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Williams SR, Sebok-Syer SS, Caretta-Weyer H, Katznelson L, Dohn AM, Park YS, Gisondi MA, Tekian A. Patient handoffs and multi-specialty trainee perspectives across an institution: informing recommendations for health systems and an expanded conceptual framework for handoffs. BMC MEDICAL EDUCATION 2023; 23:434. [PMID: 37312085 PMCID: PMC10262514 DOI: 10.1186/s12909-023-04355-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 05/12/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Safe and effective physician-to-physician patient handoffs are integral to patient safety. Unfortunately, poor handoffs continue to be a major cause of medical errors. Developing a better understanding of challenges faced by health care providers is critical to address this continued patient safety threat. This study addresses the gap in the literature exploring broad, cross-specialty trainee perspectives around handoffs and provides a set of trainee-informed recommendations for both training programs and institutions. METHODS Using a constructivist paradigm, the authors conducted a concurrent/embedded mixed method study to investigate trainees' experiences with patient handoffs across Stanford University Hospital, a large academic medical center. The authors designed and administered a survey instrument including Likert-style and open-ended questions to solicit information about trainee experiences from multiple specialties. The authors performed a thematic analysis of open-ended responses. RESULTS 687/1138 (60.4%) of residents and fellows responded to the survey, representing 46 training programs and over 30 specialties. There was wide variability in handoff content and process, most notably code status not being consistently mentioned a third of the time for patients who were not full code. Supervision and feedback about handoffs were inconsistently provided. Trainees identified multiple health-systems level issues that complicated handoffs and suggested solutions to these threats. Our thematic analysis identified five important aspects of handoffs: (1) handoff elements, (2) health-systems-level factors, (3) impact of the handoff, (4) agency (duty), and (5) blame and shame. CONCLUSIONS Health systems, interpersonal, and intrapersonal issues affect handoff communication. The authors propose an expanded theoretical framework for effective patient handoffs and provide a set of trainee-informed recommendations for training programs and sponsoring institutions. Cultural and health-systems issues must be prioritized and addressed, as an undercurrent of blame and shame permeates the clinical environment.
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Affiliation(s)
- Sarah R Williams
- Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Road, Suite 350, Palo Alto, CA, 94304, USA.
| | - Stefanie S Sebok-Syer
- Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Road, Suite 350, Palo Alto, CA, 94304, USA
| | - Holly Caretta-Weyer
- Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Road, Suite 350, Palo Alto, CA, 94304, USA
| | - Laurence Katznelson
- Departments of Neurosurgery and Medicine, Stanford University School of Medicine, Stanford, USA
- Graduate Medical Education, Stanford University School of Medicine and Stanford Health Care, Stanford, USA
| | - Ann M Dohn
- Graduate Medical Education, Stanford University School of Medicine and Stanford Health Care, Stanford, USA
| | - Yoon Soo Park
- Department of Medical Education, University of Illinois at Chicago College of Medicine, Chicago, USA
| | - Michael A Gisondi
- Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Road, Suite 350, Palo Alto, CA, 94304, USA
| | - Ara Tekian
- Department of Medical Education, University of Illinois at Chicago College of Medicine, Chicago, USA
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Oladiran A, Imediegwu K, Ezeh F, Yakubu M, Igwe O. Awareness of hazard risks and prevention among orthopaedic surgery residents in South East Nigeria. JOURNAL OF WEST AFRICAN COLLEGE OF SURGEONS 2022; 12:11-16. [PMID: 36203929 PMCID: PMC9531746 DOI: 10.4103/jwas.jwas_85_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/28/2022] [Indexed: 11/04/2022]
Abstract
Background: Objectives: Materials and Methods: Results: Conclusion: Recommendation:
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Cheng PF, Li DP, He JQ, Zhou XH, Wang JQ, Zhang HY. Evaluating Surgical Risk Using FMEA and MULTIMOORA Methods under a Single-Valued Trapezoidal Neutrosophic Environment. Risk Manag Healthc Policy 2020; 13:865-881. [PMID: 32801962 PMCID: PMC7384878 DOI: 10.2147/rmhp.s243331] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 06/23/2020] [Indexed: 12/03/2022] Open
Abstract
