Safety Movement Research Articles

Emotional harm from disrespect: the neglected preventable harm

Consider these actual patient experiences: Despite being simultaneously dreadful and familiar to healthcare professionals,1 cases like these are not systematically identified or addressed in hospital quality improvement programmes.2 As a...

An analysis of near misses identified by anesthesia providers in the intensive care unit.

BackgroundLearning from adverse events and near misses may reduce the incidence of preventable errors. Current literature on adverse events and near misses in the ICU focuses on errors reported by nurses and intensivists. ICU near misses identified by anesthesia providers may reveal critical events, causal mechanisms and system weaknesses not identified by other providers, and may differ in character and causality from near misses in other anesthesia locations.MethodsWe analyzed events reported to our anesthesia near miss reporting system from 2009 to 2011. We compared causative mechanisms of ICU near misses with near misses in other anesthesia locations.ResultsA total of 1,811 near misses were reported, of which 22 (1.2 %) originated in the ICU. Five causal mechanisms explained over half of ICU near misses. Compared to near misses from other locations, near misses from the ICU were more likely to occur while on call (45 % vs. 19 %, p = 0.001), and were more likely to be associated with airway management (50 % vs. 12 %, p < 0.001). ICU near misses were less likely to be associated with equipment issues (23 % vs. 48 %, p = 0.02).ConclusionsA limited number of causal mechanisms explained the majority of ICU near misses, providing targets for quality improvement. Errors associated with airway management in the ICU may be underappreciated. Specialist consultants can identify systems weaknesses not identified by critical care providers, and should be engaged in the ICU patient safety movement.

Associations between safety culture and employee engagement over time: a retrospective analysis

With the growth of the patient safety movement and development of methods to measure workforce health and success have come multiple modes of assessing healthcare worker opinions and attitudes about...

Occupational Health and Safety Movement in Korea : Politics of Expertise and Building OHS Citizenship

Occupational Health and Safety Movement in Korea : Politics of Expertise and Building OHS Citizenship

Some reflections from the past and some ideas for the future: The 2014 Kempe Oration

Although the physical features of child abuse had been described before 1962, it was Henry Kempe et al.’s article “The Battered Child Syndrome” that is regarded as the beginning of widespread awareness and acceptance of this previously hidden problem. It was another 15 years before child sex abuse started to receive similar widespread recognition. As awareness of child abuse increased, its size became apparent. Funds were poured into child abuse detection and Child Protective Services, although evaluation of the effects of these initiatives did not proceed at the same pace. In those early days, child abuse was conceived in pathological terms, as a problem found only in particular types of families. We now know it is more helpful to use an ecological model and in so doing to consider societal, community, family, and individual factors in interaction. As for the future, we have much to learn from areas such as: public health, where a preventive approach is emphasized; the interaction between researchers and front line workers and insights from high reliability organizations that have been so beneficial to the patient safety movement. In particular, new research about the way our environment and our experiences can influence the way our genes function may reveal new opportunities for prevention, early intervention, and treatment.

Quality in otolaryngology: where we have been and where we are going.

The patient safety and quality improvement era began in 1999, and it has exploded in otolaryngology in the last decade. Although there have been some successes, it is not clear that, overall, otolaryngology is much safer than 15 years ago. We discuss why a prolonged lag between improvement efforts and improvements is not surprising and how the safety and quality movement is likely to evolve in the upcoming years.

NURSE'S AWARENESS REGARDING PATIENT SAFETY CULTURE AT MANSOURA UNIVERSITY HOSPITAL

Background: The initiative of developing safety to assure patients’ safe from harm have become central concerns in quality improvement in the healthcare system. Developing and maintaining safety is a principal aspiration of the current patient safety movement, and sustaining a strong safety culture is seen as imperative to the delivery of safe, high quality and cost-effective patient care. Aim of the study: The aim of this study is to assess the nurse's awareness regarding patient safety culture at Mansoura University Hospital. Subjects and Methods: A descriptive comparative design was utilized to attain the aim of the present study. The study sample composed of 102 staff nurse. Data was collected by using the hospital survey of patient safety culture (HSPSC) questionnaire (Aboshaiqah, 2010). Results: more than half of the nurses under study have unawareness of the patient safety culture. There were no statistically significant differences between the awareness of nurses working in medical units and nurses working in surgical units regarding to patient safety culture in all sub dimensions. The majority of the nurses under study did not report the safety events errors in their work areas. Number of events written in the last 6 months was very low. Recommendation: It is recommended that Policy makers and leaders should develop acceptable standards for patient safety system. This can be achieved through initiated and supported an effective safety culture assessment among all working nurses, Staff development programs are needed for all nurses to understand the values, beliefs, and norms about what is important in an organization and what attitudes and behaviors related to patient safety are expected and appropriate for achieving a culture of safety.

