Patient Safety Program Research Articles

A Customized Triggers Program: A Children’s Hospital’s Experience in Improving Trigger Usability

Despite the growth of patient safety programs across the United States, errors and adverse events remain a source of patient harm. Many hospitals rely on retrospective voluntary reporting systems; however, there are opportunities to improve patient safety using novel tools like trigger programs. Children's National Hospital developed a unique pediatric triggers program that offers customized, near real-time reports of potential safety events. Our team defined a measure to quantify clinical utility of triggers, termed "trigger signal," as the percentage of cases that represent true adverse or near-miss events (numerator) per total triggers activated (denominator). Our key driver diagram focused on unifying the program structure, increasing data analytics, promoting organizational awareness, and supporting multidisciplinary end user engagement. Using the model for improvement, we aimed to double overall trigger signal from 8% to 16% and sustain for 12 months. The trigger signal increased from 8% to 41% and sustained during the coronavirus disease 2019 pandemic. A balancing measure of time to implement a new trigger decreased. Key interventions to increase trigger signal were change in the program structure, increasing stakeholder engagement, and development of self-service reports for end users. Children's National Hospital's triggers program highlights successful evolution of an iterative, customized approach to increase clinical utility that hospitals can implement to impact real-time patient care. This triggers program requires an iterative, customized approach rather than a "1-size-fits-all," static paradigm to add a new dimension to current patient safety programs.

CANDOR - A Patient Safety, Medical Liability, and Healthcare Professional Wellness Program

The Communication and Optimal Resolution (CANDOR) program, a patient safety, medicolegal, and healthcare professional wellness program, has been implemented or in the process of being implemented in over 800 US hospitals. The program was designed to help patients suffering from unexpected adverse outcomes and healthcare professionals whose patients experience injury while under their care. The CANDOR program’s basic premise emphasizes honesty in medical error situations. It aims to prevent the recurrence of medical errors. Studies have found that, compared to the common US practice known as “Deny, Delay, and Defend,” using CANDOR not only benefits current and future patients but can improve the well-being of healthcare professionals. This paper therefore aimed to describe CANDOR and evidence regarding its effects on patients and the healthcare professional’s well-being at hospitals that implemented it in comparison to their previous practice of “Deny, Delay, and Defend.” This paper describes methods used by CANDOR teams, which include physicians, attorneys, patient advocates, and health policy leaders, in their successful endeavor to persuade hospital leaders to implement it, in essence to change the hospital’s culture from a culture of opaqueness regarding medical errors and their consequences to a culture embracing transparency. This paper also describes obstacles the teams faced in their endeavor to implement CANDOR at their institution and how they surmounted the obstacles.

10 years of the National Patient Safety Program: progress, obstacles and Nursing protagonism

10 years of the National Patient Safety Program: progress, obstacles and Nursing protagonism

10 years of the National Patient Safety Program: progress, obstacles and Nursing protagonism

10 years of the National Patient Safety Program: progress, obstacles and Nursing protagonism

Analysis of Patient Protection in a Medical Institution

At the General Hospital Santo Domingo, patient safety was a priority in 2022, focusing on practices that prevented unnecessary harm during healthcare delivery. A quantitative study with a descriptive, exploratory, and field approach was conducted, using methodological tools such as the questionnaire from the Agency for Healthcare Research and Quality and structured interviews with the institution's director. The sample included 100 operational staff and the administrative director, evaluating labor, social, and personal parameters in five safety categories. It was noted that 65 % of the health personnel confirmed full compliance with the patient safety program guidelines. Furthermore, a strategic analysis was performed that significantly contributed to improving patient safety at the institution. This analysis highlighted the need for ongoing training and updating parameters to meet the specific needs of the establishment, aiming to enhance the patient safety culture. It was concluded that, although the management of patient safety was efficient, it was imperative to continue training and adapting practices to optimize patient protection at the hospital

Effect of Patient Safety Program for Nurses on Medication Administration

Effect of Patient Safety Program for Nurses on Medication Administration

The Impact of TeamSTEPPS Training on Obstetric Team Attitudes and Outcomes on the Labor and Delivery Unit of a Regional Perinatal Center.

