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Search results for "Health Care Executives and Administrators"

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  • Health Care Executives and Administrators
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Book/Report

Medical Office Survey on Patient Safety Culture: 2016 User Comparative Database Report.

Famolaro T, Yount ND, Hare R, Thornton S, Sorra J. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-0028-EF.

For more than a decade, the Hospital Survey on Patient Safety Culture has been used in hospitals to evaluate aspects of local organizational culture that affect patient safety. Improved patient safety culture scores have been associated with reduced adverse events and better patient outcomes. The Medical Office Survey on Patient Safety Culture expands this widely used tool for application in the medical office setting. The 2016 User Comparative Database includes data from more than 25,000 respondents across 1,528 medical offices that completed the survey between 2013 and 2015. As with similar databases for hospitals and pharmacies, this resource serves as a tool for benchmarking performance and identifying potential areas for improvement. Teamwork and patient care tracking received the strongest positive scores, whereas work pressure and pace was identified as the area with the most potential for improvement. A prior PSNet perspective discussed establishing a safety culture.

Journal Article > Study

A comparative effectiveness analysis of the implementation of surgical safety checklists in a tertiary care hospital.

Bock M, Doz P, Fanolla A, et al. JAMA Surg. 2016;151:639-644.

The surgical safety checklist has generally been evaluated based on outcomes that occur within 30 days of the primary operation. For instance, the initial studies by the World Health Organization showed remarkable improvements in mortality and morbidity within 30 days, while a more recent retrospective study following mandated implementation of the checklist throughout Ontario failed to show any enhanced safety outcomes over this same interval. This current study evaluated the introduction of a surgical safety checklist at a single academic Italian hospital, measuring 90-day all-cause mortality, length of stay, and 30-day readmission rates, in addition to 30-day mortality rates. The study included approximately 10,000 patients undergoing noncardiac surgery, with about half in the preintervention and postintervention groups. Following checklist implementation, 90-day mortality significantly decreased, 30-day all-cause mortality was unchanged, and adjusted length of stay dropped from 10.4 to 9.6 days; no difference was found in readmission rates. A recent PSNet interview with Dr. Lucian Leape explored the conflicting findings of the efficacy of surgical safety checklists.

Journal Article > Study

Association of safety culture with surgical site infection outcomes.

  • Classic

Fan CJ, Pawlik TM, Daniels T, et al. J Am Coll Surg. 2016;222:122-128.

Safety culture is widely measured and discussed, but its link to patient outcomes has not been consistently demonstrated. Surgical site infections are considered preventable adverse events. In this cross-sectional study, investigators found that better safety culture was associated with lower rates of surgical site infections after colon surgery. Specifically, aspects of safety culture associated with teamwork, communication, engaged leadership, and nonpunitive response to error were linked to fewer infections. Although this work does not establish a clear cause-and-effect relationship between safety culture and patient outcomes, it suggests that efforts to enhance safety culture could improve patient outcomes.

Journal Article > Study

Enhancing surgical safety using digital multimedia technology.

Dixon JL, Mukhopadhyay D, Hunt J, Jupiter D, Smythe WR, Papaconstantinou HT. Am J Surg. 2016;211:1095-1098.

In this study, researchers developed a system for surgical time-outs where scanning a patient's wristband launches a presentation on the operating room monitor, which includes a video of the patient stating his or her name, date of birth, surgical procedure, and operative laterality. Although these took longer than standard timeouts (79 seconds versus 49 seconds), 87% of operating room personnel preferred the digital version, and performance of key safety elements significantly improved.

Journal Article > Study

Evaluation of perioperative medication errors and adverse drug events.

  • Classic

Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Anesthesiology. 2016;124:25-34.

Medication errors in the hospital have been studied, quantified, and systematically evaluated for potential solutions. A notable exception is the perioperative setting, where medications given by anesthesiologists often bypass standard safety checks. This study is the largest prospective observational study of anesthesia-related medication events available to date. At least one medication error or adverse drug event occurred in nearly half of the 277 operations observed. Approximately 1 in 20 perioperative medication administrations resulted in a medication error or adverse drug event; 80% of these errors were deemed preventable. None of the errors resulted in death, but 2% were considered life-threatening. There were no differences in event rates among resident physicians, nurse anesthetists, and staff anesthesiologists. The study took place at an academic hospital with substantial local expertise in medication safety, where operating rooms already used a barcode-assisted syringe labeling system. An accompanying editorial suggests that medication error rates may therefore be even higher in other settings and community hospitals.

Journal Article > Review

Undermining and bullying in surgical training: a review and recommendations by the Association of Surgeons in Training.

Wild JRL, Ferguson HJM, McDermott FD, Hornby ST, Gokani VJ; Council of the Association of Surgeons in Training. Int J Surg. 2015;23 Suppl 1:S5-59.

Disrespectful behaviors in health care have been found to have serious effects on nurses, physicians, and trainees. This review explores how experiences with bullying and undermining affect surgical trainees in the National Health Service and outlines recommendations to address the issue at national, organizational, and local levels.

Journal Article > Study

Outcomes of daytime procedures performed by attending surgeons after night work.

  • Classic

Govindarajan A, Urbach DR, Kumar M, et al. N Engl J Med. 2015;373:845-853.

The link between lack of sleep and subsequent medical errors served as an impetus for physician duty-hours reform. In trainee physicians, sleep loss is associated with attentional failures, but little is known about the relationship between attending physician performance and sleep loss. This retrospective cohort study examined outcomes of elective surgical procedures among attending surgeons who had worked after midnight on the previous night versus those who had not. The investigators found no differences in mortality, complications, or readmissions between procedures performed by surgeons with sleep loss compared to those without sleep loss, mirroring results of an earlier simulation study. This may be due to greater technical skill among attending surgeons, or the ability to cancel or postpone elective procedures as needed at times of fatigue. This study included many institutions, physicians, and procedure types, suggesting that short-term sleep deprivation might not be a high-yield safety target for attending surgeons.

