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Approach to Improving Safety
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Search results for "Health Care Executives and Administrators"

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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 > Study

Safety culture in cardiac surgical teams: data from five programs and national surgical comparison.

Marsteller JA, Wen M, Hsu YJ, et al. Ann Thorac Surg. 2015;100:2182-2189.

This study found that cardiac surgical teams had a more positive safety culture (as measured by the AHRQ Hospital Survey on Patient Safety Culture) than other surgical teams. Similar to prior studies in which managers reported a more positive safety culture than frontline staff, in this study surgeons reported more optimal safety culture compared to nurses and perfusionists. This gap in perceived safety culture requires further study.

Cases & Commentaries

Haste Makes Care Unsafe

  • Web M&M

John H. Eichhorn, MD; January 2015

While undergoing an elective coronary artery bypass graft (CABG) and ablation, an elderly man had a pulmonary artery catheter (PAC) placed to monitor his hemodynamic status. During the operation, the team was informed that another patient needed an emergency CABG. In the rush to attend to the second patient, the PAC in the first was left inflated for a prolonged period, which could have led to a catastrophic complication.

Journal Article > Study

Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room.

Bowermaster R, Miller M, Ashcraft T, et al. J Am Coll Surg. 2015;220:149–155.e3.

This observational study describes how a pediatric cardiac surgery team used the human factors approach of recording even small deviations from ideal practice in order to better characterize safety problems. The authors describe how systematically capturing small failures led to recognition of faulty processes that could be addressed. A recent AHRQ WebM&M commentary discusses the application of human factors engineering to enhance safety of medical device design.

Journal Article > Study

National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ∼85% of patient deaths.

Hickey EJ, Nosikova Y, Pham-Hung E, et al. J Thorac Cardiovasc Surg. 2015;149:496-507.

In this study, the National Aeronautics and Space Administration's error detection model was used to analyze the incidence and types of error in pediatric cardiac surgery procedures. The investigators found that errors occurred in nearly half of all operations and frequently manifested as cycles of error whereby the effect of a single error was compounded by failure to rescue.

Journal Article > Commentary

FOCUS: The Society of Cardiovascular Anesthesiologists' initiative to improve quality and safety in the cardiovascular operating room.

Barbeito A, Lau WT, Weitzel N, Abernathy JH III, Wahr J, Mark JB. Anesth Analg. 2014;119:777-783.

This commentary describes lessons learned from a multidisciplinary initiative developed to enhance safety of cardiac surgery. The intervention focused on identifying and prioritizing hazards to design risk-reduction strategies and then disseminating these findings to enable widespread improvement.

Journal Article > Study

Locating errors through networked surveillance: a multimethod approach to peer assessment, hazard identification, and prioritization of patient safety efforts in cardiac surgery.

Thompson DA, Marsteller JA, Pronovost PJ, et al. J Patient Saf. 2015;11:143-151.

This study describes a comprehensive approach to identifying safety hazards in a specific clinical environment, the cardiac surgery operating room, which jointly involved experts in organizational science, human factors, and clinical medicine. The authors detail the numerous methods they applied, including surveys, ethnographic direct observation, and analysis of a large database. Safety culture, teamwork and communication, infection prevention, handoffs, failure to adhere to standard practices, and environmental concerns were identified as six key hazards. This type of in-depth, multidisciplinary approach shows promise for determining and prioritizing safety approaches across various health care settings.

Journal Article > Organizational Policy/Guidelines

Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association.

Wahr JA, Prager RL, Abernathy JH 3rd, et al; American Heart Association Council on Cardiovascular Surgery and Anesthesia, Council on Cardiovascular and Stroke Nursing, Council on Quality of Care and Outcomes Research. Circulation. 2013;128:1139-1169.

This scientific statement from the American Heart Association (AHA) reviews the current state of knowledge on safety issues in the operating room (OR) and provides detailed recommendations for hospitals to implement to improve safety and patient outcomes. These recommendations include using checklists and formal handoff protocols for every procedure, teamwork training and other approaches to enhance safety culture, applying human factors engineering principles to optimize OR design and minimize fatigue, and taking steps to discourage disruptive behavior by clinicians. AHA scientific statements, which are considered the standard of care for cardiac patients, have traditionally focused on clinical issues, but this article (and an earlier statement on medication error prevention) illustrates the critical importance of ensuring safety in this complex group of patients.

