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Search results for "Active Errors"

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Meeting/Conference > Kansas Meeting/Conference

Second Victim Train-the-Trainer Workshop.

Center for Patient Safety and University of Missouri. November 10, 2017; Saint Luke's North Hospital, Barry Road, Kansas City, MO.

Second victims are clinicians who experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. This workshop will explore strategies to build an organizational program that addresses individual stages of recovery and trains peers to participate in that process. Sue Scott will lead the session.

Journal Article > Review

Error disclosure in pathology and laboratory medicine: a review of the literature.

Perkins IU. AMA J Ethics. 2016;18:809-816.

Disclosure of errors to patients and families contributes to transparency in health care. This review explores barriers to disclosing diagnostic errors to patients in pathology and laboratory medicine and makes recommendations to address these challenges.

Journal Article > Study

Boosting medical diagnostics by pooling independent judgments.

Kurvers RHJM, Herzog SM, Hertwig R, et al. Proc Natl Acad Sci U S A. 2016;113:8777-8782.

Diagnostic error remains a significant source of preventable patient harm. Because bias on the part of health care providers can contribute to diagnostic errors, improving the medical decision-making process may serve as an error prevention strategy, possibly through the use of collective intelligence. This study sought to better understand the conditions under which collective intelligence might augment medical judgment. Using large data sets consisting of more than 140 doctors and 20,000 diagnoses, the investigators determined that when providers have similar individual diagnostic accuracy rates, pooling their judgments improves decision accuracy. However, if accuracy levels vary across providers, pooling independent judgment leads to worse diagnostic outcomes. The authors suggest that similar diagnostic accuracy should be a key condition when creating groups for the purpose of improving medical diagnosis. A previous WebM&M commentary discussed a case of diagnostic error.

Book/Report

Learning From Mistakes.

London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764.

The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the death of a 3-year-old boy, this report highlights the need to improve organizational culture, complaint follow-up, and transparency to reduce opportunities for similar incidents.

Book/Report

Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Third Edition.

Graban M. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781498743259.

Lean methodology focuses on establishing a culture that supports employee safety and drives process improvement. This book provides information about Lean and how to implement such concepts to integrate quality and safety behaviors in health care delivery. One chapter focuses on the use of root cause problem-solving and error prevention. The author spoke about applying Lean in hospitals in a previous PSNet interview .

Newspaper/Magazine Article

Tackling disrespectful, unprofessional provider behaviors.

ED Manag. June 2016;28:S1-S4.

Disrespectful conduct among health care providers can hinder safe care delivery. This article reviews insights from one hospital's unique program to encourage staff members to help identify individuals that could benefit from personalized coaching and training to manage their disruptive behaviors.

Book/Report

PHSO Review: Quality of NHS Complaints Investigations.

First Report of Session 2016–17 Report. House of Commons Public Administration and Constitutional Affairs Committee. London, England: The Stationery Office; May 24, 2016. Publication HC 94.

Complaint investigations must be conducted in a consistent manner with a goal of learning from each incident to prevent similar occurrences. This government report summarizes an inquiry into the United Kingdom National Health Service complaint reporting system and suggests that support and training for staff must improve in order to address complaints effectively.

Book/Report

Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events. Final Report.

Schneider EC, Ridgely MS, Quigley DD, et al. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-0027-EF.

Patient safety hotlines are a strategy to improve reporting and collecting of comments from patients, clinicians, and staff to notify hospitals about problems in care processes. This report describes the development of one such program, the Health Care Safety Hotline. Drawing from design and testing of the hotline, the authors conclude that more research is needed to understand why patients were more likely to access reports than contribute to them and how to simplify goals for the tool to enhance its usefulness.

Journal Article > Commentary

'Just culture': improving safety by achieving substantive, procedural and restorative justice.

Dekker SWA, Breakey H. Saf Sci. 2016;85:187-193.

A just culture balances organizational context with appropriate accountability after an error. This commentary outlines moral and safety issues that just culture approaches should address to build trust for blame-free response to error and enable learning from failure.

Journal Article > Review

Role of cognition in generating and mitigating clinical errors.

Patel VL, Kannampallil TG, Shortliffe EH. BMJ Qual Saf. 2015;24:468-474.

Cognition has been recognized as a human factor that can contribute to failures in health care. This review examines cognitive aspects of human error that affect patient safety, methods to augment detection of flawed decision-making, and the potential for educational approaches like virtual reality simulation to train physicians to manage cognitive error once it occurs. A past AHRQ WebM&M interview with Dr. Pat Croskerry explored the role of cognition in medical error.

Journal Article > Study

Managing competing organizational priorities in clinical handover across organizational boundaries.

Sujan MA, Chessum P, Rudd M, et al. J Health Serv Res Pol. 2015;20(suppl 1):s17-s25.

