Classifying and interpreting threats to patient safety in hospitals: insights from aviation

Tamuz, Michal; Thomas, Eric J.

doi:10.1002/job.419

Cited by 30 publications

(36 citation statements)

References 27 publications

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“…Here, healthcare has sought to learn from the experience of safety-critical industries, particularly aviation. The typical criticisms and caveats clearly apply, that solutions in one industry are unlikely to travel wholesale to another, without a close analysis of the context into which they are brought (Tamuz and Thomas 2006). Comparisons across domains are less easy than this paper has perhaps suggested.…”

Section: Towards Participative Risk Regulation In Patient Safetymentioning

confidence: 75%

“…A range of cross-domain papers on incident reporting have been produced. For instance by Barach and Small (2000) in their often-cited review of incident-reporting systems in safety-critical industries, Tamuz and Thomas (2006) and Billings' (1998) extremely valuable accounts that draw on experience in aviation reporting systems, Dixon and Shofer's (2006) analysis of creating high-reliability settings in healthcare, Carroll's account of moving root-cause analysis from chemical processing to healthcare , and Vincent's (2006) review of incident reporting in his landmark book, Patient Safety.…”

Section: Learning From Patient Safety Incidents 57mentioning

confidence: 97%

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Learning from patient safety incidents: Creating participative risk regulation in healthcare

Macrae

2008

Health, Risk & Society

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Patient safety has emerged as one of the key risks facing advanced healthcare systems. Enormous efforts are being made in healthcare to manage and regulate these risks. One widespread approach involves collecting, analysing and learning from minor safety incidents and near-miss events, following the success of such systems in safety-critical industries such as aviation and chemical processing. This paper examines the nature and role of worker participation in safety incident-reporting systems. It argues that actively engaging with local personnel throughout the analysis and learning process (both drawing on their knowledge and influencing their practice) is a key reason for the success and regulatory efficacy of these reporting systems. The paper examines both the design of current patient safety reporting systems in healthcare, and the situated practices that support similar reporting systems in the airline industry. This analysis suggests that the concept of worker participation has not, at present, been heavily emphasized in patient safety reporting systems. The paper concludes by conceptualizing participation in a form that can be applied in healthcare, and examining how participation can support three key aims of risk regulation in healthcare: producing knowledge, creating accountability and supporting leadership.

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Section: Towards Participative Risk Regulation In Patient Safetymentioning

confidence: 75%

Section: Learning From Patient Safety Incidents 57mentioning

confidence: 97%

Learning from patient safety incidents: Creating participative risk regulation in healthcare

Macrae

2008

Health, Risk & Society

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“…The interviews were conducted as part of a longitudinal research project that examined how hospitals learn from medication errors 32. The research project, focused on hospitals where medication error prevention was salient because of a vulnerable patient population and/or extensive high-hazard drug usage.…”

Section: Methodsmentioning

confidence: 99%

Rethinking resident supervision to improve safety: From hierarchical to interprofessional models

Tamuz

Giardina

Thomas

et al. 2011

Journal of Hospital Medicine

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BACKGROUND:Inadequate supervision is a significant contributing factor to medical errors involving trainees, but supervision in high‐risk settings such as the intensive care unit (ICU) is not well studied.OBJECTIVE:We explored how residents in the ICU experienced supervision related to medication safety, not only from supervising physicians but also from other professionals.DESIGN, SETTING, MEASUREMENTS:Using qualitative methods, we examined in‐depth interviews with 17 residents working in ICUs of three tertiary‐care hospitals. We analyzed residents' perspectives on receiving and initiating supervision from physicians within the traditional medical hierarchy, and from other professionals, including nurses, staff pharmacists, and clinical pharmacists (“interprofessional supervision”).RESULTS:While initiating their own supervision within the traditional hierarchy, residents believed in seeking assistance from fellows and attendings, and articulated rules of thumb for doing so; however, they also experienced difficulties. Some residents were concerned that their questions would reflect poorly on them; others were embarrassed by their mistaken decisions. Conversely, residents described receiving interprofessional supervision from nurses and pharmacists, who proactively monitored, intervened in, and guided residents' decisions. Residents relied on nurses and pharmacists for nonjudgmental answers to their queries, especially after‐hours. To enhance both types of supervision, residents emphasized the importance of improving interpersonal communication skills.CONCLUSIONS:Residents depended on interprofessional supervision when making decisions regarding medications in the ICU. Improving interprofessional supervision, which thus far has been underrecognized and underemphasized in graduate medical education, can potentially improve medication safety in high‐risk settings. Journal of Hospital Medicine 2011;6:448–456. © 2011 Society of Hospital Medicine

