Creating an Integrated Patient Safety Team

Gandhi, Tejal K.; Graydon-Baker, Erin; Barnes, Janet Nally; Neppl, Camilla; Stapinski, Carl; Silverman, Jon; Churchill, William; Johnson, Paula; Gustafson, Michael L.

doi:10.1016/s1549-3741(03)29046-8

Cited by 20 publications

(27 citation statements)

References 13 publications

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“…[20,47] In May 2001, BWH, a teaching affiliate of Harvard Medical School in Boston, created a Patient Safety Team that consists of a medical director (30% time), a full-time patient safety manager, a full-time pharmacist and a full-time data manager. [21,48] Witnesses of events can submit an incident report to Patient safety Division at KUH via fax and to Patient Safety Team at BWH via a web-based hospital-wide system that was adopted in 2003. An electrical incident-reporting system was implemented at KUH in August 2005.…”

Section: Resultsmentioning

confidence: 99%

Is patient safety sufficient in Japan? Differences in patient safety between Japan and the United States – Learning from the United States

Hirose

2016

JHA

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In Japan, patient safety has been promoted at all levels since the 1999 landmark adverse medical event at Yokohama City University Hospital (YCUH). However, patients do not believe that health care is becoming safer. Furthermore, two university hospitals (UHs) that were designated as "advanced treatment hospitals" had their status revoked by the Health Ministry as of June 1, 2015 due to patient safety problems. The history of patient safety in Japan can be roughly divided into two terms: 1999-2009 and since 2010. In the first term, a basic patient safety system was established that included the creation of a patient safety division and an incident-reporting system from the perspective of systems error rather than individual responsibility. Additionally, many companies have promoted the improvement and development of drugs and medical devices in collaboration with health care providers. The two recent serious medical errors at UHs seemed to occur partially due to a lack of medical ethics. Unlike in the United States (US), in Japan, there is no medical license renewal system, the organizations that govern physicians are weak, and the framework of lifelong education is inadequate. Therefore, the second term involves a mindset of quality-driven patient safety. It requires health care providers and policy makers to change their mindset toward medical ethics and patient safety by learning from the US and demands a strong organization and framework to govern physicians in Japan.

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Section: Resultsmentioning

confidence: 99%

Is patient safety sufficient in Japan? Differences in patient safety between Japan and the United States – Learning from the United States

Hirose

2016

JHA

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“…Ideally, the medication safety programme in a large teaching hospital should be managed by a full-time MSO 11–13. Because patient safety has only come to be recognised as a key consideration in healthcare recently, the role of medication or patient safety officers is still rapidly evolving.…”

Section: Infrastructurementioning

confidence: 99%

“…The operational lead for the medication safety programme is typically the MSO 12 13. However, additional support is required to implement optimally a medication safety programme in a large teaching hospital 11–13.…”

Section: Infrastructurementioning

confidence: 99%

Design template for a medication safety programme in an acute teaching hospital

2012

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“…In this sample, a patient event occurred in approximately 10% of admissions, 1% of which resulted in permanent or lifethreatening harm or death. For a reporting system to be successful, health care workers must be able to report quickly and easily and perceive that a reported event results in a real response and subsequent change [45]. Increasing reporting will be futile without proper analysis and followup.…”

Section: Error Reporting and Analysismentioning

confidence: 99%

“…An additional strategy is to evaluate current and new processes for potential failures before they happen and to make continuous improvements [45]. This process is called Failure Mode and Effect Analysis (FMEA).…”

Section: Error Reporting and Analysismentioning

confidence: 99%

Patient safety in obstetrics

Zeeman

2006

Eur Clinics Obstet Gynaecol

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Obstetrical care providers are highly trained, highly skilled professionals working with complex systems in an unpredictable environment. Perinatal units have many built-in mechanisms that work to prevent errors from occurring. Unintentional failures usually are the result of a chain of events, almost never from a single cause or a single provider. Within most unintentional failures, there is usually no single explanatory cause for the event. Rather, there is a complex interaction between a varied set of systems, including human behavior, performance and interdependency, technological aspects, socio-cultural factors, and a range of organizational and procedural weaknesses. To enable meaningful analysis of the underlying causes of an adverse event, errors and near-misses must be made visible. The challenge lies in the integration of labor and delivery clinical core business with highreliability organization principles. The human factors knowledge should be considered a required part of the undergraduate and postgraduate medical education. Safety science and human factors engineering need to be applied to perinatal care, and each health care professional should be able to recognize the basic theories, rules, and principles. Business and industry provide many lessons for perinatal care when focusing on error prevention through standardization, information technology, and, last but not least, acknowledging the relationship between team-building and improved performance. This will allow all obstetrical caregivers to build and maintain confidence and competency in their daily clinical activities, which ultimately is believed to result in reduction of clinical error. This review on current patient safety issues as they are applicable to the field of perinatal care attempts to create a sense of urgency towards the creation of a safety-conscious culture in obstetrics. Such a culture fosters a collective approach of responsibility to learn and improve constantly. This process takes time to develop and requires dedicated and highly visible leadership support at every level.

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Creating an Integrated Patient Safety Team

Cited by 20 publications

References 13 publications

Is patient safety sufficient in Japan? Differences in patient safety between Japan and the United States – Learning from the United States

Is patient safety sufficient in Japan? Differences in patient safety between Japan and the United States – Learning from the United States

Design template for a medication safety programme in an acute teaching hospital

Patient safety in obstetrics

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