The morbidity and mortality conference as an adverse event surveillance tool in a paediatric intensive care unit
Conclusions
Standardised chart review applied to records of patients discussed at a PICU MMC identified significantly more safety events not initially discovered through the MMC. However, the MMC was superior to chart review in identifying broader problems such as communication errors, workflow issues and certain diagnostic errors not captured by chart review, which can potentially affect many aspects of care. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - October 14, 2014 Category: Health Management Authors: Cifra, C. L., Jones, K. L., Ascenzi, J., Bhalala, U. S., Bembea, M. M., Fackler, J. C., Miller, M. R. Tags: Original research Source Type: research
Assessing distractors and teamwork during surgery: developing an event-based method for direct observation
Discussion
The observational method developed allows a single observer to simultaneously assess distractors and communication/teamwork. Even for long procedures, high interobserver agreement can be achieved. Data collected with this method allow for investigating separate or combined effects of distractions and communication/teamwork on surgical performance and patient outcomes. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - October 14, 2014 Category: Health Management Authors: Seelandt, J. C., Tschan, F., Keller, S., Beldi, G., Jenni, N., Kurmann, A., Candinas, D., Semmer, N. K. Tags: Original research Source Type: research
'It sounds like a great idea but...': a qualitative study of GPs' attitudes towards the development of a national diabetes register
Conclusions
This study highlights the growing sense of scepticism and inertia towards change within the health system. This inertia stems from previous experience and the competing demands of maintaining versus improving care in a system with dwindling resources. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - October 14, 2014 Category: Health Management Authors: Mc Hugh, S. M., O'Mullane, M., Perry, I. J., Bradley, C., On behalf of the National Diabetes Register Project (NDRP) Tags: Original research Source Type: research
Parents' perspectives on safety in neonatal intensive care: a mixed-methods study
Conclusions
Parents have safety concerns that cannot be addressed solely by reducing errors in the NICU. Parent engagement strategies that respect parents as partners in safety and address how clinical treatment articulates with physical, developmental and emotional safety domains may result in safety improvements. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - October 14, 2014 Category: Health Management Authors: Lyndon, A., Jacobson, C. H., Fagan, K. M., Wisner, K., Franck, L. S. Tags: Original research Source Type: research
Clinician perspectives on considering radiation exposure to patients when ordering imaging tests: a qualitative study
Conclusions
Displaying clinically relevant radiation exposure information at order entry may improve clinician knowledge and inform patient–clinician discussions regarding risks and benefits of imaging. However, limited access to tests with lower radiation exposure in safety-net settings may trump efforts to minimise patient radiation exposure. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - October 14, 2014 Category: Health Management Authors: Kruger, J. F., Chen, A. H., Rybkin, A., Leeds, K., Frosch, D. L., Goldman, L. E. Tags: Original research Source Type: research
Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting
Conclusions
Interruptions can lead to medication verification and administration errors. Interventions were highly effective at reducing unanticipated errors of commission in medication administration tasks, but showed mixed effectiveness at reducing predictable errors of detection in medication verification tasks. These findings can be generalised and adapted to mitigate interruption-related errors in other settings where medication verification and administration are required. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - October 14, 2014 Category: Health Management Authors: Prakash, V., Koczmara, C., Savage, P., Trip, K., Stewart, J., McCurdie, T., Cafazzo, J. A., Trbovich, P. Tags: Open access, Editor's choice Original research Source Type: research
Positive deviance: a different approach to achieving patient safety
Patient safety management within healthcare systems globally can feel like a relentlessly negative treadmill. Mortality reviews, incident reporting systems and audits all focus attention on what goes wrong and how often, why errors occur, and who or what is at the root of the problem. Sometimes these methods help us to understand why patients are harmed. However, such ‘find and fix’ approaches tell us little about the presence of patient safety, alerting us instead to its absence. These efforts aim to prevent harm by striving to reduce the number of things that go wrong,1 as opposed to identifying instances whe...
Source: Quality and Safety in Health Care - October 14, 2014 Category: Health Management Authors: Lawton, R., Taylor, N., Clay-Williams, R., Braithwaite, J. Tags: Open access Viewpoints Source Type: research
Interruptions and multi-tasking: moving the research agenda in new directions
When the media-savvy US psychiatrist Edward Hallowell first asked people to imagine how they would perform on a tennis court with two, three or even more balls in play, it seemed obvious that, no matter how talented or fit, everyone would be hard pressed to keep up, let alone execute any precision shots.1 Dr Hallowell's book, CrazyBusy, went a long way towards raising popular awareness of something that many people felt intuitively. That is, that multi-tasking—and the associated interruptions that demand we either switch between competing tasks or load one task on top of another, say by talking on the phone while res...
