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  1. Article ; Online: Patient safety and error management: what causes adverse events and how can they be prevented?

    Hoffmann, Barbara / Rohe, Julia

    Deutsches Arzteblatt international

    2010  Volume 107, Issue 6, Page(s) 92–99

    Abstract: ... patient safety" denotes the non-occurrence of adverse events and the presence of measures to prevent ... in which critical incidents are identified, reported, and analyzed so that similar events can be prevented, and ... of preventable adverse events (PAE), as well as on measures that can increase patient safety.: Results ...

    Abstract Background: Even in industrialized countries, health care is not as safe as it should be. The term "patient safety" denotes the non-occurrence of adverse events and the presence of measures to prevent them.
    Methods: The literature was selectively reviewed to obtain information on the epidemiology and causes of preventable adverse events (PAE), as well as on measures that can increase patient safety.
    Results: Preventable adverse events occur in Germany both in the hospital and in outpatient settings, although their precise frequency is currently a disputed matter. PAE should be analyzed systematically. They are caused both by active errors and by latent failures that are inherent in components of the health care system.
    Conclusion: Three main strategies should be pursued to improve patient safety. A safety management system involving error reporting, learning from errors, and the fair exchange of information should be established in hospitals and in doctors' outpatient practices. An error management system should be implemented in which critical incidents are identified, reported, and analyzed so that similar events can be prevented, and measures for the prevention of critical incidents and errors should also be implemented and evaluated. Finally, whenever preventable adverse events do occur, the persons involved should take action to prevent further harm to the patient and other involved individuals.
    MeSH term(s) Germany ; Humans ; Medical Errors/prevention & control ; Medical Errors/statistics & numerical data ; Quality Assurance, Health Care/organization & administration ; Safety Management/organization & administration
    Language English
    Publishing date 2010-02
    Publishing country Germany
    Document type Journal Article ; Review
    ZDB-ID 2406159-1
    ISSN 1866-0452 ; 1866-0452
    ISSN (online) 1866-0452
    ISSN 1866-0452
    DOI 10.3238/arztebl.2010.0092
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  2. Article: Patientensicherheit und Fehlermanagement: Ursachen unerwünschter Ereignisse und Maßnahmen zu ihrer Vermeidung. Patient Safety and Error Management - What Causes Adverse Events and How Can They Be Prevented?

    Deutsches Ärzteblatt : Ausgabe A, Praxis-Ausgabe : niedergelassene Ärzte

    2010  Volume 107, Issue 31/32, Page(s) 557

    Language German
    Document type Article
    ZDB-ID 1453475-7
    ISSN 0012-1207
    Database Current Contents Medicine

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  3. Article: Patientensicherheit und Fehlermanagement. Ursachen unerwünschter Ereignisse und Maßnahmen zu ihrer Vermeidung. Patient Safety and Error Management - What Causes Adverse Events and How Can They Be Prevented?

    Hoffmann, Barbara / Rohe, Julia

    Deutsches Ärzteblatt : Ausgabe A, Praxis-Ausgabe : niedergelasene Ärzte

    2010  Volume 107, Issue 6, Page(s) 92

    Language German
    Document type Article
    ZDB-ID 1453475-7
    ISSN 0012-1207
    Database Current Contents Medicine

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  4. Article ; Online: Enhancing Communication to Improve Patient Safety and to Increase Patient Satisfaction.

    Burgener, Audrey M

    The health care manager

    2020  Volume 39, Issue 3, Page(s) 128–132

    Abstract: With the continuous rise of sentinel and adverse events due to ineffective communication, it is ... in which will, in turn, improve patient safety and experience, boosting the bottom line. This article identifies and ... care organizations which improves patient safety and increases patient satisfaction. ...

    Abstract With the continuous rise of sentinel and adverse events due to ineffective communication, it is time for health care organizations to start implementing a focus on enhancing effective communication in which will, in turn, improve patient safety and experience, boosting the bottom line. This article identifies and discusses different communication protocols that can be used to enhance the consistency of more efficient and effective communication within a health care organization to overall improve patient care and patient satisfaction. The rising importance of patient satisfaction and Hospital Consumer Assessment of Healthcare Providers and Systems scores required by the Centers for Medicare and Medicaid Services are causing a shift in how hospitals evaluate and manage their health care organizations today. Following the situation-background-assessment-recommendation and acknowledge-introduce-duration-explain-thank protocols, as well as proper and effective training and educational programs, enhances more effective communication in health care organizations which improves patient safety and increases patient satisfaction.
    MeSH term(s) Centers for Medicare and Medicaid Services, U.S. ; Communication ; Hospitals ; Humans ; Medical Errors/prevention & control ; Patient Handoff/standards ; Patient Safety ; Patient Satisfaction ; Surveys and Questionnaires ; United States
    Language English
    Publishing date 2020-07-20
    Publishing country United States
    Document type Journal Article
    ZDB-ID 2000690-1
    ISSN 1550-512X ; 1525-5794
    ISSN (online) 1550-512X
    ISSN 1525-5794
    DOI 10.1097/HCM.0000000000000298
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  5. Article ; Online: Patient safety: Part II. Opportunities for improvement in patient safety.

