Abstract In losing Lucian Leape to heart failure last 30 June, at the age of 94 years, we lost a rare physician whose insights fundamentally changed how clinicians and the..
Read MoreAbstract Background Medical safety huddles are short, structured meetings for physicians to proactively discuss and respond to profession-specific patient safety concerns, with the goal of decreasing future adverse events. Prior observational..
Read MoreAbstract Background Surgery-related adverse events are among the most common adverse events in-hospital. However, no comprehensive, multidisciplinary perioperative guidelines exist at the European level. The aim of this study is..
Read MoreAbstract Objective: This study aimed to identify disruptions perceived by operating theatre staff to improve concentration, patient safety and quality of care. Methods: A survey of 156 medical staff at..
Read MoreAbstract Background Routine clinical debriefings (RCDs) have been shown to improve communication, team reflexivity, and safety in clinical settings. When combined with incident reports (IRs), RCDs offer a potential tool..
Read MoreAbstract A Core Measures Set (CMS) is an agreed standardized group of measures that should be assessed and reported in research for a specific condition or clinical area. This study..
Read MoreAbstract Traditional patient safety protocols are based on the historic principle of the Hippocratic oath intended to abstain from inflicting harm on our patients (”Primum non nocere”) []. In spite..
Read MoreAbstract Background Communication failures contribute to quality gaps and may lead to serious safety events (SSEs) in the operating room (OR). Our perioperative services team experienced an increased rate of..
Read MoreAbstract OBJECTIVES Adequate theoretical and practical training of prospective clinical perfusionists is essential for maintaining clinical standards and ensuring patient safety during cardiac surgery procedures. Perfusion schools play a crucial..
Read MoreAbstract Importance Adequate situational awareness in patient care increases patient safety and quality of care. To improve situational awareness, an innovative, low-fidelity simulation method referred to as Room of Improvement, has..
Read MoreAbstract Objectives Patient safety incident reporting in our institution’s intensive care units (ICUs) had fallen 30% below national benchmarks during the COVID-19 pandemic. Underreporting diminishes awareness of risks and precludes..
Read MoreAbstract Background Adverse events (AEs) affect 10% of in-hospital patients, causing increased costs, injuries, disability and mortality. Patient safety culture (PSC) is an indicator of quality in healthcare services and..
Read MoreAbstract Background The Safety Case is a regulatory technique that requires organisations to demonstrate to regulators that they have systematically identified hazards in their systems and reduced risks to being as..
Read MoreAbstract Ensuring organisations learn from patient safety incidents is a key aim for healthcare organisations. The role that human factors and systems thinking can have to enable organisations learn from..
Read MoreAbstract The purpose of patient safety work is to reduce avoidable patient harm. This requires us to slay dragons—to eliminate or at least mitigate risks to patients. Instead, current practice focuses..
Read MoreAbstract Background Training nursing students on quality and patient safety (PS) is crucial to ensuring safe healthcare practices given the key role nurses play on the healthcare team. The aim..
Read MoreAbstract Objectives Attempts to understand patient safety using administrative data in Korea have been rare. This study develops a Korean patient safety incident code classification system and identifies its characteristics..
Read MoreAbstract Patient safety is typically assessed by the frequency of adverse events or incidents, which means we seek to determine safety by its absence rather than its presence. The Safety-II perspective..
Read MoreAbstract Background Computer-assisted communication is shown to prevent critical omissions (“errors”) in the handoff process. Objective The aim of the study was to study this effect and related provider satisfaction,..
Read MoreAbstract Objective This novel preliminary study sought to capture dynamic changes in heart rate variability (HRV) as a proxy for cognitive workload among perfusionists while operating the cardiopulmonary bypass (CPB)..
Read MoreAbstract Patient safety events are common in healthcare. We can learn from other safety-critical industries that further incidents are most likely to be prevented where lessons are learned at the..
Read MoreAbstract Human factors and ergonomics (HF/E) is concerned with the design of work and work systems. There is an increasing appreciation of the value that HF/E can bring to enhancing..
Read MoreAbstract The use of clinical debriefing promotes team reflexivity, aligns with Safety II principles and allows organisation leaders to engage clinicians in collaborative change. There is ample evidence of its..
Read MoreAbstract Objectives This study aimed to develop the Perfusionists' Intraoperative Non-Technical Skills tool, specifically to the perfusionists' context, and test its inter-rater reliability. Methods An expert panel was convened to..
Read MoreAbstract The importance of teamwork in health care delivery and patient safety is increasingly being recognized and has benefitted substantially by adopting a human factors' perspective and approach. The scientific..
Read MoreAbstract Background: Monitoring oxygen delivery to the oxygenator of a heart lung machine (HLM) is typically accomplished with an O2 analyzer connected to the gas inflow line. It is assumed when..
Read MoreAbstract Effectiveness of computer vision techniques has been demonstrated through a number of applications, both within and outside healthcare. The operating room environment specifically is a setting with rich data..
Read MoreAbstract Background: Monitoring oxygen delivery to the oxygenator of a heart lung machine (HLM) is typically accomplished with an O2 analyzer connected to the gas inflow line. It is assumed when..
Read MoreAbstract Objective To examine narrative feedback to understand surgical team perceptions about surgical safety checklists (SSCs) and their impact on the safety of surgical practice. Design We reviewed free-text comments..
Read MoreAbstract Since 2013, rotational thromboelastometry has been available in our hospital to assess coagulopathy. The aim of the study was to retrospectively evaluate the effect of thromboelastometry testing in cardiac..
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