Patient Safety Problems Research Articles

Assessment of patient safety culture in Brazilian hospitals through HSOPSC: a scoping review

to describe, from literature, the characteristics of patient safety culture in Brazilian hospitals that applied the Hospital Survey on Patient Safety Culture. this is a scoping review. A search was performed in the databases LILACS, PubMed, SciELO, CINAHL, Web of Science, Scopus and in the CAPES Dissertations and Theses Database in September and October 2020. thirty-six studies were identified. Nine studies identified strengthened areas such as: "teamwork within the units", "expectations of supervisor/boss and actions promoting safety", "organizational learning", "support of hospital management for patient safety" and "frequency of report of events". As a critical area, the dimension "non-punitive response to error" was evidenced in 30 of 36 studies. the identification of areas of strength and critical areas of safety culture is relevant to encourage improvement of patient safety problems in an institution.

An Overall Assessment of the Problem of Patient Safety in a Cultural Context

Bu çalışma, kültürel bağlamda hasta güveliği problemini incelemeyi amaçlamaktadır. Araştırma güvenlik ve hasta güvenliği kavramlarını konu edinmekle birlikte kültürel bağlamda hasta güvenliğine odaklanmaktadır. Sağlık çalışanlarının iş yapabilme biçimleri ve alışkanlıkları, çalışılan kurumda var olan örgütün iklimi ve kültürü, sağlık hizmeti alanların sağlık, hastalık ve hasta güvenliği konusundaki tutum, inanç, zihniyet ve sosyal ilişkilerin toplumun kültürel unsurlarıyla doğrudan ilişkili olduğunu söylemek mümkündür. Çalışmanın sonuçlarına göre, kültürel yapı sonucu oluşan örüntüleşmiş bazı davranış şekilleri, hastaların sağlığı ve güvenliği üzerinde bazen pozitif ve bazen de negatif etki oluşturabilmektedir. Söz konusu negatif etki ise, tedavinin gidişatında bir problem olarak ortaya çıkmaktadır.

Harnessing the Power of Residents as Change Agents in Quality Improvement.

Residency training represents a unique period when learners begin to personally experience the patient safety and quality-of-care issues that affect health care systems and increasingly take responsibility to address them. Their integration into the clinical workflow in clinics, wards, and operating rooms positions them perfectly to observe and characterize the underlying processes that contribute to patient safety and health care quality problems. Residents' practices and perspectives are less entrenched than those of their faculty counterparts, which enables them to offer fresh ideas on the quality improvement (QI) process. Their creativity and ingenuity serve as assets when coming up with new and innovative changes to test using rapid change cycles. As such, they are ideally suited to serve as health systems change agents. Training programs and clinical institutions typically see residents as frontline care providers whose primary role is to treat the patient in front of them. Yet, by enabling residents to "treat the system" through QI work, they can take on the role of residents as change agents, which has the potential to have long-lasting effects on patient care on a much wider scale. However, training programs must do more than simply harness residents' enthusiasm and root them on from the sidelines. Instead, they must create an environment that is conducive to successfully implementing changes at the curricular, institutional, and health systems levels.

Peningkatan Kemampuan Keterampilan Basic Life Support (BLS) Melalui Pelatihan BLS Pada Perawat dan Bidan

Background: In Hospital Cardiac Arrest (IHCA) is a major problem of patient safety and public health. the rescue action taken is Basic Life Support with CPR. BLS training needs to be provided to nurses and midwives in order to increase the ability of BLS skills. The purpose of this study was to analyze the effect of Basic Life Support (BLS) Training on the ability of BLS skills of Nurses and Midwives. Methods: This research is an experimental study with a Pre-Test-Post Test Group design approach through through testing the research hypothesis. The population of this study was nurses and midwives, amounting to 51 respondents with a total sampling technique so that the number of respondents was 51. Statistical tests in the paired group used the nonparametric Wilcoxon test. Results: Based on the Wilcoxon test results obtained a p value of 0,001 which means there is a difference between pre and post training, Conclusion: BLS training has an effect on improving the BLS skills of nurses and midwives. BLS skills training needs to be carried out on an ongoing basis so that nurses and midwives have good skills in conducting BLS.

