Objective To evaluate the performance of a routine incident reporting system in identifying patient safety incidents. Design Two stage retrospective review of patients case notes and analysis of data submitted to the routine incident reporting system on the same patients. Setting A large NHS hospital in England. Population 1006 hospital admissions between January and May 2004: surgery (n=311), general medicine (n=251), elderly care (n=184), orthopaedics (n=131), urology (n=61), and three other specialties (n=68). Main outcome measures Proportion of admissions with at least one patient safety incident; proportion and type of patient safety incidents missed by routine incident reporting and case note review methods. Results 324 patient safety incidents were identified in 230/1006 admissions (22.9%; 95% confidence interval 20.3% to 25.5%). 270 (83%) patient safety incidents were identified by case note review only, 21 (7%) by the routine reporting system only, and 33 (10%) by both methods. 110 ...
The Credit Valley Hospital and Trillium Health Centre is the recipient of the 2012 Patient Safety Education Program - Canada (PSEP - Canada) Innovations in Patient Safety Education Award, recognizing their work in fostering a culture of patient safety.The PSEP - Canada Innovations in Patient Safety Education Award was Credit Valley Hospital and Trillium Health Centre on November 1, 2012. The Innovations in Patient Safety Education Award recognizes organizations that demonstrate best practices in patient safety and quality improvement, says Hugh MacLeod, CEO of the Canadian Patient Safety Institute. Credit Valley Hospital and Trillium Health Centre have effectively adapted the PSEP - Canada program to foster peer-to-peer spread in advancing a patient safety culture throughout their organization. They are truly a deserving recipient of this award.. This award is a further validation and confirmation that we are on the right track in making patients a priority in everything that we do, says ...
Boston, MA (February 17, 2015)-The National Patient Safety Foundation (NPSF), a central voice for patient safety since 1997, recently welcomed TeleTracking Technologies, Inc., as a member of the NPSF Patient Safety Coalition. TeleTracking provides operational management software solutions and services to help hospitals staff efficiently, manage change, optimize capacity, fight hospital acquired infection, and make cultural transformations, all with the goal of enhancing safety. Our intelligent operational software platform can track infected patients, exposed workers, and equipment, as well as monitor hand-washing compliance, said Michael Gallup, president, TeleTracking. These capabilities are critical to containing infection and maintaining patient safety, so our work is very much aligned with the Foundations focus.. The NPSF Patient Safety Coalition was created to align stakeholders from across the continuum of care in a unifying mission to make health care safer for all. Membership is ...
The Leading Improvement in Patient Safety programme is enabling acute trusts to develop their capability and frontline teams by giving them a framework from which to develop their safety strategy.
There is widespread recognition of the problem of unsafe care and extensive efforts have been made over the last 15 years to improve patient safety. In Sweden, a new patient safety law obliges the 21 county councils to assemble a yearly patient safety report (PSR). The aim of this study was to describe the patient safety work carried out in Sweden by analysing the PSRs with regard to the structure, process and result elements reported, and to investigate the perceived usefulness of the PSRs as a tool to achieve improved patient safety. The study was based on two sources of data: patient safety reports obtained from county councils in Sweden published in 2014 and a survey of health care practitioners with strategic positions in patient safety work, acting as key informants for their county councils. Answers to open-ended questions were analysed using conventional content analysis. A total of 14 structure elements, 31 process elements and 23 outcome elements were identified. The most frequently reported
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Global Patient Safety Alerts is a publicly available, evidence-informed, online collection of patient safety alerts, advisories, and recommendations from 26 international organizations around the world. Recognized by the World Health Organization and its member countries, the collection contains more than 1,200 alerts and 6,100 recommendations from contributing organizations and serves as a centralized location for sharing and learning from patient safety incidents. Visit the site ...
SARASOTA, Fla. (May 22, 2012) - Sarasota Memorial Health Care System received HealthGrades 2012 Patient Safety Excellence Award™ today - a designation given to the nations top 5% hospitals for patient safety. It is the ninth consecutive year that Sarasota Memorial has received the independent healthcare rating organizations safety award.. To evaluate patient safety, HeathGrades analyzed millions of hospitalization records from the Medicare Provider Analysis and Review (MedPAR) database and used Patient Safety Indicator software from the Agency for Healthcare Research and Quality (AHRQ) to calculate event rates for 13 indicators of patient safety for the nations hospitals.. The best-performing hospitals - those that ranked in the top 5 percent of this years analysis - received this years HealthGrades Patient Safety Excellence Award.. Delivering safe patient care is not a process, procedure or safety list that you check off at the end of each day - it is a mindset and way of caring for ...