Source: Quality and Safety in Health Care - October 14, 2014 Category: Health Management Authors: Westbrook, J. I. Tags: Editorials Source Type: research
Determinants of treatment plan implementation in multidisciplinary team meetings for patients with chronic diseases: a mixed-methods study
Conclusions
Greater multidisciplinarity is not necessarily associated with more effective decision making. Explicit goals and procedures are also crucial. Decision implementation should be routinely monitored to ensure the equitable provision of care. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - September 16, 2014 Category: Health Management Authors: Raine, R., Xanthopoulou, P., Wallace, I., Nic a' Bhaird, C., Lanceley, A., Clarke, A., Livingston, G., Prentice, A., Ardron, D., Harris, M., King, M., Michie, S., Blazeby, J. M., Austin-Parsons, N., Gibbs, S., Barber, J. Tags: Open access Original research Source Type: research
User-generated quality standards for youth mental health in primary care: a participatory research design using mixed methods
Conclusions
We have demonstrated the feasibility of using participatory research methods in order to develop user-generated quality standards. The development of patient-generated quality standards may offer a more formal method of incorporating the views of service users into quality improvement initiatives. This method can be adapted for generating quality standards applicable to other patient groups. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - September 16, 2014 Category: Health Management Authors: Graham, T., Rose, D., Murray, J., Ashworth, M., Tylee, A. Tags: Open access Original research Source Type: research
Development of a patient safety climate survey for Chinese hospitals: cross-national adaptation and psychometric evaluation
Conclusions
The Chinese Hospital Survey on Patient Safety Climate demonstrates adequate dimensionality, reliability and validity. The integration of qualitative and quantitative methods is essential to produce an instrument that is culturally appropriate for Chinese hospitals. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - September 16, 2014 Category: Health Management Authors: Zhu, J., Li, L., Zhao, H., Han, G., Wu, A. W., Weingart, S. N. Tags: Original research Source Type: research
Tweets about hospital quality: a mixed methods study
Conclusions
Only a small proportion of tweets directed at hospitals discuss quality of care and there was no clear relationship between Twitter sentiment and other measures of quality, potentially limiting Twitter as a medium for quality monitoring. However, tweets did contain information useful to target quality improvement activity. Recent enthusiasm by policy makers to use social media as a quality monitoring and improvement tool needs to be carefully considered and subjected to formal evaluation. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - September 16, 2014 Category: Health Management Authors: Greaves, F., Laverty, A. A., Cano, D. R., Moilanen, K., Pulman, S., Darzi, A., Millett, C. Tags: Open access Original research Source Type: research
Adverse drug events and medication errors in Japanese paediatric inpatients: a retrospective cohort study
Conclusions
ADEs and medication errors were common in paediatric inpatients in Japan, though the proportion of ADEs that were preventable was low. The ordering and monitoring stages appeared most important for improving safety. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - September 16, 2014 Category: Health Management Authors: Sakuma, M., Ida, H., Nakamura, T., Ohta, Y., Yamamoto, K., Seki, S., Hiroi, K., Kikuchi, K., Nakayama, K., Bates, D. W., Morimoto, T. Tags: Original research Source Type: research
'I think we should just listen and get out': a qualitative exploration of views and experiences of Patient Safety Walkrounds
This article is an exploration of views and experiences of Patient Safety Walkrounds, a widely recommended strategy for identifying patient safety problems and improving safety culture.
Design and setting
Qualitative analysis of semistructured, in-depth interviews with 11 senior leaders and 33 front-line staff at two major teaching hospitals with mature walkrounds programmes, collected as part of a larger mixed-methods evaluation.
Results
Despite differences in the structure of the two walkrounds programmes, senior leaders at both institutions reported attitudes and behaviours that contradict the stated goals and princip...
Source: Quality and Safety in Health Care - September 16, 2014 Category: Health Management Authors: Rotteau, L., Shojania, K. G., Webster, F. Tags: Original research Source Type: research
Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout
Conclusions
WR are linked to patient safety and burnout. In NICUs, where they occurred more often, the workplace appears to be a better place to deliver and to receive care. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - September 16, 2014 Category: Health Management Authors: Sexton, J. B., Sharek, P. J., Thomas, E. J., Gould, J. B., Nisbet, C. C., Amspoker, A. B., Kowalkowski, M. A., Schwendimann, R., Profit, J. Tags: Original research Source Type: research