    Elston, Dirk M / Stratman, Erik / Johnson-Jahangir, Hillary / Watson, Alice / Swiggum, Susan / Hanke, C William

    Journal of the American Academy of Dermatology

    2009  Volume 61, Issue 2, Page(s) 193–205; quiz 206

    Abstract: ... medical errors and threats to patient safety can be identified, and how engineering tools can be used to improve ... to improve patient safety through an understanding of both the beneficial and adverse consequences of quality ... reporting, apply safety engineering tools to the practice of dermatology, and be able to establish ...

    Abstract Unlabelled: The quality movement in medicine has prompted a shift from a "name, shame, blame" approach to medical errors to one in which each error is regarded as an opportunity to prevent future patient harm. This new culture of patient safety requires the involvement of all members of the health care team and learned skill sets related to quality improvement. A root cause analysis identifies the sources of medical errors, allowing system changes that reduce the risk. In large organizations, sentinel events and signals prompt chart reviews and reduce the reliance on voluntary reporting. Failure mode analysis prompts the development of safety nets in the case of a system failure. The second part of this two-part series on patient safety examines how the culture of patient safety is taught, how medical errors and threats to patient safety can be identified, and how engineering tools can be used to improve patient care. It also examines efforts to measure clinical effectiveness and outcomes in the practice of medicine.
    Learning objectives: After completing this learning activity, participants should be able to improve patient safety through an understanding of both the beneficial and adverse consequences of quality reporting, apply safety engineering tools to the practice of dermatology, and be able to establish a quality improvement plan for a dermatologic practice.
    MeSH term(s) Canada ; Clinical Competence ; Dermatology/standards ; Dermatology/trends ; Education, Medical, Continuing/standards ; Female ; Humans ; Male ; Medical Errors/prevention & control ; Office Visits ; Organizational Culture ; Practice Guidelines as Topic ; Practice Patterns, Physicians'/standards ; Practice Patterns, Physicians'/trends ; Quality Assurance, Health Care ; Risk Management/standards ; Risk Management/trends ; Safety Management/standards ; Safety Management/trends ; Societies, Medical ; United States
    Language English
    Publishing date 2009-08
    Publishing country United States
    Document type Journal Article ; Review
    ZDB-ID 603641-7
    ISSN 1097-6787 ; 0190-9622
    ISSN (online) 1097-6787
    ISSN 0190-9622
    DOI 10.1016/j.jaad.2009.04.055
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  6. Article ; Online: Focusing on patient safety in the Neonatal Intensive Care Unit environment

    Ilias Chatziioannidis / George Mitsiakos / Fotis Vouzas

    Journal of Pediatric and Neonatal Individualized Medicine, Vol 6, Iss 1, Pp e060132-e

    2017  Volume 060132

    Abstract: ... and accidents. Adverse events and near misses that comprise the majority of human errors, cause ... familiar with patient safety language, implement best practices, and support safety culture, maximizing ... by detailed analysis of consequences and prevention measures. NICU’s medical and nursing staff should be ...

    Abstract Patient safety in the Neonatal Intensive Care Unit (NICU) environment is an under-researched area, but recently seems to get high priority on the healthcare quality agenda worldwide. NICU, as a highly sensitive and technological driven environment, signals the importance for awareness in causation of mistakes and accidents. Adverse events and near misses that comprise the majority of human errors, cause morbidity often with devastating results, even death. Likewise in other organizations, errors causes are multiple and complex. Other high reliability organizations, such as air force and nuclear industry, offer examples of how standardized/homogenized work and removal of systems weaknesses can minimize errors. It is widely accepted that medical errors can be explained based on personal and/or system approach. The impact/effect of medical errors can be reduced when thorough/causative identification approach is followed by detailed analysis of consequences and prevention measures. NICU’s medical and nursing staff should be familiar with patient safety language, implement best practices, and support safety culture, maximizing efforts for reducing errors. Furthermore, top management commitment and support in developing patient safety culture is essential in order to assure the achievement of the desirable organizational safety outcomes. The aim of the paper is to review patient safety issues in the NICU environment, focusing on development and implementation of strategies, enhancing high quality standards for health care.
    Keywords patient safety ; quality ; medical errors ; neonatal intensive care unit ; neonate ; Medicine ; R ; Pediatrics ; RJ1-570
    Language English
    Publishing date 2017-02-01T00:00:00Z
    Publisher Hygeia Press di Corridori Marinella
    Document type Article ; Online
    Database BASE - Bielefeld Academic Search Engine (life sciences selection)

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  7. Article: "SWARMing" to Improve Patient Care: A Novel Approach to Root Cause Analysis.

