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Found 654 results
  1. Content Article
    This article from the Agency for Healthcare Research and Quality (AHRQ) in the United States is the transcript of a conversation between AHRQ’s Acting Director David Meyers, MD, and the Agency’s chief patient safety official, Jeff Brady, MD MPH, about key issues in diagnostic safety. Diagnostic safety is “the newest frontier in patient safety,” according to Dr Brady, who emphasises the Agency’s commitment to improve diagnostic safety and explains how researchers are working to better understand diagnostic errors and design systems and processes to reduce errors.
  2. Content Article
    This toolkit created by The National Academies of Sciences, Engineering and Medicine contains information and resources to help patients learn about and engage in the diagnostic process. There are many barriers to patients fully engaging in their diagnosis, and this toolkit aims to help patients take control of their role in the process, as well as equipping healthcare providers to create an atmosphere that allows patients to contribute meaningfully.
  3. Content Article
    This report from The National Academies of Sciences, Engineering and Medicine highlights three key themes around the issue of diagnostic error: The importance of diagnostic error in patient safety and the need to give the subject more research attention The central role that patients play in helping to avoid diagnostic error. The idea that diagnosis is a collaborative effort involving intra- and interprofessional teamwork. It also looks at several specific issues that must be addressed to reduce diagnostic errors.
  4. Content Article
    This narrative review in BMJ Quality & Safety argues that being able to measure the incidence of diagnostic error is essential to enable research studies on diagnostic error and to initiate quality improvement projects aimed at reducing the risk of error and harm. It highlights three approaches that may help with measuring the incidence of diagnostic error: Using ‘trigger tools’ to identify from electronic health records cases at high risk for diagnostic error Using standardised patients (secret shoppers) to study the rate of error in practice Encouraging both patients and physicians to voluntarily report errors they encounter, and facilitating this process
  5. Content Article
    Racial and ethnic disparities in health and healthcare continue to be widespread. Research has repeatedly confirmed that members of racial and ethnic minority groups in the US are more likely to experience disparities in care, including having an increased risk of being uninsured or underinsured, lacking access to care, and experiencing worse health outcomes for treatable and preventable conditions. This brief from the Emergency Care Research Institute (ECRI) outlines strategies for understanding, detecting and reducing disparities. It demonstrates that alongside the moral case for addressing racial and ethnic disparities in care, there are further benefits for staff and healthcare organisations.
  6. Content Article
    This animation by the Rockefeller Foundation explains how the 'Swiss Cheese' model can be applied to containing the spread of COVID-19. Combining different methods of infection control such as wearing face masks, social distancing and vaccination, creates a more solid and resilient barrier to transmission.
  7. Content Article
    This article by the Patient Safety Network provides an overview of the impact of diagnostic errors on patient safety. It gives examples of incorrect applications of heuristics and suggests ways to overcome cognitive bias in the diagnostic process.
  8. Content Article
    Numerous studies show a link between a positive safety culture (where safety is a shared priority) and improved patient safety within a healthcare organisation. The evidence is so convincing that the US National Patient Safety Foundation (NPSF) lists leadership support for a safety culture as the most important of eight recommendations for achieving patient safety. This overview from the Emergency Care Research Institute (ECRI) provides guidance and recommendations on how to embed approaches to safety culture within healthcare organisations.
  9. Content Article
    Delayed, missed and incorrect diagnoses are common causes of errors that result in patient harm and inappropriate care. However, some diagnostic errors may be avoided by effectively using health information technology. These resources from the Emergency Care Research Institute provide information on how to implement IT processes to close the loop on diagnostic evaluations.
  10. Content Article
    Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is a common treatment of symptomatic gallstones and other gallbladder conditions. This study from MacFadyen et al. reviewd laparoscopic cholecystectomy in the United States from 1989 to 1995. A total of 114,005 cases were analysed and 561 major bile duct injuries (0.50%) and 401 bile leaks from the cystic duct or liver bed (0.38%) were recorded. Based on this review of laparoscopic cholecystectomies, the authors found that the morbidity and mortality rates are similar to open surgery. In addition, the rate of bile duct injuries and leaks is higher than in open cholecystectomy. Furthermore, bile duct injuries can be minimised by lateral retraction of the gallbladder neck and careful dissection of Calot's triangle, the cystic duct-gallbladder junction, and the cystic duct-common bile duct junction.
  11. Content Article
    This blog by consultancy firm Gallup highlights seven questions leaders should ask to about their huddles, to ensure they are effective in improving patient safety and preventing staff burnout.
  12. Content Article
    This systematic review in BMJ Quality & Safety looks at existing research into the impact of hospital-based safety huddles. The authors found that while there are many anecdotal accounts of successful huddle programmes, there is not yet much high-quality peer-reviewed evidence regarding the effectiveness of hospital-based safety huddles. They suggest that additional rigorous research is needed to enhance collective understanding of how huddles impact patient safety and other outcomes. The review proposes a taxonomy and standardised reporting measures for future studies, to enhance comparability and evidence quality.