The National Patient Safety Foundation (NPSF), the nations leading voice for patient safety, will host the 2011 Patient Safety Congress May 25-27 at Washington, D.C.s Gaylord National Hotel & Convention Center. Now in its 13th year, the gathering is a cornerstone of the Foundations educational activities and the only conference whose sole focus is sharing the latest best practices and tools for delivering safe patient care. This is an opportunity to learn from and exchange ideas with patient safety experts and practitioners from around the globe at the only conference with a singular focus on patient safety
The sixth annual HealthGrades Patient Safety in American Hospitals Study applies methodology developed by the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality to identify the incident rates of 15 patient safety indicators among Medicare patients at virtually all of the nations nearly 5,000 nonfederal hospitals. Additionally, HealthGrades applied its methodology using 12 patient safety indicators to identify the best-performing hospitals, or Patient Safety Excellence Award hospitals, which represent the top five percent of all U.S. hospitals. HealthGrades developed this award to give patients more information about choosing a hospital. ...
Predictive validity. The results of the linear regression models are shown in Table 4.. DISCUSSION. The metric proprieties of the final version of the Latino Student Patient Safety Questionnaire allow for assessment of the attitudes and basic knowledge of students of health disciplines about patient safety. Because attitudes and knowledge form the basis of professional skills, this questionnaire could be used to indirectly evaluate whether or not nursing and medical students are likely to put into practice the skills considered most appropriate for patient safety.. The structure of the Latino Student Patient Safety Questionnaire is very similar to the one proposed by Flin et al. (28). The results of the validation study yielded a five-factor structure (Knowledge of error and patient safety or Awareness of error, Knowledge of workplace safety or Understanding of human factor, Feelings about making errors or Openness in communication, Attitudes toward patient safety or Proactive attitude to ...
More than 200,000 people die every year in U.S. hospitals in ways that could have been prevented. The Patient Safety Movement Foundation was established through the support of the Masimo Foundation for Ethics, Innovation, and Competition in Healthcare, to reduce that number of preventable deaths to 0 by 2020 (0X2020). Improving patient safety will require a collaborative effort from all stakeholders, including patients, healthcare providers, medical technology companies, government, employers, and private payers. The Patient Safety Movement Foundation works with all stakeholders to address the problems and solutions of patient safety. The Foundation also convenes Patient Safety, Science and Technology Summits. The first annual Summit was held in January 2013, and brought together some of our nations best minds for thought-provoking discussions and new ideas to challenge the status quo. By presenting specific, high-impact recipes to meet patient safety challenges, encouraging medical technology ...
Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting, and analysis of medical error that often leads to adverse effects. The frequency and magnitude of avoidable adverse events experienced by patients was not well known until the 1990s, when multiple countries reported staggering numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety. The resulting patient safety knowledge continually informs improvement efforts such as: applying lessons learned from business and industry, adopting innovative technologies, educating providers ...
Scotland is the first country in the world to mandate a structured safety improvement program for its whole health care system. The Scottish Patient Safety Program, in which all acute care hospitals take part, aims to reduce mortality by 15 percent and patient harm by 30 percent by the end of 2012. Three years into the program, patients and hospitals have made significant progress, including a 7 percent reduction in hospital standardized mortality ratios and dramatic drops in hospital-acquired infection rates.. The program is the first major initiative of the Scottish Patient Safety Alliance, a collaboration of the Scottish government, the National Health Service (NHS), and two leading health care organizations that was established in 2007.. While acute care is the starting point, the Alliances overall approach recognizes that care will take place in a range of settings, with primary care and community-based care becoming increasingly prominent. Safety programs in mental health and pediatrics ...
Nursing Issues On Patient Safety, Patient safety is a critical component of the care Nurses deliver as we endeavor to prevent harm. Topics will include fall preventions, how to improve... - pg. 49
The CODE Charter on Patient Safety keeps up to date with the latest changes to regulations and patient safety guidelines and regularly train the team.
Canadian Patient Safety Week is a national, annual campaign that started in 2005 to inspire extraordinary improvement in patient safety and quality. As the momentum for promoting best practices in patient safety has grown, so has the participation in Canadian Patient Safety Week. Canadian Patient Safety week is relevant to anyone who engages with our healthcare system: providers, patients, and citizens. Working together, thousands help spread the message to Ask. Listen. Talk.. If your organization is interested in sponsoring a portion of CPSW 2017, please contact [email protected] We have many sponsorship opportunities available. ...
Since the release of 2 landmark reports by the Institute of Medicine (IOM) Committee on Quality of Health Care in America in 1999 and 2001,1,2 patient safety has become a priority issue and area of focus for health care professionals and researchers, hospital administrators, policy makers, accrediting agencies, health care purchasers, and patients and families. The US Department of Health and Human Services, through the Agency for Healthcare Research and Quality, launched a $50 million initiative in 2001 to increase and improve research in patient safety.. Despite an increased focus on patient safety at a national level, leaders in patient safety and quality improvement have reported little progress in reduction of harm since the release of the IOM reports.3 Professional societies, national health care agencies, individual health care systems, and hospitals have demonstrated some successes such as a reduction in serious infections or fewer patients dying from accidental injections of ...