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“…This finding has spurred research on turning healthcare facilities into high-performance organizations through state-of-the-art management knowledge of human resources, work processes and systems, as well as a range of factors such as leadership and organizational culture, drawing on lessons from healthcare and other industries (e.g., Gittell 2009;Tamuz and Thomas 2006). Evidence-based change is now a strategic priority for health system improvement in many regions of the world (ferlie and Shortell 2001; Iles and Sutherland 2001;Law et al 2008), supported by mounting descriptions of successful transformation (Baker and denis 2011).…”

Section: Résumémentioning

confidence: 99%

Mining the Management Literature for Insights into Implementing Evidence-Based Change in Healthcare

Harlos¹,

Tetroe²,

Graham³

et al. 2012

hcpol

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Objective: We synthesized the management and health literatures for insights into implementing evidence-based change in healthcare drawn from industry-specific data. Because change principles based on evidence often fail to be translated into organizational practice or policy, we sought studies at the nexus of organizational change and knowledge translation. Methods: We reviewed five top management journals to identify an initial pool of 3,091 studies, which yielded a final sample of 100 studies. data were abstracted, verified by the original authors and revised before entry into a database. We employed a systematic narrative synthesis approach using words and text to distill data and explain relationships. We categorized studies by varying levels of relevance for knowledge translation as (1) primary, direct; (2) intermediate; and (3) secondary, indirect. We also identified recurring categories of change-related organizational factors. The current analysis examines these factors in studies of primary relevance to knowledge translation, which we also coded for intervention readiness to reflect how readily change can be implemented. Preliminary Results and Conclusions:Results centred on five change-related categories: Tailoring the Intervention message; Institutional Links/Social Networks; Training; quality of Work Relationships; and fit to Organization. In particular, networks across institutional and individual levels appeared as prominent pathways for changing healthcare organizations. Power dynamics, positive social relations and team structures also played key roles in implementing change and translating it into practice. We analyzed journals in which first authors of these studies typically publish, and found evidence that management and health sciences remain divided. Bridging these disciplines through research syntheses promises a wealth of evidence and insights, well worth mining in the search for change that works in healthcare transformation. RésuméObjectif : Nous avons effectué une synthèse de la littérature sur la gestion et sur la santé pour obtenir des pistes quant à la mise en oeuvre de changements fondés sur les données probantes dans les services de santé, et ce, à partir de données propres au secteur d' activité. Puisque la transposition des principes du changement fondé sur les données probantes dans la pratique ou politique organisationnelles est souvent vouée à l' échec, nous avons tenté de comprendre les liens entre le changement organisationnel et la transposition des connaissances. Méthodes : L' examen de cinq importantes revues de gestion nous a permis de repérer un bassin initial de 3 091 études, desquelles nous avons tiré un échantillon final de 100 études. Les données ont été résumées, vérifiées par leurs auteurs et révisées avant d' être versées dans une base de données. Nous avons employé une démarche de synthèse narrative systématique au moyen de mots et de texte afin de raffiner les données et d' expliquer les relations. Nous avons catégorisé les études en fonction de diffé...

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Classifying and interpreting threats to patient safety in hospitals: insights from aviation

Cited by 30 publications

References 27 publications

Learning from patient safety incidents: Creating participative risk regulation in healthcare

Learning from patient safety incidents: Creating participative risk regulation in healthcare

Rethinking resident supervision to improve safety: From hierarchical to interprofessional models

Mining the Management Literature for Insights into Implementing Evidence-Based Change in Healthcare

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