Patient Safety Program Research Articles

Integrating Care Coordination and Mental Health Research Into Dialysis Practice: Stakeholder Perspectives, Methods, and Outcomes

Despite many studies suggesting beneficial innovations for patients, few make it into clinical practice. This study aims to enhance patient care by facilitating effective dissemination of patient-centered outcomes research to health care workers in outpatient dialysis facilities, aided by the Patient-Centered Outcomes Research Institute's (PCORI) dissemination and implementation framework. Dissemination and implementation project. Outpatient hemodialysis facilities in the United States. We brought together panels of key stakeholders, which included researchers, patient subject matter experts, and dialysis personnel. Their role was to provide guidance on the content and methods for disseminating research findings. With a focus on 2 critical patient safety areas-care coordination or care transitions and mental or behavioral health-we developed virtual education modules. These modules were then made available to outpatient dialysis facilities by the national 5-Diamond Patient Safety Program. In 2022, the training was used by more than 2,500 dialysis facilities and approximately 40,000 dialysis staff in the care coordination module, and by more than 300 dialysis facilities and 5,000 staff for the mental health module. Cumulatively, the modules affected more than 179,000 patients. Evidence of efficacy was the significant increase in trainee knowledge of research findings and implementation considerations (P≤0.05). Potential selection bias because dialysis facilities that did not participate in the program may differ significantly from those that did, which may affect generalizability. In addition, variable timing in release of the different modules may have influenced uptake by facilities. By using key stakeholder guidance and accessible virtual education modules, the implementation framework shows promise in effectively disseminating research findings within outpatient dialysis settings. This method potentially carries implications for broader health care settings as well. Our study addresses a common health care challenge-many promising ideas for improving patient care never actually reach the patients. We aimed to bridge the dissemination gap by sharing research with health care workers in outpatient dialysis, promoting evidence-based practice. We collaborated with experts, patients, and dialysis personnel to develop easy-to-understand educational materials focused on 2 critical topics: care coordination and mental health. In 2022, our training benefited more than 2,500 facilities and 40,000 staff for care coordination, and 300 facilities with 5,000 staff for mental health, positively affecting more than 179,000 patients. We found that the training significantly increased knowledge among staff. Our approach shows promise for sharing research effectively in dialysis centers and potentially in other health care settings.

GAMBARAN BUDAYA KESELAMATAN PASIEN PADA PERAWAT DI RUMAH SAKIT X. BEKASI TAHUN 2022

The implementation of a culture of patient safety is crucial in hospitals so that patients do not experience unwanted or unexpected hazards during hospitalization. Hospital X. Bekasi has a quality unit, but incident reporting at Hospital X. Bekasi is not going well. This illustrates the implementation of a patient safety culture that is not running well. This study aims to look at the culture of patient safety among nurses in RSX. The year 2022 is seen in the 12 dimensions of the culture of patient safety, according to the Association for Health Care and Research Quality (AHRQ). This research uses a cross-sectional design. The population in this study is the nurse who directly serves the patient. A large sample in this study of 90 nurses was taken with total sampling techniques. The instrument used in this study is the Hospital Survey on Patient Safety Culture (HSOPSC), which has 12 dimensions. The results showed average positive responses from 12 dimensions of patient safety culture (62.5%), Higher Expectations and Action in Promoting Patient Safety (53.3%), Learning for Organizational Continuous Improvement (64.8%), Unit Collaboration (57.5%), Open Communication (61.1), Feedback and Communication on Errors (63.2%), Non-Positive Response (79.6%), Staffing (69.4%), Management Support Dimension for Patient Security (92.2%), Inter-Units Cooperation (64.4%), Overall Perception of Patients Safety (50.2%), Incident Reporting Frequency (50.7%) and Incident Reports Frequencies (50.7%). Hospital X. Bekasi is expected to continue and maintain patient safety programs, evaluate the number of existing staff, improve incident reporting motivation, and conduct comprehensive and periodic patient safety culture measurements.

Health Science Students' Perceptions of Hand Hygiene Education and Practice in a South African University: Introducing the University Hand Hygiene Improvement Model.

