Search results for "Health Care Executives and Administrators"

Disruptive physician behavior is a recognized patient safety problem. Fear of confrontation with a disruptive individual may inhibit speaking up about potential errors and worsen safety culture and teamwork. In this simulation study, neonatal intensive care unit teams were exposed to either rude or neutral comments from an observer during their assigned simulated task. Compared to teams receiving neutral comments, those who were exposed to rudeness performed worse. This study complements prior studies which document perceived consequences of disruptive behavior by demonstrating worse simulated task performance. This work also reveals that rudeness external to a team can affect performance and suggests that a polite work culture would foster patient safety.

Health care–associated infections (HAIs) are a significant source of preventable harm to patients. Although prior research has shown that clean hands are essential for reducing HAIs, health care institutions continue to struggle with hand hygiene compliance. In this study, investigators surveyed 400 nurses at a pediatric hospital and found a positive correlation between psychological safety and belief in personal responsibility for preventing the spread of infection. The authors argue that improving the psychological safety of staff may augment the response to hand hygiene initiatives.

This randomized controlled trial randomized head nurses in inpatient settings to either receive individual feedback based on questionnaires from frontline nurses followed by goal-setting, versus a summary report of feedback at the end of the intervention. In the intervention group, patient care messages increased and blaming decreased, demonstrating that a brief and feasible intervention can enhance safety culture.

Burnout among nurses has been linked to safety hazards. This cross-sectional study found that burnout among nurses is associated with a worse safety climate and higher levels of stress. A recent Annual Perspective discussed the relationship between safety and burnout.

This pre-post study found that a human factors approach improved blood collection procedures in the emergency department, which is important for preventing adverse events such as transfusion errors. This demonstrates the benefits of applying human factors engineering in patient safety efforts across health care settings.

Diagnosis is a critical area of patient safety. Prior research demonstrates that physicians perceive time pressure as an impediment to diagnosis, but this has not been objectively documented. This educational simulation study examined the ability of internal medicine residents to correctly diagnose written cases with and without time pressure. Residents under time pressure had reduced diagnostic accuracy, and this decrement was more marked for difficult cases. These results demonstrate the benefit of allowing physicians more time for accurate diagnosis, consistent with recent Institute of Medicine recommendations to examine novel models of care and reimbursement to foster diagnostic safety. A recent PSNet interview discussed diagnostic errors and how to reduce them.

Investigators presented medical students and physicians at three university medical centers with a clinical vignette to explore levels of confidence, accuracy, and comfort with admitting a mistake. Physicians had higher levels of confidence but less accuracy compared to medical students, and they were less willing to admit making an error. There was a weak association between overconfidence and discomfort with error disclosure.

Miscommunication during transitions of care can contribute to medication errors. This commentary describes an initiative to involve pharmacy students in care transitions services. Although the authors found that scheduling and training the students for the program was a challenge, 30-day readmission rates were lower for patients who received transitions of care services with pharmacy students versus those who did not.

Patient safety programs should reflect local needs, motivate clinician and leadership engagement, and support sustainable enhancements. This toolkit provides information about how to establish a patient safety program, implement interventions, determine areas needing improvement, and build a culture of safety.

Direct observation of staff members at an eye care institute in Uganda was used to identify domains of patient safety in low-resource areas. Results of this study provide a basis for developing further methods of assessing patient safety specific to low-resource settings.

Look-alike sound-alike medications can contribute to confusion and result in drug administration errors. This commentary illustrates how switching to a generic brand of medication to save costs was a factor in recurring underdosing errors. The authors provide recommendations to improve the safety of stocking medications.

This conference focused on persisting barriers to patient safety worldwide and recommended strategies to achieve lasting improvement, including dedication to systems engineering, patient-centeredness, and process integration. The session summarized findings of a report developed for the event, Transforming Patient Safety: a Sector-wide Systems Approach. The proceedings collection includes the full text of the report, video of the panel, and podcasts with Margaret Murphy, Dr. Mary Dixon-Woods, Dr. Peter Pronovost, and other participants.

This prospective study examined 200 hospital nurse handovers. Documentation was missing in nearly half of patients' files, and dosage discrepancies were identified in 23% of cases. Use of strategies that emphasized the input and interaction of the incoming team—such as face-to-face verbal updates with questions—were associated with fewer treatment errors.

This survey study examined the relationship between medical errors and resident autonomy, consultation with supervising physicians, and knowledge of the medical literature (as perceived by supervising physicians). Researchers found that closer supervision and greater knowledge were associated with lower error rates, suggesting that increasing trainee supervision holds promise in improving patient safety.

This study conducted a retrospective chart review of more than 15,000 hospitalization records in 8 countries and found an adverse event rate range of 2.5% to 18.4% per country. Investigators estimated that more than 80% were preventable, suggesting a call to action for broader international efforts to promote patient safety.

This Web site establishes a forum for hospitals in Europe and Africa to support partnership development and share learnings to drive patient safety improvements.

This study used root cause analysis methodology to identify system factors leading to excess radiation exposure in patients undergoing radiotherapy.

This prospective study conducted in Morocco found that nearly 1 in 6 patients experienced an adverse drug event. However, only one-third of these events were preventable.

This initiative provides a surgical safety checklist and related educational and training materials to encourage international adoption of a core set of safety standards. Implementation of this World Health Organization's checklist has resulted in dramatic reductions in surgical mortality and complications across diverse international hospitals. Surgical checklists have now become one of the clearest success stories in the patient safety movement, although some have described challenges to effective implementation. Dr. Atul Gawande discussed the history of checklists as a quality and safety tool in his book, The Checklist Manifesto: How to Get Things Right.

This publication shares news related to the World Health Organization's Global Patient Safety Challenge.