We investigated the effect of TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) training on teamwork perceptions and patient safety outcomes in an inpatient obstetrics setting. Physicians and nurses from the regional perinatal center were offered TeamSTEPPS instruction and administered a voluntary survey to assess subjective perceptions of team dynamics and patient safety prior to and 6 months following TeamSTEPPS training. Responses were analyzed using analysis of variance (ANOVA) and Chi-square test. Objective measures of patient safety outcomes were the incidence and blood loss of postpartum hemorrhage after vaginal delivery (PPH-VD) or cesarean section (PPH-CS) and incidence of shoulder dystocia (SD). Outcomes were analyzed using Mann-Whitney and Kruskal-Wallis tests. Surveys were collected from 20 physicians and 15 nurses prior to training and from 9 physicians and 20 nurses 6 months following training. Survey data showed an overall positive perception of teamwork and patient safety behaviors across all respondents. However, we found no significant changes in perception of team dynamics or behaviors to promote patient safety between pre- and posttraining time points. Physicians and nurses differed in perception of team dynamics (p = 0.001) and patient safety behaviors (p < 0.001), with nurses reporting more negative perception of safety behaviors posttraining. Physician attendees experienced a nonsignificant lower rate of PPH-VD and PPH-CS with unchanged blood loss, and an increased rate of SD compared with nonattendees in the 6 months following TeamSTEPPS training (p = 0.058, 0.20, and 0.21, respectively). Our experience with perinatal TeamSTEPPS training as a singular intervention was not demonstrative of improvement in teamwork and patient safety perceptions or incidences of obstetric emergencies suggesting that integration into a more comprehensive patient safety program and ongoing training of a larger proportion of providers per department may be necessary to realize tangible benefits of TeamSTEPPS. Our survey results also highlight important differences between physician and nursing staff perceptions. · There is value in a comprehensive patient safety program, such as TEAMSTEPPS, with ongoing training.. · Patient safety perceptions may differ between physician and nursing staff in the same unit.. · Health care staff must agree about the situation to improve patient safety..

Programa de entrenamiento basado en TeamSTEPPS® mediante simulación clínica en profesionales de cuidados intensivos: un estudio con metodología mixta

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).

The status and the factors that influence patient safety in health care institutions in Africa: A systematic review.

Poor patient safety practices may result in disability, injury, poor prognosis, or even death and are primarily associated with a common concern in Africa. This study synthesized the factors influencing the maintenance of patient safety in Africa's healthcare institutions. There was an in-depth search in PubMed Central, CINAHL, Cochrane library, web of science, and Embase using the PICO framework. The search results were filtered for Africa and from 2011 to September 2021 to yield 9,656 titles after duplicates were removed using endnote software, and 211 titles were selected for full-text reading as 16 were selected based on predetermined criteria. The quality appraisal was done using the Mixed Methods Appraisal Tool. A matrix was developed, discussed, accepted, and used as a guide for the data extraction. A convergent synthesis design was adopted for data analysis as the data was transformed into qualitative descriptive statements. Patient safety ratings ranged from 12.4% to 44.8% as being good. Patient safety was identified as an essential structure to improve patient outcomes. The factors associated with patient safety were level of education, professional category, hours worked per week, participation in a patient safety program, reporting of adverse events, openness in communication, organizational learning, teamwork, physical space environment, exchange of feedback about error, and support by hospital management. Poor patient safety environment could lead to the staff being prosecuted or imprisoned, lack of respect and confidence by colleagues, embarrassment, loss of confidence and trust in the health team by patients, documentation errors, drug errors, blood transfusion-related incidences, development of bedsores, and disability. These strategies by health institutions to promote patient safety must focus on reducing punitive culture, creating a culture of open communication, and encouraging incidence reporting and investigations to ensure continuous learning among all health care professionals.

FROM HOSPITAL READINESS TO PATIENT SAFETY: BUILDING LEADERSHIP CAPACITY FOR PATIENT SAFETY IN INDONESIA

The COVID-19 pandemic has had an influence on patient safety and quality of care. A research undertaken in numerous countries found a deterioration in the quality of care during the pandemic. Leaders can improve patient safety in any circumstances, pandemic or not, by building a safety culture, reacting to patient and staff concerns, supporting safety activities, and tracking progress. Good leadership is essential to the success of patient safety programs and improving patient safety. Leaders must first establish strategic priorities and plans for culture and infrastructure that will aid in increasing patient safety. They must also actively inquire about patient safety situations and regularly examine patient safety data. Leaders must also collect data in order to foster a culture of patient safety. It is also critical to ensure that adequate infrastructure is available to support safety activities. Leaders have an important role in establishing the optimal methods for enhancing patient safety. Measures and improvement actions are rarely carried out in many nations; thus, leaders must ensure and encourage quality and safety development. Leadership commitment is the foundation for both pandemic and non-pandemic safety and quality improvement. Patient safety recommendations frameworks can help leaders improve patient safety in their organizations.