Patientensicherheit

Almost 10 years ago, the German Coalition for Patient Safety (Aktionsbündnis Patientensicherheit) was founded as a cooperation covering most institutions of the German health care system. As in other countries facing the issue of patient safety, methods for the analysis of "never events" have been developed, instruments for the identification of the "unknown unknowns" have been established (e.g., CIRS), and the paradigm of individual blame has been replaced by organizational, team and management factors. After these first steps, further developments can only be achieved in so far as patient safety is understood as a system property, which leads to specific implications for the further evolution of the healthccare system. The "patient safety movement" has to participate in this discussion in order to avoid misuse of the patient safety concept as a defensive means, merely confined to overcome the adverse events of payment and structural incentives (e.g., diagnosis related groups in the inpatient sector). Because the dominant requirements for the future healthcare system consist of care for an elderly population with chronic and multiple diseases, the focus has to be shifted away from acute and surgical procedures and diseases, as given in the present quality assurance programs in Germany, to prevention and coordination of chronic care. Efforts to improve drug and medication safety of elderly people can be regarded as perfect examples, but other efforts are still missing. Second, the structural problems as the sector-associated optimization of care should be addressed, because typical safety issues are not limited to single sectors but represent problems of missing integration and suboptimal population care (e.g., MRSA). In the third line, the perspectives of society and institutions on safety (and quality of care) must urgently be enlarged to the perspectives of patients on the one hand and the benefit of treatments (e.g., overuse) on the other hand. All these issues are only to be implemented as far as the general societal attitude supportings further improvement of patient safety and is ready to regard it as a major aim for future developments. Cost arguments alone - costs of suboptimal safety can be estimated to around <euro> 1 billion in Germany per year - are considered as insufficient to guarantee further improvements because other issues in the healthcare system show similar magnitudes. As a consequence, ethical implications remain as major arguments for ongoing professional and public discussions.

Fundamentals of Quality and Safety in Diagnostic Radiology

The most fundamental aspects of quality and safety in radiology are reviewed, including a brief history of the quality and safety movement as applied to radiology, the overarching considerations of organizational culture, team building, choosing appropriate goals and metrics, and the radiologist's quality "tool kit."

Quality Management in Anesthesiology, Volume 2: Advanced Topics (International Anesthesiology Clinics 52, Number 1, Winter 2014).