Inpatient patient safety events in vulnerable populations: a retrospective cohort study

BackgroundWidespread attention to structural racism has heightened interest in disparities in the quality of care delivered to racial/ethnic minorities and other vulnerable populations. These groups may also be at increased...

Numbers and Potential Causes of Medication Error in Inpatient Service of Rumah Sakit Islam Malang

Medication errors, ranging from prescription to administration errors, are still problems of patient safety with an average error rate of 8% - 10% and can cause severe morbidity, prolonged length of stay (LOS) in a hospital, unnecessary diagnostic tests and care, and mortality. The objective of this study is to describe the number of medication errors and their potential causes according to the perceptions of health personnel. The study was carried out by questionnaires, interviews, and data exploration on prescriptions made before the observation period and new prescriptions made during the observation period. The priority determination of the solutions was carried out using Capability, Assessibility, Readiness, and Leverage method (CARL) and discussions with related units. The priority root factors that caused medication errors in the inpatient pharmacy at RSI Malang were high workloads and high turnover of inpatient pharmacist, incomplete prescription identity, illegible doctor's writing, and lack of training for the pharmacist. The priority outcome of the alternative solutions to overcome the medication errors in inpatient pharmacist is to regularly conduct training or knowledge refreshing for the inpatient pharmacist at RSI Malang and the implementation of e-prescription.

Issues of patient safety in the context of preventing medical errors
 (analytical review)

Introduction. Patient safety is the absence of preventable harm to the patient in the course of medical care and the reduction of the risk of unnecessary harm associated with medical care to an acceptable minimum. Over the past two decades, the problem of patient safety has become the object and target area of public health for specific efforts to improve it. The study aims to analyze modern scientific literature to consider problems related to clinical safety, the global burden of harming patients. Material and methods. In the context of studying the problem, the results of modern research were used to identify the causes of medical errors and to find ways to prevent them. Results. The desire to improve the level of safety and the quality of medical care is growing in the world. Consequently, significant measures to evaluate the safety of medical care and its quality will be of paramount importance. To date, there is no gold standard or established array of quality indices (QI) for measuring the quality and safety of medical care. However, many indices have been developed, and some have even been tested to measure specific aspects of patient quality and safety. Such studies are in demand to achieve a clinically significant reduction in the incidence of medical errors. Conclusion. Despite the growing recognition of the role of human medical error in medicine, to prevent or mitigate their consequences requires the search for adequate ways both at the individual and systemic levels.

Description of healthcare professionals’ attitudes on patient safety in the Tunisian operating rooms

Abstract Background Currently, ensuring surgical safety remain a worldwide challenge. The description of operating room professionals' attitudes toward patient safety in their work units helps to identify strengths and weaknesses in term of patient safety, allowing a clearer vision of the safety aspects that require special attention. This study aimed to describe healthcare professionals' attitudes on patient safety in the Tunisian operating rooms. Methods This is a cross-sectional descriptive study spread over a 6-month period (October-April 2018). It was conducted among healthcare professionals working in the operating rooms of the two teaching hospitals of Sousse (Tunisia). The measuring instrument used is the Operating Room Management Attitudes Questionnaire (ORMAQ), which consists of 60 items spread over 8 dimensions. The latter has been subjected to a transcultural validation process inspired from the Vallerand method. Data entry and analysis was done by the Statistical Package for Social Sciences (SPSS.20) software. Results A total of 303 professionals participated in the study (participation rate= 76.13%). The most developed dimension was teamwork and the least developed was “Procedural errors/ compliance”. Items' results show that 94.8% of professionals confirmed that seniors should encourage medical and paramedical staff to ask questions, 53.5% of professionals stated that personal problems can adversely affect their performance and 87.5% agreed that operating rooms' team members share responsibilities for prioritizing activities in high workload situations. In addition, 50.9% of participants reported that the managers don't listen to staff or care about their concerns. Conclusions Operating rooms professionals' attitudes toward patient safety in their work units reflect an alarming situation regarding the quality of healthcare provided to patients. These results should be taken into consideration to guide future intervention on quality management improvement. Key messages Considering human factors is essential to improve safety in operating rooms and has an important role in reducing the occurrence of adverse events in these settings. It is important to study the underlying attitudes that determine the human factors for a better understanding and resolution of patient safety problems.

