Journal of patient safety and risk management最新文献

{"title":"Things are only fine until they are not! Personal risk management in the newborn nursery and neonatal intensive care unit","authors":"Bengt-Ola S. Bengtsson","doi":"10.1177/25160435231171241","DOIUrl":"https://doi.org/10.1177/25160435231171241","url":null,"abstract":"Most neonatologists will be named as a defendant in a medical malpractice lawsuit during their careers. Most are until it happens likely poorly prepared for the process. This article reviews common and uncommon situations that can result in adverse outcomes and potential liability for neonatologists and newborn providers and discusses ways to mitigate this risk in advance. The ramifications of a medical malpractice lawsuit and whether to settle the case out of court or going to trial, followed by potential review by the State's Medical Board are discussed. Finally, knowledge of the process before, rather than after it happens, may help to reduce the stress and uncertainty that naturally follows for the individual involved.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"46 1","pages":"133 - 144"},"PeriodicalIF":0.0,"publicationDate":"2023-05-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77929251","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Creating a “just culture”: More work to be done","authors":"A. Wu, Allen Kachalia","doi":"10.1177/25160435231168152","DOIUrl":"https://doi.org/10.1177/25160435231168152","url":null,"abstract":"A fundamental lesson for healthcare leaders is that individual providers are not solely to blame for medical errors. This dictum is at the core of the 2000 Institute of Medicine report To Err is Human. The report asserts that “the problem is not bad people in health care—it is that good people are working in bad systems that need to be made safer.” This message charted a new course of action for healthcare organizations seeking to improve patient safety. The aim was to replace the prevailing culture of blame—in which individuals are singled out, faulted, and often punished for errors— with one that is blame-free and non-punitive. James Reason described “vulnerable system syndrome,” a condition that afflicts organizations that blame front-line workers and deny the role of systemic error in creating vulnerabilities. This inevitably leads to denial by individuals and reduces the ability of organizations to learn from their mistakes. A blame-free culture is one in which individuals feel able to report errors without fear of punishment. This permits more reporting of harmful incidents and nearmisses, encourages more collaboration across disciplines, and allows a focus on finding systemic solutions. Thought leaders began calling for a blame-free approach to handling mistakes in medicine. Others justifiably pointed out the conflict between instituting a blame-free culture in the health system and the need in some cases to attribute responsibility. They worried that a “no blame” stance seems to dismiss any form of accountability for individuals. Some even argued for the benefits of punishment.6–8 Reason developed a theory of a “just culture” as a component of a culture of safety, which he thought was required to build trust and allow reporting. In 2001, David Marx expanded the concept of “just culture” to one “that is in between a blame-free culture and a punitive culture...one that encourages people to raise their hands and say they made a mistake, yet still holds them accountable if they choose behavior that knowingly puts someone at risk.” In this framework, individuals are held accountable for reckless or willful misconduct. Human error may result in an individual being offered additional training or education. However, willful misconduct may result in disciplinary action including termination of employment, even if no harm resulted. Just culture has been embraced as a mechanism for hospital administrators to assign worker accountability for medical errors and adverse events. In practice, is it an improvement on the blame-free approach? In general, it takes a long time, perhaps decades, for new ideas to catch on in medicine. Nearly 25 years after To Err is Human, most healthcare professionals understand the importance of patient safety and the system causation of medical errors and patient harm. The idea of a blame-free, non-punitive approach to handling medical errors is relatively easy to comprehend and is reassuring to healthcare workers. When it ","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"2674 1","pages":"56 - 58"},"PeriodicalIF":0.0,"publicationDate":"2023-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75771107","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Supply side stakeholders’ viewpoints about medical tourism in India and the effects of COVID 19","authors":"Jiwanjot Kaur Hira, Ratinder Kaur","doi":"10.1177/25160435231161125","DOIUrl":"https://doi.org/10.1177/25160435231161125","url":null,"abstract":"Medical tourism is a field where healthcare and travel both coincide. Herein, people from different parts of the world travel to different countries in order to avail world-class treatment at an affordable price. With the onset of COVID-19 pandemic, this industry has been hit hard. However, this industry has still reflected back the waves of COVID-19 and has emerged better. This paper has made an effort to comprehend the viewpoints and opinions of the providers that accept medical tourism in India. The participants were selected using judgement and snowball sampling. The data was gathered through semi-structured interviews conducted using both face-to-face method as well as telephonic method. The data was then analysed using Atlas.ti software to highlight the various factors affecting medical tourism as well as its interaction with COVID19 pandemic.