Effect of after action review on safety culture and second victim experience and its implementation in an Irish hospital: A mixed methods study protocol (original) (raw)
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Patient safety is a top priority for all healthcare systems globally. Promoting the adoption of policies for reporting and learning from errors is an important strategy for improving care safety. Therefore, the aim of our study was to detect how much patient safety culture influences the reporting of adverse events and the use of the incident reporting tool. The study protocol was developed according to PRISMA guidelines. Articles were searched electronically in PubMed/MEDLINE, the COCHRANE library, and Google Scholar by two independent reviewers, and those that met the eligibility criteria were included. Synthesis of qualitative data from included studies was performed by graphical descriptive statistical analysis. The results of the systematic review showed that health care organizations' increasing focus on staff development of a safety culture has led to a significant increase in incident reporting rates over the years. Moreover, in situations where safety culture is placed ...
2015
Patient safety has been on the research agenda since 2000, when unnecessary harm to patients in providers’ care came to light. In 2005, the improvements in patient safety fell short of expectations, and the patient safety research community recognized that the issues are more difficult to resolve than first thought. One of the tools to address this vexing problem has been voluntary incident reporting systems, although the literature has given incident reporting systems mixed reviews. This qualitative comparative case study comprises 85 semi-structured interviews in two separate divisions of a tertiary care hospital, General Internal Medicine (GIM) and Obstetrics and Neonatology (OBS/NEO). The main line of questioning concerned incident reporting; general views of patient safety were also sought. This is a thesis by publication. The thesis consists of a general introduction to patient safety, a literature review, a description of the methods and cases, followed by the manuscripts. Th...
BMJ Quality & Safety, 2013
Background The measurement of safety culture in healthcare is generally regarded as a first step towards improvement. Based on a selfassessment of safety culture, the Frankfurt Patient Safety Matrix (FraTrix) aims to enable healthcare teams to improve safety culture in their organisations. In this study we assessed the effects of FraTrix on safety culture in general practice. Methods We conducted an open randomised controlled trial in 60 general practices. FraTrix was applied over a period of 9 months during three facilitated team sessions in intervention practices. At baseline and after 12 months, scores were allocated for safety culture as expressed in practice structure and processes (indicators), in safety climate and in patient safety incident reporting. The primary outcome was the indicator error management. Results During the team sessions, practice teams reflected on their safety culture and decided on about 10 actions per practice to improve it. After 12 months, no significant differences were found between intervention and control groups in terms of error management (competing probability=0.48, 95% CI 0.34 to 0.63, p=0.823), 11 further patient safety culture indicators and safety climate scales. Intervention practices showed better reporting of patient safety incidents, reflected in a higher number of incident reports (mean (SD) 4.85 (4.94) vs 3.10 (5.42), p=0.045) and incident reports of higher quality (scoring 2.27 (1.93) vs 1.49 (1.67), p=0.038) than control practices. Conclusions Applied as a team-based instrument to assess safety culture, FraTrix did not lead to measurable improvements in error management. Comparable studies with more positive results had less robust study designs. In future research, validated combined methods to measure safety culture will be required. In addition, more attention should be paid to evaluation of process parameters. Implemented actions and incident reporting may be more appropriate target endpoints. Trial registration German Clinical Trials Register (Deutsches Register Klinischer Studien, DRKS) No. DRKS00000145
Jurnal Medicoeticolegal dan Manajemen Rumah Sakit, 2017