Since the release of 2 landmark reports by the Institute of Medicine (IOM) Committee on Quality of Health Care in America in 1999 and 2001,1,2 patient safety has become a priority issue and area of focus for health care professionals and researchers, hospital administrators, policy makers, accrediting agencies, health care purchasers, and patients and families. The US Department of Health and Human Services, through the Agency for Healthcare Research and Quality, launched a $50 million initiative in 2001 to increase and improve research in patient safety.. Despite an increased focus on patient safety at a national level, leaders in patient safety and quality improvement have reported little progress in reduction of harm since the release of the IOM reports.3 Professional societies, national health care agencies, individual health care systems, and hospitals have demonstrated some successes such as a reduction in serious infections or fewer patients dying from accidental injections of ...
A representative from the nurses union said nurses were being told to take out trash and change linens because of Lean. Thats puzzling, since that seems to be a waste of their talent. Ive seen Lean drive hospitals to REDUCE the amount of time nurses are doing non-nursing tasks, which allows them to focus MORE on the patients. Thats what I see as a Lean approach - having support staff let nurses be nurses, pharmacists be pharmacists, etc. The nursing union admits that Lean has things to offer but they are concerned about patient safety. Well, Lean has a lot to offer to improve quality and patient safety. […]. ...
The SPA is pleased to announce the availability of young investigator research grants through the Patient Safety, Education and Research Fund (PSERF).
NQF 34 Patient Safety Practices for Hospitals 2011 Part 1 of 2 – A free PowerPoint PPT presentation (displayed as a Flash slide show) on PowerShow.com - id: 6bfac0-NDc5N
The Council on Patient Safety in Womens Health Care is pleased to sponsor and convene the Safety Action Series. The Series is comprised of free teleconferences on various topics relevant to promoting a culture of safety in womens health care. The series is designed to be interactive and collaborative, with ample time allotted during each session for audience participation.. ...
The Council on Patient Safety in Womens Health Care is pleased to sponsor and convene the Safety Action Series. The Series is comprised of free teleconferences on various topics relevant to promoting a culture of safety in womens health care. The series is designed to be interactive and collaborative, with ample time allotted during each session for audience participation.. ...
Adverse patient safety events will drive a $383.7 billion cost burden in the U.S. and Western Europe over the next four years, according to a new report, but some of the biggest challenges also offer significant opportunities for solutions.
Filipino nurses to organise talk on patient safety. #1 source of information for nurses all over the world. NurseReview.Org - Free Online Review for Nurses
A nationwide study co-authored by a Grand Valley State University nursing professor found that the long hours worked by hospital staff nurses may have adverse effects on patient safety.
BACKGROUND: Despite the enormous potential for adverse events in primary care, the knowledge base about patient safety in this context is still sparse. The lack of appropriate measurement methods is a key factor limiting the development of research in this field. OBJECTIVE: To identify and characterize available patient reported instruments to measure patient safety in primary care. METHODS: We conducted a systematic literature review. We searched in bibliographic sources for empirical studies describing the development, evaluation or use of patient reported instruments assessing patient safety in primary care. Study selection and data extraction were independently conducted by two researchers. RESULTS: We identified 28 studies reporting on 23 different instruments. Fifteen instruments were designed for paper-based self-administration, six for phone interview and two consisted in electronic reporting systems. Most instruments focused on specific aspects of patient safety, most commonly on experiences of
Journal of Patient Safety (ISSN 1549-8417; online ISSN 1549-8425) is dedicated to presenting research advances and field applications in every area of patient safety. While Journal of Patient Safety has a research emphasis, it also publishes articles describing near-miss opportunities, system modifications that are barriers to error, and the impact of regulatory changes on healthcare delivery. This mix of research and real-world findings makes Journal of Patient Safety a valuable resource across the breadth of health professions and from bench to bedside.
Journal of Patient Safety (ISSN 1549-8417; online ISSN 1549-8425) is dedicated to presenting research advances and field applications in every area of patient safety. While Journal of Patient Safety has a research emphasis, it also publishes articles describing near-miss opportunities, system modifications that are barriers to error, and the impact of regulatory changes on healthcare delivery. This mix of research and real-world findings makes Journal of Patient Safety a valuable resource across the breadth of health professions and from bench to bedside.
Intravenous literature: McHale, J.V. (2010) Patient safety and professional practice across European borders. British Journal of Nursing. 19(8), p.520 - 521. Summary:. Patient safety issues have increasingly become an issue of concern by the European Union (EU). This paper explores some recent EU proposals in the area of patient safety. It suggests that these proposals may have broad implications at member state level and ultimately may impact on professional practice standards in the UK.. ...
Prospective controlled study to compare the effects of a basic patient safety course on healthcare worker patient safety culture ...
From March 2nd to the 8th is the celebration of the annual Patient Safety Awareness Week, an educational health movement focused on providing relevant information to everyone on safety practices when tending for a patient. This awareness week is led by the National Patient Safety Foundation (NPSF) and this years theme is
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The College of Physicians and Surgeons of British Columbia regulates the practice of medicine under the authority of provincial law. All physicians who practise medicine in the province must be registrants of the College.
