Safety Culture and Care: A Program to Prevent Surgical Errors

Hemingway, Maureen; O'Malley, C.; Silvestri, Sandra

doi:10.1016/j.aorn.2015.01.002

Cited by 20 publications

(22 citation statements)

References 5 publications

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“…The highest number of reported good catches occurred in the second month of the project, possibly after staff members realized that the project team took action to improve the issues identified in the first month. In similar studies, staff members have reported that lack of action or feedback about actions taken was a deterrent to reporting . Compared with the year before the project in which personnel completed 85 electronic risk management reports, all of which came from the preoperative area and 83 (98%) of which were related to procedure cancellation, after project implementation, OR personnel reported most good catches (66%, n = 258) with many of the reported problems stemming from the sterile processing department.…”

Section: Discussionmentioning

confidence: 99%

Good Catch Campaign: Improving the Perioperative Culture of Safety

Lozito¹,

Whiteman²,

Swanson-Biearman³

et al. 2018

AORN Journal

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Although health care workers feel pressure to reduce adverse events in the perioperative department, a lack of education, communication, and leadership can prevent hospital personnel from reporting good catches. The purpose of this evidence-based quality improvement project was to improve the culture of safety in our perioperative department by implementing the Good Catch Campaign. An interprofessional team led staff member education after implementing a standardized electronic reporting system and debriefing process to occur after good catches. Staff members reported 391 good catches from all perioperative areas during the six-month postimplementation period. Staff members completed the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture before and six months after implementation; scores improved in five areas: communication openness, feedback and communication about error, frequency of event reporting, nonpunitive response to error, and organizational learning and continuous improvement. The campaign was a successful strategy for improving perioperative patient safety.

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Section: Discussionmentioning

confidence: 99%

Good Catch Campaign: Improving the Perioperative Culture of Safety

Lozito¹,

Whiteman²,

Swanson-Biearman³

et al. 2018

AORN Journal

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“…Education around the importance of speaking up and challenging authority is essential; however, unless supported by accessible reporting systems and transparency of organisations, education on its own will not be enough. 42,44 A transformation in culture regarding hierarchy will be required, which is arguably the most important modifiable factor. Future research could consider the effect of a change in the undergraduate curriculum to try and address the lack of education around speaking up.…”

Section: Discussionmentioning

confidence: 99%

“…42 This contrasts with a Massachusetts General Hospital initiative which was undertaken to improve the quality and safety program, particularly in the perioperative department. 44 A survey showed that 44% of staff did not feel able to speak up if they felt something was wrong, but felt they would do so 'knowing I have the support of management and my peers' and 'engaging in a conversation with all parties involved in the incident'. To this end, the development of an electronic safety reporting system, and formal debriefings and feedback after adverse events was initiated.…”

Section: Do Qualitatively Identified Barriers Have a Significant Effementioning

confidence: 99%

Challenging authority and speaking up in the operating room environment: a narrative synthesis

Pattni

Arzola

Malavade

et al. 2019

British Journal of Anaesthesia

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Multidisciplinary care teams exist throughout healthcare systems. In the operating room (OR), effective communication between teams is essential, especially during crisis situations where patient safety can be in acute danger. An oftenneglected skillset in educational curriculums is challenging authority. This narrative synthesis aims to explore the literature on challenging authority in the OR environment. A systematic search of Medline, EBM reviews and PsycINFO was conducted using terms related to challenging authority, speaking up, communication, patient safety, gradients and hierarchy. The initial search identified 4822 publications, out of which 31 studies were included. The data synthesis of the included studies was grouped into three distinct categories following a meta-aggregative approach: discussion and review articles, observational or qualitative studies, and studies identifying the role of specific barriers or investigating the effect of educational interventions. Themes emerging from expert beliefs, what reality tells us and what we test are consistent. Hierarchy, organisational culture and education are the most frequently observed and tested themes. Simulation research has been successful in eliciting and confirming the role of specific barriers to speaking up. Barriers and enablers are largely modifiable within institutions however, education regarding the importance of speaking up will need to accompany these modifications for any significant changes to occur. Editor's key pointsThe authors examined the literature on speaking up in the operating theatre environment using narrative synthesis. They demonstrate emerging themes from the literature consistent with our intuitive understanding e hierarchy gradients, organisational culture, and education are the most frequently observed factors affecting ability to challenge authority. Barriers and enablers to speaking up are largely modifiable. Promoting speaking up within health teams requires organisations to cultivate a culture of open, safe communication, accompanied by education regarding the importance of speaking up.

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“…There continues to be a greater emphasis on a culture of safety in health care and team members are encouraged to speak up if they have concerns about patient safety. Similar results from recent studies support the main theme of the environment as a major cause of errors in which distractions, communication, and being rushed appear as variables . Researchers identified distractions (eg, loud music, cell phones) as posing a threat to patient safety, consistent with findings from our study …”

Section: Discussionmentioning

confidence: 99%

The Meaning of Intraoperative Errors: Perioperative Nurse Perspectives

Chard¹,

Tovin²

2018

AORN Journal

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Medical errors involve different health care professionals, are multifaceted, and can occur at the individual practitioner or system level. The conditions for errors vary in the health care environment; some practice areas may be more vulnerable to errors than others. Limited research exists that explores perioperative nursing errors. The purpose of this study was to describe and interpret the experiences of perioperative nurses related to intraoperative errors. We used the hermeneutic phenomenological method. Ten perioperative RNs participated in focus group interviews that we audio-recorded and transcribed. We analyzed data using thematic analysis, and three themes emerged that represent the essence of the experience of nurses involved in intraoperative errors: environment, being human, and moving forward. The findings support efforts to improve quality care and foster a culture of safety in the OR through strategies such as perioperative staff training, interprofessional team building, and controlling environmental factors that are distracting.

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Safety Culture and Care: A Program to Prevent Surgical Errors

Cited by 20 publications

References 5 publications

Good Catch Campaign: Improving the Perioperative Culture of Safety

Good Catch Campaign: Improving the Perioperative Culture of Safety

Challenging authority and speaking up in the operating room environment: a narrative synthesis

The Meaning of Intraoperative Errors: Perioperative Nurse Perspectives

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