Patient Safety Program Research Articles

P004] Measurment of entrance surface dose during chest X-ray examinations in neonatal intensive care unit using OSL and TLD dosimeters

Purpose Pediatric patient are known to have higher sensitivity to exposure to radiation. Therefore monitoring of radiation doses received by neonatal patients in our hospital is of primary importance element of our patient safety program in diagnostic radiology. We are proposing to measure the entrance surface dose (ESD) using OSL dosimeters due to their higher sensitivity and fast analysis in comparison with TLD both used for occupational dose monitoring at our institution. Methods and materials Entrance surface dose was measured using the IAEA TRS-457 dosimetry protocol. Measured entrance surface dose using neonatal phantom and OSL dosimeters. The X-ray beam is the one produced by a portable X-ray machine routinely used in the hospital in ICU set up. We have used a neonatal body phantom (Model: 610 GAMMAX) to simulate the patient body. Both OSL and TLD readings were cross checked using a diagnostic X-ray shadow free PTW ionization chamber model: SFD34060 coupled to an electrometer model: UNIDOS E, linear calibration curves were obtained for the OSL and TLD. Results The average measured ESD using the OSL and the TLD were 66 and 70 μGy respectively. The OSL were found suitable to conduct ESD measurements during chest X-ray exam for the neonatal patient. The obtained patient dose measurement will serve as an indicator of quality and patient safety standard in diagnostic radiology services. Conclusion The measured values are within internationally published data. The study serves as a benchmark to our clinical practice against international diagnostic reference levels (DRL) in pediatric radiology.

The Overarching Themes From the CLER National Report of Findings 2018.

The Overarching Themes From the CLER National Report of Findings 2018.

Building a culture of safety in interventional radiology

Safety in medicine is a pressing issue. It has been shown that deaths due to medical error range from 98,000 to 400,000 per year in the United States. Since this issue was broached in 1999, a variety of clinical and institutional safety interventions have been pioneered; however, the medical community has realized that without a strong institutional safety culture, the efficacy of these interventions is limited. Changing culture is often a long and difficult process. Just as the wider medical community slowly moves towards the practice of safety culture, interventional radiology must uphold a culture of safety along with its other core tenets throughout its continued evolution. The Agency for Healthcare Research and Quality provides many effective evidence-based training programs to help in the process of improving safety culture. Herein, we focus on the Agency for Healthcare Research and Quality's comprehensive unit-based safety program and Team Strategies and Tools to Enhance Performance and Patient Safety programs and how they pertain to the interventional radiology setting. We also highlight key concepts that should be considered when embarking on an institutional cultural change. Finally, we focus on the role of safety culture as it pertains to those healthcare providers affected in the aftermath of an error, the "second victims."

Analysis of Factors Related to Employee Behavior in Implementing Patient Safety Program at Insan Permata Woman and Child Hospital Tangerang

Insan Permata Woman and Child Hospital was facing Patient Safety Incidence especially for periode of mid to late 2016 there were 12 incidents and 11 phlebitis cases. This indicated a gap between the conditions in the field and the ideal situation that should be achieved. This study aimed to see how the behavior of employees in implementing patient safety program and the factors that influence it. The sample of this study were 151 respondents as sample, consist of health and non health workers. The patient safety program focused on the accuracy of patient identification, reduction of risk of infection and reduction of risk of falling patients. This research was a quantitative research followed by qualitative method. The results showed that most employees already had good patient safety behavior, age and attitude were the most affecting factors in patient safety behavior. The lack of socialization of accreditation and patient safety, poor monitoring and some incomplete facilities should became the concern for the hospital as it was considered to have great influences in the daily implementation of patient safety program.