Evaluation Of Patient Safety Policy To Nurse In Anutapura General Hospital Palu City

Patient safety in the hospital is a system where the hospital makes the nurture of the patients safer which includes risk assessment, identification and management of patient-related risks. Patient safety problems in general in Anutapura Palu General Hospital are the occurrence of mismanagement by officers, including errors in discipline, communication, to technical errors.This research aimed to evaluate the implementation of patient safety policies for nurses at Anutapura Public Hospital at Palu. This research was quantitative in nature, as many as 72 respondents by using the Slovin formula. The results showed that the variable results in this research were input with value frequency of ≥50 % respondents who stated the good input. Process variables in this research were obtained from the value that in the process it was quite good seen from the value the frequency of ≥50 % respondents who stated that the process was good. The results of the analysis of variable output with value frequency of≥50 % respondents who stated that the output was good. The conclusion that can be drawn is that the results of the evaluation of the implementation of patient safety policies have been applied in Anutapura Public Hospital at Palu. It is expected that the hospital performs performance evaluation and monitoring complaints as well as satisfaction of service users on a regular basis in order todevelop the satisfaction of service users and the community.

Neither protective nor harmonized: the crossborder regulation of medical devices in the EU.

To what extent does inadequate market regulation contribute to poor health outcomes? A series of prominent scandals involving harmful medical devices has made improving the regulation of these devices an urgent problem for the European Union (EU). This is, however, a specific example of a general phenomenon. The EU remains first and foremost a large and integrated market within which the EU institutions have considerable regulatory authority. Even if there is little EU commitment to a health or social policy agenda, its use of that regulatory authority shapes health care cost and quality and should be understood as health policy. We use data from EU-level and national policy documents to analyse the EU's current regulatory framework for medical devices and assess its likely future efficacy. Despite revising the medical devices directive to require more stringent pre-authorization requirements for high-risk medical devices and improvements in post-market surveillance, the key underlying problems of market fragmentation and patient safety persist. Without strong and consistent support for the implementation of the new directive, the likely result is the status quo, with significant consequences for health in Europe.

Priorities for Patient Safety Improvement

Priority means precedence in right or rank and is set for resource allocation in patient safety targeting efforts to obtain the maximum benefit for the patients and the public. This research aims to understand Korean patient safety priorities in researches and activities supporting better social efforts for patient safety improvement. When Korean priority of patient safety research has been done using WHO’s global patient safety research priorities with patient safety experts, the result shows the mixed priorities of developed country type and developing country type. ‘Lack of communication and coordination’, ‘poor patient safety culture’ etc were similar to developed countries high ranks. But ‘health care associated infections’ and ‘extent and nature of the problem of patient safety’ were get high ranks similar to developing countries. ‘Effect of work pressure on safety’ ranks the highest in Korea compare to any other country types. This priority results were similar to another priority research for patient safety standards and indicators development which showed high ranks for ‘manpower levels’ and ‘patient identification and communication supporting technologies’. ‘Adverse drug events’ related incidents showed commonly high in priorities, incident rates, and reporting rates through studies and Korean Patient Safety reporting and learning system. But there was discrepancy between the patient safety priorities and governmental support. Therefore, it will be needed for patient safety improvement not only investment from hospitals and government focusing on high priority areas including manpower shortage & workload, communication technologies, and adverse drug events but also priority information sharing and periodic priority re-setting.

