An organizational culture of safety affects employees' attitudes, beliefs, perceptions, and values related to safe practice as well as their behaviors and level of engagement. The purpose of this project was to determine the influence of introducing the just culture model through staff engagement in an interactive workshop. A convenience sample of acute care staff were recruited for this 1-sample pretest and posttest project design. The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture instrument was used to measure safety culture perceptions on 7 dimensions pre and post intervention. For the theoretical framework, Ajzen's theory of planned behavior and Kantar's empowerment theory were used. Welch's t test results showed significant improvement in perception scores overall (t = 2.7, p < 0.01), with posttest mean scores ('= 3.7) higher than pretest mean scores ('= 3.5). The dimension-specific mean posttest scores were significantly higher on 3 of the 7 dimensions including teamwork (t = 2.99, p < 0.05), feedback and communication (t = 2.14, p < 0.05), and frequency of event reporting (t = 2.31, p < 0.05). Major implications for social change include reduction of preventable errors and iatrogenic events; creating a healthcare environment that is safe, fair, transparent, and reliable; creating organizational learning through evidence-based patient safety training; and promoting the use of perception surveys to measure and improve the culture in one's organization. The project may provide a road map for just culture implementation. Future qualitative and quantitative research should explore effects of a just culture on safety reporting patterns and specific events such reducing medication errors or risk-taking behaviors.

A identificação do paciente tem sido reconhecida como um componente essencial e crucial na segurança do paciente e a ausência de processo padronizado de identificação nos serviços de saúde pode contribuir para a ocorrência de falhas. O estudo teve como objetivo investigar a temática de identificação dos pacientes em serviços de saúde. Para alcançar os objetivos propostos, a pesquisa foi conduzida em três fases: a elaboração da revisão integrativa (RI) e a condução de dois estudos descritivos. A busca dos estudos primários para inclusão na RI foi realizada nas bases de dados: PubMed, CINHAL, LILACS, SciELO, Scopus e Embase. A amostra da revisão integrativa foi composta por 17 estudos primários, agrupados em seis categorias temáticas. A estratégia do uso da pulseira de identificação de forma individualizada e que atenda às necessidades tanto das instituições quanto dos pacientes têm sido apontada pelos autores. O estudo descritivo da fase dois foi conduzido em 17 instituições de saúde sendo 12 hospitais e 5 unidades de pronto atendimento selecionados com a participação dos 17 enfermeiros responsáveis técnicos (RT). Para coleta de dados foi elaborado um instrumento submetido à validação aparente e de conteúdo por cinco juízes. Os enfermeiros RT responderam sobre as estratégias utilizadas pelos serviços de saúde para identificação dos pacientes.Todos os hospitais (100%) identificam seus pacientes internados, destacando-se o uso de pulseira e nenhum pronto atendimento independente utiliza essa estratégia. A admissão do paciente representa a etapa do atendimento em que as pulseiras de identificação são colocadas. Em 75% das instituições pesquisadas foi apontado como problema a falta de padronização na utilização das pulseiras, assim como a adoção de modelos não padronizados, destacada a variedade de cores, para identificar determinadas informações sobre o paciente. Em 33,3% dos hospitais mais de uma pulseira é colocada no mesmo paciente. Para a identificação de alergias, 50% dos hospitais usam pulseira vermelha. O nome completo, sobrenome, registro hospitalar e data de nascimento são dados que devem constar na pulseira de identificação do paciente. A pulseira de identificação tem sido reconhecida como a melhor forma de identificação do paciente nas instituições de saúde, mas além do uso desta metodologia é importante que todos, ao prestar um cuidado realizem a checagem da identificação confirmando neste momento os identificadores preconizados. O estudo descritivo da fase três foi conduzido em uma instituição hospitalar selecionada com vistas a analisar a influência da identificação do paciente na ocorrência de eventos adversos (EA) quanto às causas, locais das ocorrências, frequência, se a identificação foi uma barreira, danos causados, consequências, medidas corretivas e preventivas. No período analisado, de agosto de 2012 a agosto de 2014, foi notificado um total de 1673 ocorrências no sistema de notificação, sendo que dessas, 38 estavam relacionadas à identificação do paciente, representando 2,3% do total das ocorrências. A identificação do paciente atuou como barreira para identificar uma falha no processo relacionada ao EA em 45% das notificações. A quebra de protocolo foi responsável por 