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Search results for "United States of America"

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Meeting/Conference > Kansas Meeting/Conference

Second Victim Train-the-Trainer Workshop.

Center for Patient Safety and University of Missouri. November 10, 2017; Saint Luke's North Hospital, Barry Road, Kansas City, MO.

Second victims are clinicians who experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. This workshop will explore strategies to build an organizational program that addresses individual stages of recovery and trains peers to participate in that process. Sue Scott will lead the session.

Journal Article > Commentary

A piece of my mind. Speak up.

Merrill DG. JAMA. 2017;317:2373-2374.

Team support and respect are key elements of a culture of safety. This commentary highlights how clinicians can experience disrespectful encounters with patients and explains why insufficient awareness and reporting by team members of such incidents can normalize the behavior to diminish the safety of the practice environment.

Newspaper/Magazine Article

Rude providers jeopardize patient safety. So stop it.

Thew J. HealthLeaders Media. June 14, 2017.

Rudeness can affect teamwork and hinder safe, transparent care. This news article reports on one hospital's approach to manage disruptive behavior through strategies such as peer identification and proactive behavior adjustment.

Newspaper/Magazine Article

Day passes for vulnerable patients of psychiatric hospitals can have dangerous, even fatal consequences.

Woodruff E. Baltimore Sun. June 9, 2017.

Psychiatric patients are vulnerable to particular safety hazards. This news article reports on unintended consequences associated with a strategy to help patients adapt to being discharged home by providing passes for them to adjust to independent living.

Journal Article > Commentary

Assumptions of quality medicine: the role of uncertainty.

Scott-Wittenborn N, Schneider JS. JAMA Otolaryngol Head Neck Surg. 2017 Jun 1; [Epub ahead of print].

Uncertainty is common in health care delivery due to the complexity of the decision-making process. This commentary explores various factors that contribute to uncertainty and suggests that policy initiatives to improve the safety and quality of care must take uncertainty into account.

Journal Article > Study

Workplace factors associated with burnout of family physicians.

Rassolian M, Peterson LE, Fang B, et al. JAMA Intern Med. 2017 May 8; [Epub ahead of print].

Professional burnout is a pervasive problem among health care workers that can have serious effects on patient safety. This survey of family medicine physicians found that a chaotic work environment and the time burden related to electronic health record documentation were both associated with burnout. These results underscore the need to address workplace conditions that contribute to burnout in primary care.

Journal Article > Commentary

Applying lessons from social psychology to transform the culture of error disclosure.

Han J, LaMarra D, Vapiwala N. Med Educ. 2017 May 18; [Epub ahead of print].

Developing disclosure skills can help physicians manage and respond to errors and near misses. Discussing social psychology principles that influence effective disclosure, this commentary highlights cognitive biases and group decision making as factors that can negatively affect the disclosure process.

Journal Article > Study

Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports.

Riblet N, Shiner B, Watts BV, Mills P, Rusch B, Hemphill RR. J Nerv Ment Dis. 2017;205:436-442.

This review of root cause analysis reports about suicide within 7 days of discharge from inpatient mental health facilities determined that most cases of suicide occurred prior to scheduled outpatient postdischarge follow-up. Many patients who went on to die by suicide left against medical advice but did not meet criteria to be held against their wishes, highlighting the conflict between safety and patient autonomy.

Journal Article > Study

Causes of death of residents in ACGME-accredited programs 2000 through 2014: implications for the learning environment.

Yaghmour NA, Brigham TP, Richter T, et al. Acad Med. 2017;92:976-983.

This retrospective cohort study found that the leading cause of death among resident physicians is cancer, and the second leading cause of death is suicide. Investigators note that there are fewer deaths overall and from suicide compared to age- and gender-matched general populations. They suggest monitoring and interventions to prevent burnout and provide support for medical trainees.

Journal Article > Study

Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis.

Schulz CM, Burden A, Posner KL, et al. Anesthesiology. 2017 May 1; [Epub ahead of print].

Failure to maintain situational awareness can adversely impact patient safety. In this closed claims analysis of anesthesia malpractice claims for death or brain damage, researchers found that situational awareness errors on the part of the anesthesiologist contributed to death or brain damage in 74% of claims.

Journal Article > Study

Cost–benefit analysis of a support program for nursing staff.

Moran D, Wu AW, Connors C, et al. J Patient Saf. 2017 Apr 27; [Epub ahead of print].

Medical errors and adverse events can have a devastating psychological impact on the providers involved, often referred to as second victims. Increasingly, health care institutions are implementing programs designed to provide emotional support to team members who experience emotional distress as a result of adverse events. This study provides an economic cost–benefit evaluation of the Resiliency In Stressful Events (RISE) program at Johns Hopkins Hospital. Investigators estimate a savings of $22,576.05 per nurse who used the RISE program and suggest that the hospital might save as much as $1.81 million annually as a result of RISE. These findings are consistent with a previous study, which demonstrated the positive impact of an emotional support program on work-related outcomes such as turnover intentions and absenteeism. In a past PSNet perspective, Susan Scott discussed the second victim phenomenon and its impact on health care providers.

Journal Article > Commentary

Changing the narratives for patient safety.

Pronovost PJ, Sutcliffe KM, Basu L, Dixon-Woods M. Bull World Health Organ. 2017;95:478-480.