Adequação de um instrumento de monitoramento de higienização das mãos de um hospital do Rio de Janeiro

Justificativa e Objetivo: Apesar da presença de indicadores obrigatórios nos protocolos de higiene das mãos, presentes no Programa Nacional de Segurança do Paciente do Brasil, não foram recomendados instrumentos de monitoramento, com indicadores que avaliem os componentes estruturais, de processo e resultado que permitam análise periódica e construção de ações de melhoria no âmbito da prevenção de controle das infecções relacionadas à assistência à saúde. O objetivo foi adequar um instrumento de monitoramento da higienização das mãos dos profissionais de saúde de um hospital do Rio de Janeiro. Métodos: um questionário foi aplicado aos auditores que avaliam o desempenho da política de qualidade do hospital para verificar a adequação de um instrumento de verificação da prática de higienização das mãos. Os achados deste questionário e os dados do levantamento na literatura - sobre a segurança do paciente, infecções relacionadas à assistência à saúde e instrumentos de monitoramento - possibilitaram a criação de um novo instrumento, que foi
 submetido ao julgamento de especialistas, usando a técnica de consenso Delphi. Resultados: em duas rodadas foi obtido um consenso dos especialistas. As questões que não atingiram 75% de concordância foram modificadas. Conclusão: O novo instrumento validado por especialistas permite a avaliação e monitoramento de implantação do protocolo de
 higienização das mãos, comparação entre sistemas e avanços nas metodologias e processos de trabalho, permitindo que sejam cada vez mais seguros.

Proactive, Transdisciplinary Safer-System Redesign. A Field Report from the Hospital Frontline

OCCUPATIONAL APPLICATIONS Safety science disciplines, such as Systems Engineering, Human Factors and Ergonomics, or Design Thinking, promise to deliver a breakthrough in proactive, safer systems redesign. But what does the work with clinicians look like when redesigning systems for safer, more effective patient-centered care? The Stanford Health Care Advancing Patient Safety Program is trailblazing by integrating safety science experts and systems designers into clinical practice. This application report provides an overview of the structure, the approach, and methodology, as well as the lessons learned of the program. Two use case examples of analyzing and redesigning complex clinical work systems—the safe administration of blood and blood products and the standardization of set-up and management of cerebrospinal fluid drainage systems—demonstrate the successful application of the human-centered design approach in clinical settings.TECHNICAL ABSTRACT Background (or Rationale): Today, most healthcare systems can be described as “compliant organizations.” However, as the patient safety movement continues to prosper, many scholars have proposed to evolve from a reactive approach toward a more proactive one that better addresses risks for preventable harm. Purpose: Proactive organizations aim to achieve resilience. Stanford Health Care is trailblazing by integrating safety science experts into clinical practice who work in tandem with clinicians to proactively design work systems for safer, more effective, patient-centered care. Methods: Adapting the human-centered design approach, a transdisciplinary team of engineers, physicians, and nurses utilizes an array of methods and tools to identify and analyze systems-related issues proactively and comprehensively, to search for and test a variety of solutions, to select the best options, implement solutions successfully, and to monitor sustainability of improvement. Results: The team-conducted projects, e.g., to improve blood administration and to standardize set-up and management of cerebrospinal fluid drainage systems. Our accomplishments so far, include the systematic examination and comprehensive description of clinical work systems, their components and interactions, successful collaboration with clinical and support services throughout the organization, and the redesign of IT systems, medical devices, and nursing procedures. The efforts also led to price reductions by 50% for a single medical device. Since the completion of the projects, we have had no related adverse patient event, no associated litigation, and the nursing and service-quality indicators are within the satisfactory target range. Conclusions: The SHC Advancing Patient Safety Program is a novel endeavor that analyzes systems issues in an organization-wide manner, executes improvement work in a comprehensive and integrated fashion, is a conduit for innovation, and is a medium for breaking through boundaries and silos thus fostering deeper collaboration among disciplines.

Mixed-Methods Evaluation of Real-Time Safety Reporting by Hospitalized Patients and Their Care Partners: The MySafeCare Application.