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Wantagh, NY /ePRNews/ Patient safety education group Pulse Center for Patient Safety Education and Advocacy (formerly PULSE of NY) announces an unbeatable offer on tickets for its May 1 Symposium, Infection Prevention: It…
South Shore Hospital is committed to providing safe, efficient and effective healthcare to our patients. As part of this effort, the hospital has an organized Patient Safety Committee to address patient safety issues. If you have questions regarding patient safety issues, please do not hesitate to call the Patient Safety Hotline (773) 356-5446 - this hotline is a confidential voice mail box where patients/family or staff can leave concerns or ideas for patient safety.. ...
Out of the 10 clinical cases responded to by the GPs in our study, failure to record or inadequate notation of information in the medical records of patients was judged to constitute the greatest threat to patient safety. This finding is consistent with the results of other studies which show missing information to be common and possibly harmful for patients in primary care [12]. One of the lessons from the Threats to Australian Patient Safety (TAPS) study, moreover, is the importance of complete and accurate medical records. Errors can arise from missing clinical information (missing lab results) and/or suboptimal recording of contacts within an episode of care [13]. Our findings confirm this. The GPs in our study considered good record keeping to be highly important for patient safety.. Medication safety was also perceived by the GPs in our study to be highly critical for the safety of their primary care patients. This included the clinical cases of overruling medical alerts, nonresponse to ...
Sites providing information on improving safety for patients and residents in health care organizations. Issues include implementation of patient safety programs, the responsibility of organization leadership to create a culture of safety, prevention of medical errors, and the hospitals responsibility to tell a patient if he or she has been harmed by the care provided.
This week, Patient Safety First is launching an insulin prescription bundle focus week to encourage NHS trusts to improve the clarity of insulin prescriptions and reduce errors caused by the prescription of high risk medications.Patient Safety First has put together a simple insulin prescription bundle data collection tool, which trusts can use to test the clarity of their insulin prescriptions. A bundle is a grouping of best practices that individually improve care but when applied together result in substantial improvement to patient safety.
The following are statistics on hospital-acquired conditions, adverse events and patient safety extracted from chapter three, Patient Safety Importance, from the 2012 National Healthcare Quality Report. The report is produced by the Agency for Healthcare Research and Quality.
Respondents to our survey were predominantly nurses (75%) and pharmacists (16%) working at a staff (51%) or managerial/director level (28%) in hospitals (87%). It was clear from respondents that the survey touched upon a worrisome topic, generating thousands of additional comments (see Table 1 in the PDF version of the newsletter for several examples) covering more than 70 pages of printed text. Nearly one-quarter (20%) of respondents reported a large negative impact on medication safety in their hospitals due to the economy; another 21% reported a moderate negative impact. Similar results were found regarding the impact on patient safety in general. General Patient Safety Findings. More than two-thirds of respondents reported that the economy has affected their staffing. Survey comments suggest that layoffs, staff attrition without replacement, hiring less experienced staff, and reductions in salary/paid vacation have occurred widely, and that remaining staff often fear losing their jobs, ...
Introduction. Patient safety is at the forefront of service delivery in South Africa (SA), as the health system is struggling to cope with the collision of four excessive health burdens, namely communicable diseases (especially HIV/AIDS); non-communicable diseases; maternal, neonatal and child deaths; and deaths from injury and violence (Coovadia et al. 2009:817-843). At the same time, SA experiences acute shortages of health professionals in the publicly funded sector. This combination of increasing numbers of patients and a shortage of professionals is a real concern for nurse managers, as nurse practitioners are responsible for all acts and omissions in the delivery of quality patient care (Eygelaar & Stellenberg 2012:1) and patients have little guarantee that they are receiving safe health care.. Many healthcare quality problems have been identified in both the private and public sectors in SA. The most notable are: under- and over-use of services; avoidable errors; lack of resources; ...
Participants mostly agreed that MMCs were beneficial in terms of healthcare quality and safety improvement. MMCs were perceived as beneficial for teamwork and the functioning of the unit. The improvement of practices and organization seemed to be the main objective perceived by the participants. Moreover, an educational role, for initial and continuing education, was perceived by most participants, particularly by the senior physicians. Most of participants were satisfied with MMCs and experienced a friendly and non-blaming environment.. The search for failures and the discussion of errors are well-documented opportunities for improvement of safety and education [2, 14]. The present results suggest that the analysis of these failures was perceived as determinant in improving patient safety. However, without a thorough analysis, this discussion seems to result in a blaming environment that is incompatible with constructive discussion [6, 15-18]. Indeed, personal failures are often spontaneously ...