Mental models represent established mindsets that can either hinder or enhance safety. This commentary describes mental models about patient safety that may limit progress, such as acceptance of harm as an expected byproduct of medical care. The authors provide suggested changes to these mindsets, including focusing on developing effective patient safety measures and a systems approach to designing and implementing improvement initiatives.

Journal Article > Study

Examination of the relationship between management and clinician perception of patient safety climate and patient satisfaction.

Mazurenko O, Richter J, Kazley AS, Ford E. Health Care Manage Rev. 2017 Apr 25; [Epub ahead of print].

Establishing a climate of safety is essential for improving safety in hospitals. Although a robust safety climate is associated with measurable improvements in safety, the question remains whether patients perceive their care differently in hospitals with a stronger safety culture. This cross-sectional study used data from the AHRQ Hospital Survey on Patient Safety Culture (HSPSC) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) to examine the relationship between safety culture and patient satisfaction with care. Investigators found a moderately strong association between HSPSC and HCAHPS scores, indicating that hospitals with a more robust culture of safety also had higher patient satisfaction scores. This correlation was particularly strong for the teamwork and communication domains of the HSPSC, indicating that improvement in relationships between staff may translate to enhanced communication with patients. A prior multinational study also found a positive association between nurses' perception of care quality and patient satisfaction. A recent PSNet interview discussed recent advancements in understanding safety culture.

Journal Article > Study

Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.

Martinez W, Lehmann LS, Thomas EJ, et al. BMJ Qual Saf. 2017 Apr 25; [Epub ahead of print].

Health care provider comfort with raising patient safety concerns is a critical aspect of safety culture. This survey of resident physicians at six academic medical centers demonstrated that trainees remain reluctant to speak up. Nearly half reported observing a patient safety threat. The majority spoke up about patient safety concerns, but a significant proportion did not. Although unprofessional behavior was more frequently observed, fewer trainees raised concerns about lack of professionalism than about patient safety. Even when respondents perceived the unprofessional behavior as having high potential for adverse patient consequences, they were not as likely to speak up about this compared to a traditional patient safety threat such as inadequate hand hygiene. The authors recommend specifically measuring tolerance for unprofessional behaviors as a part of safety culture assessment.

Journal Article > Study

Video analysis of factors associated with response time to physiologic monitor alarms in a children's hospital.

Bonafide CP, Localio AR, Holmes JH, et al. JAMA Pediatr. 2017 Apr 10; [Epub ahead of print].

Bedside monitors alert nurses to clinical deterioration. This prospective observational study examined nurse responses to bedside physiologic monitors. The mean response time was over 10 minutes. Less than 1% of alarms were actionable, underscoring the importance of addressing alarm fatigue.

Newspaper/Magazine Article

How redesigning the abrasive alarms of hospital soundscapes can save lives.

Couch C. Fast Company. April 3, 2017.

Alarm frequency can contribute to distractions and stress in the hospital environment. Reporting on alarm fatigue as a safety issue, this magazine article describes innovative strategies to manage noise in the hospital environment such as sound design and customizing alarms.

Journal Article > Study

Barriers and facilitators of adverse event reporting by adolescent patients and their families.

Sawhney PN, Davis LS, Daraiseh NM, Belle L, Walsh KE. J Patient Saf. 2017 Mar 7; [Epub ahead of print].

Prior studies have demonstrated that patients and families can report adverse events that would not otherwise have been detected. This qualitative study explored perceptions of adolescent patients and their parents about adverse event reporting. Positive perceptions of care led to participants being more willing to report an adverse event; whereas, if they felt the quality of care was poor, they would be less likely to report. In addition, families who perceived providers as good communicators were more comfortable with reporting adverse events. Families were interested in multiple modes of reporting including face-to-face meetings, internet-based reporting, live telephone calls, paper mail, and smartphone-enabled reporting of adverse events.

Journal Article > Study

Common predictors of nurse-reported quality of care and patient safety.

Stimpfel AW, Djukic M, Brewer CS, Kovner CT. Health Care Manage Rev. 2017 Mar 3; [Epub ahead of print].

Researchers analyzed survey data from 731 nurses to understand predictors of nurse-reported quality of care and patient safety. They found that both job satisfaction and organizational constraints were significant predictors of quality and safety.

Journal Article > Review

Evaluating situation awareness: an integrative review.

Orique SB, Despins L. West J Nurs Res. 2017 Mar 1; [Epub ahead of print].

Situation awareness in teams contributes to their reliability. Examining tools to monitor situation awareness among nurses, this review determined that measures to track this safety behavior are lacking. A WebM&M commentary discussed situation awareness and patient safety.

Journal Article > Study

Emergency medical services responders' perceptions of the effect of stress and anxiety on patient safety in the out-of-hospital emergency care of children: a qualitative study.

Guise JM, Hansen M, O'Brien K, et al. BMJ Open. 2017;7:e014057.

Prehospital emergencies are time critical, and they occur in uncontrolled and often challenging environments. Although emergency medical services (EMS) providers are known to experience high levels of stress, whether their stress contributes to patient safety problems is unclear. In this qualitative study, investigators analyzed perceptions of stress and safety in pediatric out-of-hospital emergencies. They identified factors that contribute to increased stress and therefore adversely affect patient safety, including provider sympathy for children and identification with children or family, which participants felt could cloud their clinical judgment, and lack of familiarity with pediatric emergencies, as seen in other clinical settings. This study highlights a need for specific pediatric training for EMS providers to enhance safety.

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