Hand hygiene serves as a critical preventative measure against the spread of acquired infections in healthcare facilities and is an integral component of patient safety programs. While healthcare students in training are typically introduced to the principles underlying hand hygiene, the translation of this understanding into practice is often lacking, and compliance has remained low. This study aimed to evaluate health science students' in biomedical sciences, chiropractic and emergency medical care, environmental health, complementary medicine, medical imaging and radiation sciences, nursing, optometry, podiatry, and sports and movement studies perceptions regarding hand hygiene education (knowledge and attitude) and practice at a university in South Africa. Consenting students were asked to complete an online questionnaire that tested their knowledge, practices, and skills in handwashing. The ANOVA analysis results suggested significant differences in hand hygiene scores across departments and years of study. The multiple regression analyses confirmed these findings, suggesting that the department of study significantly influenced all aspects of hand hygiene, while the year of study affected hand hygiene skills, and age group influenced hand hygiene practices. Based on these findings, a conceptual model, the University Hand Hygiene Improvement Model (UHHIM), was proposed to enhance the teaching and learning of hand hygiene at the university level. The model underscores the necessity of targeted education, continuous monitoring, and feedback, and the pivotal roles of hand hygiene facilitators and student participation in enhancing hand hygiene behaviors.

Acute Stress in Health Workers in Colombia 2017-2021: A Cross-Sectional Study.

Objectives: Analyze the presence of acute stress response after adverse events in human talent in Colombian health institutions from 2017 to 2021. Methods: Cross-sectional study of prevalence, carried out on 838 members of the human talent in health (professionals, technicians, technologists, and auxiliaries) of Colombian health institutions in the study period with the application of the EASE instrument. Univariate analysis using descriptive statistical techniques, chi-square and Student's t-test, and bivariate analysis with a Poisson regression model using the institucional SPSS v. 26. Results: The prevalence of adverse events in the last 5years was 33.8%, presenting levels of acute stress qualifying as Medium-high emotional overload at 21.91%, while extreme acute stress was at 3.53%. The prevalence of risk for presenting acute stress after being involved in an adverse event was PR: 1.30 (CI: 1.24-1.36). Conclusion: Acute stress in human talent after adverse events is limiting health and care capacity and must be efficiently addressed by health institutions. Psychosocial risk is linked within the framework of the patient safety program and the institutional occupational health and safety management systems.

Clinical risk and patient safety: a multicenter cross-sectional study to explore knowledge, attitudes and practice of hospital nurses


 Objectives: To investigate knowledge, attitudes, and behavior of nurses working in acute care hospitals regarding clinical risk and patient safety, and to identify predisposing factors.
 Design: Cross-sectional multicenter study.
 Methods: The study was conducted in thirteen non-teaching acute public and private hospitals of a region of southern Italy from September through December 2015. A structured self-report questionnaire was administered to clinical nurses working in the hospitals involved. Three multivariate linear and logistic regression models have been constructed: knowledge of the definition of an adverse event; attitude towards risk of making an error while working and nurses who reported at least one error in the past 12 months.
 Results: The sample consisted of 484 respondents out of 670 (72.2%) nurses approached. The final multivariable model showed that educational courses about patient safety play a significant role in nurses gaining knowledge of adverse events. In the absence of organization-wide patient safety programs, nurses with low knowledge levels showed a significantly higher perceived risk. Nurses (n=96) who made errors over the past 12 months had discussed them with head nurses (75%) and colleagues (41.7%). Anonymous reporting to the organization was very low, with only 8.3% of nurses who had made an error submitting an anonymous report.
 Conclusions: Managers should implement multimodal improvement strategies aimed at enabling nurses’ to recognize the critical issues of the system and to increase their reporting, in order to make the organizations safer.