The aims of the study were to evaluate the amount and content of data patients and care partners reported using a real-time electronic safety tool compared with other reporting mechanisms and to understand their perspectives on safety concerns and reporting in the hospital. This study used mixed methods including 20-month preimplementation and postimplementation trial evaluating MySafeCare, a web-based application, which allows hospitalized patients/care partners to report safety concerns in real time. The study compared MySafeCare submission rates for three hospital units (oncology acute care, vascular intermediate care, medical intensive care) with submissions rates of Patient Family Relations (PFR) Department, a hospital service to address patient/family concerns. The study used triangulation of quantitative data with thematic analysis of safety concern submissions and patient/care partner interviews to understand submission content and perspectives on safety reporting. Thirty-two MySafeCare submissions were received with an average rate of 1.7 submissions per 1000 patient-days and a range of 0.3 to 4.8 submissions per 1000 patient-days across all units, indicating notable variation between units. MySafeCare submission rates were significantly higher than PFR submission rates during the postintervention period on the vascular unit (4.3 [95% confidence interval = 2.8-6.5] versus 1.5 [95% confidence interval = 0.7-3.1], Poisson) (P = 0.01). Overall trends indicated a decrease in PFR submissions after MySafeCare implementation. Triangulated data indicated patients preferred to report anonymously and did not want concerns submitted directly to their care team. MySafeCare evaluation confirmed the potential value of providing an electronic, anonymous reporting tool in the hospital to capture safety concerns in real time. Such applications should be tested further as part of patient safety programs.

National Patient Safety Program in Brazil: Incidents Reported Between 2014 and 2017.

The aim of the study was to analyze the patient safety incidents reported to the Brazilian National Health Surveillance System from March 2014 to March 2017. A documentary study that used the records of the incidents published in the Reports of Adverse Events (AE) in Brazil. The following variables were selected: number of incidents by type, type of health service, hospital unit, and degree of harm. To find whether there was a significant difference across the Brazilian regions by notifications related to general incidents, AE, and deaths, the analysis of variance and the Tukey tests were used. A total of 109,082 incidents were reported, of which 75,088 were AE, with 649 deaths. In relation to the types of incidents reported, there was a higher frequency in the categories other (30.04%) and failures during health care (26.72%). A total of 93.90% of the incidents occurred in hospitals, with 54,950 cases registered in hospitalization units and 30,141 cases in intensive care units. Statistically significant differences across the Brazilian regions were observed in the number of incidents (P = 0.004), AE (P = 0.004), and deaths (P = 0.024). A significant underreporting of incidents was found in Brazil, demonstrating only the tip of a giant iceberg. More than half of the incidents were reported as AE and were registered in hospitals, reiterating the importance of establishing public health policies at national, state, and municipal levels, with adequate supervision of the health service regarding the implementation of the Patient Safety Nuclei and the preparation of new protocols based on the most prevalent incidents.

Reducing Serious Safety Events and Priority Hospital-Acquired Conditions in a Pediatric Hospital with the Implementation of a Patient Safety Program

A freestanding children's hospital evaluated the impact of a patient safety program on serious safety events (SSEs) and hospital-acquired conditions (HACs). The No Harm Patient Safety Program was developed throughout the organization using a multifaceted approach that included safety moments, leadership rounding, cause analysis changes, event reporting enhancements, error prevention training, leadership training, identifying priority HACs, Eye on Safety Campaign, and safety coaches. The organization set strategic goals for improvement of SSEs and priority HACs. The rate of SSEs decreased from 0.19 in 2014 to 0.09 in 2015. The rate significantly declined from 2015 to 2016 to a rate of 0.00, for a rate difference of -0.00009 (95% confidence interval [CI]: -0.00016, -0.00002; p = 0.012). The organization reached two years without an SSE in July 2017. The central line-associated bloodstream infection rate significantly declined from 2.8 per 1,000 line-days in 2015 to 1.6 in 2016, for a difference of -0.00118 (95% CI: -0.002270, -0.00008; p = 0.036). Surgical site infection rates declined from a 2015 rate of 3.8 infections per 100 procedures to a 2016 rate of 2.6 (p = 0.2962), and catheter-associated urinary tract infection rates declined from a 2015 rate of 2.7 per 1,000 catheter-days to a 2016 rate of 1.4 (p = 0.2770). The No Harm Patient Safety Program was interwoven into the organization's strategic mission and values, and key messaging was used to purposefully tie the many interventions being implemented back to it. These interventions were associated with improvements in patient safety outcomes.

