Estimates of the number of U.S. deaths each year resulting from medical errors range from 44,000 (Institute of Medicine, 1999) to 195,000 (HealthGrades, 2004). Additionally, instances of medical harm are estimated to occur at a rate of approximately 15 million per year in the U.S., or about 40,000 per day (Institute for Healthcare Improvement, 2007). Although several organizational behavior management (OBM) intervention techniques have been used to improve particular behaviors related to patient safety, there remains a lack of patient-safety-focused behavioral interventions among healthcare workers. OBM interventions are often applied to needs already identified within an organization, and the means by which these needs are determined vary across applications. The current research addresses gaps in the literature by applying a broad needs-assessment methodology to identify patient-safety intervention targets in a hospital and then translating OBM intervention techniques to identify and improve the prevention potential of responses to reported medical errors. A content analysis of 17 months of descriptions of follow-up actions to error reports for nine types of the most-frequently-occurring errors was conducted. Follow-up actions were coded according to a taxonomy of behavioral intervention components, with accompanying prevention scores based on criteria developed by Geller et al. (1990). Two error types were selected for intervention; based on the highest frequency of reporting and lowest average follow-up prevention score. Over a three-month intervention period, managers were instructed to respond to these two error types with active communication, group feedback, and positive reinforcement strategies. Results indicate improved prevention potential as a consequence of improved corrective action for targeted errors. Future implications for identifying and classifying responses to medical error are discussed. / Ph. D.

Yes / Poor medicines management places patients at risk, particularly during care transitions. For patients with heart failure (HF), optimal medicines management is crucial to control symptoms and prevent hospital readmission. This study explored the concept of resilience using HF as an example condition to understand how the system compensates for known and unknown weaknesses. We explored resilience using a mixed-methods approach in four healthcare economies in the north of England. Data from hospital site observations, healthcare staff and patient interviews, and documentary analysis were collected between June 2016 and March 2017. Data were synthesised and analysed using framework analysis. Interviews were conducted with 45 healthcare professionals, with 20 patients at three timepoints and 189 hours of observation were undertaken. We identified four primary inter-related themes concerning organisational resilience. These were named as gaps, traps, bridges and props. Gaps were discontinuities in processes that had the potential to result in poorly optimised medicines. Traps were features of the system that could produce errors or unintended adverse medication events. ‘Bridges’ were features of the medicines management system that promoted safety and continuity which ensured that, despite varying conditions, care could be delivered successfully. ‘Props’ were informal, temporary or impromptu actions taken by patients or healthcare staff to avoid potential adverse events. The numerous opportunities for HF patient safety to be compromised and sub-optimal medicines management during this common care transition are mitigated by system resilience. Cross-organisational bridges and temporary fixes or ‘props’ put in place by patients and carers, healthcare teams and organisations are critical for safe and optimal care to be delivered in the face of continued system pressures.

Thesis (MCur (Interdisciplinary Health Sciences. Nursing Science))--University of Stellenbosch, 2010. / ENGLISH ABSTRACT: Patient safety remains one of the biggest challenges to healthcare organizations. With the escalation in health care costs due to medical errors, many organizations are adopting a number of strategies like the keeping of electronic medical records, the use of medication bar coding, instituting protocol for common procedures and checklists. Although each of these interventions has had a positive impact, problems of preventable medical errors still persist in many health care organizations throughout the world. In order to combat this, a small but increasing number of organizations are trying out basic technology as a low cost solution for patient safety in order to adopt this culture. Approval was given to the researcher to conduct an assessment of the safety culture in a specialized obstetric