Background Human errors during operations may seriously threaten patient recovery and safety and affect the doctor–patient relationship. Therefore, risk evaluation of the surgical process is critical. Risk evaluation by failure mode and effect analysis (FMEA) is a prospective technology that can identify and evaluate potential failure modes in the surgical process to ensure surgical quality and patient safety. In this study, a hybrid surgical risk–evaluation model was proposed using FMEA and multiobjective optimization on the basis of ratio analysis plus full multiplicative form (MULTIMOORA) method under a single-valued trapezoidal neutrosophic environment. This work aimed to determine the most critical risk points during the surgical process and analyze corresponding solutions. Methods A team for FMEA was established from domain experts from different departments in a hospital in Hunan Province. Single-valued trapezoidal neutrosophic numbers (SVTNNs) were used to evaluate potential risk factors in the surgical process. Cmprehensive weights combining subjective and objective weights were determined by the best–worst method and entropy method to differentiate the importance of risk factors. The SVTNN–MULTIMOORA method was utilized to calculate the risk-priority order of failure modes in a surgical process. Results The hybrid FMEA model under the SVTNN–MULTIMOORA method was used to calculate the ranking of severity of 21 failure modes in the surgical process. An unclear diagnosis is the most critical failure in the surgical process of a hospital in Hunan Province. Conclusion The proposed model can identify and evaluate the most critical potential failure modes of the surgical process effectively. In addition, such a model can help hospitals to reduce surgical risk and improve the safety of surgery.
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Affiliation(s)
- Peng-Fei Cheng
- School of Business, Hunan University of Science and Technology, Xiangtan 411201, People's Republic of China.,Hunan Engineering Research Center of Intelligent Decision Making and Big Data on Industrial Development, Xiangtan 411201, People's Republic of China
| | - Dan-Ping Li
- School of Business, Hunan University of Science and Technology, Xiangtan 411201, People's Republic of China
| | - Ji-Qun He
- Xiangya Hospital, Central South University, Changsha 410008, People's Republic of China.,Xiangya Nursing School, Central South University, Changsha 410011, People's Republic of China
| | - Xiang-Hong Zhou
- School of Business, Hunan University of Science and Technology, Xiangtan 411201, People's Republic of China.,Hunan Engineering Research Center of Intelligent Decision Making and Big Data on Industrial Development, Xiangtan 411201, People's Republic of China
| | - Jian-Qiang Wang
- Hunan Engineering Research Center of Intelligent Decision Making and Big Data on Industrial Development, Xiangtan 411201, People's Republic of China.,School of Business, Central South University, Changsha 410083, People's Republic of China
| | - Hong-Yu Zhang
- Hunan Engineering Research Center of Intelligent Decision Making and Big Data on Industrial Development, Xiangtan 411201, People's Republic of China.,School of Business, Central South University, Changsha 410083, People's Republic of China
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Heideveld-Chevalking AJ, Calsbeek H, Hofland J, Meijerink WJHJ, Wolff AP. Prospective methods for identifying perioperative risk-assessment methods for patient safety over 20 years: a systematic review. BJS Open 2019; 4:197-205. [PMID: 32207569 PMCID: PMC7093778 DOI: 10.1002/bjs5.50246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/03/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Serious preventable surgical events still occur despite considerable efforts to improve patient safety. In addition to learning from retrospective analyses, prospective risk-assessment methods may help to decrease preventable events further by targeting perioperative hazards. The aim of this systematic review was to assess the methods used to identify perioperative patient safety risks prospectively, and to describe the risk areas targeted, the quality characteristics and feasibility of methods. METHODS MEDLINE, Embase, CINAHL and Cochrane databases were searched, adhering to PRISMA guidelines. All studies describing the development and results of prospective methods to identify perioperative patient safety risks were included and assessed on methodological quality. Exclusion criteria were interventional studies, studies targeting one specific issue, studies reporting on structural factors relating to fundamental hospital items, and non-original or case studies. RESULTS The electronic search resulted in 16 708 publications, but only 20 were included for final analysis, describing five prospective risk-assessment methods. Direct observation was used in most studies, often in combination. Direct (16 studies) and indirect (4 studies) observations identified (potential) adverse events (P)AEs, process flow disruptions, poor protocol compliance and poor practice performance. (Modified) Healthcare Failure Mode and Effect Analysis (HFMEA™) (5 studies) targeted potential process flow disruption failures, and direct (P)AE surveillance (3 studies) identified (P)AEs prospectively. Questionnaires (3 studies) identified poor protocol compliance, surgical flow disturbances and patients' willingness to ask questions about their care. Overall, quality characteristics and feasibility of the methods were poorly reported. CONCLUSION The direct (in-person) observation appears to be the primary prospective risk-assessment method that currently may best help to target perioperative hazards. This is a reliable method and covers a broad spectrum of perioperative risk areas.
