Patient Safety Topics Research Articles

150 years since “The etiology, concept, and prophylasix of childbed fever”

2011 marks the sesquicentennial anniversary of the publication of “The etiology, concept, and prophylaxis of childbed fever”, the magnum opus of Ignaz Philipp Semmelweis' (1818–1865) determined, but not infrequently self-defeating, efforts to prove his theories regarding this disease. Now widely regarded as “the father of infection control”, his struggle to improve patient safety continues to provide an example – both good and bad – to those who seek to implement system change. He may or may not have been the first person to attribute an infectious aetiology to childbed fever, but he was certainly not the last person to make a few unwise decisions regarding the best means of influencing healthcare worker behaviour. His story remains relevant and this anniversary offers an opportunity to reflect on current challenges in patient safety; what would Ignaz make of the current landscape in patient safety and hand hygiene? Here we compare and contrast Semmelweis’ innovations with current approaches to implementation of quality improvement programs, and other patient safety topics such as patient participation and public reporting.

Focus on Life-Long Learning and Self-Assessment

483 issues, the SAMs will be focused on noninterpretive skills. This will include patient safety, contrast reactions, and other noninterpretive skills topics. There are too few of these SAMs currently available, yet one of the five modules on the cognitive examination (Part III of MOC) is on this topic whereas the other four modules are clinical and based on the individual’s practice profile. Dr. Felix Chew, Section Editor of AJR Integrative Imaging, has agreed to head this new section in AJR, which he will coordinate with the section editor of the highlighted issues in advance. This new approach will provide more than the required SAMs for our readers each year. Additional SAMs will be available at the ARRS, Radiological Society of North America, and subspecialty society meetings. Our journal and the ARRS should also look at the additional changes proposed by the ABMS regarding Part II of MOC to determine if we can provide our readership with assistance in all areas. We must remain on the forefront and evolve with changes as they are required to maintain ourselves as physicians, improve patient care, and continually improve our practices and the confidence of the public in American medicine. Thomas H. Berquist Editor in Chief ajrsubmit@arrs.org DOI:10.2214/AJR.10.6334

Raising concerns

A recurring theme of patient safety is trainees feeling too junior to question a consultant’s actions. Kathy Oxtoby looks at the problem

Medical Education in the United States and Canada, 2010

The authors present an overview of the educational programs, infrastructure to support them, and the assessment strategies of 128 medical schools in the United States and Canada, based on reports submitted by those schools and published in this supplement to Academic Medicine. The authors explore many important changes that have occurred since the publication of the Flexner Report in 1910 as well as the progress that is evident since a similar collection of medical school reports was published in September 2000, also as a supplement to Academic Medicine. Drawing on the reports, the authors summarize, among other topics, the advances that have taken place in the support for faculty, the funding of medical student education, changes in pedagogy and assessment, and the expansion of medical education to distributed models and regional campuses.The authors observe that the reports from the 128 schools illustrate that medical student education has undergone and continues to undergo substantive change, has advanced markedly since the reforms stimulated by the Flexner Report, and has continued to evolve during the past decade. The reports illustrate the strength of support for the educational programs, even in a time of financial constraints, and the increasing recognition of the scholarly contributions of faculty through teaching. The authors provide examples of the changes in pedagogy and new topics in the required curriculum in the past decade and describe selected highlights of the 128 educational programs.