Approximately 10% of admissions to acute-care hospitals are associated with an adverse event. Analysis of incident reports helps to understand how and why incidents occur and can inform policy and practice for safer care. Unfortunately our capacity to monitor and respond to incident reports in a timely manner is limited by the sheer volumes of data collected. In this study, we aim to evaluate the feasibility of using multiclass classification to automate the identification of patient safety incidents in hospitals. Text based classifiers were applied to identify 10 incident types and 4 severity levels. Using the one-versus-one (OvsO) and one-versus-all (OvsA) ensemble strategies, we evaluated regularized logistic regression, linear support vector machine (SVM) and SVM with a radial-basis function (RBF) kernel. Classifiers were trained and tested with
Results: Of the respondents, 25% (7 persons) and 75% (21 persons) were men and women respectively. The majority of the respondents, i.e. 60% (17 persons), had a bachelors degree. Moreover, 21.6% of the sample had more than 5 years of professional experience. The items in the improved surgical safety checklist were as follows: including a space for the signature of the scrub nurse and personnel during the shift change and mentioning instruments used during an operation as well as different phases of surgery one by one. In general, the personnels perspectives on the improved checklist, compared with the present checklist, were statistically significantly different (p,0.05). That is to say the improved checklist is a more comprehensive guide than the existing checklist as for keeping a checklist of instruments applied and procedures adopted. Furthermore, it is crucial to mention names of instruments on the checklist completely and individually. ...
The quality/patient safety department assists hospitals with meeting The Joint Commissions National Patient Safety Goals, addressing CMS patient safety-related regulations, ensuring patient satisfaction, and improving the overall quality of care.
The quality/patient safety department assists hospitals with meeting The Joint Commissions National Patient Safety Goals, addressing CMS patient safety-related regulations, ensuring patient satisfaction, and improving the overall quality of care.
Introduction: We studied the effects of the national Perinatal Patient Safety Program in Sweden, addressing local improvement measures, changes in the proportion of low Apgar score and the number of settled injury claims due to asphyxia.. Material and methods: Final reports on achieved improvements from all Swedish obstetric units were analyzed and categories of the improvement measures taken in perinatal risk areas were established. Data on all term newborns during 2006-12 were obtained from the Medical Birth Registry. Incidence of 5-min Apgar score ,7 was analyzed before, during and after the intervention. The odds ratio for low Apgar score in period ÍII vs. period I was calculated. Patient injury claims from The Swedish National Patient Insurance Company (LÖF) were analyzed.. Results: Numerous local improvement initiatives were reported. The incidence of 5-min Apgar score ,7 on a national level remained unchanged during the study periods. The units with the highest rate of Apgar score ,7 ...
National Patient Safety Goals for Hospitals Date: November 30, 2017 Time: 12pm PT/1pm MT/2pm CT/3pm ET Duration: 120 min Speaker: Sue Dill Calloway, RN, MSN, JD Code: T17113052. This is a must-attend program for any nurse working in healthcare today. This program will discuss legal issues in documentation, offer advices on TJC and CMS Hospital CoP issues related to documentation, and provide over 50 recommendations to help attendees improve their documentation skills...
Only 5-10% of serious incidents in the NHS with the potential to compromise patients safety are actually reported, MPs have been told.. Witnesses giving evidence to MPs on the parliamentary health select committee last week admitted that under-reporting of patient safety incidents was significant but defended the system.. Committee members, who were taking evidence for their inquiry into patient safety, asked witnesses from the Department of Health and the National Patient Safety Agency how much harm the NHS did to patients.. Martin Fletcher, the agencys chief executive, said that statistics from his organisations national reporting and learning system (covering England and Wales) for 2007-8 showed that 796 142 patient safety incidents were reported by staff, most of which (583 000) came from the acute … ...
Asked what stood out about UMHS, Danforth noted the institutions computerized physician order entry technology, which allows doctors and other prescribers to order medication electronically, reducing the likelihood for things like drug interaction.. UMHS implemented its CareLink system 2008. U-M CareLink allows technicians, nurses and physicians to order lab tests, medications and nutrition online, ridding the need for paper forms and reducing room for error that can result from multiple hand-offs and hand-written orders.. Patient safety issues have been a top priority at UMHS for a decade. Darrell Campbell Jr., chief medical officer of U-M hospitals, leads the patient safety program.. Recent strides made in patient safety include reduced medication errors, improved hygiene by clinical staff, required flu shots for clinical staff and a 40 percent reduction in infections at the site of surgical procedures, Campbell noted in a release.. Leapfrog is funded by its members, Danforth said. In ...
Competing interests Dr Gurses reports receiving grant or contract support from the National Patient Safety Foundation, consulting fees from a grant funded by the National Council of State Boards of Nursing, and an honorarium from a healthcare system for speaking at a patient safety workshop. Dr Lubomski reports receiving funding from the Michigan Health & Hospital Association Keystone Center for Quality and Patient Safety, and consultancy fees from the Society for Paediatric Anaesthesia. Dr Thompson was supported by the SCA Foundation, but has no other conflicts to report. Dr Pronovost reports receiving grant or contract support from the Agency for Healthcare Research and Quality, the National Institutes of Health, the Robert Wood Johnson Foundation, and The Commonwealth Fund for research related to measuring and improving patient safety; honoraria from various hospitals and healthcare systems and the Leigh Bureau to speak on quality and safety; consultancy with the Association for Professionals ...