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Affiliation(s)
| | - H Calsbeek
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - J Hofland
- Department of Anaesthesiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - W J H J Meijerink
- Department of Operating Rooms, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - A P Wolff
- Department of Anaesthesiology, University of Groningen Medical Centre, Groningen, the Netherlands
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de Vries M, Fan M, Tscheng D, Hamilton M, Trbovich P. Clinical observations and a ealthcare ailure ode and ffect nalysis to identify vulnerabilities in the security and accounting of medications in Ontario hospitals: a study protocol. BMJ Open 2019; 9:e027629. [PMID: 31256028 PMCID: PMC6609086 DOI: 10.1136/bmjopen-2018-027629] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 04/10/2019] [Accepted: 05/22/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION An increasing number of opioids and other controlled substances are being stolen from healthcare facilities, diverting medications from their intended medical use to be used or sold illicitly. Many incidents of medication loss from Canadian hospitals are reported as unexplained losses. Together, this suggests not only that vulnerabilities for diversion exist within current medication-use processes (MUPs), but that hospitals lack robust mechanisms to accurately track and account for discrepancies and loss in inventory. There is a paucity of primary research investigating vulnerabilities in the security and accounting of medications across hospital processes. The purpose of this study is to map hospital MUPs, systematically identify risks for diversion or unintentional loss and proactively assess opportunities for improvements to medication accounting and security. METHODS AND ANALYSIS We will conduct human factors-informed clinical observations and a Healthcare Failure Mode and Effect Analysis (HFMEA). We will observe hospital personnel in the intensive care unit, emergency department and inpatient pharmacy in two hospitals in Ontario, Canada. Observations will capture how participants complete tasks, as well as gather contextual information about the environment, technologies and processes. A multidisciplinary team will complete an HFMEA to map process flow diagrams for the MUPs in the observed clinical units, identify and prioritise potential methods of medication loss (failure modes) and describe mechanisms or actions to prevent, detect and trace medication loss. ETHICS AND DISSEMINATION We received province-wide research ethics approval via Clinical Trials Ontario Streamlined Research Review System, and site-specific approvals from each participating hospital. The results from this study will be presented at conferences and meetings, as well as published in peer-reviewed journals. The findings will be shared with hospitals; professional, regulatory and accreditation organisations; patient safety and healthcare quality organisations and equipment and drug manufacturers.
