Reducing Adverse Drug Events: Lessons from a Breakthrough Series Collaborative

Leape, Lucian L.; Kabcenell, Andrea; Gandhi, Tejal K.; Carver, Penny; Nolan, Thomas; Berwick, Donald M.

doi:10.1016/s1070-3241(00)26026-4

Cited by 137 publications

(108 citation statements)

References 12 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Finally, we found evidence of a significant interaction between workshop participation and leadership for improvement for the fear of repercussions culture variable suggesting that, together, leadership for improvement and training workshops are likely important for explaining variation in at least certain aspects of perceived safety culture. Our results are consistent with other work showing that success in making changes aimed at reducing adverse drug events was associated with strong leadership, among other variables (Leape et al 2000). Indeed, this kind of leadership support has been suggested to play an important ''agenda-setting'' role in various other organizational improvement activities including the utilization of research findings (Huberman 1994), perceptions of performance data (Soberman Ginsburg 2003), response to hospital performance data (Baker and Soberman 2001), and clinical involvement in CQI (Weiner, Shortell, and Alexander 1997).…”

Section: Discussionsupporting

confidence: 92%

“…For instance, the Institute for Healthcare Improvement breakthrough collaboratives ultimately targeted at reducing adverse drug events actually used the implementation and development of various medication error prevention practices as the outcome measure (Leape et al 2000). A more recent study by Pronovost et al (2003) described a strategic plan aimed at improving intermediate outcomes of patient safety culture and safety climate.…”

Section: Literaturementioning

confidence: 99%

See 1 more Smart Citation

An Educational Intervention to Enhance Nurse Leaders' Perceptions of Patient Safety Culture

Ginsburg¹,

Norton²,

Casebeer³

et al. 2005

Health Services Research

View full text Add to dashboard Cite

Objective. To design a training intervention and then test its effect on nurse leaders' perceptions of patient safety culture. Study Setting. Three hundred and fifty-six nurses in clinical leadership roles (nurse managers and educators/CNSs) in two Canadian multi-site teaching hospitals (study and control). Study Design. A prospective evaluation of a patient safety training intervention using a quasi-experimental untreated control group design with pretest and posttest. Nurses in clinical leadership roles in the study group were invited to participate in two patient safety workshops over a 6-month period. Individuals in the study and control groups completed surveys measuring patient safety culture and leadership for improvement prior to training and 4 months following the second workshop. Extraction Methods. Individual nurse clinical leaders were the unit of analysis. Exploratory factor analysis of the safety culture items was conducted; repeatedmeasures analysis of variance and paired t-tests were used to evaluate the effect of the training intervention on perceived safety culture (three factors). Hierarchical regression analyses looked at the influence of demographics, leadership for improvement, and the training intervention on nurse leaders' perceptions of safety culture. Principal Findings. A statistically significant improvement in one of three safety culture measures was shown for the study group ( po.001) and a significant decline was seen on one of the safety culture measures for the control group ( po.05). Leadership support for improvement was found to explain significant amounts of variance in all three patient safety culture measures; workshop attendance explained significant amounts of variance in one of the three safety culture measures. The total R 2 for the three full hierarchical regression models ranged from 0.338 and 0.554. Conclusions. Sensitively delivered training initiatives for nurse leaders can help to foster a safety culture. Organizational leadership support for improvement is, however, also critical for fostering a culture of safety. Together, training interventions and leadership support may have the most significant impact on patient safety culture.

show abstract

Section: Discussionsupporting

confidence: 92%

Section: Literaturementioning

confidence: 99%

An Educational Intervention to Enhance Nurse Leaders' Perceptions of Patient Safety Culture

Ginsburg¹,

Norton²,

Casebeer³

et al. 2005

Health Services Research

View full text Add to dashboard Cite

show abstract

“…The early phase of the movement was dominated by the view that error was not the result of individual failing, but instead was an inescapable feature of poorly designed systems. Accordingly, it was argued individuals should not be blamed for safety lapses: the proper response was said to involve the re-engineering of systems to avert or mitigate error (Leape, et al, 2000). More recently, this so-called "systems" approach has been argued to result in an unwarranted, misguided and risky attribution of all responsibility for safety to systems (Wachter & Pronovost, 2009).…”

Section: Introductionmentioning

confidence: 99%

What is the Role of Individual Accountability in Patient Safety? A Multi‐Site Ethnographic Study