In Volume 2 of this two-volume International Anesthesiology Clinics set focusing on quality in anesthesia, Richard Dutton, a world renowned expert, expands on the basics of setting up a quality management program and introduces the reader to more advanced topics. We live in a time of increasing need to exhibit safety and value in health care. This is particularly true in anesthesia practices. Hence, having and understanding of the topics discussed in Volume 2 is both timely and important for those in anesthesia quality management.In Chapter 1, Dr. Dutton gives a brief history of safety in anesthesia, which has often been at the forefront of medical safety movements. He then introduces the reader to the Anesthesia Quality Institute and the National Anesthesia Clinical Outcomes Registry, which Anesthesia Quality Institute maintains. He also discusses the National Anesthesia Clinical Outcomes Registry, Anesthesia Incident Reporting System, Closed Claims Project, and Patient Awareness Registry. By doing so, he gives the reader an understanding of where to look for research databases as well as projects in which to participate for those who wish to contribute to the rapidly growing entity of anesthesia quality management. He finishes the chapter with possible future registries, including a very interesting thought of having a patient-facing incident-reporting system where information will be elicited from patients. This may lead to a new focus of what is important in anesthesia quality measurement and outcomes.Chapter 2 focuses on high-performing anesthesia practices. Three senior members of the American Society of Anesthesiologists’ Committee write this chapter on Quality Management—Drs. Hattamer, Hicks, and Arnold. This highly informative and useful chapter gives great insight on how to run a quality assurance meeting. It answers the questions pertaining to legal risk and “discovery” associated with having such meetings that many of us have when participating in similar groups. It also provides information about using outside consultants as well as other tools that could be useful as a practice starts to evaluate its own quality. The sections on professionalism, communication, and leadership are concise and should be read by all who practice anesthesia. There are useful chapters on using anesthesia information systems, which is a heavy focus throughout the text. Additionally, there are well-written chapters on how to learn from sentinel events, as well as the principles and importance of incident reporting. In one of the more unique chapters, Drs. Stieglar and Dhillion discuss what a cognitive error is and make excellent use of common anesthesia cases demonstrating how decision-making errors occur. They provide a framework for understanding how we can all recognize decision errors in colleagues and ourselves and what can be done to prevent them. Through the use of timely, specific, and rational feedback, this chapter also provides insight into what a quality review committee could do to prevent errors when they are the reason for an adverse event in their practice. The text concludes with quality management discussion in two specific locations, namely the outpatient setting and in global health. In the chapter on outpatient anesthesia, the reader will find discussions pertaining to measuring quality and how that will be linked to Medicare payments to be of great importance. The last chapter, which discusses anesthesia from a global perspective, is brief but highlights the importance of taking quality advances to low- and middle-income countries and the challenges facing such endeavors.Overall, this text is a logical and complementary addition to the first. There is very little redundancy between the two texts, which is surprising given their singular focus. After reading this volume, the reader will have greater insight into the work that is going on in anesthesia quality management. Without question, this second volume gives great insight into how to establish a quality management program at one’s institution. Although the chapters in this second volume are more advanced, according to Dr. Dutton this text is as readable as the first. Novice and experienced quality managers alike will find this second volume useful and easy to read and understand. I highly recommend anyone interested in quality in anesthesia, which should be all of us, to read both texts.

Medical Company May Be Falling Short Of Its Patient-Safety Ideals

Medical Company May Be Falling Short Of Its Patient-Safety Ideals

Patient safety and engagement at the frontlines of healthcare.

Since the release of the seminal work To Err Is Human in 1999, there has been widespread acknowledgement of the need to change our approach to patient safety in North America. Specifically, healthcare organizations must adopt a systems approach to patient safety, in which organizations take a comprehensive approach aimed at building resilient barriers and ensuring a culture of open communication and learning. Here in Canada, the patient safety movement gained momentum following the publication of the Canadian Adverse Events Study in 2004, which concluded that close to 40% of all hospital-associated adverse events were potentially preventable. Baker et al. (2004) argued for the need to modify the work environment of healthcare professionals to better ensure barriers were in place, as well as the need to improve communication and coordination among healthcare providers. The changes proposed a decade ago required greater healthcare worker engagement in patient safety and the creation of a culture of patient safety.

Why has the safety and quality movement been slow to improve care?

Buist and Middleton lament that the safety and quality 'agenda' has failed to fundamentally alter the safety of healthcare systems, in part because of the disengagement of doctors from their responsibilities for patient safety . While there have been discernable improvements in the efficiency and effectiveness of care in some settings, patients still experience unacceptable harm and often struggle to have their voices heard; processes are not as efficient as they could be; and costs continue to rise at alarming rates while quality issues remain . Perhaps of most concern, recent public reports into health system failures continue to document a widespread lack of attentiveness to patient concerns, a culture of denial and widespread lack of professionalism . Alarmingly, clinician discontentment, cynicism and burn-out are reflected in antagonistic language by clinicians about the healthcare system and their patients. Taken together with the many dissatisfied and now more vocal patient groups, all point to an unprecedented crisis of faith in our healthcare systems which has been getting worse over past decade . This personal perspective aims to address the fundamental tensions that are keeping much of healthcare reform efforts from successfully transforming the culture and outcomes except at the margins.

Quantifying Accidents: Cars, Statistics, and Unintended Consequences in the Construction of Social Problems Over Time

This paper investigates the potential effects of a single cultural means of claimsmaking—quantification—on the construction of a social problem through time. By analyzing salient historical uses of statistics in public debates on traffic accidents in the United States, the study seeks to advance the understanding of the role played by numerical claims in the broader dynamics of problem evolution and development. Specifically, key employments of numbers by early automobile clubs, the private insurance industry, safety movement and establishment, and printed media are closely traced and interrelated to flesh out their impacts on dominant representations of the issue over the long term. While numerical claimsmaking produced divergent, often contradictory effects on the construction of the problem, I argue that figures ultimately contributed to the gradual waning of the moralist and political zest that characterized much of the claimsmaking activities on the issue in the first half of the twentieth century. The argument provides one explanation of how traffic accidents can come to be defined in contemporary society as a “necessary evil”—a regrettable yet largely unalterable price to pay for the benefits of the automobile. To the extent that many of these quantification effects are unintended, they are linked to both the nature of statistical argumentation employed in this case and its institutional contexts.

