Awareness Of Patient Safety Research Articles

放射線部の医療安全における危険予知トレーニング(KYT)導入の効果

In this report, we evaluated whether radiological technologists' (RTs') awareness of patient safety would improve and what kind of effects would be seen at the department of radiological technology by introducing KYT [K: kiken (hazard), Y: yochi (prediction), T: (training)]. KYT was carried out by ten RTs based on a KYT sheet for the department of radiological technology. To evaluate the effects of KYT, we asked nine questions each to ten participants before and after KYT enforcement with regard to their attitude to patient safety and to operating procedures for working safely. Significant improvements after KYT enforcement were obtained in two items concerning medical safety: It is important for any risk to be considered by more than one person; The interest in preventive measures against medical accident degree conducted now) and one concerning operating procedures (It is necessary to have a nurse assist during testing with the mobile X-ray apparatus) (p<0.05). Performing KYT resulted in improved awareness of the importance of patient safety. KYT also enabled medical staffers to evaluate objectively whether the medical safety measures currently performed would be effective for patients.

Application of the hospital survey on patient safety culture (HSOPSC) to dentistry

Copyright © 2013 by Journal of Korean Academy of Oral Health This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives: The topic of patient safety has recently gained attention across healthcare institutes. Building a broad awareness of patient safety issues among dental care personnel, thus establishing a sound patient safety culture, has beneficial prophylactic effects on the quality assurance of dental care services. This study examines the adequacy and validity of the Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire developed by the Agency for Healthcare Research and Quality (AHRQ) for application to Korean dental care institutes. Methods: The HSOPSC, which is a self-administered questionnaire survey, was administered to dental care workers who participated in the 2011 Dental Care Quality Assurance Symposium. The reliability and construct validity of the questionnaire were tested using STATA 11.0; factor, reliability, and correlation analyses were performed. Results: Awareness of patient safety was dealt with in 10 subareas comprising 38 items. The 10 subareas were included patient safety policy at the institute level, open communication, patient safety-related expectations and behaviors of managers, frequency of reporting on patient safety-related incidents, and teamwork within the department. Both the construct validity and internal consistency of each factor were confirmed to be adequate. Conclusions: The results of the adequacy test for the application of this questionnaire to dental care institutes revealed that most items had a certain level of validity and reliability. However, it is necessary to reflect upon the specificity of dental care services to assess patient safety culture within dental care institutes more accurately.

Patient Safety Movement in the Hospital and Public Health Center

Hospitals and public health care center are fraught with hazards, which may threaten patient safety. Thus, patient safety movement in the hospital and public health center are critical to be performed as a promotion to enhance the awareness of patient safety as well as a prevention of the incident of patient safety. The program which was conducted in 2012 aimed to improve visitors' behavior in safety in the Fatmawati General Hospital and Beji Primary Health Center that eventually may increase the degree of community health quality. This program consisted of reassessment (Focus Group Discussion), observation, giving questionnaire to workers and visitors in the hospital and public health care), planning, implementation (providing education and warning media, books titled Safe in Hospital and Public Health Center, physical facilities, and socializing patient safety movement in the hospital and public health center), and evaluation. This activity reached an agreement on the action plan to continue the patient safety movement in their institutions. This activity could be a model for other hospitals and public health care centers, which have not yet implemented patient safety program. Keywords- hazard, hospital, nurses, patient safety, public health center.

Avoiding never events: Improving nasogastric intubation practice and standards

To identify and rectify weaknesses in nasogastric (NG) intubation practice in the North Bristol NHS Trust that resulted in the occurrence of a National patient Safety Agency defined "never event". Root-cause analysis identified that a change in culture was required. Recommendations divided into four categories: documentation, intubation, interpretation training, and radiology. A 6 month prospective audit covering all aspects of NG intubation practice preceded implementation of the recommendations. All patients whose tubes were mis-sited formed the cohort of the study. A re-audit was undertaken 12 months after the implementation of the recommended changes. Re-audit suggested significant improvements had occurred in all categories, particularly junior doctor check image interpretation errors, which in the study group were reduced from seven to one, and documentation, which has so far improved by 22%. Protocols and guidelines associated with NG tube check imaging have now been developed for radiologists and radiographers with check imaging and image interpretation being made a priority and respiratory tract intubation treated as an emergency. The service is still not perfect, but there is a focal awareness of patient safety associated with intubation practice, and image interpretation by junior doctors significantly improved with the introduction of the e-learning package. However, it is considered that the responsibility for developing safe practice with respect to NG tube check image interpretation ultimately lies with the department of radiology, which should take the lead on reducing the risk of never events being caused by the misinterpretation of these images.