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"28 1","pages":"78 - 88"},"PeriodicalIF":0.0,"publicationDate":"2023-03-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85181090","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The association of patient safety culture with patient satisfaction: The role of the pharmacist's performance","authors":"M. Alolayyan, Bushra M. Hijazi, R. A. Jalaileh","doi":"10.1177/25160435231160445","DOIUrl":"https://doi.org/10.1177/25160435231160445","url":null,"abstract":"Background and objective A cross-sectional research, the questionnaire-based study aimed to investigate the association between patient safety culture and patient satisfaction through pharmacist performance, between patient safety culture and pharmacist performance, between pharmacist performance and patient satisfaction, and between patient safety culture and patient satisfaction. Methods Pharmacists and pharmacy technicians working in the community pharmacies evaluated the patient safety culture using an online self-administrated questionnaire filled out by participants. The first research questionnaire was adopted from the agency of healthcare research and quality (AHRQ), which was reliable and valid. Pharmacist performance and patient satisfaction were measured by using an online self-completion questionnaire that patients filled out. To measure performance, a previously validated questionnaire was used. For measuring patient satisfaction, The Patient Satisfaction with Pharmacist Clinical Services Questionnaire the final version (PSPSQ 2.0) was used. A total of 204 pharmacists, pharmacy technicians, and 204 patients constitute the research sample. Results The results showed that there is a significant association between the patient safety culture and the pharmacist's performance; an insignificant association between the patient safety culture and patient satisfaction; a significant association between the pharmacist’s performance and patient satisfaction; and a pharmacist’s performance mediates the relationship between patient safety culture and patient satisfaction. Conclusion The pharmacy sector may effectively reinforce patient safety culture in community pharmacies and enhance pharmacists’ performance to improve the quality of care and increase patient satisfaction.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"6 1","pages":"68 - 77"},"PeriodicalIF":0.0,"publicationDate":"2023-02-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79258105","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Improving patient safety: Did we learn from the story of Jean-Pierre Adams?","authors":"David Mawufemor Azilagbetor, Maimuna Jawara","doi":"10.1177/25160435231157235","DOIUrl":"https://doi.org/10.1177/25160435231157235","url":null,"abstract":"The safety of surgery and anesthesia has seen many advances over the last several decades; however, the frequency of complications experienced by patients undergoing surgical operations remains high. Most of these complications are avoidable, with a considerable portion of surgical patient injuries originating from human factors. Telling stories and assessing what went wrong and why for lessons to be learned are proven methods used to improve patient safety in anesthesia. In this narrative, we revisited a case of an anesthesia mishap that occurred in 1982, leaving the victim in a coma for nearly four decades until his death in September 2021. The patient reported for his operation, but a number of the hospital's staff were on strike. His operation, however, went ahead and the reduction in anesthesia care team members and its consequential increase in workload resulted in a series of avoidable errors. Decades after this event, many of the issues identified still remain a challenge in anesthesia care; there are still lessons to learn. We identified and discussed three major issues of concern: the non-cancellation of his procedure amid a strike action, giving a delicate anesthetic duty to a trainee without active supervision, and poor coordination and teamwork among team members in the operating room.