Journal Article > Study

Preventability of hospital-acquired venous thromboembolism.

  • Classic

Haut ER, Lau BD, Kraus PS, et al. JAMA Surg. 2015;150:912-915.

Prevention of hospital-acquired venous thromboembolism (VTE) is a strongly recommended patient safety practice. This retrospective review of hospital-acquired VTE at one tertiary care hospital found that many patients who developed VTE while hospitalized were prescribed appropriate prophylaxis but did not receive all of the prescribed doses. The authors point out that since current quality metrics measure only prescription of VTE prophylaxis and not actual administration, they may overestimate hospital performance on this safety issue. Moreover, nearly half of the patients with VTE had received prophylaxis that is currently considered optimal, an important finding since VTE is often referred to as a "preventable adverse event."

Journal Article > Study

An electronic checklist improves transfer and retention of critical information at intraoperative handoff of care.

Agarwala AV, Firth PG, Albrecht MA, Warren L, Musch G. Anesth Analg. 2015;120:96-104.

In this before-and-after study, implementation of a checklist to improve handoffs between anesthesiologists led to better information transfer and enhanced provider satisfaction. These findings echo prior studies of structured handoff communication.

Book/Report

2015 MHA Patient Safety and Quality Annual Report.

Okemos, MI: Michigan Health & Hospital Association; October 2015.

This publication annually reports on the successful outcomes of the Michigan Keystone Center collaborative activities. Achievements covered in the current year include a reduction in patient readmissions and continued improvements in the incidents of central-line-associated bloodstream infections.

Perspectives on Safety > Perspective

Organizational Change in the Face of Highly Public Errors—II. The Duke Experience

with commentary by Karen Frush, MD, Errors in the Media and Organizational Change, May 2005

In February 2003, 17-year-old Jessica Santillan died at Duke University Medical Center due to a mismatched heart-lung transplantation. As with the Dana-Farber experience, the death made headlines around the world and devastated the leaders and providers at...

Journal Article > Review

Mobilising or standing still? A narrative review of Surgical Safety Checklist knowledge as developed in 25 highly cited papers from 2009 to 2016.

Mitchell B, Cristancho S, Nyhof BB, Lingard LA. BMJ Qual Saf. 2017 Jun 3; [Epub ahead of print].

Checklists have been heralded as an important tool to improve health care safety. This review examined whether the science supports that recognition. Numerous studies have been published, but the literature base hasn't been developed to fully understand the complexities of surgical checklist implementation programs.

Patient Safety Primers

Patient Safety 101

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

Journal Article > Study

Proactive risk assessment of surgical site infections in ambulatory surgery centers.

Bish EK, Azadeh-Fard N, Steighner LA, Hall KK, Slonim AD. J Patient Saf. 2017;13:69-75.

This study reports on the use of a prospective risk assessment tool to identify risks for surgical site infection in an ambulatory surgery center. A safety intervention was developed that specifically targeted the vulnerabilities identified by the risk assessment. Other methods of prospective error detection are discussed in the Detection of Safety Hazards Patient Safety Primer.

Journal Article > Commentary

Investigating the causes of adverse events.

Sanchez JA, Lobdell KW, Moffatt-Bruce SD, Fann JI. Ann Thorac Surg. 2017;103:1693-1699.

Incident analysis enables learning from errors. This commentary explores elements of successful event investigation such as determining causal factors, describes root cause analysis, and reviews biases that can influence such investigations.

Journal Article > Commentary

Who is responsible for the safe introduction of new surgical technology? An important legal precedent from the da Vinci Surgical System Trials.

Pradarelli JC, Thornton JP, Dimick JB. JAMA Surg. 2017 May 3; [Epub ahead of print].

This commentary explores the responsibility of organizations, device manufacturers, and clinicians for ensuring surgeon technical expertise in the use of robotic surgical equipment. The authors describe how hospitals and individual practitioners can enhance their capabilities with new technology to ensure safe patient care.

Journal Article > Study

Effect of day of the week on short- and long-term mortality after emergency general surgery.

Gillies MA, Lone NI, Pearse RM, et al. Br J Surg. 2017;104:936-945.

Prior research supports the existence of a weekend effect across numerous health care outcomes. However, in this observational study, the day of the week had no impact on the short- or long-term mortality of patients after emergency general surgery.

Journal Article > Study

Association between state medical malpractice environment and postoperative outcomes in the United States.

Minami CA, Sheils CR, Pavey E, et al. J Am Coll Surg. 2017;224:310-318.e2.

This retrospective observational study determined that state malpractice climate was not associated with postoperative outcomes. These data are consistent with previous studies suggesting that more stringent malpractice law does not prevent adverse events.

Journal Article > Commentary

Fundamental Use of Surgical Energy (FUSE): an essential educational program for operating room safety.

Jones SB, Munro MG, Feldman LS, et al. Perm J. 2017;21:16-050.

Operating rooms are high-risk work environments. Improper use of energy-based surgical devices can increase risks of surgical fires. This commentary describes an initiative to address this safety concern by educating physicians and staff who work in the operating room environment about how to safely use the equipment. A past WebM&M commentary discussed operating room fires and how to prevent them.

Journal Article > Commentary

Learning and mindfulness: improving perioperative patient safety.

Graling PR, Sanchez JA. AORN J. 2017;105:317-321.

The surgical environment is complex, and strategies to address human error and learn from mistakes are important to improve safety in this setting. This commentary discusses how organizational learning and mindfulness can help perioperative staff manage and prevent missteps in the operating room.

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