Implementation of Patient Safety Program in the Emergency Installation of H. Adam Malik General Hospital Medan

Patient Safety Program stipulated in the Minister of Health Regulation of the Republic of Indonesia No. 11 of 2017 namely Patient Safety Standards; Patient safety goals, and 7 steps towards patient safety. 8 Contributor Factors in Patient Safety are external factors, organization and management, physical environment, teamwork, officers, tasks, patients, and communication. This study uses qualitative research with a phenomenological approach by conducting in-depth interviews of several health workers at the Adam Malik Hospital Medan. Implementation of patient identification using 2 identities and is used for confirmation before the procedure, the implementation of effective communication is done by doing readback before carrying out the procedure, aware of high alert drugs by prescribing drugs into pharmacy, then drugs are formulated by pharmacy and before being given to patients with double checks, ensuring the accuracy of location, procedure and patients by site marking on body parts and signed in the medical recording, preventing the infection of medical Reducing the risk of patients falling by giving yellow bracelets and assistance to patients. In external contributors, the regulations used by Adam Malik Hospital are adapted from the Law of the Republic of Indonesia and the Regulation of the Minister of Health of the Republic of Indonesia, organizations and management support the staff in carrying out patient safety programs, the hospital environment is appropriate but there are several facilities that must be improved, the team's work has been running without difficulties. It patient information and educating patients.

Evaluation of the patient safety situation in Abuzar Teaching Hospital of Ahvaz based on patient safety friendly standards in 1401

Introduction: Patient safety is a fundamental principle in health care. Patient safety friendly standards are a set of requirements that are critical to the implementation of a hospital-wide patient safety program. This study was conducted with the aim of investigating the patient safety situation in Ahvaz Abuzar Hospital based on patient safety friendly standards.
 Method: This cross-sectional descriptive study was conducted in 1401 on 30 employees related to patient safety with a non-random and purpose-based sampling method. The required data were collected by the first two axes of the World Health Organization's patient safety friendly standards checklist, including governance and leadership - gaining participation and interaction with the patient and society, using observation, interview and hospital documentation techniques. The data was analyzed using statistical tests (mean and standard deviation) of SPSS26 software and scored on a three-point Likert scale.
 Results: The level of compliance of the hospital with the first two axes of patient safety friendly standards (64 standards in total) was evaluated at a good level with an average of 80/4%. Mandatory and basic standards were at a good level and advanced standards were at an average level. The group of attracting participation and interacting with the patient and society with an average of 82/7% had more compliance than the governance and leadership group with an average of 78/09%.
 Conclusion: The condition of Abuzar Hospital was evaluated at a good level in terms of compliance with patient safety-friendly standards. It is better to consider the level of compliance with basic and advanced standards in future researches.

Patient safety culture and associated factors among health care providers in government and private hospitals, Bahir Dar City Northwest, Ethiopia, 2022: a comparative cross-sectional study

BackgroundPatient safety in a healthcare setting is now a major global concern. Millions of people suffer disabling injuries or death directly related to medical care errors, particularly in developing countries. Evidence about patient safety culture in Ethiopia is limited. Therefore, this study was designed to assess the level of patient safety culture and associated factors among healthcare providers in government and private healthcare providers.Methods and materialsInstitution based cross-sectional study was conducted from May to June 30, 2022. Self-administered hospital survey on Patient Safety Culture (HSOPSC) tool was used to select 448 study participants. Epi Data version 4.6 and SPSS version 26 were used for data entry and analysis. Chi-square test, Bi-variable, and multivariable logistic regressions were done to determine the association between the independent and outcome variable.ResultA total of 448 healthcare providers with a response rate of 99.6% participated. The prevalence of good patient safety culture was 50.9%( 95%CI: 46.2, 55.6%). Patient safety culture difference was observed between government and private healthcare providers (× 2 = 22.6, df = 1, p = 0.000). Type of hospitals (AOR = 0.37(95% CI:(0.21, 0.68), profession (AOR = 2.16 (95% CI:(1.02,4.62), job satisfaction (AOR = 0.19,95%CI:(0.12,0.30), participated in patient safety programs(AOR = 2.69:(95%CI:1.53,4.75), providing necessary equipment and materials (AOR = 2.05(95%CI: 1.18,3.55%), and work shift (AOR = 0.47( 95%CI: 0.25,0.93) were found significantly associated with good patient safety culture among healthcare providers.ConclusionThe prevalence of good patient safety culture was relatively low. Patient safety culture difference is observed between government and private healthcare providers. Type of hospitals (public or private), profession, job satisfaction, participation in patient safety programs, providing necessary equipment and materials, and work shifts were associated factors for patient safety culture. Therefore, it is better to design patient safety improvement strategies for both government and private healthcare providers.