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"12 1","pages":"89 - 94"},"PeriodicalIF":0.0,"publicationDate":"2023-02-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89043223","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Risk mapping in community pharmacies","authors":"Joon Ho Lee, B. Aubert, James R. Barker","doi":"10.1177/25160435231154167","DOIUrl":"https://doi.org/10.1177/25160435231154167","url":null,"abstract":"Community pharmacists worldwide operate with the continual risk of errors (Quality Related Events—QREs) occurring in their dispensing processes. Contemporary analysis of community pharmacy QREs tends to concentrate on the outcomes of the error, such as the degree of patient harm, rather than on the risks associated with the triggering of a QRE. Drawing on risk identification and mapping techniques from the information security sector, we conducted a risk mapping exercise of QREs occurring in Canadian community pharmacies as identified in publicly available accident investigations. The findings from the present study identified relationships and patterns between various risk factors, types of errors, and patient outcomes. For example, the risk factors most associated with errors that result in patient fatality were the “sound-alike/look-alike” medication labeling and the dispensing checking and verification processes in the pharmacy. Study findings support the application of risk identification and mapping techniques to community pharmacy risk and QRE mitigation practices and regulations.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"13 1","pages":"59 - 67"},"PeriodicalIF":0.0,"publicationDate":"2023-02-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84288829","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Getting better: Staying ahead of the curve on patient safety","authors":"A. Wu","doi":"10.1177/25160435231156689","DOIUrl":"https://doi.org/10.1177/25160435231156689","url":null,"abstract":"In patient safety, we are witnesses to a disturbing paradox: Even as the field has developed and matured over its three decades of existence, adverse events persist. There has been no sign of an overall decrease in the number of these events. Harm due to health care continues to be alarmingly common. The clearest evidence is from the inpatient setting. In repeated studies of the frequency of patient harm in acute care hospitals worldwide, the needle appears to be stuck at around 10%. A few studies have found rates of harm to be even higher. A recent study found at least one adverse event in nearly a quarter of all admissions to hospitals randomly sampled in the US state of Massachusetts. There have been some advances in specific areas, most prominently in healthcare-acquired infections, led by reductions in catheter-related bloodstream infections. It has been possible to reduce deaths related to cardiac surgery, and general surgery using quality improvement strategies and the World Health Organization (WHO) safe surgery checklist. Although there have been others, they are more difficult to measure. During the pandemic, many of these gains have been wiped out, with increases in healthcare-acquired infections, falls, pressure injuries, and medication errors. There were also harms due to delays in diagnoses and provision of surgical care. But even without the pandemic-related problems, there are potential explanations for the apparent standstill in reductions in healthcare-related harm. Health care has become more complex, with many more individuals involved in delivering care, and more places for errors to slip through. There has been a profusion of new therapeutic modalities, each with its own benefits but also with new risks. Each new procedure also has its own learning curve, as demonstrated by the early surge in complications with the introduction of laparoscopic cholecystectomy. New medications, with increased potency, also carry new adverse effects. In addition, with changes in healthcare delivery, the average patient treated in the hospital is sicker than in the past. Noninvasive treatments allow sicker patients to be treated. Economic and other forces have resulted in shifts of many complex treatments from hospitals to ambulatory settings. In addition, the population is aging, resulting in a greater prevalence of patients living with multimorbidity, and subjected to polypharmacy. All these factors render inpatients less resilient and more vulnerable to adverse events. The COVID-19 pandemic has layered on additional risks to patient safety. The global shortage of health workers and the parallel pandemic of worker burnout further endanger patient safety. WHO projects a shortfall of 10 million health workers by 2030, mostly in lowand middle-income countries. However, even high-income countries face problems in the training, employment, performance, and retention of their workforce. The problem of health worker burnout had already reached crisi","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"46 1","pages":"3 - 4"},"PeriodicalIF":0.0,"publicationDate":"2023-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91386352","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Perioperative safety determinants in ethnic patient groups","authors":"G. Bloo, H. Calsbeek, G. Westert, W. Dekkers, G. Akkersdijk, Robbert Jan van Krugten, A. Wolff, H. Wollersheim","doi":"10.1177/25160435231151545","DOIUrl":"https://doi.org/10.1177/25160435231151545","url":null,"abstract":"Background In a Dutch hospital, unexpectedly, safer perioperative care was found in non-western ethnic minority patients compared to Dutch ethnic majority patients undergoing high-risk surgery with a mortality risk >1%. We explored determinants in order to find tools for nurses and physicians to improve patients’ safety and safety experience during the perioperative period. Methods A qualitative grounded theory design was applied to understand patients’ perspective on their needs and safety in the perioperative