The aim of this study was to modify and determine the dimensions and themes of the patient safety culture tool by MaPSaF. This study was a qualitative design with study literature approach. The result of this study was MaPSaF composed of 10 dimensions of patient safety culture with 24 aspects which contain with the statements in each theme. The dimensions are commitment to overall continuous improvement, priority given to safety, system errors and individual responsibility, recording incidents and best practice, evaluating incidents and best practice, learning and affecting change, communication about safety issues, personnel management and safety issues, staff education and training, and teamwork. The aspects are the commitment to improvement, audit, policies, priority of patient safety, risk management system, implementation of patient safety, the cause of the incident, patient safety culture, reporting feeling and system, data analysis, the focus and result of investigation, incidents learning, the people in deciding of change, communication about patient safety between staff, patient or both, share the information, supporting the staff, training needs and purposes, team structure, the flow of information and sharing. Tujuan dari penelitian ini adalah untuk memodifikasi dan menentukan dimensi dan tema alat budaya keselamatan pasien oleh MaPSaF. Metode yang digunakan adalah penelitian kualitatif dengan pendekatan studi literatur. Hasil penelitian ini adalah MaPSaF yang terdiri dari 10 dimensi budaya keselamatan pasien dengan 24 aspek yang berisi pernyataan di setiap tema. Dimensi adalah komitmen terhadap perbaikan terus-menerus secara keseluruhan, prioritas yang diberikan untuk keselamatan, kesalahan sistem dan tanggung jawab individu, pencatatan insiden dan praktik terbaik, evaluasi insiden dan praktik terbaik, pembelajaran dan perubahan, komunikasi tentang isu keselamatan, manajemen personil dan isu keselamatan, pendidikan staf dan pelatihan, dan kerja tim. Aspeknya adalah komitmen terhadap perbaikan, audit, kebijakan, prioritas keselamatan pasien, sistem manajemen risiko, pelaksanaan keselamatan pasien, penyebab kejadian, budaya keselamatan pasien, pelaporan perasaan dan sistem, analisis data, fokus dan hasil penyelidikan, insiden belajar, orang-orang dalam menentukan perubahan, komunikasi tentang keselamatan pasien antara staf, pasien atau keduanya, berbagi informasi, mendukung staf, kebutuhan dan tujuan pelatihan, struktur tim, arus informasi dan berbagi.
The International journal of risk & safety in medicine, 2016
We modified the departmental mortality and morbidity (M&M) meetings to evaluate whether patient safety incident review as a part of this meeting was associated with reduced patient safety incidents. A pilot programme of peer review of patient safety incidents (PSI) supported by education relevant to that event and follow-on action plan was introduced as a part of an extended morbidity and mortality meeting in a university hospital orthopaedic department. The pilot programme was conducted over six months (January 2012-June 2012). This programme involved junior and senior doctors including consultants although multidisciplinary groups were invited to attend. We investigated PSI rate/1000 hospital admissions for trauma and elective surgery, which were collected prospectively and independently between Jan 2011 to June 2013. We noted if the incident was caused by a medical or a nursing error and compared PSI rates. Rates of PSI (33/1000) were 7.8 times higher in trauma cases (80.2/1000) ...
International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua, 2013
Objectives. Recent critiques of incident reporting suggest that its role in managing safety has been over emphasized. The objective of this study was to examine the perceived effectiveness of incident reporting in improving safety in mental health and acute hospital settings by asking staff about their perceptions and experiences.
The long road to an efficient safety culture
Halo 194, 2022
Introduction/Objective Patient safety is defined as the prevention of errors and adverse effects aimed at patients and associated with health care. Patient safety culture (PSC) is "the product of individual and group values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organization's health and safety management." Improving the perception of the PSC within the healthcare sector plays a key role in improving its overall quality, efficacy and productivity. This article aims to point out the importance of the inexhaustible and very interesting topic of safety culture as a basis for further research and strategy creation. Methods This is a qualitative research paper, based on a scientific review of the literature. Relevant articles for this review have been identified by searching digital databases: PubMed, Medline and Google Scholar. The research was retrospective and covered a timeframe of five years. Articles were selected by introducing keywords relevant to the subject. Results The results are based on the analysis and review of 12 published scientific articles from 2017 to 2021. Conclusion Patient safety must be the priority of the healthcare provider. Theoretical foundations should be combined with educational experiences following the development of knowledge, skills and attitudes for effective patient safety. Adverse event reporting should include learning from mistakes, supporting an environment that encourages reporting without blame or fear of punishment. The healthcare system needs to be made as safe as possible for both the patients and all those providing healthcare. Improving and developing the quality of healthcare requires knowledge, selection and application of specific methods and tools tailored to the capabilities of individual healthcare institutions.