  13. Content Article
    This article in The Health Care Manager examines the value of 'huddles' - regular, interdisciplinary group meetings - in improving communication among disciplines, resolving problems and sharing information.  The authors found that the primary function of huddles was the exchange of information that posed or had the potential to pose safety risks to patients. Staff reported that huddles were useful in improving awareness of safety concerns and also improved communication between disciplines.
  14. Content Article
    Patients and their families are usually the first to notice new or changing symptoms and they can play an important role in preventing diagnostic errors. This blog in BMJ Opinion describes how researchers, healthcare professionals and patients worked together to develop OurDX, an online tool designed to improve the efficiency of medical appointments and reduce diagnostic errors.
  15. Content Article
    Appreciative inquiry is a collaborative, strengths-based approach to change in organisations and other human systems. It identifies the positive strengths of an organisation or system and builds on these, rather than focusing on problems that need to be fixed. This article for PositivePsychology.com outlines the history, theory and framework of appreciative inquiry, as well as looking at real-life examples.
  16. Content Article
    The Anesthesia Patient Safety Foundation Newsletter is the official publication of the non-profit Anesthesia Patient Safety Foundation and is published three times per year in Wilmington, Delaware, USA. Download all copies of the newsletter
  17. Content Article
    Research shows that peer support is an effective way to help healthcare staff recover when something goes wrong in patient care. The Betsy Lehman Center for Patient Safety has developed a toolkit that aims to help healthcare organisations create or expand peer support opportunities for staff. Each section of the online toolkit focuses on key elements of a successful peer support program - from gaining leadership buy-in to creating policies and collecting data.
  18. Content Article
    This report by Charles River Laboratories looks at the results of a survey of more than 1,500 Americans conducted in May 2021 by The Harris Poll. The survey showed that 64% respondents believed that closer collaboration between industry organisations would lead to higher quality healthcare. The report contains data on: patient views about the state of the US healthcare system how much patients know about drug and vaccine development processes patient attitudes towards the US Food & Drugs Administration (FDA) how the COVID-19 pandemic has increased collaboration in healthcare.
  19. Content Article
    A study by Charles River found that patients believe the overall quality of healthcare would increase if stakeholders across the life sciences collaborated more. In this interview with Outsourcing-Pharma, Birgit Girshick, corporate executive vice-president of Charles River, discusses the results of the survey.
  20. Content Article
    Full articles require a subscription to the journal but the abstracts can be viewed free of charge.
  21. Content Article
    This article in Patient Safety looks at a new approach to identifying and monitoring patients with sepsis developed by a team of nurses at WellSpan Health in the USA. The Central Alert Team (CAT) works remotely, looking for indicators of sepsis in patient charts and vital signs. They relay information and treatment advice to nurses working at the bedside and take an adaptive approach to find the best ways of working. This focused approach means the CAT nurses are able to quickly identify patients who are deteriorating and ensure treatment is administered at the right time.
  22. Content Article
    This article published in Patient Safety discusses the role of patients and families in supporting a culture of safety. It looks at the concept of 'preoccupation with failure', a feature of high reliability organisations (HROs) and examines how patients can contribute to safety by being engaged in this process. The authors discuss a case study in which a patient contributes to safety improvements by sharing specific concerns. They draw out the importance of encouraging and empowering patients and their families to raise issues.
  23. Content Article
    This article in The Joint Commission Journal on Quality and Patient Safety reports on the findings of a pilot programme to improve healthcare staff wellbeing. Between November 2018 and May 2020, researchers engaged five healthcare sites to take part in a pilot intervention. The pilot used evidence-based approaches to wellbeing including a comprehensive culture assessment, redesigning daily workflow and leadership and team development. The researchers found that healthcare worker wellbeing improved when: an integrated, skills-based approach was taken there was a focus on team culture, interactions and leadership workflows were redesigned to promote positive emotions. This study suggests that combining a number of these approaches at the same time can improve healthcare working environments and reduce levels of staff burnout.
  24. Content Article
    This study, published online by Cambridge University Press, looks at the impact of the Covid-19 pandemic on incidences of healthcare-associated infection in hospitals in the United States of America. The authors analyse events reported to the National Healthcare Safety Network for 2019 and 2020 by acute-care hospitals.
  25. Content Article
    Previous research suggests that surgical safety checklists (SSCs) are associated with reductions in postoperative morbidity and mortality as well as improvement in teamwork and communication. These findings stem from evaluations of individual or small groups of hospitals. Studies with more hospitals have assessed the relationship of checklists with teamwork at a single point in time. The objective of this study from Molina et al. was to evaluate the impact of a large-scale implementation of SSCs on staff perceptions of perioperative safety in the operating room. They concluded that a large-scale initiative to implement SSCs is associated with improved staff perceptions of mutual respect, clinical leadership, assertiveness on behalf of safety, team coordination and communication, safe practice, and perceived checklist outcomes.
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