Tool For Patient Safety Research Articles

Tools for ICU patient safety and quality improvement plans. Critical care safety: Essentials for ICU patient care and technology. ECRI Institute Staff. Publisher: ECRI Institute; 146 pages, plus CD

Tools for ICU patient safety and quality improvement plans. Critical care safety: Essentials for ICU patient care and technology. ECRI Institute Staff. Publisher: ECRI Institute; 146 pages, plus CD

Using web‐based simulation learning to deal with shoulder dystocia

Simulation-based learning can provide education and training to individuals in a variety of industries. The military, aviation and nuclear power industries have seen demonstrable improvement in critical event handling through the use of this type of learning when coupled with crew resource management techniques. Simulation training is also emerging in the healthcare field as an effective patient safety and risk management tool. In the area of obstetrics, healthcare risk managers can have an impact on injury and claim reduction rates related to shoulder dystocia by advocating for and implementing simulation training for obstetrical providers. This article will describe a shoulder dystocia simulation training program that uses a high-fidelity mannequin, and illustrate the impact that the healthcare risk manager can have in reducing injuries due to shoulder dystocia.

Medical Malpractice: Understanding the Law, Managing the Risk.

* The Law of Malpractice and Informed Consent: * Condition Critical, Prognosis Guarded * What Is and Isn't Malpractice * Legal Duty * Standard of Care * Causation * Damages * Expert Testimony * Affirmative Defenses * Physician Countersuits * Informed Consent * Patients Who Drive: A New Worry for Doctors * End-of-Life Issues * Complementary and Alternative Medicine * Products Liability * Institutional and Managed Care Liability * Medical Trainees * Risk Management: * Medical Reports and Confidentiality * Cyber-Medicine * What Do Malpractice Lawsuits Look Like? * How to Avoid Becoming a Horror Story * Medical Errors and Their Disclosure * Understanding Malpractice Insurance * What to Expect Now that You've Been Sued * Reforming the System: * Medical and Legal Reforms * Multiple Choice Questions and Answers * Glossary of Legal Terms

The Objective Structured Clinical Examination as an Educational Tool in Patient Safety

The Objective Structured Clinical Examination (OSCE) is an assessment tool characterized by the use of "lay" people trained to respond to questions in a standardized fashion. The learner's performance is observed and scored against a checklist of responses or behaviors. An OSCE station related to the communication and management of prescription errors was introduced in 2003 as part of a quality improvement (QI) curriculum at Mayo Medical School. All 42 third-year medical students took part in this pilot study, which was designed to evaluate the usefulness of an OSCE station as an assessment and educational tool for managing prescription errors. Thirty-three (76.7%) students agreed that the OSCE station enhanced their awareness of medication errors. Thirty (71.4%) students felt that their comfort level with communicating prescription errors to patients increased. Specific feedback regarding root cause analysis, collaboration with the pharmacist for error analysis, interpersonal and communication skills feedback from the faculty, and use of the standardized patient and of an actual prescription that led to a medication error, were found especially valuable. This pilot study demonstrates the potential use of the OSCE as an assessment and educational tool in QI and patient safety. The OSCE approximates a "live clinical setting" and provides an opportunity for the assessment of situational awareness and response, as well as formative and summative feedback to students.

Human error and its impact on anesthesiology

Health care in the United States is tragically complicated by medical error. This article focuses on understanding how we learn, how we err, and how the features of human cognition interact to produce errors in medical care. In terms of lives affected adversely and dollars lost to the economy, the magnitude of this problem is staggering. Federal and state governments are now involved in moving forward with private groups, third party-payors, and health care providers to bring the successes of other industries, such as commercial nuclear power and aviation, to the bedside. Anesthesiology has taken a first position in this effort with organizations like the Anesthesia Patient Safety Foundation (http://www.apsf.org) and tools such as the Crisis Management Manual from the Australian Patient Safety Foundation (http://www.apsf.net.au).