Prevalence of fall injuries and risk factors for fall among hospitalized children in a specialized childrens hospital in Saudi Arabia.

BACKGROUNDFall injuries among children during hospital stay is a major patient safety issue. Inpatient pediatric falls can lead to numerous negative consequences. In contrast to adults, there is a paucity of information on the prevalence and risk factors associated with children’s falls during hospitalization.OBJECTIVESIdentify the prevalence of fall injuries among hospitalized children and describe the demographic and environmental factors that could predict a higher risk of severe outcomes of fall.DESIGNDescriptive, cross-sectional prevalence study.SETTINGSpecialized children’s hospital.PATIENTS AND METHODSData was obtained through the electronic Safety Reporting System (SRS). All reported fall events during hospitalization in children ≤14 years of age for the period from 1 April 2015 to 30 April 2016 were included. Fall events that occurred in the day care unit and the outpatient clinic were excluded.MAIN OUTCOME MEASURESPrevalence and possible risk factors for fall events.SAMPLE SIZE48.RESULTSThe prevalence of falls among the 4860 admitted children was 9.9 (95% CI=7.5, 13.1) per 1000 patients (48/4860). A majority of the falls were among boys (n=26, 54%), in the age group from 1–5 years old (n=22, 46%), in children at high risk of falling (n=35, 73%), with normal mobility status (n=21, 44%), and with no history of previous falls (n=33, 69%). Severe injuries accounted for 25% of falls (n=12). However, falls among the moderate risk category (n=9, 69%) were more often severe than falls among the high risk category of children (n=12, 34%) (P=.03).CONCLUSIONRisk factor identification is required to prevent falls and their severe outcomes.LIMITATIONSUnderreporting and single-centered study.

Physical deterioration in an acute mental health unit: A quantitative retrospective analysis of medical emergencies.

Nursing management of physical deterioration of patients within acute mental health settings is observed, recorded, and actively managed with the use of standardized Adult Deterioration Detection System (ADDS) charts. Patient deterioration may require the urgent assistance of a hospital rapid response or Medical Emergency Team. A five-and-a-half-year (2011-2016) audit of hospital-wide Medical Emergency Team attendances was conducted in an acute mental health unit of a single large 250 bed regional hospital in Victoria, Australia. Data were extracted from the hospitals' quality and patient safety program, RISKMan, and entered into a statistical data program for analysis. A total of 140 patient records were analysed, and the 'Worried' category (34%, n=47) was the principle reason for a Medical Emergency Team call in a mental health ward, followed by hypotension (23%, n=31) and a low Glasgow Coma Score (16%, n=22). Upon further investigation of the 'Worried' category, the most common conditions recorded were an altered conscious state (22%, n=9), low oxygen saturation (20%, n=8), or chest pain (17%, n=7). Activation of Medical Emergency Team calls predominantly occurred in the daylight morning hours (6am-12md). When data were compared to the general hospital patients, the context of the physiological deterioration of the mental health patients was strikingly similar. Further research is recommended to ascertain the extent and frequency with which staff working in mental health units are performing vital signs monitoring as an essential component of detection of early signs of physiological deterioration.