and gynecology operating room setting in Abu Dhabi. The aim of the study was to explore the patient safety culture and the contributing factors influencing patient safety in the operating room, as part of the preparations for accreditation by the Joint Commission International. A quantitative descriptive survey as research design was implemented for this purpose. In May 2010 the researcher surveyed the entire population of operating room staff, i.e. 250 participants, following a pilot study consisting of 10% of the total sample. The popular hospital wide survey questionnaire of the Agency for Healthcare Research and Quality (AHRQ) was adjusted and used to assess the safety culture among the operating room staff. The survey measured four common dimensions of patient safety, namely an overall perception and grade of patient safety, and the frequency and number of events reported. Further sub-dimensions were also measured in terms of leadership support, team work, and communication. A total of 118 completed questionnaires were received, which represents a 52% response rate. All of the participants had direct interaction or contact with patients. The composite overall score for the perception of safety was 48%. Although findings of the survey indicate that the operating room has patient safety problems, the findings also show much positive strength in the operating room and the organization as a whole. The positive composite scores are reflected in the findings of 74% for hospital management support for patient safety, 70% for teamwork within the units, and 61% for teamwork across hospital units, and 60% for feedback and communication regarding medical errors. The implications of the survey findings were taken into consideration in order for the organization to comply with the requirements for the Joint Commission International’s recertification with the focus on staff education and improving safety standards. / AFRIKAANSE OPSOMMING:Pasiëntbeveiliging bly een van de grootste uitdagings vir gesondheidsorganisasies. Met die toename in onkoste vir gesondheidsorg vanweë mediese misstappe, pas baie organisasies ’n aantal strategieë toe, soos die byhou van elektroniese mediese rekords, die aanbring van strepieskodes op medisyne, die daarstelling van protokolle vir algemene prosedures en kontrolelyste. Alhoewel elkeen van hierdie intervensies ’n positiewe impak gehad het, bestaan probleme vanweë mediese misstappe nog steeds in vele gesondheidsorg organisasies dwarsoor die wêreld. Om dit te voorkom, probeer ’n klein, maar toenemende aantal organisasies om ‚n kultuur van basiese tegnologie as ’n lae-koste oplossing vir pasiëntbeveiliging te kweek. Toestemming is aan die navorser gegee om ’n assessering te doen van die veiligheidskultuur in ’n gespesialiseerde verloskundige en ginekologiese operasiesaal in Abu Dhabi. Die doel van hierdie studie is om die pasiëntveiligheidskultuur te ondersoek, asook die bydraende faktore wat pasiëntbeveiliging in die operasiesaal beïnvloed as deel van die voorbereiding vir akkreditasie deur die Gesamentlike Kommissie Internasionaal (GKI). ’n Kwantitatiewe, beskrywende opname as navorsingsontwerp is toegepas vir hierdie doel. Gedurende Mei 2010 het die navorser ’n opname van die totale populasie van die operasiesaalpersoneel gedoen, naamlik 250 deelnemers, na ’n loodsondersoek wat 10% van die totale steekproef uitgemaak het. Die bekende Agentskap vir Gesondheidsnavorsing en Kwaliteit (AGNK) se hospitaalwye opnamevraelys is aangepas en gebruik om die veiligheidskultuur in die operasiesaal te assesseer. Die opname het vier algemene dimensies van pasiëntveiligheid gemeet, naamlik ’n algemene persepsie en gradering van pasiëntveiligheid, as ook die frekwensie en die aantal ongunstige gebeure wat plaasvind. ’n Totaal van 118 voltooide vraelyste is ontvang wat ’n 52% responskoers verteenwoordig. Al die deelnemers het direkte interaksie of kontak met pasiënte. Die samegestelde algehele telling van persepsie van veiligheid is 48%. Alhoewel bevindinge van die opname aandui dat die operasiesaal pasiëntveiligheidsprobleme het, wys bevindinge ook baie positiewe aspekte in die operasiesaal en die organisasie as ’n geheel uit. Die positiewe samegestelde telling word gereflekteer in die bevindinge van 74% vir ondersteuning vanaf die hospitaalbestuur vir pasiëntbeveiliging, 70% vir spanwerk binne die eenhede, 61% vir spanwerk dwarsoor die hospitaaleenhede en 60% vir terugvoering en kommunikasie ten opsigte van mediese misstappe. Die implikasies van die opname se bevindinge is in ag geneem ten einde die organisasie in staat te stel om te voldoen aan die Gesamentlike Kommissie Internasionaal se hersertifisering met die fokus op personeelopleiding en verbetering van veiligheidstandaarde.

