Cucchiaro SÉ, Princen F, Goreux JË, et al. Int J Qual Health Care. 2022;34:mzac014.
Patient satisfaction surveys, unexpected event reports and patient complaints can each be used to improve patient safety. This radiotherapy service combined the three sources to make improvements in safety and quality. Results highlighted areas of strength (e.g., physical healing, kindness) and areas to improve (e.g., scheduling, comfort). Involving the patient in this way could lead to improvements in quality and safety.
Hospital-acquired pressure injuries (HAPI) can lead to increase costs and length of stay. Through root cause analysis, this geriatric rehabilitation hospital identified factors that contributed to the development of HAPI in its facility. Recommendations for improvement targeted both system- and human-level factors.
Mills PD, Soncrant C, Gunnar W. BMJ Qual Saf. 2021;30:567-576.
This retrospective analysis used root cause analysis reports of suicide events in VA hospitals to characterize suicide attempts and deaths and provide prevention recommendations. Recommendations include avoidance of environmental hazards, medication monitoring, control of firearms, and close observation.
Williams H, Donaldson SL, Noble S, et al. Palliat Med. 2019;33:346-356.
Patients receiving palliative care are often medically complex and may be at increased risk for safety events, especially when cared for outside of routine clinic hours. In this mixed-methods study, researchers analyzed patient safety incident reports regarding patients who received inadequate palliative care during nights and weekends from primary care services in the United Kingdom. Incidents related to medications were common, accounting for 613 out of the 1072 safety events included in the study.
Sanner M, Halford C, Vengberg S, et al. J Healthc Risk Manag. 2018;38:47-55.
In this qualitative study at a single university hospital in Sweden, researchers found that hospital middle managers perceived patient safety to be a low priority and that leadership support for patient safety was considered lacking. Underreporting of patient safety incidents and insufficient availability of resources to do patient safety–related work were also cited as significant concerns among the managers interviewed.
Meacock R, Sutton M. Emerg Med J. 2018;35:108-113.
The weekend effect refers to higher rates of adverse outcomes experienced by patients admitted on the weekends. Researchers sought to determine whether adoption of clinical standards for emergency hospital care put forth by the National Health Service in England is associated with the degree to which weekend mortality is increased. Using data from 123 Trusts, they found no association between adoption of these clinical standards and the extent of the weekend effect. This finding suggests that adoption of these standards is unlikely to reduce mortality among patients admitted to the emergency department on the weekend.
Mira JJ, Lorenzo S, Carrillo I, et al. Int J Qual Health Care. 2017;29:450-460.
This review study examined policies to address the consequences of adverse events for patients, providers, and organizations. The methods included focus groups and a literature review. The team generated recommendations such as involving patients in event investigation, providing time away from usual work for second victims, and establishing a crisis plan for organizations.
Comptroller and Auditor General; Department of Health; National Audit Office.
Applying evidence generated from complaints submitted to health care services has been promoted as a way to inform improvement. This report assesses management of claims against National Health Services trusts to determine the costs involved, ensure appropriate patient compensation, and control incidence of future claims through collaborative care improvement efforts.
Bathla S, Chadwick M, Nevins EJ, et al. J Patient Saf. 2021;17:e503-e508.
Wrong-site surgery represents a never event. In the United States, The Joint Commission requires marking of the surgical site prior to surgery as part of the Universal Protocol. Researchers conducted a survey study of 120 surgeons in the United Kingdom and found significant variation in adherence to the national mandate for preoperative surgical site-marking.
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