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Affiliation(s)
- Maaike de Vries
- HumanEra, Research and Innovation, North York General Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Mark Fan
- HumanEra, Research and Innovation, North York General Hospital, Toronto, Ontario, Canada
| | - Dorothy Tscheng
- Institute for Safe Medication Practices Canada, Toronto, Ontario, Canada
| | - Michael Hamilton
- Institute for Safe Medication Practices Canada, Toronto, Ontario, Canada
| | - Patricia Trbovich
- HumanEra, Research and Innovation, North York General Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Hassen Y, Singh P, Pucher PH, Johnston MJ, Darzi A. Identifying quality markers of a safe surgical ward: An interview study of patients, clinical staff, and administrators. Surgery 2018; 163:1226-1233. [DOI: 10.1016/j.surg.2017.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 11/09/2017] [Accepted: 12/02/2017] [Indexed: 11/30/2022]
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Taleghani YM, Rezaei F, Sheikhbardsiri H. Risk assessment of the emergency processes: Healthcare failure mode and effect analysis. World J Emerg Med 2016; 7:97-105. [PMID: 27313803 DOI: 10.5847/wjem.j.1920-8642.2016.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Ensuring about the patient's safety is the first vital step in improving the quality of care and the emergency ward is known as a high-risk area in treatment health care. The present study was conducted to evaluate the selected risk processes of emergency surgery department of a treatment-educational Qaem center in Mashhad by using analysis method of the conditions and failure effects in health care. METHODS In this study, in combination (qualitative action research and quantitative cross-sectional), failure modes and effects of 5 high-risk procedures of the emergency surgery department were identified and analyzed according to Healthcare Failure Mode and Effects Analysis (HFMEA). To classify the failure modes from the "nursing errors in clinical management model (NECM)", the classification of the effective causes of error from "Eindhoven model" and determination of the strategies to improve from the "theory of solving problem by an inventive method" were used. To analyze the quantitative data of descriptive statistics (total points) and to analyze the qualitative data, content analysis and agreement of comments of the members were used. RESULTS In 5 selected processes by "voting method using rating", 23 steps, 61 sub-processes and 217 potential failure modes were identified by HFMEA. 25 (11.5%) failure modes as the high risk errors were detected and transferred to the decision tree. The most and the least failure modes were placed in the categories of care errors (54.7%) and knowledge and skill (9.5%), respectively. Also, 29.4% of preventive measures were in the category of human resource management strategy. CONCLUSION "Revision and re-engineering of processes", "continuous monitoring of the works", "preparation and revision of operating procedures and policies", "developing the criteria for evaluating the performance of the personnel", "designing a suitable educational content for needs of employee", "training patients", "reducing the workload and power shortage", "improving team communication" and "preventive management of equipment's" were on the agenda as the guidelines.
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Affiliation(s)
- Yasamin Molavi Taleghani
- Health Management and Economics Research Center, School of Management and Medical Information, Isfahan University of Medical Science, Isfahan, Iran
| | - Fatemeh Rezaei
- Health Management and Economics Research Center, School of Management and Medical Information, Isfahan University of Medical Science, Isfahan, Iran
| | - Hojat Sheikhbardsiri
- Department of Disaster and Emergency Medical Management Center, Kerman University of Medical Science, Kerman, Iran
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Improving Escalation of Care: Development and Validation of the Quality of Information Transfer Tool. Ann Surg 2016; 263:477-86. [PMID: 25775058 DOI: 10.1097/sla.0000000000001164] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To develop and provide validity and feasibility evidence for the QUality of Information Transfer (QUIT) tool. BACKGROUND Prompt escalation of care in the setting of patient deterioration can prevent further harm. Escalation and information transfer skills are not currently measured in surgery. METHODS This study comprised 3 phases: the development (phase 1), validation (phase 2), and feasibility analysis (phase 3) of the QUIT tool. Phase 1 involved identification of core skills needed for successful escalation of care through literature review and 33 semistructured interviews with stakeholders. Phase 2 involved the generation of validity evidence for the tool using a simulated setting. Thirty surgeons assessed a deteriorating postoperative patient in a simulated ward and escalated their care to a senior colleague. The face and content validity were assessed using a survey. Construct and concurrent validity of the tool were determined by comparing performance scores using the QUIT tool with those measured using the Situation-Background-Assessment-Recommendation (SBAR) tool. Phase 3 was conducted using direct observation of escalation scenarios on surgical wards in 2 hospitals. RESULTS A 7-category assessment tool was developed from phase 1 consisting of 24 items. Twenty-one of 24 items had excellent content validity (content validity index >0.8). All 7 categories and 18 of 24 (P < 0.05) items demonstrated construct validity. The correlation between the QUIT and SBAR tools used was strong indicating concurrent validity (r = 0.694, P < 0.001). Real-time scoring of escalation referrals was feasible and indicated that doctors currently have better information transfer skills than nurses when faced with a deteriorating patient. CONCLUSIONS A validated tool to assess information transfer for deteriorating surgical patients was developed and tested using simulation and real-time clinical scenarios. It may improve the quality and safety of patient care on the surgical ward.