Patient safety experts identify changes in culture as critical to creating safer care (Flin, 2007; Leape, 1994; Reason, 1997; Vincent, Taylor-Adams & Stanhope, 1998). Yet there is limited understanding of how to best study, evaluate and make changes to patient safety culture. The literature on organizational culture, safety sciences and health services research suggests varying perspectives on studying culture and an evolving approach to creating tools to measure culture change. This thesis reports two projects. The first project used the Manchester Patient Safety Culture Assessment Tool, the Modified Stanford Instrument, and qualitative interviews to examine whether safety culture profiles varied by research method and instrument used to assess culture. Comparative assessment of the results suggests that while the quantitative measurement tools provide a high level organizational summary of safety issues, the qualitative interviews provide a more fine-grained understanding of the contextual and local features of the culture. The second research project used a multiple case study design to understand what hospitals have learned from trying to improve patient safety culture. Interviews in three organizations were used to determine how these organizations shifted their cultures. Although each organization had different experiences and used varying methods, they all created culture change through the simultaneous implementation of practice, policies and strategic framing of patient safety culture concepts in their everyday work. The third research paper examined how leaders measured changes in patient safety culture. Both leaders and front line workers look to both process measures (e.g., talking about safety and encouraging patient safety activities) together with outcome measures (e.g., adverse events, infection rates, and culture survey results) to evaluate their success in culture change. Overall this dissertation deepens our knowledge of how methods influence our assessment of patient safety culture and how leaders influence culture change. Future research needs to assess in more detail the roles of leaders and middle managers to understand how these individuals are able to reconcile the practice environment challenges while continuing to create a culture of patient safety.

Patient safety experts identify changes in culture as critical to creating safer care (Flin, 2007; Leape, 1994; Reason, 1997; Vincent, Taylor-Adams & Stanhope, 1998). Yet there is limited understanding of how to best study, evaluate and make changes to patient safety culture. The literature on organizational culture, safety sciences and health services research suggests varying perspectives on studying culture and an evolving approach to creating tools to measure culture change. This thesis reports two projects. The first project used the Manchester Patient Safety Culture Assessment Tool, the Modified Stanford Instrument, and qualitative interviews to examine whether safety culture profiles varied by research method and instrument used to assess culture. Comparative assessment of the results suggests that while the quantitative measurement tools provide a high level organizational summary of safety issues, the qualitative interviews provide a more fine-grained understanding of the contextual and local features of the culture. The second research project used a multiple case study design to understand what hospitals have learned from trying to improve patient safety culture. Interviews in three organizations were used to determine how these organizations shifted their cultures. Although each organization had different experiences and used varying methods, they all created culture change through the simultaneous implementation of practice, policies and strategic framing of patient safety culture concepts in their everyday work. The third research paper examined how leaders measured changes in patient safety culture. Both leaders and front line workers look to both process measures (e.g., talking about safety and encouraging patient safety activities) together with outcome measures (e.g., adverse events, infection rates, and culture survey results) to evaluate their success in culture change. Overall this dissertation deepens our knowledge of how methods influence our assessment of patient safety culture and how leaders influence culture change. Future research needs to assess in more detail the roles of leaders and middle managers to understand how these individuals are able to reconcile the practice environment challenges while continuing to create a culture of patient safety.

