Burnout in the NICU setting and its relation to safety culture
Conclusions
NICU caregiver burnout appears to have ‘climate-like’ features, is prevalent, and associated with lower perceptions of patient safety culture. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - September 16, 2014 Category: Health Management Authors: Profit, J., Sharek, P. J., Amspoker, A. B., Kowalkowski, M. A., Nisbet, C. C., Thomas, E. J., Chadwick, W. A., Sexton, J. B. Tags: Original research Source Type: research
Moving improvement research closer to practice: the Researcher-in-Residence model
The traditional separation of the producers of research evidence in academia from the users of that evidence in healthcare organisations has not succeeded in closing the gap between what is known about the organisation and delivery of health services and what is actually done in practice. As a consequence, there is growing interest in alternative models of knowledge creation and mobilisation, ones which emphasise collaboration, active participation of all stakeholders, and a commitment to shared learning. Such models have robust historical, philosophical and methodological foundations but have not yet been embraced by many...
Source: Quality and Safety in Health Care - September 16, 2014 Category: Health Management Authors: Marshall, M., Pagel, C., French, C., Utley, M., Allwood, D., Fulop, N., Pope, C., Banks, V., Goldmann, A. Tags: Open access Viewpoints Source Type: research
The evolving literature on safety WalkRounds: emerging themes and practical messages
The road to walking around The evidence is clear: a strong culture of safety is necessary to deliver reliably safe care.1 Safety culture encompasses a group's shared values, assumptions, attitudes and patterns of behaviour regarding safety.2 3 In healthcare organisations with weak safety culture, employees perceive the low priority assigned to safety, and patient safety suffers as a result.4 Researchers measure safety culture using surveys that include items eliciting perceptions of policies, procedures and practices that reflect the extent to which the organisation prioritises safety relative to competing goals.4 Numerous...
Source: Quality and Safety in Health Care - September 16, 2014 Category: Health Management Authors: Singer, S. J., Tucker, A. L. Tags: Editor's choice Editorials Source Type: research
Differences in case-mix can influence the comparison of standardised mortality ratios even with optimal risk adjustment: an analysis of data from paediatric intensive care
Conclusions
Even if two healthcare providers are performing equally for each type of patient, if their patient populations differ in case-mix their SMRs will not necessarily take the same value. Clinical teams and commissioners must always keep in mind this weakness of the SMR when making decisions. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - August 12, 2014 Category: Health Management Authors: Manktelow, B. N., Evans, T. A., Draper, E. S. Tags: Research and reporting methodology Source Type: research
Computerised provider order entry combined with clinical decision support systems to improve medication safety: a narrative review
Conclusions
CPOE+CDSS does not appear to reliably prevent clinical ADEs. Despite more widespread implementation over the past decade, it remains a work in progress. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - August 12, 2014 Category: Health Management Authors: Ranji, S. R., Rennke, S., Wachter, R. M. Tags: Narrative review Source Type: research
Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids
Conclusions
We identified areas of concern even within the context of a highly controlled standardised national process. If incident reporting systems include and encourage reports of no-harm incidents in addition to actual patient harm, they can facilitate monitoring the resilience of healthcare processes. Patient safety incidents that produce the most serious harm are often rare, and it is difficult to know whether patients are adequately protected. Our approach provides a potential solution. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - August 12, 2014 Category: Health Management Authors: Franklin, B. D., Panesar, S. S., Vincent, C., Donaldson, L. J. Tags: Open access Original research Source Type: research
An observational study: associations between nurse-reported hospital characteristics and estimated 30-day survival probabilities
Conclusions
This study showed that perceived staffing adequacy and nurses’ assessments of quality of nursing were correlated with survival probabilities. It is suggested that the way nurses characterise the microsystems they belong to, also reflects the general performance of hospitals. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - August 12, 2014 Category: Health Management Authors: Tvedt, C., Sjetne, I. S., Helgeland, J., Bukholm, G. Tags: Open access Original research Source Type: research
Dissemination of a simulation-based mastery learning intervention reduces central line-associated bloodstream infections
Conclusions