The University of Texas Medical School at Houston

The University of Texas Medical School at Houston

Georgetown University School of Medicine

Georgetown University School of Medicine

Patient Safety and Quality Improvement: Medical Errors and Adverse Events

1. Michael S. Leonard, MD, MS* 1. *Chief Quality & Safety Officer for Children's Services, Associate Professor of Pediatrics, University of Rochester Medical Center, Rochester, NY. After completing this article, readers should be able to: 1. Define terms commonly used in patient safety discourse. 2. Describe the scope of medical errors and adverse events, focusing on medication-related issues. 3. Identify barriers to improving patient safety. 4. Address disclosure of medical errors and adverse events. 5. Review principles and practices that can reduce the risk of harm to patients. This is the first in a series of articles to review the topics of patient safety and quality improvement in pediatrics. Patient safety is a subject that traverses all medical specialties and affects every health-care professional. The attention to medical errors and adverse events as well as the resultant literature has grown exponentially over the past decade. A number of practicing physicians, however, remain unaware of the extent of the problem, the impact on patients, and the burden on the health-care system. Many also are unfamiliar with strategies to reduce the risk of harm. It is important to note that definitions used in patient safety can vary across studies, between organizations, and over time. A medical error, as defined by the Institute of Medicine (IOM), is “the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim.” (1)(2) It is a mistake in action or judgment. A medical error must be distinguished from an adverse event, which is “an injury caused by medical management rather than by the underlying disease or condition of the patient.” An adverse event results in harm to the patient. Not all medical errors lead to adverse events. In fact, most do not. A medication error is the most common …

Patient safety research: an overview of the global evidence

BackgroundUnsafe medical care may cause substantial morbidity and mortality globally, despite imprecise estimates of the magnitude of the problem. To better understand the extent and nature of the problem of...

Patient safety in dermatology: A review of the literature

We performed a literature review of patient safety topics pertinent to dermatology and related to outpatient settings for situations in which data from dermatology are lacking. Searches in MEDLINE via PubMed interface, OVID and Google Scholar were carried out from October, 2008 through May, 2009 for English-language articles published between 1948 and 2009. Each search combined 2 or 3 of the following terms: patient safety, medical error, human error, preventable adverse event, dermatology, outpatient, ambulatory care, medication error, diagnostic error, laboratory error, pathology error, office-based surgery, wrong-site procedure, infections, falls, laser safety, scope of practice. Personal communications, websites, books, dermatology newsletters and major textbooks were also scrutinized. Potentially relevant articles and communications were critically evaluated by the authors. References from these articles were searched for "other relevant articles." Patient safety studies in dermatology and outpatient settings are lagging behind those in inpatient settings. Systems changes are needed to reduce medical errors rather than penalize individual healthcare workers. Although technology may improve patient safety in numerous aspects, it introduces new sources of errors. Our review reveals few studies on dermatologic patient safety, supporting the pressing need for such studies and reports in the future.

Mr Slop investigates: MRSA and all that

For this month's article from our irreverent occasional correspondent, we asked Mr Slop FRCS (Eng) to embrace the issue's theme of patient safety. He needed no further encouragement…

A Patient Safety Curriculum for Graduate Medical Education: Results From a Needs Assessment of Educators and Patient Safety Experts

Graduate medical education (GME) has traditionally focused on the diagnosis and management of disease with little attention devoted to patient safety and systems thinking. In this article, we describe the results of a needs assessment conducted to develop a patient safety curriculum for GME. Eight program directors, 10 patient safety experts, and 9 experts in education technology were interviewed for this project. A total of 21 patient safety topics were identified in the categories of cultural, cognitive, and technical content and included communications and handoffs, sentinel event reporting and management, calling for help when in doubt, hand hygiene, universal protocol, fatigue, and the culture of safety and transparency. Objective structured clinical examinations and experiential learning (including simulation) were viewed as the most effective methods for teaching and assessing competence in patient safety. The results of this study provide a framework for the development of patient safety curricula in GME.

Attitudes to patient safety amongst medical students and tutors: Developing a reliable and valid measure

Background: Patient safety education is an increasingly important component of the medical school curricula.Aims: This study reports on the development of a valid and reliable patient safety attitude measure targeted at medical students, which could be used to compare the effectiveness of different forms of patient safety education delivery.Methods: The Attitudes to Patient Safety Questionnaire (APSQ) was developed as a 45-item measure of attitudes towards five patient safety themes. In Study 1, factor analysis conducted on the responses of 420 medical students and tutors, revealed nine interpretable factors. The revised 37-item APSQ-II was then administered to 301 students and their tutors at two further medical schools.Results: Good stability of factor structure was revealed with reliability coefficients ranging from 0.64 to 0.82 for the nine factors. The questionnaire also demonstrated good criterion validity, being able to distinguish between tutors and students across a range of domains.Conclusions: This article reports on the first attempt to develop a valid and reliable measure of patient safety attitudes which can distinguish responses between different groups. The predictive validity of the measure is yet to be assessed. The APSQ could be used to measure patient safety attitudes in other healthcare contexts in addition to evaluating changes in undergraduate curricula.