Aveling¹,

Parker²,

Dixon‐Woods³

2016

The Sociology of Healthcare Safety and Quality

View full text Add to dashboard Cite

An enduring debate concerns how responsibility for patient safety should be distributed between organizational systems and individual professionals. Though rule-based, calculus-like approaches intended to support a "just culture" have become popular, they perpetuate an asocial and atomised account. In this article, we use insights from practice theory -which sees organizational phenomena as accomplished in everyday actions, with individual agency and structural conditions as a mutually constitutive, dynamic duality -along with contributions from the political science and ethics literature as a starting point for analysis. Presenting ethnographic data from five hospitals, three in one highincome country and two in low-income countries, we offer an empirically informed, normative rethinking of the role of personal accountability, identifying the collective nature of the healthcare enterprise and the extent to which patient safety depends on contributions from many hands. We show that moral responsibility for actions and behaviours is an irreducible element of professional practice, but that individuals are not somehow "outside" and separate from "systems": they create, modify and are subject to the social forces that are an inescapable feature of any organisational system; each element acts on the other. Our work illustrates starkly the structuring effects of the broader institutional and socio-economic context on opportunities to "be good" .These findings imply that one of the key responsibilities of organisations and wider institutions in relation to patient safety is the fostering of the conditions of moral community.

show abstract

“…In this sense, attempts are made to enable each individual to assess the environment for potential danger, receiving institutional support to identify errors and routes to appropriately eliminate, reduce or control them (4,(6)(7) . In short, attempts are made to insert a collective awareness of AE prevention, using a proactive, non-punishment approach to encourage spontaneous and anonymous event notification (2)(3)(4)(8)(9)(10) .…”

Section: Introductionmentioning

confidence: 99%

“…The literature review shows increased AE analysis and, hence, patient safety research, exploring specific and general events, focusing on the environments where care takes place, proposing prevention strategies (6,(11)(12)(13)(14) , among other approaches. Studies and organizations recommending a non-punishment culture are also unanimous regarding the establishment of prevention measures (2)(3)(4)(7)(8)14) . Little is known about the non-punishment culture in the daily practice of ICUs where the nurses work, however, according to these professionals' perception.…”

Section: Introductionmentioning

confidence: 99%

Eventos adversos em Unidade de Terapia Intensiva: percepção dos enfermeiros sobre a cultura não punitiva

Claro

Krocockz

Toffolleto

et al. 2011

Rev. esc. enferm. USP

View full text Add to dashboard Cite

A cultura de segurança nas unidades de terapia intensiva (UTI) pressupõe a abordagem não-punitiva dos eventos adversos (EA), porém questiona-se a sua existência segundo a percepção dos enfermeiros. Foram objetivos do estudo: caracterizar os sistemas de notificação de EA; verificar a freqüência dos eventos e conseqüências para os profissionais; verificar o grau de segurança dos enfermeiros para notificá-los. Estudo descritivo, com questionário respondido por 70 enfermeiros, em 2007, seguido da análise descritiva dos dados. A maioria dos enfermeiros (70,0%) referiuse à existência de um sistema de notificação de EA nas instituições onde atuam. A ocorrência de EA algumas e várias vezes foram citadas por 51,4% e 28,6% dos enfermeiros, respectivamente. Para 74,3% da amostra, a punição ocorre às vezes e sempre, predominando a advertência verbal (49,0%). A maioria (74,3%) referiu sentirse seguro e totalmente seguro para notificar um EA. Conclui-se que a cultura punitiva ainda persiste nas UTIs. DESCRITORES RESUMENLa cultura de seguridad en las unidades de terapia intensiva (UTI) presupone el abordaje no punitivo de los eventos adversos (EA), no obstante, se cuestiona su existencia según la percepción de los enfermeros. Fueron objetivos del estudio: caracterizar los sistemas de notificación de EA, verificar la frecuencia de los eventos y consecuencias para los profesionales, verificar el grado de seguridad de los enfermeros para notificarlos. Estudio descriptivo, con cuestionario respondido por 70 enfermeros, en 2007, seguido del análisis descriptivo de los datos. La mayoría de los enfermeros (7%) refirió la existencia de un sistema de notificación de EA en las instituciones donde se desempeñan. La ocurrencia de EA algunas y varias veces fue citada por el 51,4% y 28,6% de los enfermeros, respectivamente. Para el 74,3 de la muestra, el acto punitivo ocurre a veces y siempre, predominando la advertencia verbal (49,3%). La mayoría (74,3%) refirió sentirse seguro y totalmente seguro para notificar un EA. Se concluye en que la cultura punitiva persiste aún en las UTIs. DESCRIPTORESUnidades de Terapia Intensiva. Medidas de seguridad. Enfermería.

show abstract

Reducing Adverse Drug Events: Lessons from a Breakthrough Series Collaborative

Cited by 137 publications

References 12 publications

An Educational Intervention to Enhance Nurse Leaders' Perceptions of Patient Safety Culture

An Educational Intervention to Enhance Nurse Leaders' Perceptions of Patient Safety Culture

What is the Role of Individual Accountability in Patient Safety? A Multi‐Site Ethnographic Study

Eventos adversos em Unidade de Terapia Intensiva: percepção dos enfermeiros sobre a cultura não punitiva

Contact Info

Product

Resources

About