Patient Safety Program in Emergency Department (ED) at Prof. Dr. Chairuddin Panusunan Lubis Hospital in 2023

This research explores the implementation of patient safety goals in the Emergency Department (ED) of Prof. Dr. Chairuddin Panusunan Lubis Hospital in 2022. Qualitative data gathered from key informants, including the Head of the ED, Head Nurse, and staff nurses, reveals determinants impacting patient safety. The study identifies several findings: good patient identification, the need for improved communication, positive progress in medication safety, effective implementation of site marking, successful reduction of infection risk, and adequate measures to minimize patient falls. Recommendations include enhancing communication among nurses and reinforcing medication safety protocols. The systematic application of site marking ensures precise location and procedures. Efforts to reduce infection risk and prevent patient falls are commendable, supported by appropriate policies, procedures, and training programs

#3410 COVID-19 PANDEMIC: STRUCTURAL AND FINANCIAL CHALLENGES AND QUALITY OF TREATMENT IN HEMODIALYSIS CLINICS

Abstract Background and Aims In December 2019, Chinese Centers for Disease Control and Prevention was the first to report an outbreak of febrile respiratory disease where a new coronavirus identified, called SARS-CoV-2 that triggered a complex multisystemic disease, Covid-19. It spread rapidly, reaching countries in all five continents. The World Health Organization declared Covid-19 a pandemic in March 2020. The following years were a challenge for humanity and health systems around the world. Studies show that Chronic Kidney Disease (CKD) with glomerular filtration rate <30 ml/min/1.73 m2 is an important risk factor for critical disease. Patients undergoing in-center hemodialysis (HD) are at higher risk for COVID-19, as they stay indoors without renewed air, which is important to control transmission, the same occurring with the professionals involved in the treatment. In our units, in order to mitigate the contamination, in addition to all measures required by health authorities, all SARS-Cov-2 positive patients performed their treatment in a separate room and with an in-center different flow from negative patients. The aim of this study was to verify whether the significant structural disarrangement that occurred in this period could interfere with the goals of the quality indicators established by the Patient Safety Program (PSP). Method We conducted a retrospective cross-sectional study to evaluate the evolution of both operating costs and PSP quality markers during 2019 to 2022. We studied 457 patients undergoing in-center HD, with no distinction by gender, race, age or underlying disease. In the measurement of costs, only materials/medications specifically to HD, as well as the expenses in the remuneration of the constant changes of the care team, the absence due to contracting the disease or the established health standards. The following were analyzed: Conversion of viral hepatitis, with a target of 0%; SpKt/V ≥1.2, target 70%; Healthcare-Related Infections for Arterio-Venous Fistula (HRI-AVF) target <1%. Hospitalization/deaths ratio as an index of the impact of the disease on our population was also calculated. All indexes were measured monthly and annualized using mean (costs), median and standard deviation, as a measure of central trend. Statistical analysis was used ANOVA and Kruskal-Wallis Test. Results In 2019, the cost of items corresponded 22.2% SD±1.6 of the value of the dialysis session; 30.4% SD±2.8 in 2020; 32.3% SD±3.0 in 2021 and finally 31.1% SD±3.0 in 2022. Obtaining statistical significance only from 2019 for other periods, p<0.05. We did not observe viral hepatitis conversion at all times, reaching the goal. In the SpKt/V indicator, we observed 78% SD±4 in 2019, 73% SD±4 in 2020, 72% SD±6 in 2021 and 79% SD±6 in 2022, with no statistical significance observed between years. HRI-AVF rate was 1% in 2019, 3%, 2% and 2% in 2020, 2021 and 2022, respectively. No static significance found. The hospitalization/deaths ratio was 13% in 2019, 45% in 2020, 41% and 31% in 2021 and 2022, respectively. Conclusion The pressure in health units, a large increase in hospital costs due to the scarcity of materials/medicines and equipment for patient care, and especially the absence of sick professionals and/or increased workload, led to structural and financial disorganization in all health units including HD centres. This destructuring could somehow interfere with the quality of treatment. However, we did not show this relationship, because we found increased costs, and achievement of the goals of Viral Conversion Rates, SpKt/V>1.2 and AVF-related IRAS. The number of hospitalizations was large, as in the whole world, with high lethality. We are in line with the official Brazilian Government: a fall in the prevalence of CKD per 100,000 inhabitants and a fall in deaths due to CKD, leading cause of death from Covid-19, as shown in the graphs below. The implementation of the PSP with a work of solidification of its standards and its objectives, go through continuous work with each patient, and incessant training of all professionals involved. With this, they become a strong barrier of protection to adverse events of the size to those caused by the Covid-19 pandemic.

