Tags Archives: Patient safety

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Lucian Leape’s legacy for patient safety

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..

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Impact of medical safety huddles on patient safety: a stepped-wedge cluster randomised study

Abstract 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..

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Multidisciplinary, evidence-based, patient-centred perioperative patient safety recommendations: a European consensus study

Abstract 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..

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A survey on factors distracting operating theatre staff during surgery in Korea

Abstract 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..

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Comparative analysis of routine clinical debriefings and incident reports: insights for patient safety and teamwork enhancement

Abstract 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..

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Moving towards a core measures set for patient safety in perioperative care: An e-Delphi consensus study

Abstract 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..

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Machine learning approaches for improvement of patient safety in surgery

Abstract 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..

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Impact of a Daily Huddle on Safety in Perioperative Services

Abstract 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..

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Evaluation of university and training standards in clinical perfusion, an European-wide survey

Abstract 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..

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Enhancing patient safety: detection of in-hospital hazards and effect of training on detection (by training in a low-fidelity simulation Room…

Abstract 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..

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Multifaceted Intervention to Improve Patient Safety Incident Reporting in Intensive Care Units

Abstract 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..

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The association between patient safety culture and adverse events – a scoping review

Abstract 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..

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What can Safety Cases offer for patient safety? A multisite case study

Abstract 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..

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Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report

Abstract 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..

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Patient Safety 2.0: Slaying Dragons, Not Just Investigating Them

Abstract 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..

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Incorporating a Patient Safety and Quality Course Into the Nursing Curriculum: An Assessment of Student Gains

Abstract 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..

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Development of the Korean Patient Safety Incidents Code Classification System

Abstract 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..

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The problem with making Safety-II work in healthcare

Abstract 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..

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A Handoffs Software Led to Fewer Errors of Omission and Better Provider Satisfaction: A Randomized Control Trial

Abstract 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,..

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Analysis of Dynamic Changes in Cognitive Workload During Cardiac Surgery Perfusionists′ Interactions With the Cardiopulmonary Bypass Pump

Abstract 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)..

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Systems-based investigation of patient safety incidents

Abstract 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..

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The contribution of human factors and ergonomics to the design and delivery of safe future healthcare

Abstract 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..

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Clinical debriefing: TALK© to learn and improve together in healthcare environments

Abstract 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..

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A tool to assess nontechnical skills of perfusionists in the cardiac operating room

Abstract 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..

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Importance of high-performing teams in the cardiovascular intensive care unit

Abstract 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..

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Fraction of expired oxygen: an additional safety approach to monitor oxygen delivery to the heart lung machine oxygenator.

Abstract 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..

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Computer Vision in the Operating Room: Opportunities and Caveats

Abstract 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..

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The Use of Extracorporeal Circulation in Suspected Brain Dead Organ Donors with Cardiopulmonary Collapse

Abstract 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..

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Narrative feedback from OR personnel about the safety of their surgical practice before and after a surgical safety checklist intervention

Abstract 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..

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Effects of Implementing Rotational Thromboelastometry in Cardiac Surgery: A Retrospective Cohort Study

Abstract 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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