Infection Prevention and Control in North-East Nigeria: An Assessment ofHand Hygiene in Health Care Facilities in Protracted Crisis EnvironmentFebruary 2019

Introduction: Hand hygiene is the single most effective action to prevent the spread of Healthcare-Associated Infections and Antimicrobial Resistance among health care workers and patients. The lack of effective hand hygiene and materials for hand hygiene is a major problem for patient safety in health care facilities. We conducted this survey in February 2019 to assess the situation of hand hygiene in health care facilities in Borno State, the epicenter of insurgency in North-East Nigeria. Method: An interviewer-administered questionnaire was used to assess the situation of hand hygiene from 103 health care facilities selected from across Borno State. The questionnaire used was adopted from the WHO Hand Hygiene Self-Assessment Framework at the facility level. It had five sections (System change, training, and education, evaluation and feedback, reminders in the workplace, institutional safety climate for hand hygiene) and 27 indicators framed as questions with “yes” or “no” response. Each health facility’s response was scored, calculated and expressed as a proportion of the total score of 500. Based on the score obtained, each facility was assigned to one of four categories ranging from inadequate, basic, intermediate to advanced hand hygiene level. Results: One hundred and three health facilities were involved in the assessment. Eighty-nine (86.4%) were public, government-owned health care facilities. The highest participation was from the central zone of the state with 43 (41.7%) while the northern zone of the state recorded the lowest participation 25 (24.3%). Central zone participation was 43 (41.7%). Seventy-eight (75.8%) of the total health facilities had inadequate hand hygiene levels, 21 (20.4%) had basic hand hygiene levels, 4 (3.8%) had intermediate hand hygiene level and none (0%) had advanced hand hygiene level. Summary statistics (mean ± SD, Median: IQR) for the five sections showed the following; System change (availability of soap, running water, single-use hand towels)-19 ± 21, 15: 30; education and training (on hand hygiene)-10.3 ± 15.0, 0: 3.0; evaluation and feedback (assess availability of water, soap, towel, and hand hygiene compliance)-13.0 ± 17.4, 0: 25; reminders in the workplace (posters and leaflets)-19.2 ± 21.0, 20: 15 and institutional safety climate for hand hygiene (functional hand hygiene teams, patient involvement in hand hygiene and regular communication)-14 ± 25.0,0:20. The overall scores summary statistics were 75.6 ± 78.5, 55: 125. Conclusion: This assessment revealed gross inadequacies in hand hygiene practice and hand hygiene promotion in government-owned Primary Health Care Facilities in Borno state. There is a need to scale up efforts to improve hand hygiene practices and hand hygiene promotion activities in the State to enhance the quality of care and minimize the incidence of Healthcare-Associated Infections.

A Collaborative Framework Based for Semantic Patients-Behavior Analysis and Highlight Topics Discovery of Alcoholic Beverages in Online Healthcare Forums.

Medical data in online groups and social media contain valuable information, which is provided by both healthcare professionals and patients. In fact, patients can talk freely and share their personal experiences. These resources are a valuable opportunity for health professionals who can access patients' opinions, as well as discussions between patients. Recently, the data processing of the health community and, how to extract knowledge is a significant technical challenge. There are many online group and forums that users can discuss on healthcare issues. Therefore, we can examine these text documents for discovering knowledge and evaluating patients' behavior based on their opinions and discussions. For example, there are many questions and answering groups on Twitter or Facebook. Given the importance of the research, in this paper, we present a semantic framework based on topic model (LDA) and Random forest(RF) to predict and retrieval latent topics of healthcare text-documents from an online forum. We extract our healthcare records (patient-questions) from patient.info website as a real dataset. Experiments on our dataset show that social media forums could help for detecting significant patient safety problems on healthcare issues.