86% das causas que levou a ocorrência de EA, relacionadas à identificação do paciente. A existência de protocolos e procedimentos escritos por si só não garantem que falhas aconteçam, principalmente em relaçao à identificação do paciente, sendo necessário a implementação de medidas de avaliação do cumprimento dos mesmos. Isso possibilitará o aprimoramento desse processo e, com isso, garantirá qualidade e segurança / Patient identification has been acknowledged as a crucial an essential component in patients\' safety and the absence of a standard identification process in healthcare services can contribute to failures. This study aimed to investigate the theme around patient identification in healthcare services. To reach such objectives, research was conducted in three phases: elaboration of an integrative review and the conduction of two descriptive studies. Search for primary studies to be included in the integrative review was done on the following databases: PubMed, CINHAL, LILACS, SciELO, Scopus and Embase. The integrative review\'s sample concerned of 17 primary studies in six categories: identification in the healthcare teams\' and patients\' (or the patients\' tutors\') perspective (eis); identification in newborn and pediatric patients; identification in administration of chemotherapy and medication; identification in blood transfusion and sample collecting; identification in surgical patients and implementation of patient identification policies. The identification wristband strategy in an individualized manner with regards to both the patients\' and the institutions\' needs has been acclaimed by authors. Phase 2\'s descriptive study was conducted in 17 healthcare institutions, 12 hospitals and 5 emergency care units, selected with participation of 17 tech-nurses in charge. For data collection, an instrument that underwent apparent and content validation by five judges was created. Nurses answered about strategies used by healthcare services for patient identification. Every hospital reported having identification protocols; and while wristbands usage stands out in hospitals, no independent emergency care unit uses that strategy. Patient admission represents the stage during which wristbands are placed. In 75% of the researched institutions, lack of standardization in wristband use was pointed out as an issue as well as adoption of non-standardized methods; variety in color for the sake of categorization of patients sticks out in this matter. In 33% of the hospitals, more than one wristband is placed on a single patient. For identification of allergies, 50% of the hospitals use red wristbands. A patient wristband must contain a patient\'s full name, hospital record and date of birth. The identification wristband has been acknowledged as the best form of identification for patients in healthcare facilities, but apart from this method, it is important that all who are carrying out patient care check the identification, confirming the preconized identification. Phase 3\'s descriptive study was conducted in a selected hospital facility for this investigation aimed to analyze the influence of patient identification on adverse events (EA) as to causes, locale, frequency, if identification was a barrier, damage caused, consequences, and corrective and preventive measures. In the time period from August 2012 and August 2014, a total of 1673 occurrences in the institution\'s identification system was notified; among those, 38 concerned patient identification, representing 2,3% of the total. Patient identification acted as a barrier to identify a failure in an EA-related process in 45% of institutions. Protocol breach was behind 86% of the cause of EA occurrences that were connected to patient identification. Existence of protocols and procedures written alone does not guarantee failures occur, especially when it comes down to patient identification; which brings out the need for implementation of measures of evaluation that assure that these protocols are being followed by the staff. This will allow the enhancement of this process and with it a betterment in quality and safety in patient care

Bakgrund: Inom dagens slutenvård möter legitimerade sjuksköterskor en ökad arbetsbelastning samtidigt som sjuksköterskor förväntas utföra god och säker vård gentemot patienter. Situationen kan resultera i att vårdskador uppstår och patientsäkerheten äventyras.  