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Search results for "Health Care Executives and Administrators"

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  • Health Care Executives and Administrators
  • Near Miss
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Journal Article > Study

A cross-sectional analysis investigating organizational factors that influence near-miss error reporting among hospital pharmacists.

Patterson ME, Pace HA. J Patient Saf. 2016;12:114-117.

This cross-sectional analysis sought to determine how a punitive work environment, poor feedback about errors, and inadequate preventive processes affect near-miss reporting by hospital pharmacists. Using data from the AHRQ Hospital Survey of Patient Safety Culture, researchers found that pharmacists who believed error prevention procedures and error feedback to be insufficient were less likely to report near misses. A work culture in which individuals are blamed for errors was also tied to less near-miss reporting, similar to other studies of safety culture. This study underscores the consistent finding that frontline health care personnel are more likely to participate in safety efforts when they perceive that their workplace is receptive to error reporting and develops interventions to address concerns raised. A previous AHRQ WebM&M perspective explores the evidence on safety culture over the past decade.

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 > Review

Informing the design of a new pragmatic registry to stimulate near miss reporting in ambulatory care.

Pfoh ER, Engineer L, Singh H, Hall LL, Fried ED, Berger Z, Wu AW. J Patient Saf. 2017 Feb 28; [Epub ahead of print].

Patient safety in ambulatory care is emerging as an area of focus for safety improvement. This review discusses the importance of using near misses as a learning opportunity in outpatient care. The authors describe the design of a near miss registry to collect information on factors that contribute to errors as a way to enable learning and improvement.

Perspectives on Safety > Perspective

Errors and Near Misses: What Health Care Could Learn From Aviation

with commentary by Carl Macrae, PhD, Root Cause Analysis: What Have We Learned?, December 2016

This piece explores how strategies from aviation, such as just culture and monitoring technologies, can be applied in health care to improve patient safety.

Patient Safety Primers

Adverse Events, Near Misses, and Errors

The terms adverse events, near misses, and medical errors are used in patient safety to refer to events where patients were harmed (or easily could have been).

Journal Article > Study

A cross-sectional analysis investigating organizational factors that influence near-miss error reporting among hospital pharmacists.

Patterson ME, Pace HA. J Patient Saf. 2016;12:114-117.

This analysis of data from the AHRQ Hospital Survey on Patient Safety Culture found that pharmacists who perceived insufficient feedback after voluntarily reporting an error were less likely to report a near miss error. Failure to provide timely feedback to those who report an error is a recognized limitation of most existing voluntary reporting systems.

Journal Article > Study

Adverse events and near misses relating to information management in a hospital.

Jylhä V, Bates DW, Saranto K. HIM J. 2016;45:55-63.

This analysis of incident reports found that problems with handling patient clinical information were a common source of preventable adverse events. These incidents were often due to workarounds, such as recording patient information on paper instead of within the electronic medical record.

Journal Article > Commentary

Driving surgical quality using operative video.

O'Mahoney PRA, Yeo HL, Lange MM, Milsom JW. Surg Innov. 2016;23:337-340.

Although using video documentation while providing care is controversial, it has been shown to contribute to error and near miss analysis. This commentary describes how utilizing videos in operating rooms can enhance patient safety and clinician accountability.

Journal Article > Commentary

Wrong site surgery: a critical incident analysis of a near miss.

Tichanow S. J Perioper Pract. 2016;26:11-15.

Despite efforts to prevent wrong-site surgeries, they continue to occur. This commentary discusses a near miss resulting from human factors and inadequate team communication to underscore the importance of reporting and analyzing incidents to enhance individual practice and teamwork.

Journal Article > Study

The well-defined pediatric ICU: active surveillance using nonmedical personnel to capture less serious safety events.

White WA, Kennedy K, Belgum HS, Payne NR, Kurachek S. Jt Comm J Qual Patient Saf. 2015;41:550-562.

Serious reportable events in hospitals are usually captured, but less serious events and near misses often go undocumented. Such close calls can reveal important safety hazards. This study describes the development and early experience of an active surveillance program in a pediatric intensive care unit (PICU). Under the supervision of an assigned intensive care physician, premedical college graduates served as quality/safety analysts. Two analysts canvassed the PICU each morning, interviewing night nurses, physicians, respiratory therapists, and pharmacists about potential adverse events. Over a 15-month period, 2465 events were recorded, representing 5.4 events per day. Approximately 158 quality and safety improvement projects were initiated during this period. The authors describe the infrastructure, reporting, and unique web application that were developed as a part of this process. These quality/safety analyst interviews essentially created a facilitated, robust voluntary incident reporting system.

Newspaper/Magazine Article

Safety culture includes "good catches."

Traynor K. Am J Health Syst Pharm. 2015;72:1597-1599.