Results: Modified checklists contained more total items as compared to the original, averaging 33.5 ±8.4 items versus 28 in the original. The most commonly added items were procedural, not teamwork-based. 50% of all checklists removed two or more of the original seven teamwork items. Surgeon-led items were more likely to be removed. The average number of teamwork items on US checklists was significantly lower than on non-US checklists (3.98 vs. 5.64, p,0.05). US checklists were also more likely to eliminate all surgeon-led items (21.4% of US vs. 12.7% of all checklists ...
Un foro para instituciones relacionadas con la atención durante la internación: hospitales, sociedades científicas, instituciones académicas.
All facilities in the MHS Direct Care System voluntarily report their patient safety events to the Patient Safety Program. Reporting is one of the key components in the Military Health Systems (MHS) effort to achieve high reliability, continuously improve and provide the safest patient care possible.
Errors are inevitable in healthcare systems (Commission on Patient Safety and Quality Assurance, 2008). It is estimated that medical errors would rank 5 in the top 10 causes of death in the United States, ahead of accidents, diabetes, and Alzheimers disease, if included on the National Centre for Health Statistics list (Joint Commission, 2005 p.7). In Ireland, the Commission on Patient Safety and Quality Assurance (2008) acknowledge that healthcare will never be risk free but argue that it is critical that the systems in place are as safe as possible, that the right checks and balances are in place and that learning results from mistakes. To ensure this happens it is important that programmes prepare nurses to promote and enhance clinical safety. The module is guided by the National Patient Safety Framework (The Australian Council for Safety and Quality in Health Care, 2005) and the WHO Patient Safety Curriculum Guide for Medical Schools (World Health Organisation, 2009 ...
By Megan Headley. During her early research on patient safety over a decade ago, focusing on medical error disclosure and ways to improve communication with patients and families after harmful events, Sigall K. Bell, MD, director of patient safety and quality initiatives for the Raskin Fellow in Medical Education at Beth Israel Deaconess Medical Center, began to notice a pattern.. I started noticing that some of the stories of harmed patients and families shared a common narrative: I knew something was wrong, but I couldnt say anything or, I didnt know how or who to tell or, I tried to say something, but it didnt work. This resonated with themes we heard from interviewed patients and families who experienced medical error, which included a sense of guilt: If only I had been there, or, If only I had said something, Bell recalls.. As it turns out, clinicians may be overlooking, if not actively discouraging, input from a significant patient safety resource: patient ...
The Patient Safety Committee serves the Academy and the public by monitoring patient safety issues and programs as they relate to orthopaedic surgery, care, and practice. The Patient Safety Committee interacts with governmental and private organizations such as the Joint Commission (TJC), the World Health Organization (WHO), and the Centers for Disease Control and Prevention (CDC) to develop programs and materials that increase safe practices in orthopaedics.. ...
In the 1970s, after investigators reported that more than 70 percent of air crashes involved human error, the aviation community worked with psychologists to develop a training protocol to improve
We are in the midst of an exciting national movement, endorsed by health care entities and patients alike, to engage patients and families as partners with their health care providers. Including patients in the design and implementation of initiatives to improve patient safety has given new meaning to patient-centered care.. Aurora Health Care, in collaboration with Consumers Advancing Patient Safety and Midwest Airlines, implemented a patient partnership model as an intervention to improve medication safety in the outpatient setting. Bringing patients and health care providers together with a common goal offered the opportunity for collaboration and insight to the needs of our patients.. We are proud of the time, talent, and wisdom that the Walworth County, Wisconsin, Patient Safety Council invested in developing and implementing tools to improve medication safety in the outpatient setting. It was a truly phenomenal committee and provided the rewarding experience of doing something worthwhile ...
Dr Robert Stoelting (President, Anesthesia Patient Safety Foundation) on postoperative patient safety risk: Clinically significant drug-induced respiratory depression (oxygenation and/or ventilation) in the postoperative period remains a serious patient safety risk that continues to be associated with significant morbidity and mortality. Dr. Frank Overdyk (Professor of Anesthesiology and Perioperative Medicine at the Medical University of…
The Patient Safety and Quality Improvement Act of 2005, 42 U.S.C. 299b-21 to b-26, (Patient Safety Act) and the related Patient Safety and Quality Improvement Final Rule, 42 CFR part 3 (Patient Safety Rule), published in the Federal Register on November 21, 2008, (73 FR 70732-70814), provide for the formation of Patient Safety Organizations (PSOs), which collect, aggregate, and analyze confidential information regarding the quality and safety of health care delivery. The Patient Safety Rule authorizes AHRQ, on behalf of the Secretary of HHS, to list as a PSO an entity that attests that it meets the statutory and regulatory requirements for listing. A PSO can be ``delisted by the Secretary if it is found to no longer meet the requirements of the Patient Safety Act and Patient Safety Rule, when a PSO chooses to voluntarily relinquish its status as a PSO for any reason, or when a PSOs listing expires. AHRQ has accepted a notification of voluntary relinquishment from Piedmont Clinic, Inc. of its ...
