Patient Safety and Error Management

Abstract

Three main strategies should be pursued to improve patient safety. A safety management system involving error reporting, learning from errors, and the fair exchange of information should be established in hospitals and in doctors' outpatient practices. An error management system should be implemented in which critical incidents are identified, reported, and analyzed so that similar events can be prevented, and measures for the prevention of critical incidents and errors should also be implemented and evaluated. Finally, whenever preventable adverse events do occur, the persons involved should take action to prevent further harm to the patient and other involved individuals.

How transformational leadership appears in action with adverse events? A study for Finnish nurse manager

“…The analysis should be performed by a multidisciplinary team, and should begin with a process of collecting data and interviewing persons who were involved in the adverse event to get a clear picture of what happened. The goal should be to find out how and why the adverse event occurred (Agency for Healthcare Research and Quality [AHRQ] 2017; Vincent, 2010), and the results must be discussed with the staff (Hoffmann & Rohe, 2010). During these discussions, it is important to describe the adverse event in a way that ensures all attendees reach a common understanding of what happened and why it occurred.…”

“…It is important to note that it is not helpful to set goals relating to the number of reports that are generated (Hoffmann & Rohe, 2010). Discussion about adverse events should be blame-free, and staff should not fear punishment; focusing blame on individuals does not support development (Vrbnjak, Denieffe, O'Gorman, & Pajnkihar, 2016).…”

Opinions of Anesthesiologists and Surgeons about World Health Organization Surgical Safety Checklist in a Tertiary hospital in Iran, 2012

“…The WHO checklist has been presented as a major innovation in medicine; the challenges to introduce changes in the safety culture in the operating room are significant. Therefore, effective performance of checklist requires individual clinicians to adapt to a changing safety culture [5]. On the other hand, checklists are not the last step toward promoting surgical quality.…”

“…Studies in developing countries suggest a death rate of 5-10% occurring in major surgeries. Infections and other postoperative complications are also a serious concern worldwide [1][2][3][4][5][6][7][8][9].…”

About non-triviality of the concept 'patient's safety in surgery'

“…Воспроизводимость и степень реализации хирургического «чек-листа» в разных странах мира неодинакова. Так, в Великобритании только 2 / 3 клиник внедрили эту программу [25]. В Нидерландах этот показатель на уровне 71% [26].…”