Journal of patient safety and risk management最新文献

{"title":"Stakeholder perspectives on ‘Swiss quality’ healthcare in the context of inbound medical tourism to Switzerland: An exploratory qualitative study","authors":"João Couceiro, B. Elger, P. Satalkar","doi":"10.1177/25160435221102124","DOIUrl":"https://doi.org/10.1177/25160435221102124","url":null,"abstract":"Background Global literature on medical travel focuses on patients from high-income countries traveling to middle-income countries reputed for providing high quality care at significantly lower costs. However, little is known about the movement of wealthy foreign patients to high-income countries such as the USA, the UK or Switzerland. Objective In this paper, we focus on Swiss medical tourism stakeholders and their strategies to attract a niche of self-paying foreign patients to undergo medical treatment in Switzerland. We describes how they harness the label of ‘Swiss quality’ healthcare to promote Switzerland in global medical travel industry. Methods We conducted semi-structured, in-depth interviews with 30 medical tourism stakeholders including 15 healthcare professionals (HCPs) treating self-paying foreign patients in publicly funded and privately owned hospitals in French- and German-speaking regions of Switzerland. The data were inductively coded using thematic analysis. Results We present their views on ‘Swiss quality’ healthcare under three themes: health-related human resources, Swiss medical infrastructure, and foreign patients’ perceived trust in the ‘Swiss quality’ label. Participants equated Switzerland's global image and ‘Swiss quality’ as a ‘brand’ and believed that foreign patients’ trust in ‘Swiss quality’ is a unique selling point of Swiss healthcare system. Conclusion By problematizing the use of ‘Swiss quality’ label to attract wealthy patients to Switzerland, we highlight a few ethical questions that deserve further scrutiny.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"3 1","pages":"111 - 123"},"PeriodicalIF":0.0,"publicationDate":"2022-05-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89773829","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":"Safety-II and the study of healthcare safety routines: Two paths forward for research","authors":"Christofer Rydenfält","doi":"10.1177/25160435221102129","DOIUrl":"https://doi.org/10.1177/25160435221102129","url":null,"abstract":"Safety routines such as the WHO surgical safety checklist and SBAR have gained widespread attention and implementation in healthcare. However, there has also been criticism. With the ongoing Covid-19 pandemic, the need for knowledge about how safety routines work in practice is larger than ever. In light of these obstacles, I suggest two approaches to the study of healthcare safety routines, based on a human factors perspective and a safety II mind-set that so far has gained little attention. The WHO surgical safety checklist, is used as an example. However, the suggestions presented here applies to other safety routines as well. The first approach is that instead of being preoccupied with what people do not do, investigate what they value with the routine. The perceived importance of different parts of the routine can expose the rationality behind the personnel's choice of actions when using the routine. Knowledge that could be used both to investigate the dynamics of everyday performance and for redesign and adjustment of the routine. The second approach is that instead of looking for failure, investigate and highlight when the routine works. Examples of when the routine works, i.e. avert adverse events, can be used both as positive reinforcement, and as an opportunity for learning with regards to everyday performance variability. Since a safety-II perspective is largely missing in the literature on healthcare safety routines, the two approaches suggested here comes with a huge potential for learning about how to improve safety.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"123 1","pages":"124 - 128"},"PeriodicalIF":0.0,"publicationDate":"2022-05-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89654134","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":"Mentorship in patient safety: Do we need a new approach?","authors":"A. Wu","doi":"10.1177/25160435221094690","DOIUrl":"https://doi.org/10.1177/25160435221094690","url":null,"abstract":"I still remember the day the package arrived. As a young assistant professor at John Hopkins, I was happy to see it was from my mentor, Steve McPhee. Inside, was the draft of a manuscript I had started more than 5 years earlier, but never finished. In the accompanying letter, he exhorted me to resume work on the draft, which affirmed the ethical imperative to disclose errors to patients and their families, and explained how to do it. He said it was important. Oh, and he had found another collaborator, rewritten the draft, and filled out the forms for submission to JAMA – with me as the first author. ‘This is your paper’ he coaxed. ‘It just needs a bit more work – I’d be happy to help.’ Many drafts and many more hours of his time later, the paper was published, and was covered the same week in the New York Times. I continue to this day to work on the topic of disclosing adverse events to patient and families. Mentors are role models who help guide the personal and professional development of their students over time. At least as far back as when Odysseus asked the “wise and faithful” Mentor to educate his son, trusted and experienced people have taught, coached, sponsored and connected the young. One of my colleagues described a mentor as someone “who doesn’t rest until you have succeeded.” Mentorship has long played a critical role in the training and career development of physicians and scientists. A growing body of research has documented the impact of mentorship on outcomes including number of research papers published, grants received, and career satisfaction. But relatively little has been written about mentorship and patient safety. Harrison and colleagues suggested that providing mentors to newly appointed attending physicians could help enhance patient safety. The same authors suggested that having a mentor may contribute to reducing preventable harm to patients, perhaps through service as coaches to improve clinician performance. An exploratory study by Shepherd suggested that positive experiences with mentorship can help physicians learn from medical errors. We are not aware of a study suggesting beneficial outcomes of mentorship for research and careers in patient safety. However, Singh has written about the importance of mentorship in supporting patient safety researchers. My personal experience, and a study by Brancati and colleagues on predictors of success in academic medicine in general, suggest that early mentoring experiences could be important. I ventured into the field of patient safety at the start of my career in research. This was before patient safety could properly be called a field, at a time when the topic was still referred to as “medical error.” I attribute much of my early success to exceptionally good luck in finding mentors. In 1987, having completed a residency in internal medicine and a subsequent year working in an AIDS clinical trials unit, I applied to be a Clinical Scholar in a health service research and pol","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"59 1","pages":"53 - 55"},"PeriodicalIF":0.0,"publicationDate":"2022-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86113556","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":"Who killed patient safety?","authors":"Carole Hemmelgarn, M. Hatlie, Susan E. Sheridan, Beth Daley Ullem","doi":"10.1177/25160435221077778","DOIUrl":"https://doi.org/10.1177/25160435221077778","url":null,"abstract":"The medical community’s commitment to patient safety has withered to over the past 10–15 years after the original call to action in 2000 with the release of the IOM report, To Err is Human. The tragedy of this decline in action around safety lies in the lives of the families like ours, who have lost loved ones, been harmed, and often permanently injured by medical error. What was once a motivating call to action, safety in hospitals and oversight by our government has been deprioritized, defunded, and devalued leaving patients like us to wonder: What happened to Patient Safety? When the To Err is Human (IOM) report was released in 2000 it estimated that 44,000–98,000 people lose their lives every year from medical errors in U.S. hospitals. The medical community was appalled by the estimate of preventable death and injury from medical errors to patients as identified in the seminal report. More recent research published by John James, in 2013, and Marty Makary, in 2016, suggested the original estimates underrepresented the amount of harm to patients caused by medical care which amounted to 400,000 or more lives a year. In To Err is Human, the IOM called for a public-private partnership to reduce medical errors by ninety percent in 10 years. And as a follow up in its 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century, the IOM positioned patient safety as fundamental to healthcare transformation. Twenty years later, other than infection control to anesthesia, the American hospitals have not progressed in systemically meeting patient safety goals, and the medical community seems to have lost its commitment to safety. Unsafe healthcare now vies with Covid-19 as the third largest cause of preventable death in the United States, and many of those who used to be champions for safety have moved on to other issues. Yet, we the patients and families, know safety is fundamental, not something that can ever fall off the list of priorities since it is a critical part of safe care every patient deserves. Earlier this year a peer review committee of the National Academy of Sciences (NAS), which now houses the IOM, published a discouraging report on the current strategies to improve patient safety finding:","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"12 1","pages":"56 - 58"},"PeriodicalIF":0.0,"publicationDate":"2022-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75108125","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":"Studies on the second victim phenomenon and other related topics in the pan-European environment: The experience of ERNST Consortium members","authors":"I. Carrillo, Susanna Tella, R. Strametz, K. Vanhaecht, M. Panella, S. Guerra-Paiva, Bojana Knezevic, M. Ungureanu, E. Srulovici, S. Buttigieg, P. Sousa, J. Mira","doi":"10.1177/25160435221076985","DOIUrl":"https://doi.org/10.1177/25160435221076985","url":null,"abstract":"Background Patient safety is a priority worldwide. When things go wrong in the provision of patient care, the healthcare professionals involved can be psychologically affected (second victims, SVs). Recently, different initiatives have been launched to address this phenomenon. Aim To identify through the ERNST Pan-European Consortium the current study lines in Europe on SVs and other topics related to how the lack of well-being of healthcare professionals can affect the quality of care. Methods A cross-sectional study was conducted based on an ad hoc online survey. All 82 academics and clinicians who had formalized their membership to the COST Action 19113 by September 2020 and represented 27 European and one neighboring country were invited to participate. The survey consisted of 19 questions that explored the participants’ scientific profile, their interests, and previous experiences in the SVs’ topic, and related areas of work in Europe. Results Seventy (85.4%) COST Action members responded to the survey. Thirty-seven (37.1%) had conducted SV studies in the past or were doing so at the moment of the survey. Seventeen participants were involved in implementing interventions to support SVs. Future lines of study included legal issues, open disclosure, training programs, and patient safety curricula. Conclusions Studies have been conducted in Europe on the magnitude of the SV phenomenon and the usefulness of some techniques to promote resilience among healthcare professionals. New gaps have been identified. The COST Action 19113 aims to foster European collaboration to reinforce the healthcare professionals’ well-being and thus contribute to patient safety.