This study demonstrates successful dissemination and implementation of a CVC SBML curriculum and shows that rigorous medical education is a powerful quality improvement tool. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - August 12, 2014 Category: Health Management Authors: Barsuk, J. H., Cohen, E. R., Potts, S., Demo, H., Gupta, S., Feinglass, J., McGaghie, W. C., Wayne, D. B. Tags: Original research Source Type: research
Contribution of hospital mortality variations to socioeconomic disparities in in-hospital mortality
Conclusions
This study suggests that to reduce socioeconomic disparities in hospital mortality, interventions that target within-hospital effects may be more effective than interventions targeting between hospital effects. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - August 12, 2014 Category: Health Management Authors: Kim, Y., Oh, J., Jha, A. Tags: Original research Source Type: research
A multicentre cohort study assessing day of week effect and outcome from emergency appendicectomy
Conclusions
This study found that weekend appendicectomy was not associated with increased 30-day adverse events. It cannot rule out smaller increases that may be shown by larger studies. It further illustrated that patients operated on at weekends were subject to different care processes, which may expose them to risk. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - August 12, 2014 Category: Health Management Authors: Ferguson, H. J., Hall, N. J., Bhangu, A., Panagiotopoulou, Chatzizacharias, Rana, Rollins, Ejtehadi, Jha, Tan, Fanous, Markides, Tan, Marshal, Akhtar, Mullassery, Ismail, Hitchins, Sharif, Osborne, Sengupta, Challand, Pournaras, Bevan, King, Massey, Sandh Tags: Original research Source Type: research
The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations
Conclusions
Our population-based estimate suggests that diagnostic errors affect at least 1 in 20 US adults. This foundational evidence should encourage policymakers, healthcare organisations and researchers to start measuring and reducing diagnostic errors. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - August 12, 2014 Category: Health Management Authors: Singh, H., Meyer, A. N. D., Thomas, E. J. Tags: Open access Original research Source Type: research
Validation of a teamwork perceptions measure to increase patient safety
Conclusions
The T-TPQ is a construct-valid instrument for measuring perceptions of teamwork. This has beneficial implications for patient safety and future research that studies medical teamwork. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - August 12, 2014 Category: Health Management Authors: Keebler, J. R., Dietz, A. S., Lazzara, E. H., Benishek, L. E., Almeida, S. A., Toor, P. A., King, H. B., Salas, E. Tags: Original research Source Type: research
'Between the flags': implementing a rapid response system at scale
While many hospitals are implementing rapid response systems (RRSs) to attend to deteriorating patients in a systematic way, there is little documented evidence on system-wide approaches to adopting RRSs. Here, we report on an initiative which enrolled 220 hospitals in New South Wales, Australia. The ‘between the flags’ approach was modelled on Australia's surf lifesaving experience, where qualified lifesavers perform thousands of rescues each year. Patients in hospitals who are identified as being ‘between the flags’ are given special attention, just like beach goers. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - August 12, 2014 Category: Health Management Authors: Hughes, C., Pain, C., Braithwaite, J., Hillman, K. Tags: Viewpoints Source Type: research
Deafening silence? Time to reconsider whether organisations are silent or deaf when things go wrong
Several public inquiries into healthcare failings in the UK have noted that employees of failing organizations attempt to raise concerns about shortcomings in care, often over a prolonged period of time, only for those concerns to be ignored. However, healthcare literature has largely focused on how organizations and their employees are silent in the face of such failings, positioning employees as daring not to speak in response to serious workplace problems or issues. We argue that only focussing on organizational silence is a critical mistake which misrepresents actual events and overly-simplifies the complexities of wor...
Source: Quality and Safety in Health Care - August 12, 2014 Category: Health Management Authors: Jones, A., Kelly, D. Tags: Viewpoints Source Type: research
After Mid Staffordshire: from acknowledgement, through learning, to improvement
For many readers, the story of the quality of care at Mid Staffordshire NHS Trust in the UK from 2005 to 2009 will need little introduction. The substandard care provided and the combination of circumstances that allowed such a situation to persist for several years have received widespread attention in the general media as well as in healthcare journals.1–4 At the heart of this coverage are the findings of two inquiries led by Sir Robert Francis QC—the first focusing on the quality of care provided at Stafford Hospital5 and the second on the role of a wider system of governance that failed to identify and reme...
Source: Quality and Safety in Health Care - August 12, 2014 Category: Health Management Authors: Martin, G. P., Dixon-Woods, M. Tags: Editor's choice Editorials Source Type: research