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Najafi TF, Bahri N, Ebrahimipour H, Najar AV, Taleghani YM. Risk Assessment of Using Entonox for the Relief of Labor Pain: A Healthcare Failure Modes and Effects Analysis Approach. Electron Physician 2016; 8:2150-9. [PMID: 27123224 PMCID: PMC4844482 DOI: 10.19082/2150] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 01/26/2016] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION In order to prevent medical errors, it is important to know why they occur and to identify their causes. Healthcare failure modes and effects analysis (HFMEA) is a type of qualitative descriptive that is used to evaluate the risk. The aim of this study was to assess the risks of using Entonox for labor pain by HFMEA. METHODS A mixed-methods design (qualitative action research and quantitative cross-sectional research) was used. The modes and effects of failures in the process of using Entonox were detected and analyzed during 2013-2014 at Hefdahe Shahrivar Hospital, Mashhad, Iran. Overall, 52 failure modes were identified, with 25 being recognized as high-risk modes. RESULTS The results revealed that 48.5% of these errors fall into the care process type, 22.05% belong to the communicative type, 19.1% fall into the administrative type, and 10.2% are of the knowledge and skills type. Strategies were presented in the forms of acceptance (3.2%), control (90.3%), and elimination (6.4%). CONCLUSION The following actions are suggested for improving the process of using Entonox: Close supervision by the midwife, precise recording of all the stages of the process in the woman's medical record, the necessity of the presence of the anesthesiologist at the woman's bedside during labor, confirming the indications for use of Entonox, and close monitoring to ensure the safety of the gas cylinder guards.
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Affiliation(s)
- Tahereh Fathi Najafi
- Ph.D. Student of Reproductive and Sexual Health, Department of Midwifery, Islamic Azad University, Mashhad Branch, Mashhad, Iran
| | - Narjes Bahri
- Ph.D. Student of Reproductive Health, Department of Midwifery, faculty of Nursing and Midwifery, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Hosein Ebrahimipour
- Ph.D. of Health services Management, Associate Professor, Health Sciences Research Center, Faculty of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Vafaee Najar
- Ph.D. of Health Services Management, Associate Professor, Department of Health and Management, Faculty of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Yasamin Molavi Taleghani
- Ph.D. Student of Health Services Administration, Health Management and Economics Research Center, Department of Management and Medical Information, Isfahan University of Medical Sciences, Isfahan, Iran
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Anderson O, Hanna G. Effectiveness of the CareCentre® at improving contact precautions: randomized simulation and clinical evaluations. J Hosp Infect 2016; 92:332-6. [DOI: 10.1016/j.jhin.2015.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 12/06/2015] [Indexed: 11/27/2022]
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Nilsson L, Risberg MB, Montgomery A, Sjödahl R, Schildmeijer K, Rutberg H. Preventable Adverse Events in Surgical Care in Sweden: A Nationwide Review of Patient Notes. Medicine (Baltimore) 2016; 95:e3047. [PMID: 26986126 PMCID: PMC4839907 DOI: 10.1097/md.0000000000003047] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Adverse events (AEs) occur in health care and may result in harm to patients especially in the field of surgery. Our objective was to analyze AEs in surgical patient care from a nationwide perspective and to analyze the frequency of AEs that may be preventable. In total 19,141 randomly selected admissions in 63 Swedish hospitals were reviewed each month during 2013 using a 2-stage record review method based on the identification of predefined triggers. The subgroup of 3301 surgical admissions was analyzed. All AEs were categorized according to site, type, level of severity, and degree of preventability. We reviewed 3301 patients' records and 507 (15.4%) were associated with AEs. A total of 62.5% of the AEs were considered probably preventable, over half contributed to prolonged hospital care or readmission, and 4.7% to permanent harm or death. Healthcare acquired infections composed of more than one third of AEs. The majority of the most serious AEs composed of healthcare acquired infections and surgical or other invasive AEs. The incidence of AEs was 13% in patients 18 to 64 years old and 17% in ≥65 years. Pressure sores and drug-related AEs were more common in patients being ≥65 years. Urinary retention and pressure sores showed the highest degree of preventability. Patients with probably preventable AEs had in median 7.1 days longer hospital stay. We conclude that AEs are common in surgical care and the majority are probably preventable.