Syfte: Syftet var att belysa de faktorer som har betydelse för patientsäkerheten inom slutenvården utifrån sjuksköterskors perspektiv. Metod: Litteraturöversikt baserat på 20 artiklar med både kvalitativ och kvantitativ ansats. Resultat: Faktorer som påverkade patientsäkerheten identifierades som ogynnsam Arbetsmiljö, vårdpersonalens Kompetens, Kommunikation, Samarbete inom vårdlaget och Patientsäkerhetskulturen på avdelningen. Slutsats: Det är av vikt att identifiera arbetsrelaterade faktorer för att skapa en bättre arbetsmiljö och förebygga uppkomsten av vårdskador vilket leder till en förbättrad patientsäkerhet och en säker vård. / Background: Registered nurses of today in the inpatient care face increased workload concurrently when nurses are expected to deliver good and safe care for patients. The situation of today´s health care may result in patient safety events and jeopardizing patient safety. Aim: The aim of this study was to describe factors in inpatient care that can have an impact on patient safety. Method: A literature review including 20 articles with both qualitative and quantitative approach was performed. Results: Factors that have an impact on patient safety were identified as unfavorable Work environment, Healthcare workers competence, Communication, Cooperation within the task force and the patient safety culture in the department. Conclusion: It is important to identify work-related factors in order to create a better work environment and prevent patient safety events which leads to improved patient safety and safe care.

Healthcare systems require continuous monitoring of risk to prevent adverse events. Risk analysis is a time consuming activity that depends on the background of analysts and available data. Patient safety data is often incomplete and biased. This research proposes systematic approaches to monitor risk in healthcare using available patient safety data. The methodologies combine traditional healthcare risk analysis methods with safety theory concepts, in an innovative manner, to allocate available evidence to potential risk sources throughout the system. We propose the use of data mining to analyze near-miss reports and guide the identification of risk sources. In addition, we propose a Maximum-Entropy based approach to monitor risk sources and prioritize investigation efforts accordingly. The products of this research are intended to facilitate risk analysis and allow for timely identification of risks to prevent harm to patients.

”Bakgrund: Preoperativ bedömning syftar till att identifiera sjukdomar och risker för anestesiförfarandet och att planera anestesin. Syfte: Att beskriva hur ofta den planerade preoperativa anestesibedömningen ändras vid anestesi induktion. Specifika frågeställningar var om det fanns skillnader i antal ändringar mellan kön, ålder, ASA- klassificering och tid på dygnet för operation. Metod: Retrospektiv journalgranskning som redovisas med deskriptiv statistik. Resultat: Av 177 inkluderade journaler uppvisade 130 (73,4%) en avvikelse från den preoperativa planen till anestesi induktionen. Det fanns ingen signifikant skillnad mellan antalet avvikelser för kön, ålder, ASA -klassificering eller tid på dygnet för operation. Slutsats: Den preoperativt planerade anestesimetoden ändrades vid majoriteten av anestesiinduktionerna.”

The aim of the thesis was to develop and evaluate a Computerised Decision Support System (CDSS) for use in pre-hospital care.The thesis was guided by a theoretical framework for developing and evaluating a complex intervention. The four studies used different designs and methods. The first study was a systematic review of randomised controlled trials. The second and the last studies had experimental and quasi-experimental designs, where the CDSS was evaluated in a simulation setting and in a clinical setting. The third study included in the thesis had a qualitative case study design.The main findings from the studies in the thesis were that there is a weak evidence base for the use of CDSS in pre-hospital care. No studies have previously evaluated the effect of CDSS in pre-hospital care. Due to the context, pre-hospital care is dependent on protocol-based care to be able to deliver safe, high-quality care. The physical format of the current paper based guidelines and protocols are the main obstacle to their use. There is a request for guidelines and protocols in an electronic format among both clinicians and leaders of the ambulance organisations. The use of CDSS in the pre-hospital setting has a positive effect on compliance with pre-hospital guidelines. The largest effect is in the primary survey and in the anamnesis of the patient. The CDSS also increases the amount of information collected in the basic pre-hospital assessment process. The evaluated CDSS had a limited effect on on-the-scene time.The developed and evaluated CDSS has the ability to increase pre-hospital patient safety by reducing the risks of cognitive bias. Standardising the assessment process, enabling explicit decision support in the form of checklists, assessment rules, differential diagnosis lists and rule out worst-case scenario strategies, reduces the risk of premature closure in the assessment of the pre-hospital patient. / För avläggande av doktorsexamen i Kvalitetsförbättring och ledarskap inom hälsa och välfärd som med tillstånd av Nämnden för utbildning och forskarutbildning vid Högskolan i Jönköping framläggs till offentlig granskning torsdagen den 5 juni 2014 kl.13.00 i sal M 204, Högskolan i Borås.