Improving patient safety in Libya: insights from a British health system perspective

PurposePatient safety programmes aim to make healthcare safe for both patients and health professionals. The purpose of this paper is to explore the UK’s patient safety improvement programmes over the past 15 years and explore what lessons can be learnt to improve Libyan healthcare patient safety.Design/methodology/approachPublications focusing on UK patient safety were searched in academic databases and content analysed.FindingsSeveral initiatives have been undertaken over the past 15 years to improve British healthcare patient safety. Many stakeholders are involved, including regulatory and professional bodies, educational providers and non-governmental organisations. Lessons can be learnt from the British journey.Practical implicationsDeveloping a national patient safety strategy for Libya, which reflects context and needs is paramount. Above all, Libyan patient safety programmes should reference internationally approved guidelines, evidence, policy and learning from Britain’s unique experience.Originality/valueThis review examines patient safety improvement strategies adopted in Britain to help developing country managers to progress local strategies based on lessons learnt from Britain’s unique experience.

Simulation-based Assessment to Reliably Identify Key Resident Performance Attributes.

Obtaining reliable and valid information on resident performance is critical to patient safety and training program improvement. The goals were to characterize important anesthesia resident performance gaps that are not typically evaluated, and to further validate scores from a multiscenario simulation-based assessment. Seven high-fidelity scenarios reflecting core anesthesiology skills were administered to 51 first-year residents (CA-1s) and 16 third-year residents (CA-3s) from three residency programs. Twenty trained attending anesthesiologists rated resident performances using a seven-point behaviorally anchored rating scale for five domains: (1) formulate a clear plan, (2) modify the plan under changing conditions, (3) communicate effectively, (4) identify performance improvement opportunities, and (5) recognize limits. A second rater assessed 10% of encounters. Scores and variances for each domain, each scenario, and the total were compared. Low domain ratings (1, 2) were examined in detail. Interrater agreement was 0.76; reliability of the seven-scenario assessment was r = 0.70. CA-3s had a significantly higher average total score (4.9 ± 1.1 vs. 4.6 ± 1.1, P = 0.01, effect size = 0.33). CA-3s significantly outscored CA-1s for five of seven scenarios and domains 1, 2, and 3. CA-1s had a significantly higher proportion of worrisome ratings than CA-3s (chi-square = 24.1, P < 0.01, effect size = 1.50). Ninety-eight percent of residents rated the simulations more educational than an average day in the operating room. Sensitivity of the assessment to CA-1 versus CA-3 performance differences for most scenarios and domains supports validity. No differences, by experience level, were detected for two domains associated with reflective practice. Smaller score variances for CA-3s likely reflect a training effect; however, worrisome performance scores for both CA-1s and CA-3s suggest room for improvement.

Patient and health professional satisfaction with an interdisciplinary patient safety program

Background Measuring humanistic outcomes is an important component of valuating healthcareservices. There is a paucity of data on satisfaction with pharmacist implemented clinical services in long-term care settings. Objective To evaluate patient and health professional (HP) satisfaction with an interdisciplinary patient safety program performed in elderly patients with polypharmacy admitted to a long-term care hospital (LTCH). Method An interventional, longitudinal, prospective study was conducted in a Spanish LTCH. Pharmacist conducted the pharmacotherapy follow-up (reconciliation, pharmacotherapeutic optimization and educational interviews). Two satisfaction surveys were designed on a 10-point Likert-type scale. The patient survey was administered at discharge. The HP survey included the following dimensions: knowledge and program importance, pharmacist skills and pharmacist contributions to the interdisciplinary team. A reliability analysis was performed. Results 123 surveys were completed and returned; 74 patient surveys (response rate 97.4%) and 49 HP surveys (response rate 98.0%). The overall mean score of the patient survey was 9.46 ± 0.87, resulting in 82.4% very satisfied and 17.6% satisfied. The overall mean score of the HP survey was 8.85 ± 1.42, resulting in 65.3% very satisfied and 30.6% satisfied. Conclusion Elderly patients with polypharmacy and HPs reported high levels of satisfaction with the interdisciplinary patient safety program implemented in an LTCH. This positive response supports the value of pharmacists for managing older high-risk populations.