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Affiliation(s)
- Lena Nilsson
- From the Department of Anaesthesia and Intensive Care and Department of Medical and Health Sciences (LN), Linköping University; Unit for Health Analysis (MBR), Region Östergötland; Department of Surgery (AM), Skåne University Hospital, Malmö; Department of Surgery (RS), Region Östergötland, Linköping University; Development and Patient Safety Unit (RS, HR), Region Östergötland, Linköping University, Linköping; Faculty of Health and Life Sciences (KS), School of Health and Caring Sciences, Linnaeus University, Kalmar; and Swedish Association of Local Authorities and Regions (HR), Stockholm, Sweden
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Ahmed K, Anderson O, Jawad M, Tierney T, Darzi A, Athanasiou T, Hanna GB. Design and validation of the surgical ward round assessment tool: a quantitative observational study. Am J Surg 2015; 209:682-688.e2. [DOI: 10.1016/j.amjsurg.2014.08.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Revised: 07/22/2014] [Accepted: 08/04/2014] [Indexed: 10/23/2022]
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Johnston MJ, Arora S, King D, Bouras G, Almoudaris AM, Davis R, Darzi A. A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery. Surgery 2015; 157:752-63. [DOI: 10.1016/j.surg.2014.10.017] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/22/2014] [Accepted: 10/31/2014] [Indexed: 10/23/2022]
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Alba Mesa F, Sanchez Hurtado MA, Sanchez Margallo FM, Gomez Cabeza de Vaca V, Komorowski AL. Application of failure mode and effect analysis in laparoscopic colon surgery training. World J Surg 2015; 39:536-42. [PMID: 25326422 PMCID: PMC4300411 DOI: 10.1007/s00268-014-2827-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
AIM To evaluate if application of failure mode and effect analysis (FMEA) to laparoscopy training can help surgeons acquire laparoscopy skills. METHODS After preparing a FMEA matrix of laparoscopic sigmoidectomy, we have introduced it during three laparoscopy courses. Forty-eight surgeons, divided into 24 teams of two surgeons, have participated in three courses. During each course, every team has performed three laparoscopic sigmoidectomies in three experimental animals (1 OR session every day). Risk priority number (RPN) has been calculated for every surgery, and the results have been discussed at the end of each training day with all participants. RESULTS We have observed a decline in the median RPN from 1339 during the first OR session through 62 during second OR session to reach 0 in the third OR session. Only two teams out of 24 were not able to reach a RPN of less than 300 during third OR session. When the type of failures were analysed, we have observed a shift from procedure-type failures to technical failures that depended on each participant technical abilities. CONCLUSION Application of FMEA principles to laparoscopy training can help acquire non-technical skills necessary for safe laparoscopic surgery.
