Journal of patient safety
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Journal of patient safety · Sep 2013
Improving patient safety in the ICU by prospective identification of missing safety barriers using the bow-tie prospective risk analysis model.
To improve patient safety, potential critical events should be analyzed for the existence of preventive barriers. The aim of this study was to prospectively identify existing and missing barriers using the Bow-Tie model. We expected that the analysis of these barriers would lead to feasible recommendations to improve safety in daily patient care. ⋯ Prospective risk analysis using the Bow-Tie model proved usable to identify existing and missing barriers for potential critical events. Many missing barriers seemed feasible to implement and led to practical recommendations and improvements in patient safety.
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Journal of patient safety · Sep 2013
Application of an engineering problem-solving methodology to address persistent problems in patient safety: a case study on retained surgical sponges after surgery.
Despite innumerable attempts to eliminate the postoperative retention of surgical sponges, the medical error persists in operating rooms worldwide and places significant burden on patient safety, quality of care, financial resources, and hospital/physician reputation. The failure of countless solutions, from new sponge counting methods to radio labeled sponges, to truly eliminate the event in the operating room requires that the emerging field of health-care delivery science find innovative ways to approach the problem. ⋯ To make the operating room a safe environment for patients, the team identified a need to make the sponge itself safe for use as opposed to resolving the relatively innocuous counting methods. In evaluation of this case study, the need for systematic engineering evaluation to resolve problems in health-care delivery becomes clear.
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Journal of patient safety · Sep 2013
Exploring physician hand hygiene practices and perceptions in 2 community-based Canadian hospitals.
The purpose of this study was to explore the self-reported hand hygiene practices and the predictors of hand hygiene among physicians in a midsize Canadian city. ⋯ Hand hygiene compliance among physicians remains an issue. The findings emphasize the need of health-care institutions to prioritize hand hygiene by ensuring proper promotion and enforcement of current policies to all practicing HCPs.
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Journal of patient safety · Jun 2013
PCA safety data review after clinical decision support and smart pump technology implementation.
Medication errors account for 20% of medical errors in the United States with the largest risk at prescribing and administration. Analgesics or opioids are frequently used medications that can be associated with patient harm when prescribed or administered improperly. In an effort to decrease medication errors, Duke University Hospital implemented clinical decision support via computer provider order entry (CPOE) and "smart pump" technology, 2/2008, with the goal to decrease patient-controlled analgesia (PCA) adverse events. ⋯ This study demonstrated a decrease in PCA events between time periods in both the ADE-S and voluntary report system data, thus supporting the recommendation of clinical decision support via CPOE and PCA smart pump technology.
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Journal of patient safety · Dec 2012
Speaking up and sharing information improves trainee neonatal resuscitations.
To identify teamwork behaviors associated with improving efficiency and quality of simulated resuscitation training. ⋯ Teamwork behaviors of assertion and sharing information are 2 important mediators of efficiency and quality of resuscitations.