How Data Can Drive Initiatives to Improve Patient Safety and Reduce Risk

Medical errors and improper care of patients are estimated to contribute to as many as 250,000 deaths each year. Critical insight into how, why, and where these incidents occur can be gained from close examination of medical professional liability data. Detailed taxonomy and coding of data can help guide organizational leaders and healthcare providers at all levels to identify key gaps in knowledge, skill, and protocols that may contribute to unfavorable outcomes. In this article, the authors explore how a large database of malpractice cases in the United States is assisting organizations in improving their patient safety programs.

ANALISIS MENAJEMEN KESELAMATAN PASIEN TERHADAP MUTU PELAYANAN KESEHATAN DI RUANG RAWAT INAP RUMAH SAKIT X

The most significant metric in the health care system is patient safety, which is meant to serve as a guide in providing the best possible care and lowering patient occurrences. The study's objective is to examine the impact of patient safety management on the standard of care provided in the inpatient unit at X Hospital. Qualitative research methodology is used. The patient safety team, the nursing committee, and the head of quality improvement and patient safety made up the five informants for the September 2022 study. Through observations and interviews, data was gathered. Collaizzi is used in data analysis to reduce data, show data, and draw conclusions.The research results show that there are five themes, namely that the role of the organization in determining patient safety management has been supported by mentors and experts. This is shown by the results of interviews, namely that there are mandatory, meetings, in-house training, reviews and also adequate human resources. Ensuring that patient safety management is supported by mentors and experts, this is shown by the results of interviews, namely that there are mandatory requirements, meetings, in-house training, reviews and also adequate human resources. It is recommended that hospital management provide training and socialization about patient safety programs on a regular basis, provide sanctions for violating the implementation of Standard Operating Procedures and propose a report form using an online system.

A Patient Safety Solution: Evaluation of a 24/7 Nurse-led Proactive Rapid Response Program

Background: Rapid Response Systems are patient safety programs that have been implemented around the world to reduce preventable patient harm and failure to rescue.&#x0D; Problem: There was a high rate of cardiac arrests outside the intensive care unit and absence of a structured system to identify and rescue patients with signs of clinical deterioration prior to cardiac arrest.&#x0D; Objectives: To evaluate the impact of a structured 24/7 nurse-led proactive rapid response program on clinical deterioration and cardio-pulmonary arrests.&#x0D; Methods: This study took place in a 650-bed quaternary academic regional referral center. The study period was between January 2014 and February 2020. A rapid response system redesign was initiated in early 2017 and a 24/7 nurse-led proactive rapid response program launched in December 2017.&#x0D; Results: A statistically significant decrease in rates of critical care cardio-pulmonary arrests, non-critical care cardio-pulmonary arrests, rapid response consults, unplanned ICU transfers, and hospital deaths occurred following implementation of the 24/7 nurse-led proactive rapid response program.&#x0D; Conclusions: Implementation of a structured 24/7 nurse-led rapid response program can decrease cardio-pulmonary arrests, unplanned transfers to ICU, and hospital deaths.

Occupational Hazards among Health Workers in Hospitals of Mukalla City, Yemen

Background: Occupational health is a neglected public health issue among healthcare workers in developing countries like Yemen and they may expose them to various forms of hazards, which have had negative consequences on their wellbeing and performance at work. Objective: The study aims at exploring the forms of occupational health hazards prevalence and methods to mitigate these hazards among Health Care Workers (HCW) in governmental hospitals in Mukalla city. Methods: It is a cross-sectional study conducted among health workers in the main hospitals in Mukalla city in Hadhramout province in eastern Yemen. The sample size is calculated statistically as 366 workers from different categories including doctors, nurses and lab technicians. A sample of 391 workers were selected randomly who were distributed to be representative and proportional to the size of each professional category. Results: The prevalence of biological hazards among the healthcare workers accounted for 298 (76%) whereas the non-biological hazards accounted for 306 (78%). The most prevalent biological hazards are needle prick injury (80%) followed by exposure to contact with contaminated material (75%), while the most frequent non-biological hazards are back pain (79%) followed by extra-time work (72%). In logistic regression age, gender and duration of work and professional category have significant association with exposure of health workers to biological hazards while only gender is the only variable associated with non-biological hazards. Conclusion: There is a high prevalence of occupational hazards (biological and non-biological) among health workers in hospitals of Mukalla city. A prevention and infection control and patient safety programs are highly recommended in Mukalla hospitals to save health workers and patients.