Taking a Patient Safety Approach to an Integration of Two Hospitals

Consolidation of inpatient care between two acute care medical centers brings many challenges, including an increased risk of an untoward event during patient transfer and impaired hospital performance during the postintegration period. When the Jesse Brown Department of Veterans Affairs (VA) Medical Center in Chicago integrated two acute medical-surgical inpatient facilities, the challenges intrinsic to simultaneously integrating acute medical-surgical programs and academic training programs necessitated a novel approach. STRATEGIES USED: Several patient safety-related tools were used for the safe transfer of patients and for sustaining hospital performance after integration. These tools included Failure Mode and Effects Analysis (FMEA) of the move process, process action teams to bridge the differences in standard nursing unit operation, and an integration score card to monitor and evaluate the impact of the integration on organization performance. Patient care was not disrupted except for a transient reduction in elective surgical procedures during the week before the move. Postintegration data indicated reduced operating room cancellations, sustained inpatient capacity and access, and comparable findings in patient falls and methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci infections. The impact of several patient safety tools and interventions was reflected in the fact that performance remained constant or improved for the predefined measures of access and quality.

Patient safety tools to avoid disaster: Health care facility management of biologic agents, SARS, and uncommon contagion

Local hospitals experienced problems when emergencydepartment staff evaluated patients for SARS, ruled out the possibility of SARS, and admitted patients to regular rooms without documenting the rationale. Nursingunitswould then repeat epidemiologicquestions, panic, initiate room transfers to utilize negative pressure, and create unnecessary havoc at an inopportune time. Each hospital evaluated patients who had contact with travelers from Hong Kong or who had driven to Toronto (only 550miles). Experienceswere presented at statewide meetings of the Infection Control Professionals of Southern New England, Inc. This format allowed each member hospital and long-term-care facility to share its patient safety tools and improve performance. Media announcements and newspaper articles resulted in aneed todevelop quickly the tools thatwould address public concern and that would foster professional management of potential cases.

Using standardised patients in an objective structured clinical examination as a patient safety tool.

Standardised patients (SPs) are a powerful form of simulation that has now become commonplace in training and assessment in medical education throughout the world. Standardised patients are individuals, with or without actual disease, who have been trained to portray a medical case in a consistent manner. They are now the gold standard for measuring the competence of physicians and other health professionals, and the quality of their practice. A common way in which SPs are used in performance assessment has been as part of an objective structured clinical examination (OSCE). The use of an SP based OSCE can be a powerful tool in measuring continued competence in human reliability and skill performance where such skills are a critical attribute to maintaining patient safety. This article will describe how an OSCE could be used as a patient safety tool based on cases derived from actual events related to postdonation information in the blood collection process. The OSCE was developed as a competency examination for health history takers. Postdonation information events in the blood collection process account for the majority of errors reported to the US Food and Drug Administration. SP based assessment is an important patient safety tool that could be applied to a variety of patient safety settings and situations, and should be considered an important weapon in the war on medical error and patient harm.

When Patient Care Issues Arise, QIPS Is on the Job

When Patient Care Issues Arise, QIPS Is on the Job

Reducing Medication Errors and Increasing Patient Safety: Case Studies in Clinical Pharmacology