period we interviewed patients (n = 17). Results Three themes emerged: ‘Nurse & physician behaviour’, ‘Team performance’, and ‘Patient behaviour’. In the first theme ‘Nurse and physicians’ behaviour’, positive determinants related to an attitude of experienced professionals that provide patients with trust. On the other hand, negative determinants provide patients with experiences of unsafety. In the second theme ‘Team performance’, positive determinants involved effective communication and coordinated care of the nurses and physicians. Negative determinants related to visible disagreement about the treatment. In the third theme ‘Patient behaviour’, positive determinants related to seeking support from nurses, physicians, and family to recover and to endure an anxious period. Negative determinants related to missing appointments or not consulting the information provided. Conclusion and practice implications ‘Nurse & physician behaviour’ and ‘Team performance’ are relevant determinants that contribute to patients’ experiences of safe care. Stimulating an active attitude of patients in seeking support may contribute to experiences of safe care. These results can be used to improve patients’ experience of safe care in an uncertain and vulnerable perioperative period.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"75 1","pages":"31 - 46"},"PeriodicalIF":0.0,"publicationDate":"2023-01-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86379305","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Strengths and weaknesses of the incident reporting system: An Italian experience","authors":"Marcello Benevento, Simona Nicolì, G. Mandarelli, D. Ferorelli, G. Cicolini, M. Marrone, A. Dell'Erba, B. Solarino","doi":"10.1177/25160435221150568","DOIUrl":"https://doi.org/10.1177/25160435221150568","url":null,"abstract":"One of the cornerstones for enhancing the patient safety culture is the incident reporting system (IRS). It is a process for detecting, reporting, collecting, and summarizing adverse events (AEs) and near-misses in healthcare, and so it represents a vital tool for clinical risk management. We analyzed the 5-year experience of a third-level hospital's IRSs, showing its trends and highlighting its main strengths and weaknesses. Patients’ falls and physical or verbal aggression toward the providers or between patients are the most reported events. Underreporting is the main limitation of the system, especially among nurses. Visible actions, forceful analysis of the reports, operators’ education, no-blame culture promotion, and organizational adjustments may improve operators’ adherence to IRS. Providers do not willingly inform patients’ relatives about fatal incidents. Despite that, the IRS is far from its potential, and the number of data collected has increased.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"188 1","pages":"15 - 20"},"PeriodicalIF":0.0,"publicationDate":"2023-01-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83450087","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Comparing caesarean birth rates: An institutionalized habit that is hard to break","authors":"Pauline McDonagh Hull","doi":"10.1177/25160435221150373","DOIUrl":"https://doi.org/10.1177/25160435221150373","url":null,"abstract":"Commissioned by the UK government’s Secretary of State for Health and Social Care in 2017, the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust (SaTH) uncovered prolonged systemic failings, and led to an unprecedented police investigation into hundreds of deaths. Critically, the review culminated in two reports (December 2020 and March 2022) outlining 22 Immediate and Essential Actions (IEAs) to improve the safety of maternity services, that must be implemented at all trusts in England. The argument presented here is that the scope of these actions fell short, and this will have significant repercussions. Specifically, the IEAs ignored one of the review’s most glaring findings: evidence of harmful attitudes and actions around monitoring and comparing caesarean births, while perceiving a low rate as ‘the essence of good maternity care’. Responding to the final report, the President of the Royal College of Obstetricians and Gynaecologists (RCOG), Dr Edward Morris, assured the public this was ‘a watershed moment for maternity care’. He promised the college was ‘committed to enacting change,’ and owed it to families ‘to act on the recommendations’. In the same vein, Richard Stanton and Rhiannon Davies, whose newborn daughter Kate’s death in 2009 was the primary catalyst for the SaTH review, described how various bodies responsible for ensuring safety had failed in their duties; they insisted their experience ‘should never be allowed to happen again’. However, even accounting for the slow pace of change in the National Health Service (NHS), there are already signs that a cultural and structural inattentional blindness to bias against caesarean birth persists, and in the absence of clear, complete and consistent instructions for trusts, lessons have not been learned.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"21 1","pages":"5 - 8"},"PeriodicalIF":0.0,"publicationDate":"2023-01-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82220510","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}