The Effect Of Implementation Of Patient Identification Based On The Pall Accreditation Standards On Improving The Patient Safety Program At Royal Prima General Hospital In 2022

Patient safety is a variable to measure and evaluate the quality of nursingservices that have an impact on health services. One of the safety services inhospitals starts from the accuracy of patient identification. Patientidentification errors at the beginning of the service will continue to the nextservice error. The purpose of this study was to determine how the effect ofimplementing patient identification based on JCI accreditation standards onimproving the Patient Safety program at Royal Prima Hospital. This type ofresearch is a quantitative study with a cross-sectional design. Samplingtechnique The sampling technique in this study was to use the Slovinformula with a total sample of 124 patients. Data analysis in this study usedunivariate and bivariate analysis. The results of the study explained thatthere was an influence between the implementation of patient identificationbased on the Plenary accreditation standard to the improvement of thePatient Safety program at the Royal Prima Hospital Medan with ap value of&lt;0.007. Through this research, it is hoped that the Royal Prima HospitalMedan can improve the quality of nursing services, especially in theimplementation of identification based on the Plenary AccreditationStandards.

Implementation of six patient safety goals at a public health centre with in-patient services in Bali, Indonesia: A qualitative case study

Background and purpose: The Indonesian government requires all health care facilities including public health centres (PHCs) to implement a patient safety program as part of the accreditation standard process. The implementation of patient safety in PHCs have faced various problems, including human resources and infrastructure issues. This study aims to explore the implementation of patient safety target procedures in an accredited inpatient PHC in Tabanan District, Bali, Indonesia.Methods: We conducted a qualitative case study that adopts four main domains in patient safety, consisting of executive officers, community or patient who received services, systems in service delivery and methods, and elements in each domain. The research location was at Penebel I PHC, an inpatient PHC with the accreditation status of “utama”. Data collection was carried out from March to April 2020. It includes observation of the patient safety implementation, review on tracking patient safety documents and in-depth interviews with 11 informants who are PHC staff, patients’ safety task force and the family of patients. The data were analysed using thematic analysis by creating a grid of themes, sub-themes and data reduction to narrative presentation. Results:The patient safety procedure in Penebel I PHC has been carried out through the standard and procedure according to the Ministry of Health (MoH) regulation which consist of patient identification; communication between staff and patients; maintain the safety of High Alert and Look Alike Sound Alike (LASA) medications. However, there is a need to improve the capacity of implementing officers to increase their communication competencies as well as to enhance cooperation between officers in health services to avoid patient safety incidents. Conclusion:The implementation of six patient safety goals in-corporate through four main domains of health care services has been running according to the MoH’s standard. There is a need to improve the competence of officers, cooperation between officers in carrying out patient safety management and improve communication between officers and patients so that the information conveyed by officers is truly understood by patients.

Evaluating a patient safety course for undergraduate nursing students: A quasi-experimental study

BackgroundAlthough it has long been recognised that prelicensure education is essential for preparing nurses with the necessary patient safety competencies, patient safety education tends to be inadequately addressed in nursing curricula in South Korea and elsewhere. AimThis study examined the effectiveness of a recently developed 8-week standalone course on patient safety by comparing the patient safety competencies, knowledge, and attitudes of students who attended and did not attend the course, after controlling for baseline levels of each outcome measure. MethodsThe study used a quasi-experimental pretest-posttest design with a non-equivalent comparison group, with 40 undergraduate nursing students in the intervention group, and 67 in the comparison group. Outcomes included the total score and six subscale scores measured with the Health Professional Education in Patients Safety Survey, and the Patient Safety Attitude scale developed by the WHO patient safety program. Additionally, there was an objective measure of patient safety knowledge using 15 multiple-choice questions. FindingsAfter adjusting for baseline scores, Time 2 scores on all outcome measures were significantly higher in the intervention group than the comparison group, indicating the intervention's effectiveness. We found that the largest effect of the course accrued to patient safety knowledge. Overall, the students’ assessment of the course was highly positive. DiscussionOur patient safety course could be a model for teaching patient safety in undergraduate nursing curriculum. ConclusionThis study shows the potential for a standalone patient safety course to increase undergraduate nursing students’ patient safety competencies, knowledge, and attitudes towards patient safety.

The Perception of the Patient Safety Climate by Health Professionals during the COVID-19 Pandemic-International Research.