Partnerships for women’s safety in the city: “four legs for a good table”

Ten years after the first Reclaim the Night marches in the late 1970s began to galvanize women around the right to move freely in public and private space without fear of violence, a local governance-based movement to promote women’s safety developed in European and Canadian cities and was later diffused to Africa, Asia and Latin America. This movement drew on urban planning and design as a means to promote women’s empowerment. Partnerships developed around a framework we have titled “four legs for a good table”: community advocates to push for change; local politicians to galvanize government resources; “femocrats” to capture local policies and programmes for emancipatory ends; and researchers to gather evidence around the problem and to document efforts around solutions. This paper traces the collective history of this loosely coordinated movement. Focusing on three case studies, we mark the advancements of theoretical frameworks and practical tools as the women’s safety movement internationalized, and reflect on achievements and challenges.

Checklists, global health and surgery: a five-year checkup of the WHO Surgical Safety checklist programme

The WHO Surgical Safety Checklist has become a high-profile symbol for patient safety efforts in surgery. Since the landmark study by Haynes et al. 1 documenting its success at reducing peri-operative morbidity and mortality in a diversity of settings, others have gone on to show positive effects of the checklist on teamwork, communication, and patient outcomes. The widespread dissemination of the checklist has now allowed for a more global analysis of its role in surgery, and has highlighted two key points: first, the success of the checklist relies on effective and appropriate implementation; and second, the checklist needs to be introduced as part of a broader patient safety movement. Beyond universal challenges with implementation, some questions have been asked about its applicability to low- and middle-income countries. WHO acknowledges that checklist implementation in such settings needs to be well considered; limited availability of resources and less structure around patient safety provides a different context for effective use. Further research needs to be undertaken to better understand what if any modifications need to be made. WHO also hope to better coordinate patient safety efforts with the global surgery movement to maximize the effect of the checklist and improve surgical safety in low- and middle-income countries.

Determination of friction performance influence in the system "body–bogie" on the freight car dynamics

Purpose. The main requirements for the design of a new generation of cars, according to the Program of rolling stock renovation, are the requirements reducing the operating costs and increasing the cost-effectiveness of their use, taking into account the achievements of scientific and technical thought. Due to the urgency of this subject the paper is devoted to the study of the friction coefficient influence in the bearing connection «center plate – center bowl – bearers»of freight cars on their main dynamic parameters – coefficients of horizontal and vertical dynamics, body acceleration, frame strength, derailment stability factor. Methodology. The study was conducted by numerical integration and mathematical modeling of the freight car dynamic loading using the software package «Dynamics of Rail Vehicles» («DYNRAIL»). Findings. Investigations have shown that the safety movement parameters are influenced by both the friction parameters in bearing connection «center plate – center bowl – bearers» of freight cars in empty and loaded state with bogies TSNII-X3 (model 18-100). Effect have other components of freight car dynamics, namely: radii of curved track sections, height of outer rail, etc. Originality. The author investigated the friction influence on the car dynamic loading using new approaches to solving the problem of predicting the rolling stock dynamics. Prediction was carried out on the basis of significantly updated theoretical material that covers all history of the friction theory and includes the results of recent experimental studies because of the speed on the straights and curves of small-and medium-range sections of the road.Practical value. The obtained results have practical orientation. During the research and after modeling with the improved method of accounting of friction processes dependencies of main dynamic parameters of a four-freight gondola on the value of the friction coefficient in the "body – bogie" with regard to speed were obtained. The results of scientific studies have found their scientific use in a number of author publications in the special scientific and popular publications.