Demonstrating Clinician Educator Value.

Clinician educators (CEs) can feel pressured by multiple institutional forces: compliance with frequently changing Accreditation Council for Graduate Medical Education (ACGME) requirements; the dynamic operational and fiscal strains of sponsoring institutions (SIs); and personal pressures for career advancement, in both academic and community settings. The value of demonstrating contributions as a CE for academic promotion via an annotated curriculum vitae and/or portfolio is well documented.1,2 However, CEs must also find ways to continuously demonstrate value to program, clinical, and organizational leadership, regardless of the type of SI.CEs should strive to align their educational priorities with the SI's clinical priorities. Two examples of aligned CE-SI goals are achieving a reputation for being a high reliability organization and providing value-based care.3 High reliability organizations strive to provide care with zero harm, and value-based systems provide high-quality patient care focused on improved outcomes, positive patient experiences, and lower use of resources.4To accomplish these goals, most SIs develop quality improvement (QI) and patient safety (PS) programs that often operate independently from the sponsored educational programs.5 The ACGME's Common Program Requirements mandate trainee skill development to provide reliable, safe, and high-quality care. At the same time, trainee involvement in QI and PS programs often goes underrecognized by SI leadership, despite program directors reporting that resident participation in QI led to institutional-level changes.5How can CEs make their SI's and program's leadership aware of their contributions to aligned priorities? Using a framework such as mattering can help. Mattering is a psychological construct which recognizes that we all want to be valued and to add value. When someone matters, they are more engaged, are less stressed and depressed, and feel like they belong. There are 4 accepted components for CEs to incorporate when creating an environment of mattering: awareness, importance, reliance, and ego extension.6 As a CE, demonstrating how your clinical and educational work adds value to the shared goals of high reliability and value-based patient care is vital.By using the 4-part mattering framework, you can enhance how you and your program matter to your SI and program leadership. When you matter to others, they recognize your value as well as the value of your programs and activities in achieving shared goals.

TeamSTEPPS®-based clinical simulation training program for critical care professionals: A mixed-methodology study

IntroductionThe Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) programme has been shown to improve interprofessional work among healthcare professionals by enhancing teamwork. Intensive care professionals were trained in this methodology through the course “Simulation Trainer: Improving Teamwork through TeamSTEPPS®”. ObjectivesTo analyse the teamwork performance and good practice in simulation of the intensive care professionals attending the course and to explore their perceptions of the training experience carried out during the course. MethodsA cross-sectional descriptive and phenomenological study was carried out using a mixed methodology. The 18 course participants were administered the questionnaires “TeamSTEPPS™ 2.0 Team Performance Observation Tool” to evaluate teamwork performance and “Educational Practices Questionnaire” for good practices in simulation after the simulated scenarios. Subsequently, a group interview was conducted through a focus group with 8 attendees using the Zoom™ videoconferencing platform. A thematic and content analysis of the discourses was carried out using the interpretative paradigm. Quantitative and qualitative data were analysed using IBM SPSS Statistics™ 27.0 and MAXQDA Analytics Pro™ respectively. ResultsBoth the level of teamwork performance (mean = 96.25; SD = 8.257) and good practice in simulation (mean = 75; SD = 1.632) following the simulated scenarios were adequate. The following main themes were identified: satisfaction with the TeamSTEPPS® methodology, usefulness of the methodology, barriers to methodology implementation and non-technical skills improved through TeamSTEPPS®. ConclusionsTeamSTEPPS® methodology can be a good interprofessional education strategy for the improvement of communication and teamwork in intensive care professionals, both at the care level (through on-site simulation strategies) and at the teaching level (through its inclusion in the students' curriculum).