Introduktion: Hälften av alla vårdskador uppkommer i samband med operation. Operationsteamet är ett multidisciplinärt samarbete där många människor från flera yrkeskategorier arbetar tillsammans i olika konstellationer med patientsäkerheten som en av de viktigaste delarna. Operationssjuksköterskan och anestesisjuksköterskan ansvarar för patientens omvårdnad före, under och efter operationen. Syfte: Att beskriva hur omvårdnadsteamet arbetar intraoperativt beträffande patientsäkerheten. Metod: En integrerad systematisk litteraturstudie där artiklar söktes i databaserna Cinahl och PubMed. Elva artiklar med kvantitativ, kvalitativ och mixed method valdes ut och analyserades. Resultat: Materialet resulterade i tre kategorier: Att vara förberedd, att utbyta information med varandra och att vara förtrogen med varandras färdigheter. Konklusion: En stor del av resultatet visade på att förberedelser där hela omvårdnadsteamet involveras, kontinuerligt utbyter information med varandra och är förtrogna med varandras yrkesprofessionella färdigheter stärker patientsäkerheten. Resultatet av denna litteraturstudie kan leda till en ökad förståelse för operationsteamets betydelse för patientsäkerheten intraoperativt. / Introduction: Half of all health care-associated injuries occur in conjunction with surgery. The patient care team is a multidisciplinary collaboration where many people from different professions work together in different configurations with patient safety as one of the most important aspects. The operating theatre nurse and the nurse anesthetist are responsible for the patients nursing care before, during and after the surgery. Aim: To describe how the patient care team works intraoperatively regarding the patient safety. Method: An integrated systematic literature study were articles searches where made using the databases Cinahl and PubMed. Eleven articles with quantitative, qualitative and mixed method analysis has been reviewed. Result: The material resulted in three categories: To be prepared, to exchange information with each other and to be familiar with each other’s skills. Conclusion: A large part of the result showed that preparations where the whole patient care team was involved, continuously exchanging information with each other and were familiar with each other’s professional skills enhances the patient safety. The result of this literature study might lead to an increased understanding of the importance of the patient care team for patient safety intraoperatively.

