Nursing faults in the recovery period of surgical patients

Chianca, Tânia Couto Machado

doi:10.1590/s0104-11692006000600008

Cited by 4 publications

(1 citation statement)

References 6 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Errors were classified in terms of organizational, psychosocial/ equipment and severity aspects, at four basic levels: sensory-motor, procedure or service routines, abstraction or knowledge and supervision control. The situations involved included lack of care with drains and infusions during patient transportation, non-observation of patients' clinical conditions, lack of knowledge of resuscitation procedures in case of cardiorespiratory arrest, lack of a laryngoscope at the surgery room where the patient suffered a glottal edema (2) .…”

Section: Introductionmentioning

confidence: 99%

Cultural adaptation and internal consistency analysis of the MISSCARE Survey for use in Brazil

Siqueira¹,

Caliri

Kalisch

et al. 2013

Rev. Latino-Am. Enfermagem

View full text Add to dashboard Cite

Section: Introductionmentioning

confidence: 99%

Cultural adaptation and internal consistency analysis of the MISSCARE Survey for use in Brazil

Siqueira¹,

Caliri

Kalisch

et al. 2013

Rev. Latino-Am. Enfermagem

View full text Add to dashboard Cite

Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review

et al. 2012

View full text Add to dashboard Cite

ObjectiveThe aim of this systematic review was to develop a ‘contributory factors framework’ from a synthesis of empirical work which summarises factors contributing to patient safety incidents in hospital settings.DesignA mixed-methods systematic review of the literature was conducted.Data sourcesElectronic databases (Medline, PsycInfo, ISI Web of knowledge, CINAHL and EMBASE), article reference lists, patient safety websites, registered study databases and author contacts.Eligibility criteriaStudies were included that reported data from primary research in secondary care aiming to identify the contributory factors to error or threats to patient safety.Results1502 potential articles were identified. 95 papers (representing 83 studies) which met the inclusion criteria were included, and 1676 contributory factors extracted. Initial coding of contributory factors by two independent reviewers resulted in 20 domains (eg, team factors, supervision and leadership). Each contributory factor was then coded by two reviewers to one of these 20 domains. The majority of studies identified active failures (errors and violations) as factors contributing to patient safety incidents. Individual factors, communication, and equipment and supplies were the other most frequently reported factors within the existing evidence base.ConclusionsThis review has culminated in an empirically based framework of the factors contributing to patient safety incidents. This framework has the potential to be applied across hospital settings to improve the identification and prevention of factors that cause harm to patients.

show abstract

Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm

Wright

Lawton

O’Hara

et al. 2016

Programme Grants Appl Res

View full text Add to dashboard Cite

BackgroundEstimates suggest that, in NHS hospitals, incidents causing harm to patients occur in 10% of admissions, with costs to the NHS of > £2B. About one-third of harmful events are believed to be preventable. Strategies to reduce patient safety incidents (PSIs) have mostly focused on changing systems of care and professional behaviour, with the role that patients can play in enhancing the safety of care being relatively unexplored. However, although the role and effectiveness of patient involvement in safety initiatives is unclear, previous work has identified a general willingness among patients to contribute to initiatives to improve health-care safety.AimOur aim in this programme was to design, develop and evaluate four innovative approaches to engage patients in preventing PSIs: assessing risk, reporting incidents, direct engagement in preventing harm and education and training.Methods and resultsWe developed tools to report PSIs [patient incident reporting tool (PIRT)] and provide feedback on factors that might contribute to PSIs in the future [Patient Measure of Safety (PMOS)]. These were combined into a single instrument and evaluated in the Patient Reporting and Action for a Safe Environment (PRASE) intervention using a randomised design. Although take-up of the intervention by, and retention of, participating hospital wards was 100% and patient participation was high at 86%, compliance with the intervention, particularly the implementation of action plans, was poor. We found no significant effect of the intervention on outcomes at 6 or 12 months. The ThinkSAFE project involved the development and evaluation of an intervention to support patients to directly engage with health-care staff to enhance their safety through strategies such as checking their care and speaking up to staff if they had any concerns. The piloting of ThinkSAFE showed that the approach is feasible and acceptable to users and may have the potential to improve patient safety. We also developed a patient safety training programme for junior doctors based on patients who had experienced PSIs recounting their own stories. This approach was compared with traditional methods of patient safety teaching in a randomised controlled trial. The study showed that delivering patient safety training based on patient narratives is feasible and had an effect on emotional engagement and learning about communication. However, there was no effect on changing general attitudes to safety compared with the control.ConclusionThis research programme has developed a number of novel interventions to engage patients in preventing PSIs and protecting them against unintended harm. In our evaluations of these interventions we have been unable to demonstrate any improvement in patient safety although this conclusion comes with a number of caveats, mainly about the difficulty of measuring patient safety outcomes. Reflecting this difficulty, one of our recommendations for future research is to develop reliable and valid measures to help efficiently evaluate safety improvement interventions. The programme found patients to be willing to codesign, coproduce and participate in initiatives to prevent PSIs and the approaches used were feasible and acceptable. These factors together with recent calls to strengthen the patient voice in health care could suggest that the tools and interventions from this programme would benefit from further development and evaluation.Trial registrationCurrent Controlled Trials ISRCTN07689702.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

show abstract

Nursing faults in the recovery period of surgical patients

Cited by 4 publications

References 6 publications

Cultural adaptation and internal consistency analysis of the MISSCARE Survey for use in Brazil

Cultural adaptation and internal consistency analysis of the MISSCARE Survey for use in Brazil

Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review

Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm

Contact Info

Product

Resources

About