac Surg 2016; 101:426-33. [DOI: 10.1016/j.athoracsur.2015.12.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 12/15/2015] [Accepted: 12/15/2015] [Indexed: 11/21/2022]
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Higginbottom GMA, Safipour J, Yohani S, O'Brien B, Mumtaz Z, Paton P. An ethnographic study of communication challenges in maternity care for immigrant women in rural Alberta. Midwifery 2014; 31:297-304. [PMID: 25451546 DOI: 10.1016/j.midw.2014.09.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 09/03/2014] [Accepted: 09/27/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND many immigrant and ethno-cultural groups in Canada face substantial barriers to accessing health care including language barriers. The negative consequences of miscommunication in health care settings are well documented although there has been little research on communication barriers facing immigrant women seeking maternity care in Canada. This study identified the nature of communication difficulties in maternity services from the perspectives of immigrant women, health care providers and social service providers in a small city in southern Alberta, Canada. METHODS a focused ethnography was undertaken incorporating interviews with 31 participants recruited using purposive and snowball sampling. A community liaison and several gatekeepers within the community assisted with recruitment and interpretation where needed (n=1). All interviews were recorded and audio files were transcribed verbatim by a professional transcriptionist. The data was analysed drawing upon principles expounded by Roper and Shapira (2000) for the analysis of ethnographic data, because of (1) the relevance to ethnographic data, (2) the clarity and transparency of the approach, (3) the systematic approach to analysis, and (4) the compatibility of the approach with computer-assisted qualitative analysis software programs such as Atlas.ti (ATLAS.ti Scientific Software Development GmbH, Germany). This process included (1) coding for descriptive labels, (2) sorting for patterns, (3) identification of outliers, (4) generation of themes, (5) generalising to generate constructs and theories, and (6) memoing including researcher reflections. FINDINGS four main themes were identified including verbal communication, unshared meaning, non-verbal communication to build relationships, and trauma, culture and open communication. Communication difficulties extended beyond matters of language competency to those encompassing non-verbal communication and its relation to shared meaning as well as the interplay of underlying pre-migration history and cultural factors which affect open communication, accessible health care and perhaps also maternal outcomes. CONCLUSION this study provided insights regarding maternity health care communication. Communication challenges may be experienced by all parties, yet the onus remains for health care providers and for those within health care management and professional bodies to ensure that providers are equipped with the skills necessary to facilitate culturally appropriate care.
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Affiliation(s)
- Gina M A Higginbottom
- Faculty of Nursing, University of Alberta, 3rd Floor Edmonton Clinic Health Academy, 11405 87th Avenue, Edmonton, Canada T6G 1C9.
| | - Jalal Safipour
- Department of Health and Caring Sciences, Linnaeus University, Building: K 2244, 35195 Växjö, Sweden.
| | - Sophie Yohani
- Department of Educational Psychology, University of Alberta, 6-107D Education North, Edmonton, Canada T6G 2G5.
| | - Beverley O'Brien
- Faculty of Nursing, University of Alberta, 3rd Floor Edmonton Clinic Health Academy, 11405 87th Avenue, Edmonton, Canada T6G 1C9.
| | - Zubia Mumtaz
- School of Public Health, University of Alberta, Edmonton, Canada, 3rd Floor Edmonton Clinic Health Academy, 11405 87th Avenue, Edmonton, Canada T6G 1C9.
| | - Patricia Paton
- Alberta Health Services, Seventh Street Plaza 10030-107 Street NW, Edmonton, Canada T5J 3E4.
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Abstract
Buist and Middleton lament that the safety and quality 'agenda' has failed to fundamentally alter the safety of healthcare systems, in part because of the disengagement of doctors from their responsibilities for patient safety . While there have been discernable improvements in the efficiency and effectiveness of care in some settings, patients still experience unacceptable harm and often struggle to have their voices heard; processes are not as efficient as they could be; and costs continue to rise at alarming rates while quality issues remain . Perhaps of most concern, recent public reports into health system failures continue to document a widespread lack of attentiveness to patient concerns, a culture of denial and widespread lack of professionalism . Alarmingly, clinician discontentment, cynicism and burn-out are reflected in antagonistic language by clinicians about the healthcare system and their patients. Taken together with the many dissatisfied and now more vocal patient groups, all point to an unprecedented crisis of faith in our healthcare systems which has been getting worse over past decade . This personal perspective aims to address the fundamental tensions that are keeping much of healthcare reform efforts from successfully transforming the culture and outcomes except at the margins.
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Affiliation(s)
- G Phelps
- Deakin University Medical School, Melbourne, Australia.
