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Search results for "Health Care Executives and Administrators"

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Journal Article > Study

Underlying risk factors for prescribing errors in long-term aged care: a qualitative study.

Tariq A, Georgiou A, Raban M, Baysari MT, Westbrook J. BMJ Qual Saf. 2016;25:704-715.

This qualitative study of medication prescribing practices at long-term care facilities uncovered multiple safety hazards, including inadequate handoffs, insufficient information flow, and lack of a robust safety culture. The results suggest that both systems approaches and team training are needed to improve medication safety in long-term care facilities.

Journal Article > Commentary

Six habits to enhance MET performance under stress: a discussion paper reviewing team mechanisms for improved patient outcomes.

Fein EC, Mackie B, Chernyak-Hai L, O'Quinn CRV, Ahmed E. Aust Crit Care. 2016;29:104-109.

Shared mental models can augment decision-making and teamwork during stressful situations. This commentary explores the role of shared mental models in medical emergency teams (METs) and describes a team development approach to enhance performance of MET members and improve patient outcomes.

Journal Article > Study

Safety incidents in the primary care office setting.

Rees P, Edwards A, Panesar S, et al. Pediatrics. 2015;135:1027-1035.

Patient safety in outpatient settings is a growing concern. In this analysis of voluntarily reported safety events from the United Kingdom, researchers identified serious risks for children cared for in outpatient family medicine settings. Medication management, diagnostic errors, and errors in the referral process contributed significantly to patient harm, echoing prior studies about outpatient safety. The authors call for implementation of safety practices such as barcode medication administration, clinical decision support software, and electronic referral tracking, all of which remain incompletely implemented in ambulatory care. Given the known under-reporting of adverse events, this report likely underestimates the frequency of patient safety problems in this outpatient setting and emphasizes the need for active safety monitoring.

Journal Article > Study

Multicentre study to develop a medication safety package for decreasing inpatient harm from omission of time-critical medications.

Graudins LV, Ingram C, Smith BT, Ewing WJ, Vandevreede M. Int J Qual Health Care. 2015;27:67-74.

Omitted or delayed dosing of medications is an aspect of missed nursing care in inpatient settings. This quality improvement study describes an audit and feedback tool to ensure timely medication administration in hospitals. This type of standardized work and feedback, influenced by human factors engineering, has been applied to many patient safety programs.

Special or Theme Issue

The safety and quality of health care: where are we now?

Med J Aust. 2006;184:S37-S72.

This special issue includes numerous articles reviewing the activities and successes of the patient safety movement outside the United States.

Journal Article > Review

Countering cognitive biases in minimising low value care.

Scott IA, Soon J, Elshaug AG, Lindner R. Med J Aust. 2017;206:407-411.

Heuristics and cognitive biases can contribute to uninformed decision making. This review explores how biases affect overuse and suggests patient stories, huddles, and shared decision making as strategies to mitigate cognitive biases in health care.

Journal Article > Review

New graduate registered nurses' knowledge of patient safety and practice: a literature review.

Murray M, Sundin D, Cope V. J Clin Nurs. 2017 Mar 2; [Epub ahead of print].

This review spotlights the importance of closing the theory–practice gap for nurses just entering independent practice and discusses methods employed to address the potential for error during this transformative period.

Journal Article > Review

Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis.

Prgomet M, Li L, Niazkhani Z, Georgiou A, Westbrook JI. J Am Med Inform Assoc. 2017;24:413-422.

While prior research has shown that computerized provider order entry and clinical decision support systems have the potential to improve patient safety, less is known about the impact of such systems in intensive care units. In this systematic review and meta-analysis, investigators found an 85% decrease in prescribing errors and a 12% reduction in ICU mortality rates in critical care units that converted from paper orders to commercially available computerized provider order entry systems.

Journal Article > Review

Improving our understanding of multi-tasking in healthcare: drawing together the cognitive psychology and healthcare literature.

Douglas HE, Raban MZ, Walter SR, Westbrook JI. Appl Ergon. 2017;59:45-55.

Multitasking is thought to impair cognition, which in turn affects patient safety. This review found that studies of multitasking in health care rely on direct observation, whereas other fields such as cognitive psychology have used simulation experiments. The authors propose applying lessons from other fields to patient safety.

Journal Article > Study

Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study.

Westbrook JI, Li L, Hooper TD, Raban MZ, Middleton S, Lehnbom EC. BMJ Qual Saf. 2017 Feb 23; [Epub ahead of print].

This randomized controlled trial had nurses on four hospital wards wear "do not interrupt" vests during medication administration. The rate of interruptions the intervention nurses experienced was compared to the rate in four control wards that did not have nurses wear vests. Although the intervention reduced non–medication-related interruptions, nurses reported that the vests were time consuming and uncomfortable; less than half would support continuing the intervention. This study demonstrates the need to design and test sustainable interventions to improve patient safety.

Journal Article > Review

Managing the patient identification crisis in healthcare and laboratory medicine.

Lippi G, Mattiuzzi C, Bovo C, Favaloro EJ. Clin Biochem. 2017;50:562-567.

Patient identification mistakes associated with diagnostic blood testing can have serious consequences. This commentary recommends several strategies to redesign laboratory processes to reduce risks of specimen misidentification, such as utilizing at least two patient identifiers, providing staff training, and using technologies to track and manage specimens.