Reflective learning in a patient safety course for final-year medical students

Background: Patient safety has become an important topic over the last decade and has also been increasingly implemented in the undergraduate curriculum. However, the best timing and method of teaching still remains to be decided.Aims: To develop and evaluate a patient safety course for final-year students. The course is based on reflective learning and personal experiences to improve the transfer of theory into practice.Methods: We performed a mixed method evaluation study of the course. An evaluation questionnaire and the number of completed incident report cards were analyzed using descriptive statistics. Focus groups, organized two and four weeks after the course, were analyzed using template analysis; the Theory of Planned Behaviour (TPB) was used to interpret the results.Results: Students found the course overall instructive and reacted positively towards many elements of the course. Focus group analysis showed that an increase in knowledge about patient safety topics resulted in a change of attitudes towards these subjects and in an increase in awareness of patient safety. This influenced students’ behavioral intention and their behavior.Conclusions: A course based on students’ personal experiences enables them to transfer theory on patient safety issues into their own practice and has an effect on their awareness, attitudes and behavior. This could have a large impact on their future role as resident.

The Patient Safety Curriculum for Undergraduate Medical Students as a First Step Toward Improving Patient Safety

Despite the growing emphasis on patient safety and the need for patient safety education, few schools have included this subject in their curriculum. Medical students need to understand and demonstrate appropriate patient safety skills early and continuously in their professional education. Therefore, we introduced a week of patient safety curriculum as a pilot program and attempted to describe and evaluate the effectiveness of a patient safety curriculum for second-year medical students. A 1-week patient safety course was developed and taught to all second-year medical students as part of an existing patient-doctor society course. The curriculum was composed of interactive lecture, discussion, and small-group debriefing facilitated by a tutor dealing with topics about patient safety. Students were asked to complete questionnaires on awareness about patient safety before and after the curriculum. The comparison of questionnaire data obtained before and after the curriculum revealed that the students' awareness about patient safety was significantly increased. Among them, awareness of the frequency of medical errors made by physicians and the awareness of the adverse outcomes due to medical errors were remarkably changed. These findings suggest that a patient safety course could increase the medical students' awareness of patient safety and the reality of medical errors. Continued development and implementation of patient safety curriculum will make medical students, as future doctors and health-care leaders, prepared to better practice and offer safer health care services than ever.

A checklist to improve patient safety in interventional radiology.

PurposeTo develop a specific RADiological Patient Safety System (RADPASS) checklist for interventional radiology and to assess the effect of this checklist on health care processes of radiological interventions.Materials and MethodsOn the basis of available literature and expert opinion, a prototype checklist was developed. The checklist was adapted on the basis of observation of daily practice in a tertiary referral centre and evaluation by users. To assess the effect of RADPASS, in a series of radiological interventions, all deviations from optimal care were registered before and after implementation of the checklist. In addition, the checklist and its use were evaluated by interviewing all users.ResultsThe RADPASS checklist has two parts: A (Planning and Preparation) and B (Procedure). The latter part comprises checks just before starting a procedure (B1) and checks concerning the postprocedural care immediately after completion of the procedure (B2). Two cohorts of, respectively, 94 and 101 radiological interventions were observed; the mean percentage of deviations of the optimal process per intervention decreased from 24 % before implementation to 5 % after implementation (p < 0.001). Postponements and cancellations of interventions decreased from 10 % before implementation to 0 % after implementation. Most users agreed that the checklist was user-friendly and increased patient safety awareness and efficiency.ConclusionThe first validated patient safety checklist for interventional radiology was developed. The use of the RADPASS checklist reduced deviations from the optimal process by three quarters and was associated with less procedure postponements.