Patient safety curriculum for surgical residency programs: Results of a national consensus conference

The American College of Surgeons (ACS) and the Accreditation Council for Graduate Medical Education (ACGME) are committed to promoting patient safety through education. In view of the critical role of residents in the delivery of safe patient care, the ACS and ACGME sponsored jointly a national consensus conference to initiate the development of a curriculum on patient safety that may be used across all surgical residency programs. National leaders in surgery with expertise in surgical care and surgical education, patient safety experts, medical educators, key stakeholders from national organizations, and surgical residents were invited to participate in the conference. Attendees considered patient safety issues within the context of the 6 core competencies defined by the ACGME and American Board of Medical Specialties (ABMS). Discussions resulted in the development of a curriculum matrix that includes listings of patient safety topics, teaching and learning strategies, and assessment methods. Guidelines for implementation and dissemination are also provided. The curriculum content underscores the need to create an organizational culture of safety and focuses on both individuals and systems. Individual residency programs may prioritize the curriculum content based on their specific needs. The ACS and ACGME will pursue development of educational modules to address the curriculum content, disseminate helpful information, and assist in implementation of new educational interventions. This effort has the potential to positively impact residency education in surgery, help surgical program directors address the core competencies, and enhance patient safety.

In This Issue: Practice Change and Patient Safety

In this issue we present a large series of articles on the related topics of practice quality improvement and patient safety. This issue also features an updated recommendation from the US Preventive Services Task Force, 2 timely studies—one of seasonal interest and another of political timeliness

The Vermont Oxford Network

After completing this article, readers should be able to: 1. Describe the topics of study of the Neonatal Intensive Care Quality Improvement Collaboratives. 2. List the four key habits of clinical improvement. “The nation’s health care system lacks… the capabilities to ensure that services are safe, effective, patient-centered, timely, efficient and equitable… Between the health care we have and the care we could have, lies not just a gap but a chasm.” IOM 2001 (1) “More people die in a given year as a result of medical errors than from motor vehicle accidents, breast cancer, or AIDS.” IOM 2000 (2) In 2000 and 2001, the Institute of Medicine (IOM) of the National Academy of Sciences issued two landmark reports that presented a clear and compelling challenge to all health care professionals. (1)(2) We must improve the quality and safety of the medical care for the patients and families that we serve. In this article, we describe the Vermont Oxford Network (VON) and the quality improvement (QI) activities it has undertaken to meet this challenge. The VON is a not-for-profit organization whose mission is to improve the quality and safety of medical care for newborns and their families through a coordinated program of research, education, and quality improvement. (3)(4) VON currently has more than 440 member neonatal intensive care units (NICUs) from North America and around the world. Members participate in a range of Network activities, including randomized controlled trials, outcomes research, and a variety of QI projects. The focus of this article is QI. Descriptions and references for other VON activities are available on the VON Internet site (http://www.vtoxford.org). In support of its mission, VON maintains a database that includes information about the treatment and outcomes for high-risk infants receiving neonatal intensive care. Importantly, all …

The Institute of Medicine's report on medical error. Implications for pathology.

During the past several years, more attention has been focused on the topics of medical error and patient safety than in the past. At the end of 1999, the Institute of Medicine (IOM) published a seminal report concerning medical error in the United States; this report will have sweeping implications for all disciplines of medicine, including pathology. To review the major findings of the IOM report on medical error and to discuss their implications for the field of pathology. Review of the IOM report on medical error and discussion of other relevant literature on medical error. The IOM report on medical error highlights an unacceptable rate of medical error in the United States and mandates a 50% reduction in medical error during the next 5 years. It recommends regulatory solutions to this problem, as well as organizational approaches to error reduction. It proposes both mandatory and voluntary systems for reporting of medical error. The report suggests that systems should be examined for latent flaws and that individual culpability for error should not be overemphasized. The report recommends that error-reduction strategies that have been applied to other industries should be studied and that known concepts of error reduction should be applied to medicine. Strategies that the IOM suggests can be applied to pathology. Medical error occurs at an unacceptably high rate. Recommendations made in the IOM report on medical error and patient safety should be applied to the practice of pathology.