Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "Health Care Executives and Administrators"

1 - 20 of 1607 results
  • Europe
  • Health Care Executives and Administrators
Download Selected Citations

Show: 20 | 50 | 100

Journal Article > Review

From tokenism to empowerment: progressing patient and public involvement in healthcare improvement.

Ocloo J, Matthews R. BMJ Qual Saf. 2016;25:626-632.

Patient participation is considered a key component of patient safety initiatives. This review examined patient engagement programs and policies and determined that the current methods do not result in true public involvement in safety improvement. The authors suggest broader strategies are needed to engage the public in co-designing a safer health care system.

Journal Article > Commentary

Patient safety and the problem of many hands.

Dixon-Woods M, Pronovost PJ. BMJ Qual Saf. 2016;25:485-488.

Although individual and organizational accountability are important elements of safety, they can also hinder system-wide improvement. This commentary discusses challenges to coordinating actions and accountability among and throughout the various components in health care, such as hospitals, governmental agencies, insurers, and accreditors. To achieve improvements, the authors propose that health care needs to establish a collective responsibility to develop collaborative solutions that balance global standards with local interventions.

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

Crew resource management training in the intensive care unit. A multisite controlled before-after study.

Kemper PF, de Bruijne M, van Dyck C, So RL, Tangkau P, Wagner C. BMJ Qual Saf. 2016;25:577-587.

This study found that classroom-based crew resource management training for intensive care unit staff was well received and improved self-reported situational awareness tactics, safety culture, and job satisfaction. However, there were no measurable changes in professional communication or patient outcomes compared to control groups.

Journal Article > Study

Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives, an observational study.

François P, Prate F, Vidal-Trecan G, Quaranta JF, Labarere J, Sellier E. BMC Health Serv Res. 2016;16:35.

Morbidity and mortality (M&M) conferences are a classic patient safety education and feedback strategy. This study found that elements of M&M conferences, including thorough investigation of failures, predicted whether an improvement initiative was implemented. This work suggests that M&M conferences can be optimally designed to foster subsequent improvement efforts.

Journal Article > Study

Is single room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure ulcers or medication errors? A natural experiment with non-equivalent controls.

Simon M, Maben J, Murrells T, Griffiths P. J Health Serv Res Policy. 2016;21:147-155.

This study expands on analyses and conclusions from published findings exploring the effects of moving to a new hospital with 100% single room accommodations. The researchers used nonequivalent controls by comparing results to a hospital that had not changed buildings but planned to do so (steady state control) and a hospital that moved to a new building with fewer than 50% single rooms (new build control). Falls, pressure ulcers, and Clostridium difficile infections increased in the older patients' ward after the move to single rooms. However, there was also a significant change in the case mix on this ward following the move, which may have explained these changes in adverse events. On the acute assessment unit, falls and medication errors temporarily increased for the first 6 months but then returned to prior rates. The authors found neither clear evidence of benefit nor increased risk of harm attributable to moving to all single room accommodations.

Journal Article > Review

How safe is primary care? A systematic review.

  • Classic

Panesar SS, deSilva D, Carson-Stevens A, et al. BMJ Qual Saf. 2016;25:544-553.

Patient safety in ambulatory care settings has received less attention than in the hospital setting, where the patient safety movement originated. This systematic review commissioned by the World Health Organization examined patient safety incidents in primary care. Estimates diverged widely between studies, and most patient safety incidents did not lead to harm. However, the types of incidents most likely to cause harm were missed and delayed diagnoses and medication prescribing problems. The accompanying editorial highlights the need to implement consistent and clear definitions for patient safety incidents and associated harm and advocates for investment in research and improvement efforts for patient safety in primary care.

Journal Article > Study

Can patient safety incident reports be used to compare hospital safety? Results from a quantitative analysis of the English National Reporting and Learning System data.

  • Classic

Howell AM, Burns EM, Bouras G, Donaldson LJ, Athanasiou T, Darzi A. PLoS One. 2015;10:e0144107.

Measuring patient safety for individual hospitals and health systems remains a challenge. Incident reports provide one lens into patient safety, despite concerns about under-reporting. Numerous incident reports may indicate either a high number of errors or a robust safety culture that encourages blame-free event reporting. Therefore, it is unclear whether the volume of incident reports should serve as a patient safety metric. In this study, investigators analyzed all incident reports from the national reporting system in the United Kingdom and determined that hospitals with fewer litigation claims had more incident reports. They found no association between mortality or patient satisfaction and number of reports, and more incident reporting took place where survey results indicated a positive safety culture. These findings suggest that having a high quantity of incident reports does not signify an error-prone environment, and the authors recommend against using incident reporting rates as a quality metric. A past PSNet perspective discussed incident reporting systems as tools for improving patient safety.

Journal Article > Review

Beyond clinical engagement: a pragmatic model for quality improvement interventions, aligning clinical and managerial priorities.

Pannick S, Sevdalis N, Athanasiou T. BMJ Qual Saf. 2016;25:716-725.