Safety skills training for surgeons: A half-day intervention improves knowledge, attitudes and awareness of patient safety

Education and training of health care professionals is necessary to achieve sustainable improvements in patient safety. Despite its inherently risky nature, little training specifically in safety has been conducted in the surgical disciplines. In this study we explored the effects of a safety skills training program on surgical residents' knowledge, attitudes, and awareness of patient safety.A half-day training program incorporating safety awareness, analysis, and improvement skills was delivered to surgical residents from 19 hospitals in London, United Kingdom. Participants were assessed in terms of safety knowledge (MCQs) and attitudes to safety (validated questionnaire; scale 1 to 5) before and after training. To determine long-term effects, 6 months after training participants identified and reported on observed safety events in their own workplace by using an observational form for data collection.A total of 27 surgeons participated in the training program. Knowledge of safety significantly improved after the course (mean pre = 45.26% vs mean post = 70.59%, P < .01) as did attitudes to error analysis and improving safety (mean pre 3.50 vs mean post 3.97, P < .001) and ability to influence safety (mean pre 3.22 vs mean post 3.49, P < .01). After the course, participants reported richer, detailed sets of observations demonstrating enhanced understanding, recognition, and analysis of patient safety issues in their workplace.Safety skills training with positive educational outcomes can be delivered in a half day. Such a course may allow patient safety to be integrated into any curriculum, thereby training the next generation of the healthcare workforce to maintain the safety momentum.

SBAR

Awareness for patient safety led a team to develop an electronic handoff communication tool for noncomplicated routine patients. The structure of SBAR (situation, background, assessment, and recommendation) was used when transferring patients to and from the progressive care unit and cardiac laboratories. The electronic SBAR gave staff a reliable and standard way to provide a patient handoff.

Effects of graduation and working as a health professional employee on the awareness of patient safety

Tulin Yildiz1, Gulșah Eriten2, Ilknur Erdem3, Nevzat Selim Gokay3, Mustafa Kulac3, Recep Alp1, 3 1Namik Kemal Universitesi Saglik Uygulama ve Arastirma Merkezi, Namik Kemal Universitesi Saglik Yuksekokulu, Tekirdag, Turkiye, 2Namik Kemal Universitesi Saglik Uygulama ve Arastirma Merkezi, Tekirdag, Turkiye, 3Namik Kemal Universitesi Saglik Uygulama ve Arastirma Merkezi, Namik Kemal Universitesi Tip Fakultesi, Tekirdag, Turkiye

Effects of the Introduction of the WHO “Surgical Safety Checklist” on In-Hospital Mortality

To evaluate the effect of implementation of the WHO's Surgical Safety Checklist on mortality and to determine to what extent the potential effect was related to checklist compliance. Marked reductions in postoperative complications after implementation of a surgical checklist have been reported. As compliance to the checklists was reported to be incomplete, it remains unclear whether the benefits obtained were through actual completion of a checklist or from an increase in overall awareness of patient safety issues. This retrospective cohort study included 25,513 adult patients undergoing non-day case surgery in a tertiary university hospital. Hospital administrative data and electronic patient records were used to obtain data. In-hospital mortality within 30 days after surgery was the main outcome and effect estimates were adjusted for patient characteristics, surgical specialty and comorbidity. After checklist implementation, crude mortality decreased from 3.13% to 2.85% (P = 0.19). After adjustment for baseline differences, mortality was significantly decreased after checklist implementation (odds ratio [OR] 0.85; 95% CI, 0.73-0.98). This effect was strongly related to checklist compliance: the OR for the association between full checklist completion and outcome was 0.44 (95% CI, 0.28-0.70), compared to 1.09 (95% CI, 0.78-1.52) and 1.16 (95% CI, 0.86-1.56) for partial or noncompliance, respectively. Implementation of the WHO Surgical Checklist reduced in-hospital 30-day mortality. Although the impact on outcome was smaller than previously reported, the effect depended crucially upon checklist compliance.

Patient Safety Attitudes Among Respiratory Therapists in Taiwan

Safety attitude surveys have been widely conducted in various disciplines, but not among respiratory therapists (RTs), to assess clinician's awareness of patient safety. We conducted a nationwide survey in Taiwan to assess RTs' safety attitudes in several hospital settings. We adapted the Safety Attitude Questionnaire for RTs, and, via the RTs' union, invited all Taiwan RTs to take the survey. The questionnaire assessed safety attitudes in 6 domains: teamwork climate, safety climate, job satisfaction, stress recognition, perception of hospital management, and perception of working conditions. We analyzed the associations between positive attitudes and each domain. The response rate was 60%. Overall, the RTs had low positive attitudes about the teamwork climate (37%), safety climate (21%), job satisfaction (29%), stress recognition (32%), perception of hospital management (24%), and perception of working conditions (21%). The positive attitudes to all safety domains were lower among senior RTs than among junior RTs. The RTs working in the medical centers had higher positive-attitude scores for stress recognition but lower scores for the other 5 safety domains than the RTs working in the (smaller) regional and district hospitals. Taiwanese RTs had low positive attitudes about the surveyed 6 safety domains in their hospitals. High work load, management of RTs under other professions, and lack of protocol use probably contribute to their low opinions about the patient safety situation and low job satisfaction.