HUBUNGAN PENGETAHUAN PERAWAT DENGAN PENERAPAN PATIENT SAFETY

Nurses' knowledge about patient safety is very important because nurses must show a positive attitude in supporting patient safety programs so that they carry out nursing practices safely. Patient Safety is a top priority in health services and is the first step to improve service quality and is related to hospital quality and image. In Indonesia alone, new incident reports were recorded at the Hospital Patient Safety Committee (KKPRS) of incidents from September 2013 to August 2014 as many as 145 incidents due to medical error cases. RSUD Haji Makassar has one of the programs in infection prevention and control related to health services but it has not been fully realized. This study aims to determine the relationship between the level of knowledge of nurses in the class 3 treatment room at the Haji Makassar Hospital with efforts to implement patient safety. The type of research used is cross sectional using a descriptive approach. Based on the results of the analysis, there is a relationship between the level of knowledge and the application of patient safety with a p-value of 0.006 <0.05. It is recommended to the hospital to organize education, training, and socialization to all health workers regarding efforts to implement patient safety, especially to nurses in order to increase nurses' knowledge regarding the application of patient safety

Implementation of Supervision About Patient Safety with an Inguinal Hernia Diagnosed in an Inpatient Room: A Case Study

Introduction: Patient safety has become a global issue that is currently being discussed in all countries. Concerns about patient safety have increased significantly over the last decade. The implementation of supervision is very important in order to improve the implementation of patient safety goals. The purpose of this research is to analyze the implementation of supervision regarding patient safety in patients with a diagnosis of Inguinal Hernia in the Inpatient Room. Method: Used a survey method with a supervision questionnaire for patient safety and a supervision effectiveness questionnaire for patient safety. Results: The results showed that supervision of patient safety in patients with a diagnosis of Inguinal Hernia has been carried out in the Hospital Inpatient Room. Implementation of this supervision is effective to do in order to increase the motivation of nurses in implementing patient safety goals. But the implementation of supervision about patient safety is still not optimally implemented because there are several obstacles such as the patient safety program has not become a priority agenda, there is no driving force, it is carried out under forced conditions such as only because of demands from superiors, there are obstacles due to a lack of understanding of the implementation of patient safety programs, there is no sense of awareness in towards patient safety culture, and non-optimal incident reporting. Conclusion: These results can be a reference for hospitals about the attitude of nurses in monitoring patient safety and should improve existing nursing training by allowing nurses to continue their education to a higher level, by holding regular training on patient safety practices.

ANALISIS IMPLEMENTASI KESELAMATAN PASIEN DI PUSKESMAS KOTA SURABAYA DITINJAU DARI ENAM SASARAN KESELAMATAN PASIEN


 
 
 
 Patient safety is one of the essential elements of a health service system that is effective and efficient in improving the quality of health services. Puskesmas as a first-level health facility must improve the quality of health services to the maximum, especially on patient safety indicators, so that accreditation status can increase. However, the development of patient safety issues in Indonesia, especially at the Puskesmas level, is not as dynamic as in hospitals and the reporting of patient safety incidents at Puskemas is still not transparent, especially in Indonesia. This research method uses qualitative research with a case study approach. Data collection was carried out using in-depth interview techniques and secondary data collection. The implementation of the patient safety program has been running well in accordance with the Policy / SOP contained in Permenkes 11 Th.2017 by adjusting the needs of the Puskesmas. In addition, several obstacles were found in implementing patient safety, such as insufficient human resource needs, the absence of special budgeted funds, minimal facilities and infrastructure, ineffective communication between officers so that miscommunication occurred, and human error. So it is necessary to evaluate DKK Surabaya in relation to human resources, funds, facilities, and infrastructure, as well as the need to update the standards/guidelines in Permenkes related to patient safety standards. Finally, there is a need for an IKP data transparency policy, especially in Puskemas.
 
