Canadian Patient Safety Institute; CPSI; Health Standards Organization; HSO.
This draft 5-year framework aims to guide the activities in Canada to focus action, resources, and policy development on supporting care improvement. The document is structured around five goals: people-centered care, safe care, accessible care, appropriate care, and continuous care. The authors invited Canadian patients, families, clinicians, organization leaders, and policymakers to provide input on the material to ensure its applicability across the country.
This news article reports on the documentary To Err Is Human, which was produced and directed by the son of patient safety leader Dr. John M. Eisenberg. The film is structured around patient safety advocate Sue Sheridan's experience with diagnostic errors that resulted in harm for both her son and husband. It features a wide range of experts who discuss the impact of error on all involved, the role of culture in facilitating both mistakes and progress, and why continued work in health care safety is needed.
Pediatric cardiac surgery is a high-risk practice. This news investigation reports on a series of serious patient safety incidents at a health care institute dedicated to treating heart problems in children and the cultural and individual provider issues that perpetuate unsafe care.
Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing levels, lack of regulation enforcement, and misaligned financial incentives. This news investigation reports on how poor practices resulted in resident harm in Pennsylvania nursing homes and discusses strategies for improvement, such as enhancing investigation processes.
Organizational culture influences how comfortable individuals are with raising awareness of conditions that diminish patient safety. This independent inquiry report provides case studies and a detailed analysis of conditions that hindered nurses and families from acquiring answers about care concerns. The analysis determined factors such as hierarchy and poor physician regard for nursing expertise as persistent challenges to safety in health care.
Parents are important advocates for the safe care of their children. This commentary describes how one hospital built a toolkit to operationalize family members as partners to improve safety. The organization applied high reliability concepts to identify, recognize, and support projects at the hospital to successfully use patients' perspectives to design improvements.
Patient engagement in safety has evolved from obscurity to maturity over the past two decades. This Annual Perspective highlights emerging approaches to engaging patients and caregivers in safety efforts, including novel technological innovations, and summarizes the existing evidence on the efficacy of such approaches.
Dodek PM, Wong H, Heyland DK, et al. Crit Care Med. 2012;40:1506-12.
A positive safety culture has been linked to improved staff satisfaction as well as a lower incidence of errors. This study, conducted in 23 Canadian intensive care units (ICUs), sought to examine the relationship between safety culture and families' satisfaction with care. The authors found a strong positive correlation between safety culture and family satisfaction with care among a subset of patients who had prolonged and ultimately fatal ICU stays. This finding implies that families of patients who have lengthy hospitalizations are affected by the safety and organizational culture of the units where their loved ones are being cared for and that improving safety culture may also improve patient and family satisfaction with care.
The author discusses the ways in which health educators are expanding their competencies to enhance patient safety, including building a patient-centered culture and collaborating with patients and families.
Patients have three roles in improving patient safety: helping to ensure their own safety, working with health care organizations to improve safety at the organization and unit level, and advocating as citizens for public reporting and accountability of hospital and health system performance. The following case illustrates how patients can help ensure their own safety.
Anthony R, Ritter M, Davis R, et al. Jt Comm J Qual Patient Saf. 2005;31:566-72.
Authors from the 2005 American Hospital Association McKesson Quest for Quality Prize citation of merit recipient highlight their use of collaborative rounds, in which family members may participate, along with multimedia tools to enhance the patient's role in safety.
Lindblad B, Chilcott J, Rolls L. Joint Commission journal on quality and safety. 2004;30:551-8.
This rural hospital adopted a progressive approach to promote open communication with patients and families when disclosing medical errors. The initiative supported their efforts toward an improved patient safety culture.
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