Safety skills training for surgeons: A half-day educational programme improves knowledge, attitudes and awareness of patient safety

Introduction Education and training of clinicians in patient safety is necessary to achieve sustainable improvements in this domain. Despite its inherently risky nature, such training is minimal in surgery. Objective: To study the effects of a safety skills training programme on surgical residents' knowledge, attitudes and awareness of patient safety. Methods A half-day training programme incorporating safety-awareness skills, safety-analysis skills and safety-improvement skills was delivered to surgical residents from 19 hospitals in London, UK. Participants were assessed in terms of their safety knowledge (using MCQs) and attitudes to safety (using a validated questionnaire; scale 1 to 5) before and after training (analysed quantitatively using t-tests). A longer term follow-up was conducted by participants carrying out ethnographic observations of safety events in their own workplace pre and post-training(analyzed using standardised qualitative emergent theme identification). Results 26 (out of total 48 residents across the 19 hospitals) attended the training programme. Knowledge of patient safety significantly improved after the course (Mean 70.59% vs Mean 45.26%, p Conclusions Safety skills training with positive educational outcomes can be effectively delivered in a half day. Such a course may allow patient safety to be integrated into any curriculum, thereby training the next generation of surgeons to maintain the patient safety momentum.

Ten Years After the IOM Report: Engaging Residents in Quality and Patient Safety by Creating a House Staff Quality Council

Ten years after the 1999 Institute of Medicine report, it is clear that despite significant progress, much remains to be done to improve quality and patient safety (QPS). Recognizing the critical role of postgraduate trainees, an innovative approach was developed at New York-Presbyterian Hospital, Weill Cornell Medical Center to engage residents in QPS by creating a Housestaff Quality Council (HQC). HQC leaders and representatives from each clinical department communicate and partner regularly with hospital administration and other key departments to address interdisciplinary quality improvement (QI). In support of the mission to improve patient care and safety, QI initiatives included attaining greater than 90% compliance with medication reconciliation and reduction in the use of paper laboratory orders by more than 70%. A patient safety awareness campaign is expected to evolve into a transparent environment where house staff can openly discuss patient safety issues to improve the quality of care.

Laparoscopic Ventriculoperitoneal Shunts: Benefits to Resident Training and Patient Safety

Symptomatic hydrocephalus is a surprisingly common clinical condition. Neurosurgeons are expert at ventriculostomy, but minimally invasive peritoneal access is outside the realm of their current training. We have adopted a multidisciplinary approach, with general surgeons positioning the distal shunt. Our objective was to review this recent experience. All distal shunts were placed by a single surgeon with resident assistance. After ventriculostomy, the shunt tubing was tunneled onto the anterior abdominal wall. A Veress needle was placed through the tunnel incision and the abdomen insufflated. A 5-mm optical access trocar and camera were introduced via a separate stab incision. The shunt tubing was then directed into the abdominal cavity using a Hickman introducer kit, with flow confirmed visually. Study patients who had between 0 and 10 previous abdominal operations received 111 consecutive shunts. There was one intraoperative complication, a colon injury during trocar placement. In this case, the colotomy was repaired and the shunt placed in the pleural space. There were no conversions to the open abdominal approach. Postoperatively, there were no wound infections, no cases of shunt malpositioning, and there were no deaths. Laparoscopic placement of ventriculoperitoneal shunts is feasible, safe, and carries a low rate of complications. The value to resident education in the practice of this procedure has not been previously emphasized. In the era of increased awareness of patient safety, laparoscopic VP shunting serves as a model for accomplishing both goals of improved outcomes and quality surgical education.

Describing A Latent Design Cycle In 100 Years Of Innovation And Adoption In Anesthesia Equipment: The Origin Of Awkwardness

Much is understood about the human-technology relationship and the importance of user focused design. This is well recognized in anesthesia with human factors investigations leading to patient safety awareness, regulation, and workload management. Conversely, this has inspired little change in the design of equipment to reduce the awkwardness in providing anesthesia. In fact, it has increased it by not discriminating between normal use and adopted use where the anesthesia profession has, over time, created habits to overcome and accommodate design deficiencies. This study examines past and present anesthesia equipment and use methods to deduce the origin of awkwardness. By describing the latent design cycle in the evolution of anesthesia equipment, a prediction can be provided for the application and acceptance of future technologies in anesthesia. The anesthetic profession may continue with standardized equipment design; conversely, the benefits of innovation in digital technologies to reduce awkwardness will probably be associated with significant change in the convention of use.