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"18 1","pages":"59 - 65"},"PeriodicalIF":0.0,"publicationDate":"2022-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73656581","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":"Healthcare-related infections within nursing homes (NHS): A qualitative study of care practices based on a systemic approach","authors":"G. Lefosse, L. Rasero, T. Bellandi, P. Sousa","doi":"10.1177/25160435221081105","DOIUrl":"https://doi.org/10.1177/25160435221081105","url":null,"abstract":"Background Infectious events, often related to healthcare practice, occur frequently within Nursing Homes (NHs), representing one of the main causes for morbidity, hospital admissions and mortality. The aims of this study are the analysis of care delivery problems and contributory factors of healthcare-related infections in a sample of NHs. This research could help identify organizational, technological and behavioural aspects, to implement improvement actions and reduce the impact of infections in long-term care. Methods The study is a qualitative research with a systemic approach, based on the analysis of interactions in real practice between human factors, technologies and organizational structure and processes in 7 NHs in Tuscany (Italy), through extensive and structured observations of daily practices. The collected data were analyzed by applying clinical and ergonomic competences, comparing the data collected with established safe practices. The study was conducted by a nurse and a psychologist Results From the data several problems related to infection control emerge. Buildings are often not suitable for confined spaces, room ventilation, natural light and rapid emergency response. Hand washing is not sufficient, use of antibiotics is usually not adequate. The microclimate is often not adequate, hygienic procedures are not always flawless. Staff members are in small numbers. Discussions This study highlights high risk of contracting infections related to NHs. The study shows that dedicated infection prevention guidance are needed, to develop a local plan integrated with hospital setting, customized to needs of guests and characteristics of long-term care facilities, supported by a deep understanding of daily practices.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"134 1","pages":"66 - 75"},"PeriodicalIF":0.0,"publicationDate":"2022-03-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79480262","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":"Pointing and calling the way to patient safety: An introduction and initial use case","authors":"E. Violato, Iris Cheng In Chao, Charlotte McCartan, B. Concannon","doi":"10.1177/25160435221078099","DOIUrl":"https://doi.org/10.1177/25160435221078099","url":null,"abstract":"Background Using tools from outside healthcare can help improve patient safety. Pointing and Calling (Shisa Kanko) is an operational procedure developed for industry in Japan to prevent human error and has been used in healthcare in Asian countries to reduce errors during medication administration. Pointing and Calling affects cognitive task switching by pointing to a place or object and calling out the operation to be performed. Aim Conduct an initial use case to examine the willingness and ability of healthcare professionals in a Western country to use Pointing and Calling. Methods An observational initial use case was conducted with nineteen Advanced Care Paramedic students. Confidence, perceptions, and use of Pointing and Calling were measured during a simulated clinical scenario along with facilitator perceptions. Results After the simulation participants were confident in their ability to use Pointing and Calling, found the method to be beneficial, and indicated they would use Pointing and Calling in the future. Participants often used the method for tasks such as checking vitals. Aspects of the method requiring clarification and more training were identified. Facilitators indicated the method appeared beneficial during simulations and could be incorporated into existing curriculum. Conclusions The benefits of Pointing and Calling are readily apparent to students and facilitators and both groups are receptive to the method. Pointing and Calling is low risk with substantial potential benefits. With more education and training Pointing and Calling could be effectively implemented.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"22 1","pages":"86 - 93"},"PeriodicalIF":0.0,"publicationDate":"2022-02-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84401795","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":"An uncommon unintentionally retained foreign object (URFO): The retained surgical specimen","authors":"A. Simioni, Ryan B. Fransman, B. Safar, E. Haut, C. Atallah","doi":"10.1177/25160435221077802","DOIUrl":"https://doi.org/10.1177/25160435221077802","url":null,"abstract":"Unintentionally Retained Foreign Objects (URFO) are an uncommon, but significant type of patient harm. Retained surgical specimens are new entities that accompanied the surge of minimally invasive surgery (MIS). Despite being rare sentinel events, they are associated with increased morbidity, healthcare cost, and liability. We present a case of a retained surgical specimen, identified after surgical closure but before patient extubation, thanks to routine utilization of end-of-procedure checklists.