Darbo tikslas. Išaiškinti ligoninės gydytojų ir slaugytojų požiūrį į pacientų saugos gerinimo galimybes. Uždaviniai. Ištirti gydytojų ir slaugytojų nuomonę apie sveikatos priežiūros profesionalų tobulinimo ir pacientų mokymo svarbą ir tematiką saugiai sveikatos priežiūrai užtikrinti; išaiškinti gydytojų ir slaugytojų nuomonę apie tinkamiausią nepageidaujamų įvykių registravimo sistemų pobūdį; palyginti gydytojų ir slaugytojų nuomones apie profesinio tobulinimosi ir pacientų mokymo svarbą bei tinkamiausią nepageidaujamų įvykių registravimo sistemų pobūdį. Tyrimo metodika. Gydytojų ir slaugytojų požiūrio į pacientų saugos gerinimo galimybes tyrimas atliktas „N“ ligoninėje, taikant anoniminės anketinės apklausos metodą. Tyrime dalyvavo 182 medicinos darbuotojai - 45,6 proc. gydytojų ir 54,4 proc. slaugytojų (atsako dažnis 88,3 proc.). Statistinė duomenų analizė atlikta SPSS 21 for Windows. Statistinių hipotezių tikrinimui naudotas chi kvadrato kriterijus. Rezultatai. 64,8 proc. apklaustųjų mano, jog medicinos darbuotojams tobulintis, norint pagerinti pacientų saugą, yra svarbu. Jų nuomone, profesionalus svarbiausia yra mokyti apie NĮ, jų prevenciją, komandinį SP profesionalų darbą bei SP profesionalų - pacientų bendravimą. Statistiškai reikšmingai didesnė dalis gydytojų negu slaugytojų mano, kad SP profesionalus yra labai svarbu mokyti apie NĮ, jų prevenciją bei SP profesionalų - pacientų bendravimą. 70,9 proc. apklaustųjų teigia, kad pacientus mokyti jų saugos klausimais yra... [toliau žr. visą tekstą] / Aim of the study. To find out the opinion of physicians and nurses about the possibilities to improve patient safety. Objectives. To explore the opinion of physicians and nurses about the importance and subjects of health care professionals and patients education to ensure the safety of health care; to clarify the opinion of physicians and nurses about the most appropriate type of adverse event reporting system; to compare the opinions of physicians and nurses about the importance of health care professionals and patients education and the most appropriate type of adverse event reporting system. Methods. The study of the opinion of physicians and nurses about the possibilities to improve patient safety was conducted in "N" hospital, using an anonymous questionnaire survey method. There were 182 medical staff participating in the survey – 45.6 percent of them were physicians and 54.4 percent - nurses (response rate – 88.3 percent). Statistical data analysis was performed by using SSPS 21 program for Windows. Chi-square test was used to test the statistical hypothesis. Results. 64.8 percent of respondents believe that it is important for medical staff to participate in training courses in order to improve patient safety. They state that the key subjects of medical staff training courses are adverse events, prevention, teamwork in health care and health care professionals-patients communication. A statistically significantly greater proportion of physicians than nurses believe... [to full text]

Law and health policy converge with pediatric patient safety incident (PPSI) disclosure. Disclosure is vital for patient safety efforts, while respecting the decision-making autonomy of pediatric patients involves balancing parental and legal obligations with the developing independence of children. This study examined legislation potentially relevant to PPSI disclosure, along with disclosure policies from organizations providing pediatric care. Health professionals have limited legislative guidance for disclosing PPSIs and developing institutional policies. Relevant legislation is complex and varies between jurisdictions. Three jurisdictions legislatively require disclosure, including PPSI disclosure to substitute decision makers. In jurisdictions without disclosure legislation, guidance may be obtained from other legislation, including consent and capacity, substitute decision making, and child welfare. Organizations in jurisdictions with disclosure legislation may be more likely to have policies. Such policies vary between organizations. Within the policies reviewed, PPSI disclosure is based on capacity, made to a substitute decision maker, or not addressed.

Law and health policy converge with pediatric patient safety incident (PPSI) disclosure. Disclosure is vital for patient safety efforts, while respecting the decision-making autonomy of pediatric patients involves balancing parental and legal obligations with the developing independence of children. This study examined legislation potentially relevant to PPSI disclosure, along with disclosure policies from organizations providing pediatric care. Health professionals have limited legislative guidance for disclosing PPSIs and developing institutional policies. Relevant legislation is complex and varies between jurisdictions. Three jurisdictions legislatively require disclosure, including PPSI disclosure to substitute decision makers. In jurisdictions without disclosure legislation, guidance may be obtained from other legislation, including consent and capacity, substitute decision making, and child welfare. Organizations in jurisdictions with disclosure legislation may be more likely to have policies. Such policies vary between organizations. Within the policies reviewed, PPSI disclosure is based on capacity, made to a substitute decision maker, or not addressed.

