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Patient safety, human error

David C Classen, William Munier, Nancy Verzier, Noel Eldridge, David Hunt, Mark Metersky, Chesley Richards, Yun Wang, P Jeffrey Brady, Amy Helwig, James Battles
The explicit declaration in the landmark 1999 Institute of Medicine report "To Err Is Human" that, in the United States, 44,000 to 98,000 patients die each year as a consequence of "medical errors" gave widespread validation to the magnitude of the patient safety problem and catalyzed a number of U.S. federal government programs to measure and improve the safety of the national healthcare system. After more than 10 years, one of those federal programs, the Medicare Patient Safety Monitoring System (MPSMS), has reached a level of maturity and stability that has made it useful for the consistent measurement of the safety of inpatient care...
October 20, 2016: Journal of Patient Safety
Megan Delisle, Ruby Grymonpre, Rebecca Whitley, Debrah Wirtzfeld
Clinical errors due to human mistakes are estimated to result in 400,000 preventable deaths per year. Strategies to improve patient safety often rely on healthcare workers' ability to speak up with concerns. This becomes difficult during critical decision-making as a result of conflicting opinions and power differentials, themes underrepresented in many interprofessional initiatives. These elements are prominent in our interprofessional initiative, namely Crucial Conversations. We sought to evaluate this initiative as an interprofessional learning (IPL) opportunity for pre-licensure senior healthcare students, as a way to foster interprofessional collaboration, and as a method of empowering students to vocalise their concerns...
August 11, 2016: Journal of Interprofessional Care
Kyoung Ok Kim
Patient safety has become an important policy agenda in healthcare systems since publication of the 1999 report entitled "To Err Is Human." The paradigm has changed from blaming the individual for the error to identifying the weakness in the system that led to the adverse events. Anesthesia is one of the first healthcare specialties to adopt techniques and lessons from the aviation industry. The widespread use of simulation programs and the application of human factors engineering to clinical practice are the influences of the aviation industry...
October 2016: Korean Journal of Anesthesiology
Peter L Elkin, Henry C Johnson, Michael R Callahan, David C Classen
Medical errors and patient safety issues remain a significant problem for the healthcare industry in the United States. The Institute of Medicine report To Err is Human reported that there were as many as 98,000 deaths per year due to medical error as of 1999. Many authors and government officials believe that the first step on the path to improvement in patient safety is more comprehensive collection and analysis of patient safety events. The belief is that this will enable safety improvements based on data showing the nature and frequency of events that occur, and the effectiveness of interventions...
September 29, 2016: Journal of Biomedical Informatics
M Chaneliere, F Jacquet, P Occelli, S Touzet, V Siranyan, C Colin
BACKGROUND: The assessment of patient safety culture refers mainly to surveys exploring the perceptions of health professionals in hospitals. These surveys have less relevance when considering the assessment of the patient safety culture of medical students, especially at university or medical school. They are indeed not fully integrated in care units and constitute a heterogeneous population. This work aimed to find appropriate assessment tools of the patient safety culture of medical students...
September 29, 2016: BMC Medical Education
Emma Stewart-Parker, Robert Galloway, Stella Vig
BACKGROUND: Possessing adequate nontechnical skills (NTS) in operating theaters is of increasing interest to health care professionals, yet these are rarely formally taught. Teams make human errors despite technical expertise and knowledge, compromising patient safety. We designed a 1-day, multiprofessional, multidisciplinary course to teach, practice, and apply these skills through simulation. METHODS: The course, "S-TEAMS," comprised a morning of lectures, case studies, and interactive teamworking exercises...
September 20, 2016: Journal of Surgical Education
Urs Pietsch, Jürgen Knapp, Ludwig Ney, Armin Berner, Volker Lischke
OBJECTIVE: Mountain helicopter rescue operations often confront crews with unique challenges in which even minor errors can result in dangerous situations. Simulation training provides a promising tool to train the management of complex multidisciplinary settings, thus reducing the occurrence of fatal errors and increasing the safety for both the patient and the helicopter emergency medical service (HEMS) crew. METHODS: A simulation-based training, dedicated to mountain helicopter emergency medicine service, was developed and executed...
