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Search results for ""
Journal Article > Review
Healthcare scandals and the failings of doctors: do official inquiries hold the profession to account?
Mannion R, Davies H, Powell M, et al. J Health Org Manag. 2019;33:221-240.
Organizational acceptance of accountability for failures and implementation of solutions are critical to improve safety. This review explores the impact of investigations focused at the individual, practice, and system levels. The authors describe design and operational failings at each level that enable purposeful or accidental patient harm.
Journal Article > Review
Ranking hospitals based on preventable hospital death rates: a systematic review with implications for both direct measurement and indirect measurement through standardized mortality rates.
Manaseki-Holland S, Lilford RJ, Te AP, et al. Milbank Q. 2019;97:228-284.
Measuring patient safety remains an ongoing challenge. This systematic review examined whether preventable death rates could be used as a measure of hospital quality. Researchers reviewed 23 studies and found that estimates of preventable in-hospital death are consistently low. Ascertainment of preventability was not consistent across multiple clinician-reviewers, and the authors estimate that cases would need review by eight or more clinicians to achieve the precision required. The authors conclude that preventable death rates would not be a valid or reliable measure of patient safety. A past PSNet interview discussed the development of hospital standardized mortality ratios and their role in monitoring performance.
Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report.
Sturrock J. Edinburgh, Scotland: The Scottish Government; May 2019. ISBN: 9781787817760.
Disrespectful and unprofessional behaviors are a common problem in health care. The report examines cultural issues at a National Health Service trust that affected the transparency needed to report disruptive behaviors and that limited conversation needed to facilitate local actions and improvement. Recommendations for the leadership, organizational, and system levels are provided to enable constructive change.
Journal Article > Study
A culture of openness is associated with lower mortality rates among 137 English National Health Service acute trusts.
Toffolutti V, Stuckler D. Health Aff (Millwood). 2019;38:844-850.
Understanding the key factors underlying safety culture remains critical to improvement efforts. This cross-sectional study examined whether openness was associated with in-hospital mortality in the English National Health Service. Investigators measured openness with a composite measure derived from four questions from a staff survey: comfort with speaking up about safety concerns, disclosure of safety problems to staff, knowledge of reporting practices, and perceived security in reporting safety concerns. After adjustment for hospital size, the authors found that increased openness was associated with lower mortality. This relationship suggests that openness constitutes an important aspect of a positive safety culture. The results lend weight to calls for increased transparency in health systems. A past PSNet perspective discussed the evolution of patient safety and traced its development and progress in the United Kingdom.
Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2019. ISBN: 978926474260.
The overprescribing of prescription opioids heightens the likelihood of opioid dependence and harm. This report shares data from 25 countries to provide a baseline for the current crisis. The publication illustrates the complexity of the opioid epidemic and suggests that system-focused multisector strategies are required to address the problem.
Manchester, UK: General Medical Council; June 2019.
Finding the appropriate balance between assigning criminality and accountability for tragic preventable patient harm is difficult. Summarizing a high-profile case in the United Kingdom that involved the death of a pediatric patient, misdiagnosis, and a senior pediatric trainee, this report explores elements of the criminality and accountability debate across the system and discusses policy, judicial, and individual components of a fair and just response to adverse events to keep organizations, clinicians, and patients safe.
Journal Article > Commentary
Fulop NJ, Ramsay AIG. BMJ. 2019;365:l1773.
Quality and safety improvement in health care is complex and requires insights and buy-in from various perspectives to achieve lasting progress. This commentary discusses the role of leadership, systemwide staff engagement, external influences, and processes that support prioritization and implementation of sustainable quality improvement strategies.
Geneva, Switzerland: World Health Organization; 2019.
Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores key areas of concern that require action at a system level to improve: high-alert medications, polypharmacy, and medication use at care transitions. Each monograph provides an overview of the topic as well as practical improvement approaches for patients, clinicians, and organizations.
NHS Improvement. July 2, 2019.
The United Kingdom National Health Service (NHS) has been at the forefront of patient safety innovation. This strategy seeks to further implement approaches that explore and optimize the intersection of systems and human behaviors to support safe care at the NHS. The framework builds upon the perspectives of patients, staff, and organizations to achieve whole system improvement and sustain those changes through effective intervention and program design.
Tingle J, O'Neill C, Shimwell M. New York, NY: Routledge; 2019. ISBN: 9781138052789.
Improving patient safety is a global goal. This book covers error reduction methods used in developing and transitioning countries and synthesizes the concepts and theories with those from developed countries. Contributors examine strategies to transfer successes across a range of national environments and policy situations.
Journal Article > Commentary
Woodward S. J Patient Saf Risk Manag. 2019;24:96-99.
Journal Article > Study
Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis.
Panagioti M, Khan K, Keers RN, et al. BMJ. 2019;366:l4185.
The extent of harm due to patient safety problems varies across studies. This systematic review sought to estimate the prevalence of preventable harm in medical care overall. Researchers synthesized data from 70 studies and estimated that 6% of patients receiving medical care experience preventable harm. Harm related to medications, diagnosis, health care–associated infections, and procedures accounted for significant proportions of preventable harm. The authors conclude that focusing on evidenced-based strategies to address preventable patient harm would improve health care quality and subsequently reduce costs. A related editorial calls for improving measurement of preventable harm. Another editorial spotlights the importance of understanding the causes of preventable harm in health care.
Special or Theme Issue
Polit Q. 2019;90:177-342.
The National Health Service strategy of publishing their inquiries into systematic poor care in the health service is a model of transparency. Articles in this special issue summarize this legacy and the learning that has been realized by the process. The authors discuss high-profile inquiries, quality of the investigations, and the need for the work to result in sustainable change.