Diffusing Aviation Innovations in a Hospital in the Netherlands

Many authors have advocated the diffusion of innovations from other high-risk industries into health care to improve safety. The aviation industry is comparable to health care because of its similarities in (a) the use of technology, (b) the requirement of highly specialized professional teams, and (c) the existence of risk and uncertainties. For almost 20 years, The Rotterdam Eye Hospital (Rotterdam, the Netherlands) has been engaged in diffusing several innovations adapted from aviation. A case-study methodology was used to assess the application of innovations in the hospital, with a focus on the context and the detailed mechanism for each innovation. Data on hospital performance outcomes were abstracted from the hospital information data management system, quality and safety reports, and the incident reporting system. Information on the innovations was obtained from a document search; observations; and semistructured, face-to-face interviews. Aviation industry-based innovations diffused into patient care processes were as follows: patient planning and booking system, taxi service/valet parking, risk analysis (as applied to wrong-site surgery), time-out procedure (also for wrong-site surgery), Crew Resource Management training, and black box. Observations indicated that the innovations had a positive effect on quality and safety in the hospital: Waiting times were reduced, work processes became more standardized, the number of wrong-site surgeries decreased, and awareness of patient safety was heightened. A near-20-year experience with aviation-based innovation suggests that hospitals start with relatively simple innovations and use a systematic approach toward the goal of improving safety.

Frameworks for Patient Safety in the Nursing Curriculum

Patient safety has recently received a great deal of media coverage. Professional and regulatory agencies have indicated that patient safety education should be provided to health care workers to improve health outcomes. This study's primary purpose was to gain a better understanding of the current status of patient safety awareness among prelicensure nursing students. Data were collected from two samples (N = 150 and 318), and nursing curricula were examined from seven institutions. Measurement integrity studies indicated that patient safety awareness can be measured validly and reliably. Demographic variables were correlated with patient safety awareness. A content analysis found that all of the participating nursing schools included at least three of the six core competencies of the Quality and Safety Education for Nurses (QSEN) (Cronenwett et al., 2007) in their curriculum; one school exhibited all six. Our findings led to conclusions and recommendations for nurse educators and for future research on patient safety education in the nursing curriculum.

Healthcare professionals’ understanding and awareness of patient safety and quality of care in Africa: A survey study

In Africa there is currently not a wide knowledge of patient safety and healthcare quality. There is inadequate data to measure the scale of medical error and its impact on the healthcare. We investigated the frontline staff experience, their awareness of medical error and willingness to participate in patient safety initiatives. This is a qualitative survey involving 60 healthcare professionals in 2 private and 2 public hospitals in Nigeria and Uganda. Findings highlighted that frontline staff have a good knowledge and understanding of medical error. Thirty percent of the participants said errors occur frequently while only 3.3% were not sure of how often errors occur in their hospitals. Inadequate research on patient safety in literature at present does not mean that medical errors or other issues that undermine patient safety do not occur in Africa. Factors that cause medical errors and the impact of such errors are known to healthcare professionals. They are willing to participate in healthcare improvement programmes. Our findings show the relevance of patient safety in the region and provide a focus for further work that would ultimately contribute to the identification of appropriate interventions that could improve patient safety in Africa.

Expanding the SOAP Note to SOAPS (With S for Safety): A New Era in Real-time Safety Education.

The challenges inherent in medical education are multiple, including recognition of different learning styles among students, incorporation of the Accreditation Council for Graduate Medical Education competencies and outcomes measurement into the curriculum, and compliance with mandated duty hours along with a heightened awareness of patient safety required by our regulatory institutions. With the requirement that safety become an explicit part of the residency curriculum across all specialties, educators are charged with innovative ways of achieving this goal. The following commentary addresses this need and suggests an innovative approach to the traditional daily rounds' SOAP (subjective, objective, assessment, and plan) note to incorporate a second S for safety. The use of a SOAPS note elevates each encounter by integrating quality and error avoidance as a component of care. This method teaches the next generation of physicians the importance of patient safety as an integral part of every doctor-patient interaction.