Clinical–insurer engagement to improve maternity safety in the UK, Ireland, Sweden and Australia

Objective To explore different models of clinical–insurer engagement around maternity safety and to understand how state insurers could and should engage with clinical staff to improve outcomes and reduce harm. Design Semi-structured interviews and focus groups were conducted with senior representatives from state insurers. Transcripts were analysed to identify different models of engagement. Themes were also elicited from the transcripts. A further one-day focus group allowed for clarification and elaboration of these themes. Participants Senior representatives from state insurers in England, Scotland, Wales, Republic of Ireland, Sweden and Victoria, Australia. Results A variety of clinical engagement activities were undertaken by the insurers. These included training on claims and risk management, hospital site visits, facilitating multi-professional network meetings and working with clinical experts to develop best practice recommendations. Some insurers engaged with frontline clinical staff through collaborative patient safety programmes. The themes (identity and size, data and research, incentivising improvement and system integration) were important for considering the role of state insurers within health systems and how insurers could engage with clinical teams. Conclusions This study identified different examples of clinical–insurer engagement. Whilst this was encouraging, the relationships between insurers and clinical teams could be developed further. Insurers and clinical staff could still collaborate more closely and work together in improving patient outcomes. Whilst not specifically their domain, insurers do have a role in patient safety. Closer clinical collaboration may strengthen this contribution.

The association between quality system development stage and the implementation of process-level patient safety themes in Dutch hospitals: an observational study

Quality systems are believed to be positively related to quality and safety in healthcare. However, there is no convincing evidence for this relationship in the literature. This study aims to examine the association between the development stage of hospital quality systems and the implementation of patient safety themes at the process level. This study combines data from a national survey on the development stage of quality systems in Dutch hospitals with results from an evaluation study of the Dutch Hospital Patient Safety Program. Data on the development stage of quality systems were collected in Dutch hospitals in 2011. A total of 73 quality coordinators completed a questionnaire (response rate 77%) covering five quality system domains: policy and strategy, human resource management, patient involvement, practice guidelines, and systematic quality improvement. Data were included on the implementation of five patient safety themes from the Dutch Hospital Safety Program. Process indicators for each theme were measured every four to six weeks, resulting in ten measurements in each hospital. Data were analyzed using multilevel analysis. The mean score for hospital quality system development was 2.30 (range 1 to 3). The mean scores for the various quality system domains ranged from 1.56 (Patient Involvement) to 2.66 (Human Resources Management). The mean percentages for the implementation of the patient safety themes ranged from 12% for the ‘Pain’ process indicator to 73% for execution of the ‘Time-Out Procedure’. The intraclass correlation coefficients of the intercept-only model ranged between 11.6 and 51.6, which indicates large differences between hospitals in the implementation of the patient safety themes. Positive associations between quality system development stage and implementation of patient safety themes were found for four of the five patient safety themes, although they were not statistically significant. This study found no association between the development stage of a hospital quality system and the implementation of patient level safety themes at the process level. This rejects the hypothesis that quality improvement is caused by a positive relationship between structure (the quality system) and processes (the safety program implementation), which in their turn mold the quality of care at the patient level.