September 2016: Air Medical Journal
Julian Danino, Jameel Muzaffar, Chris Metcalfe, Chris Coulson
Human evaluation and judgement may include errors that can have disastrous results. Within medicine and healthcare there has been slow progress towards major changes in safety. Healthcare lags behind other specialised industries, such as aviation and nuclear power, where there have been significant improvements in overall safety, especially in reducing risk of errors. Following several high profile cases in the USA during the 1990s, a report titled "To Err Is Human: Building a Safer Health System" was published...
September 13, 2016: European Archives of Oto-rhino-laryngology
Heidi S Kramer, Frank A Drews
OBJECTIVE: We conducted a literature search to examine the effects and experiences surrounding the transition from paper to electronic checklists in healthcare settings. We explore the types of electronic checklists being used in health care, how and where they were evaluated and seek to identify the successes and failures of using electronic checklists in healthcare, including use of checklists to ensure completeness of documentation in the electronic medical record. BACKGROUND: Formalized checklist use as a memory and decision aid in aviation has resulted in significant increases in safety in that domain...
September 10, 2016: Journal of Biomedical Informatics
Antonella Casiraghi, Silvia Franzè, Paolo Rocco, Paola Minghetti
PURPOSE: The different stages of antineoplastic agent management build up a complex process, from supply to prescription, preparation, and administration. All steps in this process must be carefully monitored in order to control/reduce the risk of errors that can impact on patient safety. This work overviews the prevention of medication errors in oncology, including regulatory and legislative frameworks with specific reference to the Raccomandazione 14 (Recommendation 14) issued by the Italian Ministry of Health...
August 29, 2016: Tumori
R Seemann, M Münzberg, R Stange, M Rüsseler, M Egerth, B Bouillon, R Hoffmann, M Mutschler
Patient safety has increasingly gained significance as criterion which clinics and doctors will be measured against in terms of ethics and finances. The "human factor" moved into focus regarding the question of how to reduce treatment errors in clinical daily routine. Nevertheless, systematic mediation of interpersonal competences only plays a minor role in the catalogue of requirements for medical specialization and professional training. This is the case not only in orthopedics and traumatology, but in other medical fields as well...
October 2016: Der Unfallchirurg
Gabriella da Silva Rangel Ribeiro, Rafael Celestino da Silva, Márcia de Assunção Ferreira, Grazielle Rezende da Silva
OBJECTIVE: Toidentify the occurrence of errors in the use of equipment by nurses working in intensive careandanalyzing them in the framework of James Reason's theory of human error. METHOD: Qualitative field study in the intensive care unit of a federal hospital in the city of Rio de Janeiro. Observation and interviews were conductedwith eight nurses, from March to December 2014. Content analysis was used for the interviews, as well as the description of the scenes observed...
May 2016: Revista da Escola de Enfermagem da U S P
Moninne Howlett, Michael Curtin, Dermot Doherty, Paula Gleeson, Michelle Sheerin, Cormac Breatnach
AIM: Wide scale implementation of paediatric standardised concentration infusions (SCIs) and the use of smart pump technology has been slow despite international safety agency recommendations. Implementation rates in European hospitals fall far below those in the United States, where for the last decade accreditation has been linked to implementation.1 2 Multidisciplinary collaboration is essential, with pharmacy input and the creation of a smart pump drug library recognised as often being limiting, yet crucial factors, to implementation...
September 2016: Archives of Disease in Childhood
Ben Green, David Parry, Rachel S Oeppen, Simon Plint, Trevor Dale, Peter A Brennan
A thorough understanding of the role of human factors in error in health care for improving patient safely is paramount. One area particularly crucial for optimising clinical performance is the recognising the importance of situational awareness. Loss of situation awareness can occur in many different settings, particularly during stressful and unexpected situations. Tunnel vision is a classic example where clinicians focus on one aspect of care, often to the detriment of overall patient management. Loss of situational awareness can result in serious compromise to patient safety if it is not recognised by either the individual or clinical team...