The patient safety climate is a key element of quality in healthcare. It should be a priority in the healthcare systems of all countries in the world. The goal of patient safety programs is to prevent errors and reduce the potential harm to patients when using healthcare services. A safety climate is also necessary to ensure a safe working environment for healthcare professionals. The attitudes of healthcare workers toward patient safety in various aspects of work, organization and functioning of the ward are important elements of the organization’s safety culture. The aim of this study was to determine the perception of the patient safety climate by healthcare workers during the COVID-19 pandemic. Methods: The study was conducted in five European countries. The Safety Attitude Questionnaire (SAQ) short version was used for the study. A total of 1061 healthcare workers: physicians, nurses and paramedics, participated in this study. Results: All groups received the highest mean results on the stress recognition subscale (SR): nurses 98.77, paramedics 96.39 and physician 98.28. Nurses and physicians evaluated work conditions (WC) to be the lowest (47.19 and 44.99), while paramedics evaluated perceptions of management (PM) as the worst (46.44). Paramedics achieved statistically significantly lower scores compared to nurses and physicians in job satisfaction (JS), stress recognition (SR) and perception of management (PM) (p < 0.0001). Paramedics compared to nurses and physicians rank better in working conditions (WC) in relation to patient safety (16.21%). Most often, persons of lower seniority scored higher in all subscales (p = 0.001). In Poland, Spain, France, Turkey, and Greece, healthcare workers scored highest in stress recognition (SR). In Poland, Spain, France, and Turkey, they assessed working conditions (WC) as the worst, while in Greece, the perception of management (PM) had the lowest result. Conclusion: Participant perceptions about the patient safety climate were not at a particularly satisfactory level, and there is still a need for the development of patient safety culture in healthcare in Europe. Overall, positive working conditions, good management and effective teamwork can contribute to improving employees’ attitudes toward patient safety. This study was carried out during the COVID-19 pandemic and should be repeated after its completion, and comparative studies will allow for a more precise determination of the safety climate in the assessment of employees.

Investigating the Situation of Iranian Hospitals in Terms of Implementing Mandatory Patient Safety Standards: A Systematic Review.

Background:Evaluate the patient’s safety status in Iranian hospitals using the Patient safety friendly hospital initiative (PSFHI) assessment tool provided by the World Health Organization. PSFHI assessment tool of 140 patient safety standards, they are classified as mandatory (20 standards), basic (90 standards) and advanced (30 standards). Mandatory standards are necessary criteria that hospitals must meet to register for PSFHI. The first stage of the patient safety program in Iran is to achieve the implementation of the mandatory standards to enter the patient safety friendly hospital program. We aimed to evaluate the patient’s safety status in Iranian hospitals in terms of implementing mandatory patient safety standards.Methods:In this systematic review, articles were searched between 2001 and 2021 in Web of Science, PubMed, Scopus Google Scholar, and Iranian SID and Magiran databases. Keywords including patient safety, quality assessment, standards, patient safety friendly hospital, Iran were performed. These articles were evaluated independently by two researchers and the contradictions were discussed with the third author.Results:Finally, 7 eligible studies were included in the study. The highest score (75%) was related to the fourth domain of safe environment and the lowest score with (47%) was related to the second domain of engaging and interacting with the patient and the community. The overall average of compliance with standards in all four areas was 70%.Conclusion:Institutionalizing a patient safety culture, paying more attention to creating a culture to identify patients, educating staff and patients, and removing legal barriers, Increases the observance of mandatory patient safety standards in the Iran.

The effectiveness of radiofrequency scanning technology in preventing retained surgical items: An integrative review.

To synthesise evidence on the effectiveness of radiofrequency (RF) scanning technology as an adjunct to manual counting protocols in preventing retained surgical items (RSIs) in the operating room. Despite the implementation of rigorous manual counting protocols, RSIs remain one of the most common reported sentinel events in operating theatres that lead to adverse patient outcomes. An integrative review. This review was guided by the Whittemore and Knafl (2005) framework. A literature search using CINAHL, MEDLINE, ProQuest, PubMed, and Scopus with key search terms related to RSIs and RF was applied to select English articles from January 2011 till August 2021. The Joanna Briggs Institute (JBI) Critical Appraisal Checklist was utilised for study quality assessment while reporting of review was guided using the PRISMA checklist. A total of 15 peer-reviewed articles were included, enabling the knowledge on the RF scanning technology to be grouped into four themes, namely: detection accuracy of RF scanning technology, real-time detection of surgical items using RF identification, the impact of the RF scanning technology for detecting RSIs on patient safety, and cost-analysis of integrating the RF scanning technology in operating theatres. Radiofrequency scanning technology is effective in preventing RSIs with significant cost-savings. Perioperative leaders should develop a multidisciplinary process to evaluate and select the most appropriate RF scanning technology as part of their patient safety programs. However, future studies with a larger sample size and robust research design, such as randomised controlled trial, should be considered to enhance the generalisability and rigour of evidence. This review contributes to perioperative personnel's education/training of staff on using RF scanning technology to prevent RSIs. The cost-effectiveness analysis enables the healthcare leaders to decide on the selection of appropriate RF technology.