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Professor Robert Wears is set to present a guest lecture, titled The rise and fall of patient Safety, on Tuesday 3 May. Dr Wears is an emergency physician, Professor of Emergency Medicine at the University of Florida, and Visiting Professor in the Clinical Safety Research Unit at Imperial College London.. He serves on the board of directors of the Emergency Medicine Patient Safety Foundation, and multiple editorial boards. His research interests include technical work studies, resilience engineering, and patient safety as a social movement.. The subject of his lecture, improving patient safety, has been a recent focus of the NHS. Improving Safety through Education and Training is the first NHS report to focus on how education and training interventions can actively improve the safety of patients.. The University recently launched a new qualification for Human Factors and Ergonomics in Patient Safety to help equip healthcare staff with knowledge to tackle patient safety issues using human ...
2021 Patient Safety Learning. All rights reserved. Patient Safety Learning is registered as a charity with the Charity Commission Registration number 1180689. Registered address: Patient Safety Learning, China Works, SB203, 100 Black Prince Road, Vauxhall, London, SE1 7SJ Email address: [email protected] ...
iv) mixed methods evaluation of quality improvement initiatives implementing evidence-based interventions.. Findings from previous analyses of patient safety incidents in primary care have been used to empirically inform the design of quality improvement initiatives and projects to improve patient safety in healthcare organisations. Lessons learnt from our primary care studies are being used by the 1000 Lives Improvement service in Wales to design their national-level improvement strategy for primary care patient safety. At a local level, one health board in Wales, used our analysis of reports about anticoagulation-related errors to highlight risks to patients being initiated on Warfarin in hospital. The subsequent quality improvement project led to a national Directed Enhanced Service for anticoagulation services to be delivered to patients in community settings instead (for more detail, watch a short video on YouTube).. We conceptualise, investigate and support teams to improve patient safety ...
The New England Journal study was a prospective preintervention/postintervention study that looked at mortality rates and major complication rates after non-cardiac surgery. It involved hospitals in eight different countries, allowing the investigators to assess the utility of the checklist in both wealthy and poor countries. The intervention, of course, was introduction and use of the WHO Surgical Safety Checklist. Mortality at 30-days post-op decreased from 1.5% before introduction of the checklist to 0.8% after. Rate of any complication decreased from 11% to 7%. Both these outcomes were highly statistically significant. That s a relative risk reduction of approximately 36% for mortality and major morbidity! Of important specific surgery complications, both surgical site infections and unplanned reoperations decreased significantly. Improvements were seen at all participating sites ...
Early in the patient safety movement, the US Agency for Healthcare Research and Quality commissioned a compendium of evidence reviews in order to identify promising patient safety interventions.15 Released in 2001 (an update will appear this year), this report met with some criticism from leaders in the patient safety field because of the priority given to very clinical interventions-strategies for reducing hospital-acquired infections, thromboembolism, perioperative complications, and so on-with much lower evidence ratings for patient safety strategies from high reliability industries or for information technology.16. The lead authors of that evidence report (including one of us) replied that clinical research studies related to patient safety were more numerous and rigorous than studies of computerised order entry, teamwork training, interventions to improve safety culture, and so on.17 The debate over which patient safety interventions to pursue came down to whether we ought to prioritise ...
Patient safety in US general acute-care hospitals has improved, with fewer patients dying from medical errors, although only a little more than half get the top grades, according The Leapfrog Groups latest report.
The UKs National Institute for Health and Clinical Excellence is collaborating with the National Patient Safety Agency on a pilot project aimed at generating guidance on cost-effective interventions to prevent or mitigate patient harm in the National Health Service. - News - PharmaTimes
In this blog piece I think about what we mean when we refer to the culture of the NHS and how psychologists have already had a significant impact in shaping the patient safety world, and what a next step might be as I see it. Some background The Frances Report (2013) highlighted the need to…
Degree Types: MS, MD/MS. The masters program in Healthcare Quality and Patient Safety is designed to meet educational goals while allowing students to continue their careers or medical education, making the program accessible to medical students, clinicians, and working healthcare professionals. This program is designed for both clinical and non-clinical healthcare professionals who want to focus their career development on these important areas in health care. This is a 2-year, part-time, program which can be pursued by those living outside the Chicago area. Students are required to travel to Northwestern Universitys Chicago Campus for the classroom-based intensive sessions and complete the independent study and capstone project remotely. The program focuses on the knowledge, skills, and methods required for improving healthcare delivery systems. The topics covered include: healthcare quality context and measurement, changing systems of care delivery, healthcare disparities, accountability ...
Implementation of surgical safety checklists in Ontario, Canada, was not associated with significant reductions in operative mortality or complications. (Funded by the Canadian Institutes of Health Research.).
AHRQs Patient Safety and Health Information Technology E-Newsletter and summarizes patient safety news and information from the Agency.