Bakgrund: Patientnämnden är en förtroendenämnd dit patienter och anhöriga kan vända sig för att lämna synpunkter och klagomål på den vård de mottagit. Patientnämnden arbetar bland annat med att sammanställa de inkomna ärendena och återkopplar tillbaka till hälso- och sjukvården för att främja patientsäkerheten. Hur patienter och anhöriga använder sig av Patientnämnden för att rapportera vårdskador är ett relativt outforskat område i dagens läge. Syfte: Syftet med studien var att undersöka ärenden som inkommit till Patientnämnden i ett landsting i Mellansverige under 2015 för att identifiera, analysera och beskriva andelen somatiska vårdskador som anmäls av patienter och anhöriga. Metod: Studien är en empirisk studie där data från redan befintliga ärenden granskats och studien har en kvantitativ, beskrivande design. Huvudresultat: 86 av 395 studerade ärenden handlade om somatisk vårdskada, av dessa var 59 allvarliga somatiska vårdskador. Det var fler kvinnor än män som anmält somatiska vårdskador, både vad gäller allvarliga och lätta somatiska vårdskador. Den vanligaste orsaken till vårdskada var kirurgirelaterade komplikationer. Slutsats: Endast en liten del av de inkomna ärendena handlade om somatiska vårdskador, och då oftast om allvarliga vårdskador. Det behövs mer information och vägledning från vårdpersonal till patient för att fånga upp och synliggöra både lätta och allvarliga vårdskador. Det behövs även mer forskning om varför kvinnor anmäler vårdskada i större utsträckning än män. / Background: The patients' advisory committee is an independent committee to which patients and relatives can file complaints and comments about their recieved care. The patients' advisory committee works with patient safety through reconnecting the patients' cases to their caregiver. Research regarding the patient useage of the Patients' advisory committee for reporting care injuries is currently quite uncharted. Study aim: The aim of the study was to investigate cases recieved at the Patients' advisory committee in a county in Sweden during 2015 to identify and describe the somatic care injuries reported by patients and relatives. Method:  This study examines existing cases from the Patients' advisory committee and uses a quantitative, descriptive design. Main results: 86 out of 395 cases regarded somatic care injuries, of which 59 were severe care injuries. Women reported both severe and non severe care injuries more often than men. The most often occuring resason for a care injury was surgery-related complications. Conclusion: Only a small fraction of the total amount of cases regarded somatic care injuries. Severe care injuries appeared more often than non severe care injuries. More guidance and information to the patients and relatives is required from the caregivers to enlighten the occurance of care injuries. More research is needed regarding why women report care injuries more often than men.

Sjuksköterskor arbetar ofta i en miljö med stort ansvar och höga krav som kan leda till arbetsrelaterad stress som kan hota sjuksköterskornas hälsa och patientsäkerheten. Syftet med studien var att få ökad kunskap om sjuksköterskors upplevelser av arbetsrelaterad stress. Studien genomfördes som en litteraturstudie med sju vetenskapliga artiklar som låg till grund för studiens resultat. Efter granskning och analys av artiklarna framkom tre kategorier: kommunikationens och personalrelationers betydelse för upplevelsen av arbetsrelaterad stress, arbetsbelastningens betydelse för upplevelsen av arbetsrelaterad stress samt sjuksköterskeyrkets värde ur organisatoriskt-, samhälls- och personligt perspektiv. Studiens resultat visade att sjuksköterskor i flera länder upplevde stress i arbetet. Faktorer som i huvudsak bidrog till ökad arbetsrelaterad stress var brister i kommunikationen i sjuksköterskegruppen och även med olika professioner, hög arbetsbelastning samt sjuksköterskeyrkets nedvärdering ur organisatorisk-, samhälls- och ett personligt perspektiv. Det framkom även faktorer som bidrog till minskad arbetsrelaterad stress, till exempel reflektion i personalgruppen, möjlighet till rast samt delaktigtighet i organisationen. Vidare forskning för att belysa patienters, samt samhällets perspektiv på arbetsrelaterad stress hade varit av vikt för att uppmärksamma arbetsrelaterad stress inom sjukvården. / Nurses do often work in an environment with a big responsibility and high demands that can lead to work-related stress and can become a threat to nurses health and the patient safety. The aim of this study was to gain better knowledge about nurses ́ experiences of work-related stress. The study was performed as a literature study with seven scientific articles which formed the base for the result. After reviewing and analyzing the articles three themes occurred: The role of communication and relationship between workers for the experience of work- related stress, the role of workload for the experience of work-related stress and the worth of the nurse profession in an organizational-, societal- and a personal perspective. The result showed that nurses in several countries experienced stress in their work. The main factors for work- related stress were poor communication within a professional group and between nurses and other healthcare professionals, high workload, and the depreciation from an organizational-, societal- and personal perspective. The result also showed that work- related stress could be reduced with reflection, the opportunity to take breaks and participation in the organization. Further research to enlighten patients ́ and the society ́s perspective on work- related stress would be important to draw attention to work-related stress in healthcare.