Cognitive Autopsy of a Fatal Diagnostic Error

Background: Diagnostic error is a significant cause of preventable harm worldwide and diagnostic errors have been identified as a high priority patient safety problem by the World Health Organization. Research shows thatdiagnostic error occurs mainly due to system failures and 'cognitive errors' – that is, failure to synthesise all the available information. There is a worldwide consensus that medical schools and postgraduate training programmes rarely teachthe diagnostic process and related decision making (clinical reasoning) in a way that is explicit, systematic and consistent with what is known from research.
 Materials and methods: This paper presents a short case report and analyses it from a clinical reasoning perspective – performing a 'cognitive autopsy' of a fatal diagnostic error.
 Results: Clinicians make cognitive shortcuts through pattern recognition and this is highly accurate most of the time. However, shortcuts sometimes go wrong and these are termed 'cognitive biases'. Cognitive biases are subconscious errors of judgement or perception and common examples include 'anchoring', 'the framing effect', 'search satisficing 'and' confirmation biases. These errors are more likely when clinicians are fatigued or cognitively overloaded, and when systems are not designed to mitigate human errors.
 Conclusions: There is a vast literature on clinical reasoning, 'human factors', and reflection during decision making that show us how we can reduce diagnostic error in our everyday practice. This paper attempts to highlight some of the key findings in the literature that will hopefully encourage readers to explore the patient safety and clinical reasoning literature for themselves and work together to improve outcomes for patients.

US Food and Drug Administration and Off-Label Use of Metal Expandable Biliary Stents within the Peripheral Vasculature—Update

In the past, some medical device manufacturers were obtaining marketing clearance for metallic stents indicated for biliary use; however, these devices were being promoted and used in the peripheral vasculature, creating a patient safety problem. The US Food and Drug Administration (FDA) acted in 2006–2008 to help decrease off-label use of metal expandable biliary stents. This communication describes the early and continued efforts of the FDA to address safety concerns relating to off-label use of metal expandable biliary stents and the status of this issue. An analysis of Medical Device Reporting (MDR) data from January 1, 2005, through December 31, 2018, was conducted to determine the percentage of MDR reports associated with off-label use. The percentage was approximately 90% in 2001–2006 and decreased to < 40% a decade later. In reports associated with off-label use, these devices are still associated with death and serious injury; however, the percentage of injury MDR reports associated with off-label device use has trended down since 2007. Whereas 92%–95% of reported serious injuries were with off-label placement in 2005–2007, 43%–79% of injuries were with off-label placement in 2008–2018. Collaborative efforts among the FDA, manufacturers, and physicians appear to have made progress in addressing this issue.

Patient safety in ambulatory care from the patient's perspective: a retrospective, representative telephone survey

ObjectivesData on patient safety problems (PSPs) in ambulatory care are scarce. The aim of the study was to record the frequency, type, severity and point of origin of PSPs in...

A Study to Assess the Knowledge, Attitude and Perceived Barriers on Incident Reporting among Staff Nurses Working in a Tertiary Care Hospital, Ludhiana, Punjab

Background of the Study: The term ‘adverse event’ describes harm to the patient as a result of medical care. Patient safety event reporting systems are ubiquitous in hospitals and are a mainstay of efforts to detect patient safety and quality problems. Incident reporting is frequently used as a general term for all voluntary patient safety event reporting systems which rely on those involved in events to provide detailed information. Aim: To assess the knowledge, attitude and perceived barriers to incident reporting among the staff nurses working in a tertiary care hospital, Ludhiana. Methodology: A descriptive study was conducted in the month of May 2017 in Dayanand Medical College and Hospital, Ludhiana. A total of 60 staff nurses were selected by convenient sampling technique and 4 parts of tools were used for the collection of data. The tools included socio-demographic profile, Questionnaire to assess the knowledge, Likert scale to assess the attitude and a Checklist to assess the perceived barriers. Validity of the research tool was established under the guidance of research supervisor and other experts. Result: Most of the staff nurses working in DMC &amp; H, Ludhiana had average knowledge and positive attitude towards incident reporting and the co-relation of knowledge and attitude came out to be weakly positive. Conclusion: The staff nurses had average knowledge, positive attitude towards the incident reporting. There was weak positive correlation between knowledge and attitude of staff nurses. Fear of legal action, too busy/ lack of time and fear of career/ personal reputation were the common perceived barriers by staff nurses regarding incident reporting.