Near misses can provide opportunities for learning if there is a process in place to identify and discuss them. This commentary reveals insights from hospitals with good catch programs to illustrate how these programs can help inform improvements to medication safety processes.

Journal Article > Study

Near misses and unsafe conditions reported in a Pediatric Emergency Research Network.

Ruddy RM, Chamberlain JM, Mahajan PV, et al; Pediatric Emergency Care Applied Research Network. BMJ Open. 2015;5:e007541.

This study of incident reports from pediatric emergency departments found that a small proportion reported near misses or unsafe conditions. Common issues included medication safety, handoffs, human factors, and systems vulnerabilities, all of which are known to lead to patient harm. Prior studies have found that incident reporting is often underused. This study highlights its importance as a lens into safety problems.

Journal Article > Study

Evaluation of near-miss wrong-patient events in radiology reports.

Sadigh G, Loehfelm T, Applegate KE, Tridandapani S. AJR Am J Roentgenol. 2015;205:337-343.

Despite The Joint Commission requirement to use at least two patient identifiers when obtaining an imaging study, wrong-patient events still occur. This retrospective case review study determined the prevalence of reported near-miss wrong-patient events in radiology at two large academic hospitals. The overall event rate was 4 per 100,000 radiology studies.

Cases & Commentaries

Privacy or Safety?

  • Spotlight Case
  • CME/CEU
  • Web M&M

John D. Halamka, MD, MS, and Deven McGraw, JD, MPH, LLM; July/August 2015

A hospitalized patient with advanced dementia was to undergo a brain MRI as part of a diagnostic workup for altered mental status. Hospital policy dictated that signout documentation include only patients' initials rather than more identifiable information such as full name or birth date. In this case, the patient requiring the brain MRI had the same initials as another patient on the same unit with severe cognitive impairment from a traumatic brain injury. The cross-covering resident mixed up the two patients and placed the MRI order in the wrong chart. Because the order for a "brain MRI to evaluate worsening cognitive function" could apply to either patient, neither the bedside nurse nor radiologist noticed the error.

Journal Article > Study

Reporting and using near-miss events to improve patient safety in diverse primary care practices: a collaborative approach to learning from our mistakes.

Crane S, Sloane PD, Elder N, et al. J Am Board Fam Med. 2015;28:452-460.

This study describes the successful implementation of a Web-based reporting system for near-miss events in primary care practices. The most prevalent reports were breakdowns in office processes, with varying risk for adverse events, as found in prior studies of incident reporting. Although near-miss reporting can stimulate improvement efforts, it is not a precise method for detecting safety problems.

Journal Article > Review

Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability organizations to healthcare.

Van Spall H, Kassam A, Tollefson TT. Curr Opin Otolaryngol Head Neck Surg. 2015;23:292-296.

Near misses, also referred to as close calls, are an underutilized safety improvement resource due to lack of reporting and a clear definition. Using aviation as a high reliability model, this review outlines strategies to augment reporting and analysis of near misses in health care.

Journal Article > Study

An analysis of near misses identified by anesthesia providers in the intensive care unit.

Lipshutz AKM, Caldwell JE, Robinowitz DL, Gropper MA. BMC Anesthesiol. 2015;15:93.

This analysis of near misses in intensive care unit patients that were voluntarily reported by anesthesiologists found that the majority could be ascribed to one of five contributing factors, including a poor culture of safety and insufficient communication between teams.

Journal Article > Study

Characterising 'near miss' events in complex laparoscopic surgery through video analysis.

Bonrath EM, Gordon LE, Grantcharov TP. BMJ Qual Saf. 2015;24:516-521.

This series of blinded video reviews of laparoscopic surgeries identified the technical surgical errors that led to complications. This study adds to the emerging evidence supporting peer review of operating room videos. A recent AHRQ WebM&M interview with John Birkmeyer discussed his video study that found a link between practicing surgeons' directly observed technical skills and surgical safety outcomes.

Journal Article > Commentary

Learning from mistakes and near mistakes: using root cause analysis as a risk management tool.

Cerniglia-Lowensen J. J Radiol Nurs. 2015;34:4-7.

Root cause analysis has been promoted by The Joint Commission and other organizations as a failure analysis tool, though problems with its usefulness remain due to issues with implementation and sufficient follow-up. This commentary provides an overview of the process and uses a case study to illustrate its value as a safety improvement strategy.

Journal Article > Study

Near-miss transcription errors: a comparison of reporting rates between a novel error-reporting mechanism and a current formal reporting system.

South DA, Skelley JW, Dang M, Woolley T. Hosp Pharm. 2015;50:118-124.

This observational study compared error detection rates for medication transcription errors between a hospital's formal reporting system and a passive error identification mechanism embedded in ordering software. As with prior studies of incident reporting systems, the formal reporting mechanism identified fewer errors than electronic surveillance, emphasizing the need to build error detection into technology platforms.

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