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Affiliation(s)
- Francisco Alba Mesa
- Consorcio Sanitario Publico del Aljarafe, Hospital San Juan de Dios, Bormujos, Sevilla Spain
| | | | | | | | - Andrzej L. Komorowski
- Department of Surgical Oncology, Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, ul.Garncarska 11, 31-115 Kraków, Poland
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Norris B, West J, Anderson O, Davey G, Brodie A. Taking ergonomics to the bedside--a multi-disciplinary approach to designing safer healthcare. APPLIED ERGONOMICS 2014; 45:629-638. [PMID: 24135560 DOI: 10.1016/j.apergo.2013.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 08/14/2013] [Accepted: 09/02/2013] [Indexed: 06/02/2023]
Abstract
A multi-disciplinary approach to designing safer healthcare was utilised to investigate risks in the bed-space in elective surgical wards. The Designing Out Medical Error (DOME) project brought together clinicians, designers, psychologists, human factors and business expertise to develop solutions for the highest risk healthcare processes. System mapping and risk assessment techniques identified nearly 200 potential failure modes in hand hygiene, isolation of infection, vital signs monitoring, medication delivery and handover of information. Solutions addressed issues such as the design of equipment, reminders, monitoring, feedback and standardisation. Some of the solutions, such as the CareCentre™, which brings many of the processes and equipment together into one easy to access workstation at the foot of the bed, have been taken forward to clinical trials and manufacture. The project showed the value of the multi-disciplinary and formal human factors approaches to healthcare design for patient safety. In particular, it demonstrates the application of human factors to a complete design cycle and provides a case study for the activities required to reach a safe, marketable product.
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Affiliation(s)
- Beverley Norris
- Helen Hamlyn Centre for Design, Royal College of Art, Kensington Gore, London, UK
| | - Jonathan West
- Helen Hamlyn Centre for Design, Royal College of Art, Kensington Gore, London, UK.
| | - Oliver Anderson
- Clinical Safety Research Unit, Centre for Patient Safety and Service Quality, Imperial College London, UK; Department of Surgery and Cancer, Imperial College London, UK
| | - Grace Davey
- Helen Hamlyn Centre for Design, Royal College of Art, Kensington Gore, London, UK
| | - Andrea Brodie
- Clinical Safety Research Unit, Centre for Patient Safety and Service Quality, Imperial College London, UK
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Helling TS, Martin LC, Martin M, Mitchell ME. Failure events in transition of care for surgical patients. J Am Coll Surg 2013; 218:723-31. [PMID: 24508426 DOI: 10.1016/j.jamcollsurg.2013.12.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 12/12/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Unexpected clinical deterioration (failure events) in surgical patients on standard nursing units (WARDs) could have a significant impact on eventual survival. We sought to investigate failure events requiring intensive care (surgical ICU [SICU]) transfer of surgical patients on WARDs in a single-center academic setting. STUDY DESIGN Surgical patients admitted to WARDs over a 12-month period, who developed failure events, were retrospectively reviewed. Time to deterioration since WARD arrival, clinical factors, notification chain, and outcomes were identified. A physician review panel determined the preventability of failure events. RESULTS Ninety-eight patients experienced 111 failure events requiring SICU transfer. Most patients (85%) were emergency admissions. Of 111 events, 90% had been previously discharged from an SICU or a postanesthesia care unit (PACU). Recognition of failure was by nursing (54%) and on routine physician rounds (34%). Rapid response or code blue alone was less common (12%). A second physician notification was needed in 29%, with delays due to failure to identify severity of illness. Most commonly, respiratory events prompted notification (77 of 111, 69%). Overall mortality was 26 of 98 (27%). Median time to failure was 2 days and was associated with early transfer from the SICU or PACU. Rapid response or code blue activation was associated with higher mortality than physician notification. CONCLUSIONS Patients most at risk for WARD failures were those with acute surgical emergencies or recently discharged from the SICU or PACU. Respiratory complications were the most common cause of WARD failure events. Many early failures may have been due to premature transfer from the SICU or PACU. Failure events on WARDs can have lethal consequences. Awareness, monitoring, and communication are important components of preventative measures.
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Affiliation(s)
- Thomas S Helling
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS.
| | - Larry C Martin
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Magdeline Martin
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Marc E Mitchell
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS
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