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"90 1","pages":"83 - 85"},"PeriodicalIF":0.0,"publicationDate":"2022-02-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83076284","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":"MR- safety: Evaluation of compliance with screening routines using a structured screening interview","authors":"B. Hansson, Matea Simic, J. Olsrud, K. Markenroth Bloch, T. Owman, P. Sundgren, I. Björkman-Burtscher","doi":"10.1177/25160435221077493","DOIUrl":"https://doi.org/10.1177/25160435221077493","url":null,"abstract":"Background Magnetic resonance (MR) safety procedures are designed to allow patients, research subjects and personnel to enter the MR-scanner room under controlled conditions and without the risk to be harmed during the examination. Ferromagnetic objects in the MR-environment or inside the human body represent the main safety risks potentially leading to human injuries. Screening for MR-safety risks with dedicated procedures is therefore mandatory. As human errors during the screening procedure might align and lead to an incident compliance is essential. Purpose To evaluate compliance with a documented structured MR-safety screening process. Method Written and signed MR-safety screening documentation collected at a national 7T MR facility during a four-year period was evaluated for compliance of trained personnel with multi-step MR-safety routines. We analysed whether examinations were performed or why they were not performed. Data analysis further included descriptive statistics of the study population (age, gender and patient or healthy volunteer status), identification of missing documents and omitted or incorrect answers, and whether these compliance shortcomings concerned predominantly administrative or MR-safety related issues. Results Documentation of the screening process in 1819 subjects was incomplete in 19% of subjects. The most common documentation shortcoming was omitted fields. Out of 478 omitted answer-fields in 307 subjects, 36% were of administrative nature and 64% related directly to MR-safety issues. Conclusion Compliance with MR-safety screening procedures cannot be taken for granted and deficiencies to comply with screening routines were revealed. Documentation shortcomings concerned both administrative and MR-safety related issues.","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"11 1 1","pages":"76 - 82"},"PeriodicalIF":0.0,"publicationDate":"2022-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89497742","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":"To improve patient safety, lean in","authors":"A. Wu, M. Norvell","doi":"10.1177/25160435221081661","DOIUrl":"https://doi.org/10.1177/25160435221081661","url":null,"abstract":"Early in the last decade, “lean in” became a rallying cry for women in business, taken from the title of the book by Sheryl Sandberg, then Chief Operating Officer of Facebook, and her collaborator Neil Scovell. The expression was orginally intended to encourage women to confront workplace discrimination and aim for leadership roles. Since then, it has taken on a broader meaning, i.e., to “take on or embrace something difficult or unpleasant, usually through determination or perseverance; to find a way to benefit from, or alleviate the harm of, risk, uncertainty and difficult situations.” The expression has practical and even literal meaning in our field of health care. Recently, one of us (MN) went to see a patient in a pediatric neuro-behavioural unit. It is a place with a high staff-to-patient ratio because these patients have an elevated likelihood of being dangerous to themselves and those around them. As he was being oriented to the unit he noticed all the staff members were wearing jackets with thick sleeves, arm protection, and sturdy face shields. He asked his nurse guide about this and she said, “You never know what will happen here. If a patient bites you, don’t follow your instinct and pull away—you will make it a worse injury. If you are bitten, lean into them. It will put them off balance and others will come to help.” When attacked, when cornered, when you don’t know your next move, rather than react and run, lean into the situation. Leaning in, and the mindset that goes along with it, can improve patient safety, and help to foster a culture of safety. Important examples include disclosing adverse events to patients and families, supporting distressed colleagues, and addressing workarounds and near misses. As humans, most of us have an aversion to confronting difficult conversations. Every clinician has certainly been there. We know there are times when we must talk to a patient about something awkward and potentially volatile. Even though we know that we should have that conversation, sometimes we avoid it. Disclosing adverse events is an important example. Harmful medical errors cause great distress for patients and their families. Physicians know that when they make a mistake, they should attempt to correct it, disclose it to the patient, and apologize. It is the patient’s right to know when they have been injured by an error, and disclosure is an important component of professionalism in medicine. However, physicians are afraid of the reactions these disclosures may elicit, and that they could harm their personal careers. In reality, there is considerable evidence that supports disclosure of adverse events to patients, including some suggesting that it is helpful in resolving the issue and does not increase the chances of legal action. And, although an apology does not erase the adverse event, it can have profound healing effects for both the patient and physician. The right strategy for organizations and individuals is to lean ","PeriodicalId":73888,"journal":{"name":"Journal of patient safety and risk management","volume":"105 1","pages":"3 - 5"},"PeriodicalIF":0.0,"publicationDate":"2022-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80703286","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}