Qual Saf Health Care
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Qual Saf Health Care · Apr 2009
Development and validation of the SURgical PAtient Safety System (SURPASS) checklist.
A large number of preventable adverse events are encountered during hospital admission and in particular around surgical procedures. Checklists may well be effective in surgery to prevent errors and adverse events. We developed, validated and evaluated a SURgical PAtient Safety System (SURPASS) checklist. ⋯ The SURPASS checklist covers the vast majority of process deviations suitable for checklist assessment and can be applied in clinical practice relatively simply. SURPASS is the first validated patient safety checklist for the entire surgical pathway.
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Qual Saf Health Care · Apr 2009
The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre.
Unintended harm to patients in operating theatres is common. Correlations have been demonstrated between teamwork skills and error rates in theatres. This was a single-institution uncontrolled before-after study of the effects of "non-technical" skills training on attitudes, teamwork, technical performance and clinical outcome in laparoscopic cholecystectomy (LC) and carotid endarterectomy (CEA) operations. ⋯ Considerable cultural resistance to adoption was encountered, particularly among medical staff. Debriefing and challenging authority seemed more difficult to introduce than other parts of the training. Further studies are needed to define the optimal training package, explain variable responses and confirm clinical benefit.
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To evaluate the process of incident reporting in a surgical setting. In particular: the influence of event outcome on reporting behaviour; staff perception of surgical complications as reportable events. ⋯ An incident is more likely to be reported if harm results. Surgical complications are not generally perceived to be "reportable incidents," but they are addressed in Mortality and Morbidity meetings (M&M). Integrating M&M and incident reporting data will result in more comprehensive healthcare safety systems.
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Qual Saf Health Care · Feb 2009
ReviewFeedback from incident reporting: information and action to improve patient safety.
Effective feedback from incident reporting systems in healthcare is essential if organisations are to learn from failures in the delivery of care. Despite the wide-scale development and implementation of incident reporting in healthcare, studies in the UK suggest that information concerning system vulnerabilities could be better applied to improve operational safety within organisations. In this article, the findings and implications of research to identify forms of effective feedback from incident reporting are discussed, to promote best practices in this area. ⋯ Limited research evidence exists concerning the issue of effective forms of safety feedback within healthcare. Much valuable operational knowledge resides in safety management communities within high-risk industries. Multiple means of feeding back recommended actions and safety information may be usefully employed to promote safety awareness, improve clinical processes and promote future reporting. Further work is needed to establish best practices for feedback systems in healthcare that effectively close the safety loop.