Journal Article > Review

Systematic review of the prevalence of medication errors resulting in hospitalization and death of nursing home residents.

  • Classic

Ferrah N, Lovell JJ, Ibrahim JE. J Am Geriatr Soc. 2017;65:433-442.

Older adults living in long-term care facilities face significant safety hazards. This systematic review examined medication errors in nursing homes and found a high prevalence of errors overall. The review revealed that a significant number of errors were related to handoffs and that 75% of these older patients received at least one potentially inappropriate medication. However, serious harm associated with medication use was reported for less than 1% of errors. The authors emphasize the difficulty of attributing harm to medications versus underlying illness in nursing home residents, and they call for designing safer systems for medication administration in nursing homes. A previous WebM&M commentary discussed challenges to ensuring patient safety in long-term care facilities.

Journal Article > Study

Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios.

Jones A, Johnstone MJ. Aust Crit Care. 2017;30:219-223.

This qualitative study combined the narratives of various critical care nurses into four representative scenarios demonstrating failure to recognize clinically deteriorating patients. The authors describe inattentional blindness, a concept in which individuals in high-complexity environments can miss an important event because of competing attentional tasks, as a key factor in these failure-to-rescue events.

Journal Article > Commentary

Case report of a medication error: in the eye of the beholder.

Naunton M, Nor K, Bartholomaeus A, Thomas J, Kosari S. Medicine (Baltimore). 2016;95:e4186.

Look-alike drug names or packaging are known to contribute to medication errors. This case discussion reviews an error in the community setting involving a nonocular medication mistakenly administered as an eye drop due to look-alike packaging and recommends ways to improve storage and disposal processes to avoid similar incidents.

Journal Article > Study

Recognising and responding to 'cutting corners' when providing nursing care: a qualitative study.

Jones A, Johnstone MJ, Duke M. J Clin Nurs. 2016;25:2126-2133.

Missed nursing care is a significant patient safety concern. This qualitative study identified cutting corners—defined as partially or completely omitting a nursing task—as a safety gap in inpatient nursing. Nurses perceived that cutting corners contributes to preventable harm.

Journal Article > Review

Does clinical supervision of health professionals improve patient safety? A systematic review and meta-analysis.

Snowdon DA, Hau R, Leggat SG, Taylor NF. Int J Qual Health Care. 2016;28:447-455.

The patient safety movement catalyzed a well-known change in physician duty hours. A less known consequence of duty hour reform was an increase in clinical supervision for trainees. Although some studies have suggested that more clinical supervision leads to fewer adverse events, there were concerns that excessive trainee supervision impedes clinical learning. This systematic review examined how increased clinical supervision affects patient safety. Investigators found that complications from surgery and other invasive procedures were less likely when there was more supervision. Their data also indicated an overall mortality benefit associated with clinical supervision, but this result remains open to question because several of the included studies on mortality were of lower quality. At minimum, this meta-analysis argues for continued clinical supervision of surgeries and invasive procedures for optimal patient safety, as discussed in a previous PSNet perspective.

Journal Article > Study

Factors influencing a nurse's decision to question medication administration in a neonatal clinical care unit.

Aydon L, Hauck Y, Zimmer M, Murdoch J. J Clin Nurs. 2016;25:2468-2477.

Efforts to improve medication safety in hospital settings often target nurses, such as utilizing barcode medication administration or limiting interruptions during nurses' medication administration tasks. Nurses can also support medication safety by speaking up about medication orders that appear to be incorrect. In this interview study, neonatal intensive care unit nurses were asked to describe scenarios in which they did and did not question medication administration. Investigators found that nurses spoke up about medication administration because of concern for patients and when they felt confident in their medication knowledge. Nurses' work environment could bolster or hinder questioning of medication administration. Interventions to support a positive safety culture and to enhance nurses' medication knowledge could reinforce safe medication administration.

Journal Article > Commentary

Recommended responsibilities for management of MR safety.

Calamante F, Ittermann B, Kanal E, Norris D; Inter-Society Working Group on MR Safety. J Magn Reson Imaging. 2016;44:1067-1106.

Magnetic resonance safety events can lead to serious patient harm. This commentary provides recommendations from expert consensus to help organizations design and implement a range of magnetic resonance imaging services. The authors also define three levels of management responsibilities required to support those recommendations in a various settings.

Journal Article > Review

The impact of implementation of family-initiated escalation of care for the deteriorating patient in hospital: a systematic review.

Gill FJ, Leslie GD, Marshall AP. Worldviews Evid Based Nurs. 2016;13:303-313.

Rapid response teams (RRTs) are a widely implemented safety intervention with a growing body of literature supporting their effectiveness. At some hospitals, families can activate the RRT if they are concerned. This systematic review identified successful implementation strategies for family-activated RRTs, but researchers found no clear evidence that this approach improves patient outcomes.

Journal Article > Study

Partnered pharmacist charting on admission in the general medical and emergency short-stay unit—a cluster-randomised controlled trial in patients with complex medication regimens.

Tong EY, Roman C, Mitra B, et al. J Clin Pharm Ther. 2016;41:414-418.

Medication discrepancies during hospital admission are common and can lead to preventable harm. This study examined the impact of having a pharmacist review medical charts of patients with complex medication regimens who were admitted to a general medical or emergency short-stay unit. The authors found that partnering medical staff with a pharmacist to review patients' admission medications in the chart significantly decreased inpatient medication errors.

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