    Li, Jing / Boulanger, Bernard / Norton, Jeff / Yates, Audrey / Swartz, Colleen H / Smith, Ann / Holbrook, Paula J / Moore, Mary / Latham, Barbara / Williams, Mark V

    Joint Commission journal on quality and patient safety

    2014  Volume 41, Issue 11, Page(s) 494–501

    Abstract: Background: When errors occur with adverse events or near misses, root cause analysis (RCA) is ... and implementing processes that serve to promote transparency and a culture of safety. ... the standard approach to investigate the "how" and "why" of system vulnerabilities. However, even ...

    Abstract Background: When errors occur with adverse events or near misses, root cause analysis (RCA) is the standard approach to investigate the "how" and "why" of system vulnerabilities. However, even for facilities experienced in conducting RCAs, the process can be fraught with inconsistencies; provoke discomfort for participants; and fail to lead to meaningful, focused discussions of system issues that may have contributed to events. In 2009 University of Kentucky HealthCare Lexington developed a novel rapid approach to RCAs-colloquially called "SWARMing"--to establish a consistent approach to investigate adverse or other undesirable events.
    Methods: In SWARMs, which are conducted without unnecessary delay after an event, an interdisciplinary team undertakes thoughtful analysis of events reported by frontline staff. The SWARM process consist of five key steps: (1) introductory explanation of the process; (2) introduction of everyone in the room; (3) review of the facts that prompted the SWARM; (4) discussion of what happened, with investigation of the underlying systems factors; and (5) conclusion, with proposed focus areas for action and assignment of task leaders with specific deliverables and completion dates.
    Results: Since its implementation, incident reporting increased by 52%-from an average of 608 incidents per month (June-December 2011) to an average of 923 per month (January-May 2014). The overall health system experienced a 37% decrease in the observed-to-expected mortality ratio-from 1.17 (October 2010) to 0.74 (April 2015).
    Conclusion: SWARMs, more than an error-analysis exercise or simple RCA, represent an organizational-messaging, culture-changing, and capacity-building effort to address the challenges of creating and implementing processes that serve to promote transparency and a culture of safety.
    MeSH term(s) Hospital Administration ; Humans ; Kentucky ; Medical Errors/prevention & control ; Organizational Culture ; Organizational Objectives ; Patient Safety ; Quality Improvement ; Risk Management/methods ; Root Cause Analysis ; Safety Management/methods
    Language English
    Publishing date 2014-12-11
    Publishing country Netherlands
    Document type Journal Article
    ZDB-ID 1189890-2
    ISSN 1938-131X ; 1549-425X ; 1553-7250 ; 1070-3241 ; 1549-3741
    ISSN (online) 1938-131X ; 1549-425X
    ISSN 1553-7250 ; 1070-3241 ; 1549-3741
    DOI 10.1016/s1553-7250(15)41065-7
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  8. Article ; Online: The geography of patient safety: a topical analysis of sterility.

    Mesman, Jessica

    Social science & medicine (1982)

    2009  Volume 69, Issue 12, Page(s) 1705–1712

    Abstract: Many studies on patient safety are geared towards prevention of adverse events by eliminating ... causes of error. In this article, I argue that patient safety research needs to widen its analytical ... into the 'geography' of patient safety and perform a topical analysis, I will focus on one specific kind of space ...