Bakgrund Idag används olika medicinsktekniska produkter för helkroppsimmobilisering vid misstanke om spinal skada prehospitalt. Valet av immobiliseringsutrustning som skall användas görs av ansvarig sjuksköterska på plats. Den vanligaste utrustningen är ryggbräda, vaccummadrass, Kendric Extration Device (KED-väst) och nackkrage. Då utbildningen Pre Hospital Trauma Life Support (PHTLS) varit en del av specialistutbildningen för ambulanssjuksköterskor under en längre period har det funnits lite anledning till att ifrågasätta helkroppsimmobilisering och dess utrustning. All immobiliseringsutrustning klassificeras under klass 1 av Läkemedelsverket, vilket kan innebära att få vetenskapliga studier har gjorts för att utvärdera immobilieringsutrustning. Patientsäkerhetslagen ska efterlevas vad gäller vetenskaplig och beprövad metod i omvårdnaden av patienter med misstänkt spinal skada. Syfte Att genom en litteraturgranskning undersöka rekommendationer och eventuella risker med helkroppsimmobilisering vid misstanke av spinal skada prehospitalt utifrån patientsäkerhet och ett historiskt perspektiv. Metod Studien genomförs som litteraturgranskning med artikelgranskning och ett retrospektivt, deskriptivt perspektiv. Resultat Forskning rekommenderade helkroppsimmobilisering på traumapatienter där det fanns misstanke om spinal skada. Behandlingsriklinjerna följde nuvarande forskningsrekommendationer. Forskningskvaliten hade blivit bättre över tid och resultaten hade ökat i trovärdighet. Flera forskare påvisade risker med helkroppsimmobilisering. Riskerna var relaterade till dagens immobiliseringsutrustning. Ett antal alternativ till dagens immobiliseringsutrusning fanns beskrivna, men användes inte och var inte omnämnda i behandlingsriktlinjer. Slutsats Forskning rekommenderar helkroppsimmobilisering på traumapatienter där det finns misstanke om spinal skada. Immobiliseringutrustning har bevisligen flera risker för patienter, vilka orsakar allvarliga konsekvenser för hälsan. En lågt sittande ryggskada kanske inte behöver helkroppsimmobiliseras. Det kanske räcker med halvkroppsimmobilisering för vissa patienter. / Background Today, there are various medical devices for full body immobilisation in cases of suspected spinal injury prehospital. The choice of immobilisation devices to be used is the charge nurse’s on site. The most common equipment is back board, vaccummadrass, Kendric extraction Device (KED - West) and cervical collar. Because When training Pre Hospital Trauma Life Support (PHTLS) has been part of the specialist training of ambulance nurses over a longer period , there has been little reason to question full body immobilisation and its equipment . All immobilisation devices classified under Class 1 of the Medical Product Agency (MPA) , which may mean that few scientific studies have been done to evaluate immobilisation devices. The Patient Safety Act must be complied with in terms of scientific and proven method in the care of patients with suspected spinal injury. Aim Through a literature review examining recommendations and possible risks of full body immobilisation on suspicion of spinal injury pre-hospital based on patient safety and a historical perspective. Method The study is conducted as a literature review with the article review and a retrospective, descriptive perspective. Result Research recommended full body immobilisation on trauma patients where there was suspicion of spinal injury. Treatment guidelines followed the current research recommendations. The research quality had improved over time and results in increased credibility. Several researchers demonstrated the risks of full body immobilisation. The risks were related to today's immobilisation devices. A number of alternatives to current immobilisation devices was described, but was not used and was not mentioned in the treatment guidelines. Conclusion Research recommends full body immobilisation of trauma patients where there is a suspected spinal injury. Immobilisation devices has proven more risks for patients , which cause serious health consequences. A low sitting back injury may not need full body immobilisation. It might suffice with a half body immobilisation for some patients.