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Santos R, Bakero L, Franco P, Alves C, Fragata I, Fragata J. Characterization of non-technical skills in paediatric cardiac surgery: communication patterns. Eur J Cardiothorac Surg 2012; 41:1005-12; discussion 1012. [DOI: 10.1093/ejcts/ezs068] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Cassin BR, Barach PR. Making sense of root cause analysis investigations of surgery-related adverse events. Surg Clin North Am 2012; 92:101-15. [PMID: 22269264 DOI: 10.1016/j.suc.2011.12.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article discusses the limitations of root cause analysis (RCA) for surgical adverse events. Making sense of adverse events involves an appreciation of the unique features in a problematic situation, which resist generalization to other contexts. The top priority of adverse event investigations must be to inform the design of systems that help clinicians to adapt and respond effectively in real time to undesirable combinations of design, performance, and circumstance. RCAs can create opportunities in the clinical workplace for clinicians to reflect on local barriers and identify enablers of safe and reliable outcomes.
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Affiliation(s)
- Bryce R Cassin
- University of Western Sydney, School of Nursing and Midwifery, Locked Bag 1797, Penrith South DC, New South Wales 1797, Australia.
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Caplan L, Vener DF. Databases and Outcomes in Congenital Cardiac Anesthesia. World J Pediatr Congenit Heart Surg 2011; 2:586-92. [DOI: 10.1177/2150135111410993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Anesthesia practitioners have long been at the forefront of patient safety initiatives in the operating room and beyond. The Congenital Cardiac Anesthesia Society has partnered with the Society of Thoracic Surgeons Congenital Heart Surgery Database to develop a patient registry for patients with congenital heart defects in order to determine patient outcomes related to anesthesia in this high-risk population. A review of existing database efforts is also undertaken to determine their strengths and weaknesses.
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Affiliation(s)
- Lisa Caplan
- Department of Pediatrics and Anesthesia, Pediatric Cardiovascular Anesthesia Section, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | - David F. Vener
- Department of Pediatrics and Anesthesia, Pediatric Cardiovascular Anesthesia Section, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
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Wiegmann DA, Eggman AA, Elbardissi AW, Parker SH, Sundt TM. Improving cardiac surgical care: a work systems approach. APPLIED ERGONOMICS 2010; 41:701-12. [PMID: 20202623 PMCID: PMC2879339 DOI: 10.1016/j.apergo.2009.12.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2008] [Accepted: 09/30/2009] [Indexed: 05/11/2023]
Abstract
Over the past 50 years, significant improvements in cardiac surgical care have been achieved. Nevertheless, surgical errors that significantly impact patient safety continue to occur. In order to further improve surgical outcomes, patient safety programs must focus on rectifying work system factors in the operating room (OR) that negatively impact the delivery of reliable surgical care. The goal of this paper is to provide an integrative review of specific work system factors in the OR that may directly impact surgical care processes, as well as the subsequent recommendations that have been put forth to improve surgical outcomes and patient safety. The important role that surgeons can play in facilitating work system changes in the OR is also discussed. The paper concludes with a discussion of the challenges involved in assessing the impact that interventions have on improving surgical care. Opportunities for future research are also highlighted throughout the paper.
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Affiliation(s)
- Douglas A Wiegmann
- Department of Industrial and Systems Engineering, 1513 University Ave, 3214 Mechanical Engineering Bldg, University of Wisconsin-Madison, Madison, WI 53706, USA.
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The nomenclature of safety and quality of care for patients with congenital cardiac disease: a report of the Society of Thoracic Surgeons Congenital Database Taskforce Subcommittee on Patient Safety. Cardiol Young 2008; 18 Suppl 2:81-91. [PMID: 19063778 PMCID: PMC4242417 DOI: 10.1017/s1047951108003041] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
A large body of literature devoted to "patient safety" and error prevention exists and utilizes a nomenclature that can be applied specifically to the field of congenital cardiac disease and aid in the goals of increasing the safety of patients, decreasing medical error, minimizing mortality and morbidity, and evaluating quality of care. The purpose of this manuscript is to suggest and document a quality of health care taxonomy and the appropriate application of this nomenclature of "patient safety" to the specialty of congenital cardiac disease, with special emphasis on the following ten terms: morbidity, complication, medical error, adverse event, harm, near miss, iatrogenesis, iatrogenic complication, medical injury, and sentinel event. Each of these terms is commonly utilized in the medical literature without universal agreement on their meaning and relationship. It is our hope that the standardization of the definitions of these terms, as they are applied to the analysis of outcomes of the treatments applied to patients with congenital and paediatric cardiac disease, will facilitate improved methodologies to assess and improve quality of care in our profession.