BMC Health Services Research, 2011
Background: Patients have the potential to provide a rich source of information on both organisational aspects of safety and patient safety incidents. This project aims to develop two patient safety interventions to promote organisational learning about safety -a patient measure of organisational safety (PMOS), and a patient incident reporting tool (PIRT) -to help the NHS prevent patient safety incidents by learning more about when and why they occur. Methods: To develop the PMOS 1) literature will be reviewed to identify similar measures and key contributory factors to error; 2) four patient focus groups will ascertain practicality and feasibility; 3) 25 patient interviews will elicit approximately 60 items across 10 domains; 4) 10 patient and clinician interviews will test acceptability and understanding. Qualitative data will be analysed using thematic content analysis. To develop the PIRT 1) individual and then combined patient and clinician focus groups will provide guidance for the development of three potential reporting tools; 2) nine wards across three hospital directorates will pilot each of the tools for three months. The best performing tool will be identified from the frequency, volume and quality of reports. The validity of both measures will be tested. 300 patients will be asked to complete the PMOS and PIRT during their stay in hospital. A sub-sample (N = 50) will complete the PMOS again one week later. Health professionals in participating wards will also be asked to complete the AHRQ safety culture questionnaire. Case notes for all patients will be reviewed. The psychometric properties of the PMOS will be assessed and a final valid and reliable version developed. Concurrent validity for the PIRT will be assessed by comparing reported incidents with those identified from case note review and the existing staff reporting scheme. In a subsequent study these tools will be used to provide information to wards/units about their priorities for patient safety. A patient panel will provide steering to the research. Discussion: The PMOS and PIRT aim to provide a reliable means of eliciting patient views about patient safety. Both interventions are likely to have relevance and practical utility for all NHS hospital trusts.
Quantity and quality: Increasing safety norms through after action reviews
Workplace safety is a concern for both scholars and practitioners alike because accidents and injuries can result in time away from work and lost organizational resources. This study focuses on how one type of post-incident discussion can be effectively used to promote positive safety norms. It adds to the growing body of research on after action review (AAR) meetings, one type of post-incident discussion intervention commonly used in high reliability organizations to increase future workplace safety behaviors. This study also extends the sensemaking and high reliability literatures by examining a three-way interaction between perceived frequency of AAR meetings, ambiguity reduction, and psychological safety. Survey data were obtained from 330 firefighters. Results from the three-way interaction showed that safety norms were highest when perceived AAR frequency, ambiguity reduction, and psychological safety were simultaneously high and safety norms were lowest when perceived AAR frequency, ambiguity reduction, and psychological safety were simultaneously low. By examining both the perceived quantity and quality of AAR meetings, this study provides insight into which AAR facilitation objectives are most likely to increase positive safety norms and ultimately create a shared understanding of how to behave safely in future workplace events in high reliability organizational contexts.
Culture of Safety Environment: Findings from a Multi-Speciality Tertiary Care Hospital
International Journal of Health Sciences and Research, 2019
Introduction: A 'Culture of Safety' describes the core values and behaviors related to providing safe care. The concept of the ‘Culture of Safety’ in healthcare came to the limelight following the report of the Institute of Medicine in 1999. Material and Methods: This is a cross-sectional study doing an in-depth analysis of the findings from the ‘Culture of Safety’ Survey at the individual unit level. Data from the survey conducted in June 2018 with a sample size of 996 was collated and analyzed using Microsoft Office Excel 2013 and descriptive statistics. The validated Patient Safety Culture Survey questionnaire of the AHRQ was used and the self-reported survey was conducted through the ‘Survey Monkey. Results and Discussion: Analysis of top few positive responses and analysis of top few negative responses brought about the strengths and weaknesses. Strategies that were implemented based on these findings. The organization believes in the spirit of the ‘Culture of Safety’ a...