Introduction: In recent decades, there has been considerable international attention directed towards minimising healthcare-associated harm and improving the safety of hospital care. More recently, this attention has broadened to include primary medical care. In 2002, the World Health Assembly recognised the issue of inadequate levels of patient safety as a major threat to global public health. In the following years, many countries have developed national strategies for the measurement, monitoring and prevention of patient safety incidents (PSIs) and their outcomes. Experience accumulated from secondary care has shown that the initial steps for understanding patient safety include the systematic identification of the most frequent and most harmful threats. However, the safety profile of primary care dentistry remains poorly investigated. As a result, current evidence cannot provide reliable estimates of the types of PSIs in primary care dentistry, the causes of these incidents, or the associated disease burden caused by such incidents. In medicine, improvements in patient safety were achieved at a national level by developing a shared conceptual understanding, the standardisation of terminology and through preventive initiatives such as the introduction of a national incident reporting and learning system. In the United Kingdom (UK), the England and Wales’ National Reporting Learning System (NRLS) has been an important source of insight, from the perspectives of the reporter, into understanding why PSIs occur. This initiative has led to the implementation of patient safety oriented policies to monitor and reduce cases of healthcare-associated harm. Examples of such policy initiatives include national guidelines and national safety recommendations to encourage the reporting of serious reportable events called ‘never events’ (NEs). These are defined as serious, preventable PSIs that should not occur if the available preventive measures are implemented. At a national level, serious incidents and NEs must be reported to the NRLS and/or other reporting systems. However, little is known about NEs in dentistry as wrong-tooth extractions are the only currently defined NE that has a clear application in dentistry. Although surgical NEs, such as wrong-site surgery and wrong implants may be related to dental procedures, these overlap with procedures conducted in secondary care. As a result, there is no agreed list of NEs for primary care dentistry. The overall aim of my PhD was to explore patient safety, its concepts, including error and harm, and how these can help to create an understanding of the types of PSIs that occur in primary care dentistry, their contributory factors and their consequences. In addition, I also aimed to identify NEs with the greatest need and opportunity for future intervention strategies, in order to improve patient safety in primary care dentistry. Methodology and methods: My PhD was conducted in three phases. For the first phase, I conducted a systematic scoping review of the empirical evidence published over a 20-year period (1994-2014). To achieve this, I searched MEDLINE and EMBASE for articles reporting incidents that could have or did result in unnecessary harm from primary dental care. I also extracted and synthesised data on the types and frequencies of PSIs (including NEs) and adverse outcomes. Then, for the second phase, I undertook an exploratory sequential mixed-methods evaluation, which involved the qualitative exploration and analysis of a weighted-by-year randomised sample (n=2,000) of the most severe incident reports from primary care dentistry submitted to the England and Wales’ NRLS. This approach generated three coding frameworks, aligned to the International Classification for Patient Safety developed by the World Health Organization, for i) the classification of incidents, ii) contributor y factors and iii) incident outcomes. These coding frameworks informed the quantitative analysis, during which myself together with a trained second coder, applied codes to deconstruct the narrative of these patient safety incident reports whilst retaining the meaning of the report. To assess inter-rater reliability, Cohen’s Kappa statistic was calculated for the primary incident type which was defined as “the incident that resulted in the outcome experienced by the patient.” Finally, for the third phase, I undertook an electronic Delphi exercise to achieve international agreement on NEs for primary care dentistry. The results obtained from Phases 1 and 2 were used to identify candidate NEs. I then invited an international panel of 41 experts to complete two rounds of questionnaires; 32 (78%) agreed to participate and completed the first round, and 29 (91%) completed the second round. I provided anonymised controlled feedback between rounds and used a cut-off of 80% agreement to define consensus. The results from the first stage built the evidence base for the second and third phases. Likewise, the results from the second phase further informed the third and final stage of my PhD. Results: I undertook a systematic scoping review which demonstrated: a) there were considerable differences in definitions for terms used to describe patient safety, b) that a range of populations had been studied, and c) that major differences in sampling strategies exist between studies. The main five PSIs I identified were errors in i) diagnosis/examination, ii) treatment planning, iii) communication, iv) procedural errors and v) the accidental ingestion or inhalation of foreign objects. However, little attention has been paid to wider organisational factors such as problems within the physical environment, scheduling (e.g. errors in managing appointments) and patient access, management and lines of responsibility. Also there is very little evidence of interest in researching into the influence of policies for either quality or patient safety assurance. The