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Anaesthetic complications associated with the treatment of patients with congenital cardiac disease: consensus definitions from the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease. Cardiol Young 2008; 18 Suppl 2:271-81. [PMID: 19063802 DOI: 10.1017/s104795110800303x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Congenital heart defects are the most common cause of death in infants and young children in the developed world. As the mortality in this population has declined to less than 5%, more attention is being focused now on reducing post-procedural morbidities that may seriously impact the patient and their families. Because of multiple reasons, paediatric cardiac surgery and anaesthesia is a perfect model for studying human errors and their impact on patient safety. Congenital cardiac disease is a common lesion causing much morbidity, pain, and loss of life. Over 44,000 surgical procedures are performed yearly to repair congenital cardiac problems in the United States alone. The reduction or elimination of iatrogenic adverse outcomes, given the current mortality rates of 4.2%-4.5%, might lead to as many as 500 children achieving better outcomes or shorter hospitalizations.Efforts to quantify the frequency of complications related to anaesthesia in patients undergoing congenital cardiac surgery have been difficult to date because of the low occurrence of this surgery compared to other surgeries on children and the relatively rare incidence of complications related to anaesthesia in this population. Anaesthesiologists play a crucial role in the reduction, recognition, and timely treatment of medical errors that impact this morbidity. Paediatric cardiac surgery encompasses many complex procedures that are highly dependent upon a sophisticated organizational structure, effective communication, coordinated efforts of multiple individuals working as a team, and high levels of cognitive and technical performance. Human factor error analysis in this patient population has shown how frequently both minor and major errors occur. The goal of this paper is to outline the frequency and sources of these errors and to suggest treatment strategies which may minimize their occurrence.
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Barach P, Johnson JK, Ahmad A, Galvan C, Bognar A, Duncan R, Starr JP, Bacha EA. A prospective observational study of human factors, adverse events, and patient outcomes in surgery for pediatric cardiac disease. J Thorac Cardiovasc Surg 2008; 136:1422-8. [DOI: 10.1016/j.jtcvs.2008.03.071] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2008] [Revised: 02/26/2008] [Accepted: 03/23/2008] [Indexed: 10/21/2022]
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Cardiac complications associated with the treatment of patients with congenital cardiac disease: consensus definitions from the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease. Cardiol Young 2008; 18 Suppl 2:196-201. [PMID: 19063791 DOI: 10.1017/s1047951108002928] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
A complication is an event or occurrence that is associated with a disease or a healthcare intervention, is a departure from the desired course of events, and may cause, or be associated with, suboptimal outcome. A complication does not necessarily represent a breech in the standard of care that constitutes medical negligence or medical malpractice. An operative or procedural complication is any complication, regardless of cause, occurring (1) within 30 days after surgery or intervention in or out of the hospital, or (2) after 30 days during the same hospitalization subsequent to the operation or intervention. Operative and procedural complications include both intraoperative/intraprocedural complications and postoperative/postprocedural complications in this time interval. The MultiSocietal Database Committee for Pediatric and Congenital Heart Disease has set forth a comprehensive list of complications associated with the treatment of patients with congenital cardiac disease, related to cardiac, pulmonary, renal, haematological, infectious, neurological, gastrointestinal, and endocrinal systems, as well as those related to the management of anaesthesia and perfusion, and the transplantation of thoracic organs. The objective of this manuscript is to examine the definitions of operative morbidity as they relate specifically to the cardiac system. These specific definitions and terms will be used to track morbidity associated with surgical and transcatheter interventions and other forms of therapy in a common language across many separate databases.The MultiSocietal Database Committee for Pediatric and Congenital Heart Disease has prepared and defined a near-exhaustive list of cardiac complications, including intraoperative complications and cardiopulmonary bypass-related complications. These cardiac complications are presented in the following subgroups: 1) Cardiac (general), 2) Cardiac--Metabolic, 3) Cardiac--Residual and Recurrent cardiac lesions, 4) Arrhythmia, 5) Cardiopulmonary bypass and mechanical circulatory support, and 6) Operative/Procedural. Within each subgroup, complications are presented in alphabetical order. Clinicians caring for patients with congenital cardiac disease will be able to use this list for databases, quality improvement initiatives, reporting of complications, and comparing strategies for treatment.
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Bognár A, Barach P, Johnson JK, Duncan RC, Birnbach D, Woods D, Holl JL, Bacha EA. Errors and the Burden of Errors: Attitudes, Perceptions, and the Culture of Safety in Pediatric Cardiac Surgical Teams. Ann Thorac Surg 2008; 85:1374-81. [DOI: 10.1016/j.athoracsur.2007.11.024] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 11/07/2007] [Accepted: 11/09/2007] [Indexed: 10/22/2022]
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Bacha EA. Patient safety and human factors in pediatric cardiac surgery. Pediatr Cardiol 2007; 28:116-21. [PMID: 17487540 DOI: 10.1007/s00246-006-1448-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2006] [Accepted: 09/05/2006] [Indexed: 12/01/2022]
Abstract
The patient safety movement and human factors studies are becoming an increasingly important part of everyday clinical practice. Pediatric cardiac surgery is a high-risk field that is very much dependent on safe practices and continuous research into improvement of outcomes. This article reviews the main research frameworks, methods used, and current findings in the area of patient safety and human factors within pediatric cardiac surgery.
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Affiliation(s)
- Emile A Bacha
- Harvard Medical School and Cardiac Surgery, Children's Hospital Boston, 300 Longwood Avenue, Bader 273, Boston, MA 02115, USA.
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Realizing optimal care for children with cardiovascular disease: Funding challenges and research approaches. PROGRESS IN PEDIATRIC CARDIOLOGY 2005. [DOI: 10.1016/j.ppedcard.2005.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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