Patient handoffs are a major challenge for patient safety, especially when patients move between different units or organizations. Analysis of 270 handoffs between ambulances to emergency departments (EDs) and EDs to inpatient units uncovered many tensions and themes, such as how competing patient flow priorities can impact the quality of handoffs.

Journal Article > Study

Organizational and social-psychological conditions in healthcare and their importance for patient and staff safety. A critical incident study among doctors and nurses.

Eklöf M, Törner M, Pousette A. Safety Sci. 2014;70:211-221.

Through in-depth interviews with Swedish physicians and nurses, this study provides insights into some of the structural and psychosocial aspects that affect patient safety. Staff stress caused by work overload, lack of social support, and frustration with organizational management was felt to directly contribute to clinical mistakes and near misses.

Journal Article > Study

Error in intensive care: psychological repercussions and defense mechanisms among health professionals.

Laurent A, Aubert L, Chahraoui K, et al. Crit Care Med. 2014;42:2370-2378.

This interview study found that physicians and nurses experience guilt and shame following errors, echoing previous studies of the health care provider as the second victim in adverse events. A past AHRQ WebM&M interview with Dr. Albert Wu discusses the impact of errors on health care providers.

Book/Report

GMC National Training Survey 2014: Bullying and Undermining.

Manchester, UK: General Medical Council; November 2014.

This publication summarizes concerns reported in an annual United Kingdom survey of junior doctors regarding disrespectful behaviors in training programs. The report also describes plans to monitor these incidents and address barriers to reporting disruptive behaviors.

Journal Article > Study

Systematic biases in group decision-making: implications for patient safety.

Mannion R, Thompson C. Int J Qual Health Care. 2014;26:606-612.

Cognitive approaches to patient safety have mostly focused on individual decisions. This study instead examines group decision-making and its safety implications. The authors describe four pitfalls associated with group decisions: groupthink in which the strongly connected mentality of members hinders dissenting opinion; social loafing in which people expend less effort because of a perceived failure to obtain individual credit for efforts; group polarization in which individual moderate positions are subsumed by more extreme or effort intensive group decisions; and escalation of commitment in which a poor outcome following a significant investment results in further commitment of resources instead of exploring a new approach. These four concepts can serve as a theoretical framework for future empiric work to characterize and improve group decision-making as an aspect of safety culture.

Journal Article > Study

A qualitative analysis of physician perspectives on missed and delayed outpatient diagnosis: the focus on system-related factors.

  • Classic

Sarkar U, Simchowitz B, Bonacum D, et al. Jt Comm J Qual Patient Saf. 2014;40:461-470.

Diagnostic errors are a common cause of patient harm in ambulatory care. Although such errors have often been ascribed to cognitive biases, this study highlights physicians' concerns that health system structures and communication are major drivers of delayed and missed diagnoses. Focus group discussions involving 25 outpatient physicians—primarily from internal and family medicine—identified multiple potential sources of diagnostic errors, including insufficient information availability, disjointed workflows, and poor communication among providers and with patients. This study underscores many overlapping issues that will need to be addressed to meaningfully enhance diagnostic accuracy. In a recent AHRQ WebM&M interview, Dr. Urmimala Sarkar, the lead author of this study, discussed patient safety in the ambulatory setting.

Journal Article > Study

Work-arounds observed by fourth-year nursing students.

Westphal J, Lancaster R, Park D. West J Nurs Res. 2014;36:1002-1018.

According to this study, nursing students frequently observed registered nurses performing workarounds, or deviations from intended work practices, due to time constraints. Respondents reported that nurses did not adhere to recommended procedures for infection control and often failed to use medication use technology such as barcode medication administration or patient-controlled analgesia pumps correctly. These results are consistent with prior studies linking nurse understaffing to patient safety problems.

Journal Article > Study

The second victim experience and support tool: validation of an organizational resource for assessing second victim effects and the quality of support resources.

Burlison JD, Scott SD, Browne EK, Thompson SG, Hoffman JM. J Patient Saf. 2017;13:93-102.

The second victim phenomenon—the damaging psychological impacts of errors on the clinicians who are involved—has been well documented in the literature. This study presents the development and validation of a survey tool to examine clinicians' experiences with errors and evaluate the effectiveness of approaches to aid second victims.

Journal Article > Study

Relationship of adverse events and support to RN burnout.

Lewis EJ, Baernholdt MB, Yan G, Guterbock TG. J Nurs Care Qual. 2015;30:144-152.

Nurses involved in medical errors are often considered second victims due to the emotional harms they experience. This study found that nurses who participated in preventable adverse events had higher levels of burnout, but peer or physician support following events appeared to have a protective effect.

Journal Article > Commentary

Should health care providers be forced to apologise after things go wrong?

McLennan S, Walker S, Rich LE. J Bioeth Inq. 2014;11:431-435.

This commentary raises questions about requiring clinicians to apologize to patients following an adverse event, such as the potential impact on clinicians' ability to make moral judgments. The authors advocate for promoting voluntary apologies through training, culture, and peer support.

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