Health care professionals are expected to speak up about their concerns before a critical event reaches a patient to provide a chance to correct the plan or intervention. There have been some studies investigating the relationship between the speaking-up behaviour of health care professionals and patient safety outcomes. They indicate that hesitancy to speak up can be an important contributing factor in communication errors and/or adverse events [18-20]. Most medical and nursing professionals, irrespective of their position and specialty, have some experience of hesitating in voicing their concerns over patient safety risks, even when they are aware of the hazards and immorality of not speaking up [5, 27, 33-35, 38-40]. These studies indicate that, if health care professionals voice their concerns, it may provide the opportunity to recover from errors and avoid adverse consequences, even if there are some biases (e.g. people were likely doing what they were doing because they thought they were ...
An article by SOS Lab members et al. on unintended patient safety risks has recently been published by the Journal of Patient Safety.
With evidence-based knowledge, advancements in technology and innovative care practices, we have made great strides in the past few decades in delivering care and improving the health of populations. However, no matter how much progress we make, there are always opportunities to reduce the risk of error and enhance the overall quality of care. Recently, as part of our ongoing commitment to improving care delivery, the Envision Healthcare Center for Quality and Patient Safety became listed as a Patient Safety Organization (PSO) by the Agency for Healthcare Research and Quality (AHRQ), a division of the U.S. Department of Health and Human Services.. ...
Considering the benefits of checklists in other specialties [9,10], an endoscopy safety checklist (appendix 1) was implemented across the trust in 2012 for all GI endoscopic procedures.[11] Having implemented the checklist across our entire unit, we sought to evaluate compliance with the checklist to identify problems and optimise its effectiveness.. Many lessons were learnt through this process. Importantly, implementation of a checklist needs a detailed long-term plan with consideration of likely obstacles to ensure sustainability.. PDSA cycle 1: Checklist compliance was prospectively evaluated for consecutive patients undergoing an endoscopic procedure during a seven-day period. This was initially completed in February 2013. The medical record was assessed for the following parameters:. - Section of checklist completed (Time out / Sign out / Both). - Procedure time (AM or PM). - Grade and gender of the endoscopist. - Admission type: elective or inpatient.. PDSA cycle 2: Following this initial ...
In December 1999, the U.S. Federal Governments Institute of Medicine issued a report entitled, To Err is Human: Building a Safer Health System. This report cited between 44,000 and 98,000 deaths every year due to medical errors. While these numbers are disputed by some, they would make medical errors the 8th leading cause of death, ahead of breast cancer or AIDS.. Dialysis patient safety is a complex issue that involves highly specialized dialysis technology, staff training and turnover, cost pressures, reporting of problems, oversight and regulations, water purification, dialyzer reuse, medication errors, patient compliance, patient education, primary care, prevention, vascular access, infection, location and layout of dialysis units, and the increased age and comorbidities of the ESRD population. Patient safety and injury prevention are most effective when it involves everyone in the healthcare delivery scheme. Towards that end, RenalWEB has accumulated this list of resources that addresses ...
Strategy & Policy Submission to the Consultation by the National Patient Safety Agency on patient safety and electronic prescribing (and other health information) systems 27 January 2004 Michael Tremblay
The core mission of the Center for Healthcare Improvement & Patient Safety at the University of Pennsylvania is to improve the quality of healthcare utilizing a comprehensive approach integrating health services research and quality improvement and patient safety training.
TY - JOUR. T1 - Bundle interventions including nontechnical skills for surgeons can reduce operative time and improve patient safety. AU - Koike, Daisuke. AU - Nomura, Yukihiro. AU - Nagai, Motoki. AU - Matsunaga, Takashi. AU - Yasuda, Ayuko. N1 - Publisher Copyright: © 2020 The Author(s). Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved.. PY - 2020/10/1. Y1 - 2020/10/1. N2 - Objective: This study aimed to determine if introducing nontechnical skills to surgical trainees during surgical education can reduce the operation time and contribute to patient safety. Design: Quality improvement initiatives using the KAIZEN as a problem-solving method. Setting: Department of surgery in a referral and educational hospital. Participants: Surgical team and quality management team. Intervention: The KAIZEN was used as a problem-solving method between 2015 and 2018 to reduce the operation time. First, baseline measurement was ...
However, in many of our prior columns on delirium we have mentioned multimodality intervention programs that were promising in reducing the incidence or severity of delirium in hospitalized patients (see our Patient Safety Tips of the Week for October 21, 2008 Preventing Delirium , October 14, 2009 Managing Delirium , February 10, 2009 Sedation in the ICU: The Dexmedetomidine Study , March 31, 2009 Screening Patients for Risk of Delirium and January 26, 2010 Preventing Postoperative Delirium ). One of those interventions was HELP, the Hospital Elder Life Program (see our October 21, 2008 Patient Safety Tip of the Week Preventing Delirium ). Inouye et al (Inouye 1999) had shown in a landmark study of 852 medical patients aged 70 and older that management of 6 risk factors was able to reduce the incidence of delirium from 15% to 9.9%. The number of days with delirium and the number of episodes of delirium was also reduced by the intervention. The intervention targeted cognitive impairment, sleep ...