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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.

Newspaper/Magazine Article

Rude providers jeopardize patient safety. So stop it.

Thew J. HealthLeaders Media. June 14, 2017.

Rudeness can affect teamwork and hinder safe, transparent care. This news article reports on one hospital's approach to manage disruptive behavior through strategies such as peer identification and proactive behavior adjustment.

Journal Article > Study

Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis.

Schulz CM, Burden A, Posner KL, et al. Anesthesiology. 2017 May 1; [Epub ahead of print].

Failure to maintain situational awareness can adversely impact patient safety. In this closed claims analysis of anesthesia malpractice claims for death or brain damage, researchers found that situational awareness errors on the part of the anesthesiologist contributed to death or brain damage in 74% of claims.

Journal Article > Study

Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.

Martinez W, Lehmann LS, Thomas EJ, et al. BMJ Qual Saf. 2017 Apr 25; [Epub ahead of print].

Health care provider comfort with raising patient safety concerns is a critical aspect of safety culture. This survey of resident physicians at six academic medical centers demonstrated that trainees remain reluctant to speak up. Nearly half reported observing a patient safety threat. The majority spoke up about patient safety concerns, but a significant proportion did not. Although unprofessional behavior was more frequently observed, fewer trainees raised concerns about lack of professionalism than about patient safety. Even when respondents perceived the unprofessional behavior as having high potential for adverse patient consequences, they were not as likely to speak up about this compared to a traditional patient safety threat such as inadequate hand hygiene. The authors recommend specifically measuring tolerance for unprofessional behaviors as a part of safety culture assessment.

Newspaper/Magazine Article

Balancing doctor egos and errors.

Sweeney JF. Med Econ. November 10, 2016.

Disclosure and candor with patients after a medical error has gained support from organizations, clinicians, and patients. This magazine article discusses how initiatives such as communication-and-resolution programs can reduce lawsuits, provide opportunities for learning, and improve physician–patient relationships.

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.

Journal Article > Commentary

Care at the point of impact: insights into the second-victim experience.

Scott SD, McCoig MM. J Healthc Risk Manag. 2016;35:6-13.

Health care workers who experience emotional consequences after being involved in a medical error are known as second victims. This commentary reviews the stages of recovery that such health care workers experience, determined by a hospital-based program to provide immediate support for second victims. A PSNet perspective offers insights from one of the authors about this program.

Journal Article > Study

The experiences of risk managers in providing emotional support for health care workers after adverse events.

Edrees H, Brock DM, Wu AW, et al. J Healthc Risk Manag. 2016;35:14-21.

Second victims are health care workers who experience mental health consequences following adverse events. This study found that although risk managers feel comfortable counseling second victims, they would like to receive additional training.

Newspaper/Magazine Article

When a surgeon should just say 'I'm sorry'.

Cohen E. CNN. March 24, 2016.

Poor communication regarding medical errors can contribute to patient and family frustration and fear. Reporting on a case involving disclosure of a wrong-site surgery, this news article describes a resolution program to help patients cope after a preventable error. The program includes apology, disclosure, and explanation of what occurred as well as financial compensation.

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.

Newspaper/Magazine Article

Fatal mistakes.

Kliff S. Vox Media. March 15, 2016.

Health professionals involved in medical errors experience psychological stress, which can have serious consequences if they are unable to cope with their mistake. Reporting on the second victim phenomenon, this news article discusses a well-known incident that led to the suicide of a nurse, how insufficient organizational and peer support systems affect clinicians, initiatives to provide counseling in similar situations, and the need for more universal change.

Book/Report

When There's Harm in the Hospital: Can Transparency Replace "Deny and Defend"?

National Health Policy Forum. Washington, DC: George Washington University. March 11, 2016.

This report provides the insights from a panel exploring the need for transparency after a medical mistake occurs. The session discussed the history and evolution of new approaches to achieve transparency, such as communication-and-resolution programs. Experts participating in the session included Dr. David Mayer, Richard Boothman, and Helen Haskell.

Journal Article > Commentary

When a surgical colleague makes an error.

Antiel RM, Blinman TA, Rentea, RM et al. Pediatrics. 2016;137:e20153828.

Physicians have become more comfortable with recognizing and disclosing errors to patients in the past few decades, but speaking up about a peer's error remains challenging. Discussing a case involving a surgeon discovering a serious mistake made by a colleague, this commentary provides insights from surgical and bioethics experts on how to address the situation.

Journal Article > Commentary

Advancing the next generation of handover research and practice with cognitive load theory.

Young JQ, Wachter RM, ten Cate O, O'Sullivan PS, Irby DM. BMJ Qual Saf. 2016;25:66-70.

Implementing standardized handoff processes has garnered attention as a strategy to improve patient safety. In this commentary, the authors apply cognitive load theory to handoff tasks to demonstrate how to improve handover bundles and enhance reliability.

Journal Article > Study

Exploring attitudes and opinions of pharmacists toward delivering prescribing error feedback: a qualitative case study using focus group interviews.

Lloyd M, Watmough SD, O'Brien SV, Furlong N, Hardy K. Res Social Adm Pharm. 2016;12:461-474.

According to these focus groups, pharmacists recognized the importance of providing timely feedback to physicians regarding prescription errors, but they also described barriers to feedback such as time pressures and concerns about negative effects on interpersonal rapport.

Journal Article > Commentary

A piece of my mind. I'm sorry.

Kahn JS. JAMA. 2015;313:2427-2428.

Being accountable for errors and working to learn from them is key to improving patient safety. This commentary describes a physician's reactions following a medication ordering error that resulted in temporary patient harm, steps taken to report the error, how the incident was used as a teaching point for team members, and the patient's positive response to the physician's disclosure and apology.

Journal Article > Study

Apologies following an adverse medical event: the importance of focusing on the consumer's needs.

Allan A, McKillop D, Dooley J, Allan MM, Preece DA. Patient Educ Couns. 2015;98:1058-1062.

In this study, participants observed two video-recorded scenarios of a surgeon apologizing for an adverse event. Although apologies that focused on admissions of responsibility, expressions of regret, and offers of restitution were viewed positively, those that also explicitly accounted for the patient's perspective by understanding the impact on the patient and offering to address the harm in a meaningful manner were better received.

Journal Article > Study

How surgical trainees handle catastrophic errors: a qualitative study.

Balogun JA, Bramall AN, Bernstein M. J Surg Educ. 2015;72:1179-1184.

According to this qualitative study, surgery resident physicians perceive that catastrophic errors result from system problems and provide lessons for future practice. Participants did not feel comfortable discussing errors with staff and reported work culture as a barrier to asking for support, demonstrating the need to teach trainees about error disclosure.

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.

Newspaper/Magazine Article

The high cost of low morale in the clinical laboratory: how workplace environment impacts patient safety.

Barker T, Noguez J. Clinical Laboratory News. January 1, 2015.

Reporting on the importance of a supportive workplace environment that engages employees in tasks to help ensure safety, this news article discusses root causes for low staff morale in the laboratory environment and suggests tactics to build healthy staff relationships.

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