Uncovering, creating or constructing problems? Enacting a new role to support staff who raise concerns about quality and safety in the English National Health Service.

Employee voice is an important source of organizational intelligence about possible problems in quality and patient safety, but effective systems for encouraging and supporting those who seek to speak up have remained elusive. In the English National Health Service, a novel role known as the ‘Freedom to Speak Up Guardian’ has been introduced to address this problem. We critically examine the role and its realization in practice, drawing on semi-structured interviews with 51 key individuals, including Guardians, clinicians, managers, policymakers, regulators and others. Operationalizing the new role in organizations was not straightforward, since it had to sit in a complex set of existing systems and processes. One response was to seek to bound the scope of Guardians, casting them in a signposting or coordinating role in relation to quality and safety concerns. However, the role proved hard to delimit, not least because the concerns most frequently voiced in practice differed in character from those anticipated in the role’s development. Guardians were tasked with making sense of and dealing with issues that could not always straightforwardly be classified, deflected to the right system or escalated to the appropriate authority. Our analysis suggests that the role’s potential contribution might be understood less as supporting whistleblowers who bear witness to clear-cut wrongdoing, and more as helping those with lower-level worries to construct their concerns and what to do with them. These findings have implications for how voice is understood, imagined and addressed in healthcare organizations.

THE PROBLEM OF PATIENT SAFETY IN THE PROVISION OF MEDICAL CARE. OPINION OF DOCTORS EXPERTS ON THE QUALITY OF MEDICAL CARE AND PRACTITIONERS

The results of the survey of practicing doctors and experts of the quality of medical care about the problem of patient safety in medical organizations are presented.

Think Twice: Effects on Diagnostic Accuracy of Returning to the Case to Reflect Upon the Initial Diagnosis.

Diagnostic errors have been attributed to failure to sufficiently reflect on initial diagnoses. However, evidence of the benefits of reflection is conflicting. This study examined whether reflection upon initial diagnoses on difficult cases improved diagnostic accuracy and whether reflection triggered by confrontation with case evidence was more beneficial than simply revising initial diagnoses. Participants were physicians in Bern, Switzerland, registered for the 2018 Swiss internal medicine certification exam. They diagnosed written clinical cases, providing an initial diagnosis by following the same instructions and returning to the case to provide a final diagnosis. The latter required different types of reflection depending on the physician's experimental condition: return without instructions, identify confirmatory evidence, identify contradictory evidence, or identify both confirmatory and contradictory evidence. The authors examined diagnostic accuracy scores (range 0-1) as a function of diagnostic phase and reflection type. One hundred and sixty-seven physicians participated. Diagnostic accuracy scores did not significantly differ between the 4 groups of physicians in the initial (I) or the final (F) diagnostic phase (mean [95% CI]: return without instructions, I: 0.21 [0.17, 0.26], F: 0.23 [0.18, 0.28]; confirmatory evidence, I: 0.24 [0.19, 0.29], F: 0.31 [0.25, 0.37]; contradictory evidence, I: 0.22 [0.17, 0.26], F: 0.26 [0.22, 0.30]; confirmatory and contradictory evidence, I: 0.19 [0.15, 0.23], F: 0.25 [0.20, 0.31]). Regardless of type of reflection employed while revising the case, accuracy increased significantly between initial and final diagnosis, I: 0.22 (0.19, 0.24) vs F: 0.26 (0.24, 0.29); P < .001. Physicians' diagnostic accuracy improved after reflecting upon initial diagnoses provided for difficult cases, independently of the evidence searched for while reflecting. The findings support the importance attributed to reflection in clinical teaching. Future research should investigate whether revising the case can become more beneficial by triggering additional reflection.