Establishing a Provincial Patient Safety and Learning System: Pilot Project Results and Lessons Learned

Cochrane, D. Douglas; Taylor, A. E.; Miller, Georgene; Hait, Valoria; Matsui, Irene; Bharadwaj, Manish S.; Devine, Patrick

doi:10.12927/hcq.2009.20717

Cited by 22 publications

(22 citation statements)

References 10 publications

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“…Many healthcare providers use retrospective data to detect and monitor medical errors and adverse events (2, 21, 22). These include medical record reviews, visual or videotaped observational studies, interviews or questionnaires, automated methods adopting trigger tools, analyses of administrative databases (e.g., patient safety indicators or ICD-9 codes); analyzing malpractice claims or autopsy data, and using data from mortality and morbidity conferences.…”

Section: Generic Issues In Patient Safetymentioning

confidence: 99%

“…These include medical record reviews, visual or videotaped observational studies, interviews or questionnaires, automated methods adopting trigger tools, analyses of administrative databases (e.g., patient safety indicators or ICD-9 codes); analyzing malpractice claims or autopsy data, and using data from mortality and morbidity conferences. Thus, most published studies have been observational to investigate the epidemiology of patient safety (1, 2, 21–25). …”

Section: Generic Issues In Patient Safetymentioning

confidence: 99%

“…Consumers should be involved in training of the health care workers. Two-way communication and honesty are keys to advancing understanding (2, 31, 34). …”

Section: Unique Patient Safety Issues In Neonatal Carementioning

confidence: 99%

“…Since the publication of the IOM report (1) patient safety issues have received more attention from the scientific community (2) and regulatory agencies (3–6). The US Food and Drug Administration has systems for reporting medication errors (3) and healthcare device-related errors (4, 5).…”

Section: Introductionmentioning

confidence: 99%

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Patient Safety in the Context of Neonatal Intensive Care: Research and Educational Opportunities

Raju

Suresh²,

Higgins

2011

Pediatr Res

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Case reports and observational studies continue to report adverse events from medical errors. However, despite considerable attention to patient safety in the popular media, this topic is not a regular component of medical education, and much research needs to be carried out to understand the causes, consequences, and prevention of healthcare-related adverse events during neonatal intensive care. To address the knowledge gaps and to formulate a research and educational agenda in neonatology, the Eunice Kennedy Shriver National Institute of Child Health and Human Development invited a panel of experts to a workshop in August 2010. Patient safety issues discussed were the reasons for errors, including systems design, working conditions, and worker fatigue; a need to develop a "culture" of patient safety; the role of electronic medical records, information technology, and simulators in reducing errors; error disclosure practices; medicolegal concerns; and educational needs. Specific neonatology-related topics discussed were errors during resuscitation, mechanical ventilation, and performance of invasive procedures; medication errors including those associated with milk feedings; diagnostic errors; and misidentification of patients. This article provides an executive summary of the workshop.

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Section: Generic Issues In Patient Safetymentioning

confidence: 99%

Section: Generic Issues In Patient Safetymentioning

confidence: 99%

“…Consumers should be involved in training of the health care workers. Two-way communication and honesty are keys to advancing understanding (2, 31, 34). …”

Section: Unique Patient Safety Issues In Neonatal Carementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Patient Safety in the Context of Neonatal Intensive Care: Research and Educational Opportunities

Raju

Suresh²,

Higgins

2011

Pediatr Res

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“…5 Reported incidents can also be used as learning tools. 6 However, voluntary incident reporting systems have also been described as a source of frustration, falling short of generating intended benefits. Their effectiveness is diminished by barriers to voluntary incident reporting, some of which are related to concerns about repercussions to the reporting health care professional.…”

mentioning

confidence: 99%

Sociocultural Factors Influencing Incident Reporting Among Physicians and Nurses: Understanding Frames Underlying Self- and Peer-Reporting Practices

2017

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Patient Safety Training Simulations Based on Competency Criteria of the Accreditation Council for Graduate Medical Education

Issenberg

Chung

Devine

2011

Mount Sinai J Medicine

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This report reviews and critically evaluates the development of 3 movements in healthcare that have had a profound impact on changes occurring at all levels of medical education: patient safety, healthcare simulation, and competency-based education (exemplified by the Accreditation Council for Graduate Medical Education). The authors performed a critical and selective review of the literature from 1999 to 2011 to identify uses of simulation to address patient-safety issues aligned according to the Accreditation Council for Graduate Medical Education 6 core competencies: (1) patient care; (2) medical knowledge; (3) interpersonal and communication skills; (4) professionalism; (5) practice-based learning; and (6) systems-based practice. The research synthesis is reported to inform and provide evidence about how simulation is used to train and evaluate learners on a range of patient-safety issues for each of the core competencies: There is emerging evidence that simulation can be used in training efforts to reduce medical errors related to medical knowledge and patient care (particular invasive procedures as well as improved communication and teamwork skills). There remains limited evidence on its impact to improve patient safety related to more complex competencies of practice-based learning and systems-based practice. Simulation-based learning can lead to positive patient outcomes and reduction of medical errors particularly when used for individual skills. However, particular attention needs to be placed on the organizational context in which it is implemented if improvements in practice-based learning and systems-based practice are to be realized.

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Establishing a Provincial Patient Safety and Learning System: Pilot Project Results and Lessons Learned

Cited by 22 publications

References 10 publications

Patient Safety in the Context of Neonatal Intensive Care: Research and Educational Opportunities

Patient Safety in the Context of Neonatal Intensive Care: Research and Educational Opportunities

Sociocultural Factors Influencing Incident Reporting Among Physicians and Nurses: Understanding Frames Underlying Self- and Peer-Reporting Practices

Patient Safety Training Simulations Based on Competency Criteria of the Accreditation Council for Graduate Medical Education

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