Middle managers have a key role in successful improvement efforts, but engaging them in these activities can be challenging. This narrative review describes a model that involves middle managers and frontline clinicians in multidisciplinary teams to augment implementation of quality improvement interventions.

Journal Article > Commentary

The problem with preventable deaths.

Hogan H. BMJ Qual Saf. 2016;25:320-323.

A key goal of patient safety improvement is preventing error, but challenges remain in distinguishing which harms are preventable. Discussing approaches to measuring preventable harm related to patient mortality, this commentary highlights limitations of hospital standardized mortality ratios as a quality measure and suggests combining multiple metrics designed with the complexity of health care in mind to uncover quality issues.

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

One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs.

  • Classic

Maben J, Griffiths P, Penfold C, et al. BMJ Qual Saf. 2016;25:241-256.

This study used robust research methods to examine the expected and unanticipated effects of moving to all single-occupancy inpatient rooms. The accompanying editorial points out that on the surface this seems like a common sense intervention likely to improve patient experience and safety. However, this study demonstrates the complex effects even seemingly straightforward interventions can create. Although two-thirds of patients preferred the single rooms, some patients felt more isolated and lonely. Staff expressed concerns about worsened visibility, surveillance, teamwork, and monitoring. In addition, staff workflows had to change significantly and their hourly walking distances increased substantially. There was no evidence that single rooms reduced infections. Although fall rates increased following the move, the researchers felt that based on the patterns and comparison to the control hospital, this may not have been attributable to the single rooms. As the editorial highlights, this study supports the importance of vigorously evaluating a range of impact measures, including quality, safety, costs, and staff and patient experiences.

Book/Report

Influencing the Quality, Risk and Safety Movement in Healthcare: In Conversation with International Leaders.

Sears K, Stockley D, Broderick B, eds. Aldershot, UK: Ashgate Publishing; 2015. ISBN: 9781472449276.

This publication features interviews with leaders in patient safety to capture insights on their motivation and how they see the future of quality improvement in health care. Interviewees include Sidney Dekker, Erik Hollnagel, René Amalberti, and Charles Vincent.

Journal Article > Study

Collective intelligence meets medical decision-making: the collective outperforms the best radiologist.

  • Classic

Wolf M, Krause J, Carney PA, Bogart A, Kurvers RHJM. PLoS One. 2015;10:e0134269.

Collective intelligence encompasses several methods for summarizing input from multiple individuals, which can often be more accurate than any one expert. In this study, investigators applied several collective intelligence algorithms to mammography interpretation. They found that aggregating the interpretations of multiple radiologists resulted in higher accuracy—fewer false positive results and more true positive results—than even the most accurate single radiologist. This work builds on earlier studies of diagnostic accuracy in imaging studies. This study has profound implications for improving diagnosis through collaboration between clinicians in real time, perhaps facilitated through technology, as a complement to the long-standing diagnostic safety strategy of morbidity and mortality conferences, which provide group feedback once a case has concluded.

Journal Article > Study

Hospital board oversight of quality and safety: a stakeholder analysis exploring the role of trust and intelligence.

Millar R, Freeman T, Mannion R. BMC Health Serv Res. 2015;15:196.

This qualitative study examined mechanisms by which hospital boards could provide more effective oversight of quality and safety activities. Trust among organizational leadership and prioritization of data analysis emerged as important methods by which boards could help improve safety.

Journal Article > Study

Hospital autopsy: endangered or extinct?

Turnbull A, Osborn M, Nicholas N. J Clin Pathol. 2015;68:601-604.

This study reports the declining autopsy rate in the United Kingdom, consistent with practice in the United States. The authors raise concerns, expressed in prior studies, about the lost information, particularly around diagnosis, from fewer autopsies.

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.

Book/Report

Patient Safety Culture: Theory, Methods and Application.

Waterson P, ed. London, UK: Ashgate; 2014. ISBN: 9781409448143.

This publication covers patient safety culture including its background in high-risk industries, key concepts involved such as behavior change, measurement and assessment processes, and lessons learned from application and practice.

Book/Report

Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer.

Zipperer L, ed. London, UK: Gower Publishing; 2014. ISBN: 9781409438571.

This book provides information about utilizing safety science and disseminating published evidence, staff knowledge, and other data to enable safety improvement and organizational learning from error.

Journal Article > Study

A closer look at associations between hospital leadership walkrounds and patient safety climate and risk reduction: a cross-sectional study.

Schwendimann R, Milne J, Frush K, Ausserhofer D, Frankel A, Sexton JB. Am J Med Qual.  2013;28:414-421.

Executive walkrounds are widely used for improving safety culture, but their effect on specific patient safety attitudes and outcomes is not well established. This retrospective study found that leadership walkrounds participation was strongly associated with positive safety climates and greater risk reductions. While the application of leadership walkrounds varies widely from institution to institution, this multicenter study used a standardized strategy that included monthly hospital executive visits and scripted, open-ended questions meant to engage staff in patient safety discussions. An AHRQ WebM&M perspective discussed the importance of involving hospital leadership with safety and quality.

Back to Top