retrieved evidence was used to build a conceptual literature-derived model of patient safety risks in primary care dentistry. This model helped to bring structure to the analysis of the 1,456 patient incident reports that were eligible for analysis out of a total of 2,000. These reports described incidents across the preoperative (40.3%; n=587), intra-operative (56.1%; n=817) and post-operative (3.6%; n=52) clinical stages of care delivery. Further analysis showed the more frequently reported incidents were related to a) delays in treatment (333/1,456; 22.9%), b) procedural errors (220/11,456; 15.1%), c) medication-related adverse incidents (160/1,456; 11.0%), d) equipment failure (90/1,456; 6.2%) and e) errors in obtaining or processing x-rays (87/1,1456; 6.0%). Only 5.3% (77/1,456) of the incidents resulted in harmful outcomes. Of the 77 incidents that resulted in a harmful outcomes (n=77; 5.3%), around half were due to wrong tooth extractions (37/77; 48.1%) and resulted in unnecessary procedures. Three out of the 1,456 incidents (0.2%) resulted in death. Data from the scoping review and the mixed-method analysis informed a list of 42 candidate NEs. I further sought and achieved international consensus for 23 of these NEs. These were related to routine assessment, and pre-operative, intra-operative and post-operative stages of dental procedures. Conclusions: The findings from my PhD have revealed that patient safety research in dentistry is mostly descriptive and poorly organised with various approaches to defining and measuring PSIs and their outcomes. This poor organisation of patient safety research also includes differing study designs and patient populations studied. The evidence-based conceptual framework from the systematic scoping review, and coding frameworks from analysis of PSI reports selected from a national database, can bring structure to future work by providing a robust approach to classifying PSIs, their contributory factors and outcomes. / My research findings also show that PSI reports are an important source of information that can generate important insights about patient safety in primary care dentistry. The mixed-method analysis of PSI reports showed that most incidents in primary dental care do not result in harm. PSIs that resulted in harmful outcomes more frequently occurred intra-operatively. My findings also reveal that unsafe care in dentistry is not limited to human error, but can also be ascribed to the presence of other administrative or organisational flaws that contribute to the reported incidents. Future initiatives to improve and research clinical practice should focus on improving administrative processes to reduce delays in treatment. Also, the reduction of procedural errors through the standardisation of x-rays, medication prescription and other clinical procedures is needed. Lastly, I have constructed the first comprehensive international list of NEs for primary care dentistry. I believe my findings, including the list of NEs, can provide an evidence-base which will encourage researchers to further expand the patient safety research and development agenda in dentistry, as well as encouraging decision-makers and professional bodies to translate my findings into quality improvement strategies.

abstract: Harm to patients remains high in US hospitals despite significant progress to improve the quality of care in our health systems. Leadership, a culture of patient safety, and a climate conducive to innovation in patient care are necessary to advance positive patient safety outcomes. Yet, little is known about how leadership can impact patient safety within a climate of innovation. This study examines the effects of transformational and transactional leadership (singularly and with transactional augmenting transformational leadership) as related to nurses’ perception of patient safety, how communication elements of a culture of patient safety may strengthen that relationship, and how the mediating role of team innovation climate may help explain the relationship between transformational and transactional leadership and nurses’ perception of patient safety. The variables were measured using three validated and reliable survey instruments: The Multifactor Leadership Questionnaire (MLQ Form 5X), the Team Climate Inventory-short (TCI), the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture. A convenience sample of all staff registered nurses (N=952) from the single academic medical center with direct patient care responsibility was surveyed via e-mail for this research. A total of 210 surveys were returned, 157 met inclusion criteria for a response rate of 16%. Transformational leadership had a statistically significant relationship with patient safety perception, while the relationship of transactional leadership with patient safety perceptions was not significant. The results of the regression analysis that tested the effect of communication elements of a culture of patient safety on the relationship between transactional and transformational leadership and patient safety perception were not significant. Transformational leadership was significantly related with team innovation climate after controlling the effect of transactional leadership supporting the augmentation effect. Mediation analysis showed that team innovation climate had a significant mediating effect on the relationship between transformational leadership and patient safety perception. Team innovation climate had a significant mediating effect on the relationship between managers’ transformational leadership and patient safety perception after controlling for transactional leadership supporting the augmentation effect. This is the first study known to test the augmentation of transformational leadership related to patient safety and the role of team innovation climate. / Dissertation/Thesis / Doctoral Dissertation Nursing and Healthcare Innovation 2019