    Abstract Many studies on patient safety are geared towards prevention of adverse events by eliminating causes of error. In this article, I argue that patient safety research needs to widen its analytical scope and include causes of strength as well. This change of focus enables me to ask other questions, like why don't things go wrong more often? Or, what is the significance of time and space for patient safety? The focal point of this article is on the spatial dimension of patient safety. To gain insight into the 'geography' of patient safety and perform a topical analysis, I will focus on one specific kind of space (sterile space), one specific medical procedure (insertion of an intravenous line) and one specific medical ward (neonatology). Based on ethnographic data from research in the Netherlands, I demonstrate how spatial arrangements produce sterility and how sterility work produces spatial orders at the same time. Detailed analysis shows how a sterile line insertion involves the convergence of spatially distributed resources, relocations of the field of activity, an assemblage of an infrastructure of attention, a specific compositional order of materials, and the scaling down of one's degree of mobility. Sterility, I will argue, turns out to be a product of spatial orderings. Simultaneously, sterility work generates particular spatial orders, like open and restricted areas, by producing buffers and boundaries. However, the spatial order of sterility intersects with the spatial order of other lines of activity. Insight into the normative structure of these co-existing spatial orders turns out to be crucial for patient safety. By analyzing processes of spatial fine-tuning in everyday practice, it becomes possible to identify spatial competences and circumstances that enable staff members to provide safe health care. As such, a topical analysis offers an alternative perspective of patient safety, one that takes into account its spatial dimension.
    MeSH term(s) Catheterization, Peripheral ; Health Facility Size ; Hospital Design and Construction ; Humans ; Infant, Newborn ; Infection Control/methods ; Intensive Care Units, Neonatal/organization & administration ; Intensive Care, Neonatal ; Netherlands ; Safety Management ; Sterilization/methods
    Language English
    Publishing date 2009-12
    Publishing country England
    Document type Journal Article
    ZDB-ID 4766-1
    ISSN 1873-5347 ; 0037-7856 ; 0277-9536
    ISSN (online) 1873-5347
    ISSN 0037-7856 ; 0277-9536
    DOI 10.1016/j.socscimed.2009.09.055
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  9. Article ; Online: Patient safety risk assessment and risk management

    Gaurav Sharma / Swapnil Awasthi / Anuj Dixit / Garima Sharma

    Chronicles of Young Scientists, Vol 2, Iss 4, Pp 186-

    A review on Indian hospitals

    2011  Volume 191

    Abstract: ... management of the hospitals. Adverse events related to medication occur due to pathetic infrastructures ... and how to provide a better health facility and diluting the medication errors caused by inappropriate ... the barriers of awareness, accountability, ability, and action into accelerators of patient safety ...

    Abstract This paper is intended to discuss a critical need expressed by present healthcare system of India, and how to provide a better health facility and diluting the medication errors caused by inappropriate management of the hospitals. Adverse events related to medication occur due to pathetic infrastructures, corporal punishment by the patient if unsatisfied, doctors on strike and working only for riches, trivial financial aid, and lack of basic amenities in the government-run hospitals of India. Government should reduce the barriers of awareness, accountability, ability, and action into accelerators of patient safety in the government organizations. Physicians, nurses, and pharmacists are truly the critical ingredient to rapid safety practice adoption. Various approaches like Technological Iatrogenesis, Computerized Provider Order Entry, and Electronic Health Record should be used. Although patient safety is recognized as a serious issue in health system, there is an urgent need for development and implementation of strategies for prevention and early detection of errors.
    Keywords Adverse events ; medication errors ; technological iatrogenesis ; Therapeutics. Pharmacology ; RM1-950 ; Medicine ; R
    Subject code 027
    Language English
    Publishing date 2011-01-01T00:00:00Z
    Publisher Medknow Publications
    Document type Article ; Online
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  10. Article ; Online: Addressing prehospital patient safety using the science of injury prevention and control.

    Meisel, Zachary F / Hargarten, Stephen / Vernick, Jon

    Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors

    2008  Volume 12, Issue 4, Page(s) 411–416

    Abstract: ... prevention and control science to analyze prehospital adverse events and to help develop EMS patient safety ... There is inadequate information about the scope and character of adverse events in prehospital care ... We demonstrate how this method can be used as a complementary approach in efforts to prevent injuries caused ...

    Abstract There is inadequate information about the scope and character of adverse events in prehospital care. However, there is ample evidence to suggest that prehospital patient safety hazards are often unique and underrecognized. We first summarize what is currently understood about prehospital patient safety and identify the specific aspects of emergency medical services (EMS) care that may make conventional approaches to the evaluation and improvement of patient safety more difficult. Next we introduce the concept of using injury prevention and control science to analyze prehospital adverse events and to help develop EMS patient safety solutions. Injury prevention and control is a proven public health approach for the study and reduction of both intentional and unintentional injuries. It includes the use of a Haddon phase-factor matrix to identify possible interventions, especially environmental modifications that provide automatic protection. We demonstrate how this method can be used as a complementary approach in efforts to prevent injuries caused by prehospital adverse medical events.
    MeSH term(s) Emergency Medical Services/organization & administration ; Emergency Medical Services/standards ; Humans ; Medical Audit ; Medical Errors/prevention & control ; Observation ; Retrospective Studies ; Safety Management/methods ; Wounds and Injuries/prevention & control
    Language English
    Publishing date 2008-10
    Publishing country England
    Document type Journal Article
    ZDB-ID 1461751-1
    ISSN 1545-0066 ; 1090-3127
    ISSN (online) 1545-0066
    ISSN 1090-3127
    DOI 10.1080/10903120802290851
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