 
 

An Overview of Patient Safety Culture with the AHRQ

Safety has become a global issue, especially for hospitals. Patient safety culture is a product of values, attitudes, competencies, and behavioral patterns of individuals and groups that determine the commitment, style, and ability of health care organizations to patient safety. The purpose of this study was to determine the description of patient safety culture with the AHRQ model. Quantitative research method with cross sectional. The population of all officers in the inpatient installation of RSUD Dr. R. M Djoelham 156 samples found 61 respondents with simple random sampling technique. The results of the study describe the expectations and actions of managers promoting patient safety by 77.04%, organizational learning by 91.8%, cooperation in units of 93.85% (good or strong culture), open communication by 71.04%, feedback on errors 77.05% (good or strong culture), non-punitive response dimension to errors is 61.20% staffing is 59.01% management support for patient safety efforts is 85.8% cooperation between units is 71.32%, Handsoff work and patient transitions are 59.02% (good enough or moderately cultured), the overall perception of hospital staff about patient safety is 68.86% (good enough or moderately cultured), reporting frequency is 73.22% (good enough or moderately cultured). moderate culture). With the results of this study, it is hoped that RSUD Dr. R.M. Djoelham Kota Binjai is expected to continue, maintain, and develop ongoing patient safety programs and maintain the existing patient safety culture.

The effect of community of practice in improving the role of clinical instructor in patient safety implementation by prelicensure nursing students

Introduction: Patient safety problems caused by students leads to different adverse event, hence clinical instructor plays a role in guiding them in the implementation of patient safety programs. Furthermore, the community of practice is considered to improve the role of clinical instructors in patient safety problems. This study is then conducted to measure the impact of community of practice toward the role of clinical instructors in patient safety problems. Design and methods: This is a pre-experimental design for one group and a pre-post test design without a control group. In addition, the sample includes 36 prelicensure nursing students. Result: The results showed that the score of clinical instructors’ role before and after intervention with community of practice implementation was 58 (34-67) and 79.33 with SD of 10,960, respectively, with a significant increase of 24.27. Also, the statistic analysis depicted that the role had a significant effect after implementation, with a p-value of < 0,000. Conclusions: Based on the results, the community of practice had a significant impact in increasing the role of clinical instructors in the implementation of patient safety problems by prelicensure nursing students.

National statutory reporting: not even ticking the boxes? The quality of ‘Learning from Deaths’ reporting in quality accounts within the NHS in England 2017–2020

IntroductionRegulation through statutory reporting is used in healthcare internationally to improve accountability, quality of care and patient safety. Since 2017, within the National Health Service (NHS) in England, NHS Secondary...

Is anybody ‘Learning’ from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017–2020

IntroductionThe imperative to learn when a patient dies due to problems in care is absolute. In 2017, the Learning from Deaths (LfDs) framework, a countrywide patient safety programme, was launched...

Difference of allergic reaction on hand sanitizer gel and liquid among nurses at RSU Karsa Husada Batu

Introduction: The program to improve the hand hygiene of health workers has been declared by WHO through a patient safety program that sparked the Global Patient Safety Challenge "clean care is safe care". Hand hygiene practice, health workers may use the gel or liquid form of hand sanitizer with alcohol-based ingredients. However, alcohol is flammable, causing dryness and irritation of the skin on repeated use and increases the risk of viral infections that trigger inflammation of the digestive tract. Objectives: Researcher would like to find any difference on allergic reaction between the use of hand sanitizer gel and liquid form which were commonly used by nurses at RSU Karsa Husada Batu during hand hygiene practice. Methods: The research design used is a survey research with a cross sectional approach where the researcher observes the research subjects using a check list and questionnaire, with a sample of 80 respondents. The data analysis used non-parametric statistics Mc-Nemar test. Results: The results of the Mc-Nemar Test showed a p value of 0.033 < 0.05 which means that the use of hand sanitizer gel and liquid has a significant difference in the allergic reaction among nurses. Conclusions: Hand sanitizer in gel or liquid form were safe as long as use correctly and properly, also selecting a type of hand sanitizer must be matched with the individual skin