Patient Safety in the Era of Healthcare Reform

Many would agree that the patient safety movement, defined as a concerted effort in health care to reduce treatment-caused injuries, if not always a well-organized one, began with the release of the Institute of Medicine (IOM) report “To Err Is Human” in late 1999 [5]. Basing its conclusions on work done a decade earlier, the IOM took a clear position that the level of unintended harm in medicine is unacceptably high and that something can, and must, be done about it. It proclaimed for medicine what experts in other fields had long recognized: Errors and harm are far more likely to result from faulty systems than from careless or incompetent people. The IOM laid down the challenge: Launch a major effort to change our poorly designed and harmful systems to make them safe. This concept, that harm results from bad systems not bad people, is literally transforming, since it stands on its head what most of us instinctively believe — that errors result from carelessness or incompetence and that those who make them should be punished so they will be more careful in the future. Physicians and nurses, who have been taught how to “do it right” through long and arduous training, are especially unforgiving of themselves and others when things go wrong. So, it has been a hard sell. Yet, it works. Application of systems theory, particularly the use of human factors concepts, such as standardization, simplification, reducing reliance on memory, to change the processes of care to make it easy to do it right and hard to do it wrong has resulted in some stunning successes. One of the most striking successes has been the work of Peter Pronovost MD, PhD, FCCM and his colleagues at Johns Hopkins Medicine. Pronovost and colleagues completely eliminated central line infections in an intensive care unit by standardizing the process of catheter insertion and working effectively in teams [1]. The generalizability of this approach was later proved in Michigan, where 65 hospitals were able to drive their central line infection rates to zero for more than a year [8]. Less dramatic, but still impressive reductions have been made in medication errors through computerizing prescriptions, the use of bar coding, and elimination of nurses measuring doses of medications. Many hospitals have substantially reduced the rate of falls in their inpatient population by applying systems changes in identifying patients at risk and improving monitoring. But some errors have not yielded readily to systems change, most noticeably wrong-site surgery, and even the most successful systems changes, eg, central line protocols, have not been adopted by all hospitals. Lay observers legitimately ask why, and we have no good answer. Even when systems changes are implemented widely, the results often fall far short of those achieved in pilot studies. A recent multistate study [3] of central line protocol adoption, for example, showed only a 40% drop in infections. While achieving that rate of reduction nationwide would save 20,000 lives, an impressive gain, one can reasonably question why they fell short and suspect that many of the institutions did not really implement the protocol 100% perfectly, 100% of the time. Anecdotal evidence strongly suggests that a similar failure to scrupulously implement timeouts and site identification protocols underlies the disappointing results in preventing wrong-site surgery. These issues are very much front and center for improving safety in orthopaedic surgery, which continues to be dogged with wrong-site errors and wound infections that are particularly disastrous after joint arthroplasty. Another relevant issue that is not typically thought of as a patient safety concern is overuse, the application of a diagnostic measure or treatment that is not indicated. It has been estimated that at least 30% of care is unnecessary or inappropriate, with even higher estimates in some procedures and operations [2, 4]. Assuming that these patients suffer preventable harm at the same 10% to 20% rate as other inpatients, 3% to 6% of all hospital patients suffer preventable harm from receiving care that was not indicated in the first place. It is estimated that 1.2 million patients undergo back surgery annually. If 30% of these are unnecessary, then 360,000 of these patients are also exposed to the risk of errors and preventable harm.

Delivering the Truth

Disclosing harmful medical errors to patients is a prominent component of the patient safety movement. Patients expect it and safety agencies and experts advocate its implementation. Obstetrics presents unique challenges to carrying out disclosure recommendations: childbirth is a life-changing, emotionally charged, and dynamic family event characterized by high expectations and unpredictability, and perinatal care is provided by complex ad hoc teams in a litigious area of medicine. Despite these challenges, transparent communication with parents about unexpected adverse birth outcomes remains critical. We call on clinicians and professional societies to pursue a deeper understanding of the unique challenges of disclosure in obstetrics and prepare themselves to conduct these difficult conversations well.

COSH Groups—Mobilizing Workers, Unions, and the Community for Health and Safety: An Interview with Joel Shufro

An interview with Joel Shufro, Executive Director of the New York Committee for Occupational Safety and Health [NYCOSH], conducted shortly before he steps down after 34 years of service. Shufro discusses the recent history of the U.S. worker health and safety movement, including successes and failures of NYCOSH's efforts. He addresses some of the new issues COSH groups are facing as a result of declines in labor union density and the lack of effective government protection for large populations of workers, as well as assessing strategies that NYCOSH and other groups have adopted to strengthen and revive the U.S. health and safety movement.