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Search results for "Health Care Executives and Administrators"

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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 > 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

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.

Book/Report

Safety Culture: Theory, Method and Improvement.

Antonsen S. Burlington, VT: Ashgate; 2009. ISBN: 9780754676959.

This book describes the fundamentals of safety culture in the context of well-known incidents in high-risk industries such as aviation, space exploration, and nuclear power.

Journal Article > Study

Simulation as a tool to improve the safety of pre-hospital anaesthesia—a pilot study.

Batchelder AJ, Steel A, Mackenzie R, Hormis AP, Daniels TS, Holding N. Anaesthesia. 2009;64:978-983.

A simulation-based teamwork training intervention for paramedics and physicians resulted in a reduction in errors during simulated out-of-hospital emergency situations.

Newspaper/Magazine Article

Medical error led to death of patient, 77.

Gledhill V. The Evening Chronicle. January 25, 2007;News section:9.

This article reports on a patient death caused by medical omission and the communication failures that occurred with both the family and regulatory body after the incident.

Journal Article > Commentary

Establishing a culture for patient safety - the role of education.

Milligan FJ. Nurse Educ Today. 2007;27:95-102.

The author discusses the importance of education in creating a culture of safety and specifically focuses on how human factors theory can be applied to medication administration curricula.

Journal Article > Commentary

Involuntary automaticity: a work-system induced risk to safe health care.

Toft B, Mascie-Taylor H. Health Serv Manage Res. 2005;18:211-216.

The authors discuss the concept of automaticity, or the automation of a skilled behavior through repetition. They discuss its possible impact on patient safety and strategies to help health care managers minimize its negative effects.

Meeting/Conference > Europe Meeting/Conference

Patient Safety Congress and Awards.

Health Service Journal and the Nursing Times. July 4–5, 2017; Manchester Central Convention Complex, Manchester, UK.

This annual conference will host workshops and presentations on ways to augment safety in health care, such as how to establish and sustain a safety culture, apply human factors knowledge to inform improvement, enhance the patient experience of care and generate leadership commitment to safety. The event will present awards recognizing achievements in patient safety in the United Kingdom for both National Health Service and independent organizations.

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