Today, reducing medication errors and improving patient safety have become common topics of discussion for the president of the United States, federal and state legislators, the insurance industry, pharmaceutical companies, health care professionals, and patients. But this is not news to clinical pharmacologists. Improving the judicious use of medications and minimizing adverse drug reactions have always been key areas of research and study for those working in clinical pharmacology. However, added to the older terms of adverse drug reactions and rational therapeutics, the now politically correct expression of medication error has emerged. Focusing on the word error has drawn attention to “prevention” and what can be done to minimize mistakes and improve patient safety. Webster's New Collegiate Dictionary has several definitions of error, but the one that seems to be most appropriate in the context of medication errors is “an act that through ignorance, deficiency, or accident departs from or fails to achieve what should be done.” What should be done is generally known as “the five rights”: the right drug, right dose, right route, right time, and right patient. One can make an error of omission (failure to act correctly) or an error of commission (acted incorrectly). This article now summarizes what is currently known about medication errors and translates the information into case studies illustrating common scenarios leading to medication errors. Each case is analyzed to provide insight into how the medication error could have been prevented. “System errors” are described, and the application of failure mode effect analysis (FMEA) is presented to determine the part of the “safety net” that failed. Examples of reengineering the system to make it more “error proof” are presented. An error can be prevented. However, the practice of medicine, pharmacy, and nursing in the hospital setting is very complicated, and so many steps occur from “pen to patient” that there is a lot to analyze. Implementing safer practices requires developing safer systems. Many errors occur as a result of poor oral or written communications. Enhanced communication skills and better interactions among members of the health care team and the patient are essential. The informed consent process should be used as a patient safety tool, and the patient should be warned about material and foreseeable serious side effects and be told what signs and symptoms should be immediately reported to the physician before the patient is forced to go to the emergency department for urgent or emergency care. Last, reducing medication errors is an ongoing process of quality improvement. Faulty systems must be redesigned, and seamless, computerized integrated medication delivery must be instituted by health care professionals adequately trained to use such technological advances. Sloppy handwritten prescriptions should be replaced by computerized physician order entry, a very effective technique for reducing prescribing/ordering errors, but another far less expensive yet effective change would involve writing all drug orders in plain English, rather than continuing to use the elitists' arcane Latin words and shorthand abbreviations that are subject to misinterpretation. After all, effective communication is best accomplished when it is clear and simple.

Reducing Medication Errors and Increasing Patient Safety: Case Studies in Clinical Pharmacology

Today, reducing medication errors and improving patient safety have become common topics of discussion for the president of the United States, federal and state legislators, the insurance industry, pharmaceutical companies, health care professionals, and patients. But this is not news to clinical pharmacologists. Improving the judicious use of medications and minimizing adverse drug reactions have always been key areas of research and study for those working in clinical pharmacology. However, added to the older terms of adverse drug reactions and rational therapeutics, the now politically correct expression of medication error has emerged. Focusing on the word error has drawn attention to "prevention" and what can be done to minimize mistakes and improve patient safety. Webster's New Collegiate Dictionary has several definitions of error, but the one that seems to be most appropriate in the context of medication errors is "an act that through ingnorance, deficiency, or accident departs from or fails to achieve what should be done." What should be done is generally known as "the five rights": the right drug, right dose, right route, right time, and right patient. One can make an error of omission (failure to act correctly) or an error of commission (acted incorrectly). This article now summarizes what is currently known about medication errors and translates the information into case studies illustrating common scenarios leading to medication errors. Each case is analyzed to provide insight into how the medication error could have been prevented. "System errors" are described, and the application of failure mode effect analysis (FMEA) is presented to determine the part of the "safety net" that failed. Examples of reengineering the system to make it more "error proof" are presented. An error can be prevented. However, the practice of medicine, pharmacy, and nursing in the hospital setting is very complicated, and so many steps occur from "pen to patient" that there is a lot to analyze. Implementing safer practices requires developing safer systems. Many errors occur as a result of poor oral or written communications. Enhanced communication skills and better interactions among members of the health care team and the patient are essential. The informed consent process should be used as a patient safety tool, and the patient should be warned about material and foreseeable serious side effects and be told what signs and symptoms should be immediately reported to the physician before the patient is forced to go to the emergency department for urgent or emergency care. Last, reducing medication errors is an ongoing process of quality improvement. Faculty systems must be redesigned, and seamless, computerized integrated medication delivery must be instituted by health care professionals adequately trained to use such technological advances. Sloppy handwritten prescriptions should be replaced by computerized physician order entry, a very effective technique for reducing prescribing/ordering errors, but another far less expensive yet effective change would involve writing all drug orders in plain English, rather than continuing to use the elitists' arcane Latin words and shorthand abbreviations that are subject to misinterpretation. After all, effective communication is best accomplished when it is clear and simple.