The Long Road to Patient Safety

Longo, Daniel R.; Hewett, John E.; Ge, Bin; Schubert, Shari

doi:10.1001/jama.294.22.2858

Cited by 172 publications

(21 citation statements)

References 47 publications

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“…1,2,3,4,5,6 Safety scientists believe that this is largely because our tools for change are ineffective. 7,8 The culture in medicine has been criticized for being a “name, blame, and train” environment.…”

Section: Introductionmentioning

confidence: 99%

An evidence‐based toolkit for the development of effective and sustainable root cause analysis system safety solutions

Hettinger

Fairbanks

Hegde

et al. 2013

J of Healthc Risk Manag

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Root cause analysis (RCA) after adverse events in healthcare is a standard practice at many institutions. However, healthcare has failed to see a dramatic improvement in patient safety over the last decade. In order to improve the RCA process, this study used systems safety science, which is based partly on human factors engineering principles and has been applied with success in other high‐risk industries like aviation. A multi‐institutional dataset of 334 RCA cases and 782 solutions was analyzed using qualitative methods. A team of safety science experts developed a model of 13 RCA solutions categories through an iterative process, using semi‐structured interview data from 44 frontline staff members from 7 different hospital‐based unit types. These categories were placed in a model and toolkit to help guide RCA teams in developing sustainable and effective solutions to prevent future adverse events. This study was limited by its retrospective review of cases and use of interviews rather than clinical observations. In conclusion, systems safety principles were used to develop guidelines for RCA teams to promote systems‐level sustainable and effective solutions for adverse events.

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Section: Introductionmentioning

confidence: 99%

An evidence‐based toolkit for the development of effective and sustainable root cause analysis system safety solutions

Hettinger

Fairbanks

Hegde

et al. 2013

J of Healthc Risk Manag

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“…Formulating the hypothesis includes, data collection and analysis through personal observation of the unit, interviews, numerical data analysis of the questionnaires, data testing of the simulation model of the arena to validate and verify results, carrying out experiments in the arena to identify places to investigate, evaluate and input parameter changes. Longo, [4] said to ensure that patient safety is taken into consideration, all important steps to ensure there is compliance, improvement and adherence to procedures. …”

Section: Research Hypothesesmentioning

confidence: 99%

Enhancing high performance of emergency unit by improving the management emergency team system of the Plateau State Specialist Hospital Nigeria

Coker-Farrell

Yildam

Luka

et al. 2015

JHA

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There are challenges with the management of the emergency units of healthcare organizations in Nigeria; these have been observed from the high mortality rate, high level of left before examination (LBE) of the patients, low response time to acute care patients and poor turnaround time by the healthcare givers to address emergency situations. Therefore there is an urgent need to address the situation and solve the problems best ways possible by improving the management emergency team (MET) system of the healthcare organization. These was achieved by quantitative methodology application through the distribution of questionnaires, interviews and personal observation of the situation, hence improving the quality and quantity of the man power which is the human resources with qualified and well trained medical personnel, adding also to the management emergency team are police protocol officers who can give police report immediately for unconscious accident victims on arrival for emergency treatment, eliminating need for unavailable consent form before treatment, adding intensive training programs for MET system, emergency hotlines and ambulance assistance for patients, adequate supplies of oxygen and facilities that are up-to-date for the emergency unit. These solutions have increased the stability of the emergency unit, lower mortality rate, increased the efficiency of the team, improved response time, higher survival rate, improving the staff efficiency and effectiveness, after which it is observed that the emergency unit is on high-performance level, with good survey feedback by patients and their relatives.

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“…Le rapport de l'IOM esti me qu'entre 44 000 et 98 000 personnes décèdent tous les ans aux Etats-Unis suite à des événements indésirables (EI) 1 4 . En plus de mettre en évidence la nécessité de placer la sécurité des patients comme une priori té des autorités médicales, ce rapport centre ses recommandations sur le changement de culture à l'hôpital 5 . C'est ainsi que le terme culture de sécurité, utilisé dans le nucléaire depuis 30 ans, fait son apparition en milieu médical.…”

Section: Résumé Depuis La Publication Du Rapport "To Err Is Human" Paunclassified

Sécurité des patients et culture de sécurité: une revue de la littérature

Nascimento

2011

Ciênc. saúde coletiva

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The Long Road to Patient Safety

Abstract: The current status of hospital patient safety systems is not close to meeting IOM recommendations. Data are consistent with recent reports that patient safety system progress is slow and is a cause for great concern. Efforts for improvement must be accelerated.

Cited by 172 publications

References 47 publications

An evidence‐based toolkit for the development of effective and sustainable root cause analysis system safety solutions

An evidence‐based toolkit for the development of effective and sustainable root cause analysis system safety solutions

Enhancing high performance of emergency unit by improving the management emergency team system of the Plateau State Specialist Hospital Nigeria

Sécurité des patients et culture de sécurité: une revue de la littérature

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