Hubungan Karakteristik Individu Perawat dengan Insiden Keselamatan Pasien Tipe Administrasi Klinik di Rumah Sakit Umum Haji Surabaya

Patient safety incidents type of clinic administration are incidents that occur in the process of patient identification, handover, agreement, informed consent, queuing, referral, admission, discharge of patients from inpatient, transfer of care, division of tasks, response of emergency. Based on patient safety incidents reports of RSU Haji, there were 12 patient safety incidents type of clinic administration (standard 0% or zero accident) during January 2014-June 2016 in inpatient unit. This research aimed to analyze the correlation between nurse’s individual characteristics with patient safety incidents type of clinic administration. This research was an observational descriptive study with cross sectional design. Questionnaires were distributed to 48 nurses that divided into 6 inpatient units. The results of this research showed that the lower the nurse's knowledge about patient safety and patient safety incidents type of clinic administration, the higher the nurse’s work fatigue, the lower the nurse’s motivation toward to the application of patient safety program, the higher the tendency of patient safety incidents type of clinic administration occured in inpatient unit of RSU Haji Surabaya. The conclusion of this research are knowledge, work fatigue, motivation of nurse have a correlation with patient safety incidents type of clinic administration in inpatient unit of RSU Haji Surabaya. Keywords: patient safety incidents, clinic administration, nurse, hospital

Self perceived hand hygiene among student health professionals in a tertiary care teaching hospital in Southern India

Implementation of and adherence to practice of hand hygiene in a health care organization not only prevents health care- ssociated infections (HAI) but also limits the transmission of micro-organisms.With “Clean Care is Safer Care” as a main agenda of the global initiative taken by WHO on patient safety programs,it is time for developing countries to develop the much-needed policies for implementation of practices,which will prevent the basic infection in health care setups.The subjects involved in this study were assessed for knowledge and practice of hand hygiene.Interestingly,this study revealed that awareness & proper practice of hand hygiene was not satisfactory as the mean range of number of correct answers was 15-17 out of 28 questions.This was despite 83.3% of the sample having said that they got formal training in hand hygiene. The comparison of knowledge of the two groups showed that the nursing students were more knowledgeable than the MBBS students.There was a significant difference in the level of knowledge among Nursing and MBBS students as found in similar studies where the knowledge of Nursing students was better than that of MBBS students. Van de Mortel et al. in 2010 studied the hand hygiene knowledge, beliefs, and practices among nursing and medical students.They found that the knowledge of Nursing students was more than that of Medical students (P < 0.01), which is consistent with our study.

Gibson's theory of affordances and situational awareness occurring in urban departments of pediatrics, medicine, and emergency medicine.

The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) program provides a situation-monitoring tool that allows health-care professionals to perform an environmental scan. This process includes scanning the status of the patient, team members, and the environment, to ensure that patient care is progressing toward the goal. It is assumed that health-care professionals will act in a certain way by providing feedback and support based on the scan. However, there is limited research supporting the impact of the clinical environment on behavior among health-care professionals. This qualitative research used in situ simulation and a theoretical sampling of six day and overnight shift clinical teams (n = 34) from three departments in an urban hospital in New York City: pediatric medicine, emergency medicine, and internal medicine. Notebook entries by the participants at three intervals during the case and a debriefing following the cases captured participant views, observations, and concerns about the immediate clinical environment. In all six cases, and with every shift, there were documented examples of someone in the environment who saw something but did not speak up, possibly making a difference in regard to patient safety and the outcomes in the case. Some of the noted reasons include not wanting to be wrong, not wanting to hurt someone's feelings, or not being sure. Our research explored the environmental scan that health-care team members conducted in three unique department settings, including how they perceived affordances, and the reasons why individuals may not speak up when another team member is not performing properly. Each person possesses a unique awareness and deficit of available affordances because of his/her position in the environment. Patient safety is somewhat reliant on the views and observations of each team member. Educators should use these outcomes to justify teamwork and communication training that includes targeted emphasis on providing candid feedback, situation monitoring, and mutual support.

The Relationship of Lack of Control Factors with the basic Cause in Effort to Prevent Fall Risk on Hospitalized Patients in Muhammadiyah Lamongan Hospital

The risk assessment of falling is one of the goals of patient safety program. Risk assessment of falling risk is one of the goals of patient safety program. Falling risk incident is a lack of supervise manifestation of a whole hospital's component, begin with the system to the work environment against the subjects in it.