July 22, 2016: Oral Diseases
Lynn K D'Esmond
PROBLEM: Distracted practice is the result of individuals interacting with the environment and technology in the performance of their jobs. The resultant behaviors can lead to error and affect patient safety. METHODS: A qualitative descriptive approach was used that integrated observations with semistructured interviews. The conceptual framework was based on the distracted driving model. FINDINGS: There were 22 observation sessions and 32 interviews (12 RNs, 11 MDs, and 9 pharmacists) completed...
July 19, 2016: Nursing Forum
Rainer Gaupp, Mirjam Körner, Götz Fabry
BACKGROUND: Patient safety (PS) is influenced by a set of factors on various levels of the healthcare system. Therefore, a systems-level approach and systems thinking is required to understand and improve PS. The use of e-learning may help to develop a systems thinking approach in medical students, as case studies featuring audiovisual media can be used to visualize systemic relationships in organizations. The goal of this quasi-experimental study was to determine if an e-learning can be utilized to improve systems thinking, knowledge, and attitudes towards PS...
2016: BMC Medical Education
Emine Aysu Şalvız, Saadet İpek Edipoğlu, Mukadder Orhan Sungur, Demet Altun, Mehmet İlke Büget, Tülay Özkan Seyhan
OBJECTIVE: Critical incident reporting systems (CIRS) and morbidity-mortality meetings (MMMs) offer the advantages of identifying potential risks in patients. They are key tools in improving patient safety in healthcare systems by modifying the attitudes of clinicians, nurses and staff (human error) and also the system (human and/or technical error) according to the analysis and the results of incidents. METHODS: One anaesthetist assigned to an administrative and/or teaching position from all university hospitals (UHs) and training and research hospitals (TRHs) of Turkey (n=114) was contacted...
April 2016: Turkish Journal of Anaesthesiology and Reanimation
Wan-Ting Wu, Yung-Lung Wu, Shaw-Min Hou, Chun-Mei Kang, Chi-Hung Huang, Yu-Ju Huang, Victoria Yue An Wang, Pa-Chun Wang
This article reports the results from a study that employed an interprofessional crew resource management (CRM) education programme in the emergency and critical care departments. The study aimed to investigate the effectiveness of this intervention of participants' satisfaction and safety attitude changes using a satisfaction questionnaire and the Human Factors Attitude Survey (HFAS). Overall, participants responded positively to the CRM training-93.4% were satisfied, 93.1% agreed that it enhanced patient safety and care quality, 85...
July 2016: Journal of Interprofessional Care
Yasamin Molavi Taleghani, Fatemeh Rezaei, Hojat Sheikhbardsiri
BACKGROUND: Ensuring about the patient's safety is the first vital step in improving the quality of care and the emergency ward is known as a high-risk area in treatment health care. The present study was conducted to evaluate the selected risk processes of emergency surgery department of a treatment-educational Qaem center in Mashhad by using analysis method of the conditions and failure effects in health care. METHODS: In this study, in combination (qualitative action research and quantitative cross-sectional), failure modes and effects of 5 high-risk procedures of the emergency surgery department were identified and analyzed according to Healthcare Failure Mode and Effects Analysis (HFMEA)...
2016: World Journal of Emergency Medicine
Elimor Brand-Schieber, Sagar Munjal, Rajesh Kumar, Anthony D Andre, Will Valladao, Margarita Ramirez
BACKGROUND: Migraine pain relief is reported by more than 50% of patients who receive low dose (3 mg) of sumatriptan. Currently, there is no two-step autoinjector of low-dose sumatriptan available on the market for acute migraine treatment. To fulfill this need, a fully assembled, single-dose, subcutaneous autoinjector (sumatriptan 3 mg; product-code DFN-11) was developed. The device allows for injection with a simple two-step, push-to-inject process and provides feedback of the injection activation, progress, and completion...
2016: Medical Devices: Evidence and Research
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