Journal Article > Study

A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements in care beyond the immediate postoperative period.

Kaufman J, Twite M, Barrett C, et al. Jt Comm J Qual Patient Saf. 2013;39:306-311.

A standardized handoff protocol for cardiac surgery patients between the operating room and intensive care unit led to decreases in unplanned extubations and the amount of time spent on ventilators.

Journal Article > Review

Cardiac surgical ICU care: eliminating "preventable" complications.

Shake JG, Pronovost PJ, Whitman GJR. J Card Surg. 2013;28:406-413.

This review spotlights checklists and goal sheets as strategies to reduce preventable harm associated with cardiac surgery patients.

Journal Article > Review

Quality, patient safety, and the cardiac surgical team.

Martinez EA. Anesthesiol Clin. 2013;31:249-268.

This review discusses the importance of improving health care quality and safety and details several efforts to augment safety in cardiac surgery.

Journal Article > Study

Reducing interruptions to improve medication safety.

Freeman R, McKee S, Lee-Lehner B, Pesenecker J. J Nurs Care Qual. 2013;28:176-185.

A series of interventions was implemented in order to reduce interruptions during medication administration on a telemetry unit.

Journal Article > Study

Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study.

Gurses AP, Kim G, Martinez EA, et al. BMJ Qual Saf. 2012;21:810-818.

Failure to address both operational and cultural factors in cardiac surgery has led to serious safety problems and preventable deaths, most notably at the Bristol Royal Infirmary. This study used detailed observation of cardiac surgical procedures by a multidisciplinary team, including clinicians and human factors engineering specialists, to prospectively identify safety hazards. Many types of hazards were identified, including problems with communication and teamwork, poor interoperability of equipment, and failure to follow established safety protocols. The authors make detailed recommendations to guide institutions in addressing these problems.

Journal Article > Study

Infrequent physician use of implantable cardioverter-defibrillators risks patient safety.

Lyman S, Sedrakyan A, Do H, Razzano R, Mushlin AI. Heart. 2011;97:1655-1660.

This study found evidence of a volume–outcome relationship for implantable cardioverter-defibrillator (ICD) placement. Physicians who performed only one or fewer ICD implantations per year had a significantly higher risk of complications.

Journal Article > Study

Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures.

Chu MWA, Stitt LW, Fox SA, et al. Arch Surg. 2011;146:1080-1085.

This prospective study found no additional risk of complications or mortality in cardiac surgery patients when the attending surgeon was sleep deprived (defined as less than 6 hours of sleep the night prior to the procedure). This finding contradicts the results of an earlier study in general surgery patients.

Journal Article > Study

Dealing with unforeseen complexity in the OR: the role of heedful interrelating in medical teams.

Schraagen JM. Theor Issues Ergon Sci. 2011;12:256-272.

Through direct observation, this study analyzed how pediatric cardiac surgery teams dealt with unanticipated complications during procedures.

Journal Article > Study

A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes.

Schraagen JM, Schouten T, Smit M, et al. BMJ Qual Saf. 2011;20:599-603.

This study used structured observations to identify effective teamwork behaviors and illustrated that high performing teams are more resilient when operations become more challenging. However, patient outcomes may be worse with higher teamwork levels because those cases are more complex.

Journal Article > Study

Cardiac surgery errors: results from the UK National Reporting and Learning System.

Martinez EA, Shore A, Colantuoni E, et al. Int J Qual Health Care. 2011;23:151-158.

This study found that reducing errors associated with medical devices/equipment in the operating room (OR) was a key opportunity for error prevention, whereas medication safety was a focus for prevention outside the OR.

Journal Article > Study

Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit.

Joy BF, Elliott E, Hardy C, Sullivan C, Backer CL, Kane JM. Pediatr Crit Care Med. 2011;12:304-308.

Introduction of a formal handoff system reduced technical errors and improved the quality of handoffs when transferring cardiac surgery patients from the operating room to the intensive care unit.

Journal Article > Study

Handover after pediatric heart surgery: a simple tool improves information exchange.

Zavalkoff SR, Razack SI, Lavoie J, Dancea AB. Pediatr Crit Care Med. 2011;12:309-313.

Use of a structured tool improved the quality of handoffs for postoperative pediatric cardiac surgery patients.

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