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Mehmet Nurullah Kurutkan 0532/5214599 nkurutkan@gmail.com
Adapting strategies from high-reliability organizations to improve patient hand-offs in teaching hospitals
Philibert, Ingrid. Proquest Dissertations And Theses 2008. Section 0096, Part 0769 287 pages; [Ph.D. dissertation].United States -- Iowa: The University of Iowa; 2008. Publication Number: AAT 3323458.
Abstract (Summary)
The patient hand-off transfers responsibility for patients among physicians. It is critical to the continuity of care. Limits on resident physicians' hours have increased the frequency of hand-offs, and research suggests that information transfer problems contribute to adverse outcomes. Improving hand-off practice could enhance patient safety and educational practice.
This study assessed whether adaptation of strategies from end-of-shift transfers in high-reliability organizations and use of data summaries could improve hand-offs in teaching hospitals. A qualitative study found strategies used in resident hand-offs met selected goals of high-reliability organizations, but the approaches differed to accommodate the mobile, fluid nature of residents' work and the focus on multiple patients with differing needs for attention and care. The findings emphasized the importance of the verbal, interactive hand-off and suggested that time constraints, scheduling patterns and interpersonal factors such as trust influenced the hand-off.
To further study the contribution of these factors, 86 residents in internal medicine, surgery, pediatrics and obstetrics-gynecology completed 844 surveys for individual hand-offs. For 196 hand-offs matched surveys completed by both participants were analyzed, confirming a model in which focus on plans and likely patient contingencies positively influenced incoming physicians' confidence in the quality and completeness of the hand-off. The model explained 7% of the variance in unplanned changes in care and errors attributed to the hand-off. Analysis of scheduling patterns showed that cross-coverage significantly increased the odds of unplanned changes (OR 2.967, p = .000) and errors attributed to the hand-off (OR = 4.765, p = .000). Hand-offs using data summaries, while more efficient, also were associated with a greater incidence of unplanned changes and errors.
A taxonomy of hand-off errors was developed as a foundation for future work to explore causes and reduce occurrence. The practical relevance of the findings to teaching and practice are discussed, suggesting that improving the hand-off will require a change in culture and added faculty involvement, and will benefit from work to adapt technology and data support to the key functions and decision elements of the hand-off.
Indexing (document details)
Advisor:
Vaughn, Thomas E.
School:
The University of Iowa
School Location:
United States -- Iowa
Keyword(s):
Patient hand-offs, Teaching hospitals, Patient safety, Physician communication
A fine balance: Patient safety and trainee education on clinical teaching teams
Kennedy, Tara Jane Tingley. Proquest Dissertations And Theses 2008. Section 0779, Part 0350 215 pages; [Ph.D. dissertation].Canada: University of Toronto (Canada); 2008. Publication Number: AAT NR39880.
Abstract (Summary)
Context. Clinical supervisors of medical trainees must provide supervision to ensure patient safety, while allowing enough independence to promote education. Current focus on patient safety has led to changes in supervisory practices without exploring their educational impact, creating an urgent need for an understanding of how the safety-education balance is enacted in medical training.
Objectives. To explore the patterns of supervision currently provided by clinical supervisors, and to develop conceptual models of the factors involved in clinical teachers' decisions about supervision, and of the factors influencing trainee-supervisor communication about supervision.
Design. In Phase 1, 88 teaching team members from internal and emergency medicine were observed during clinical activities (216 hours), and 65 participants subsequently completed brief interviews. In Phase 2, 36 in-depth interviews were conducted using video vignettes to probe tacit influences on supervision. Data collection and analysis employed grounded theory methodology.
Results. Clinical supervision practices related to patient care were found to involve routine oversight (oversight activities planned in advance), backstage oversight (oversight of which trainees are not directly aware), and responsive oversight (oversight occurring in response to trainee- or patient-specific issues). Supervisors' assessments of trainee trustworthiness for independent clinical work were found to involve consideration of trainees' knowledge and skill, discernment of clinical limitations, honesty, and conscientiousness. Supervisors' reliance on language cues as a source of trustworthiness data was revealed. Trainees' decisions about seeking help from supervisors were found to involve not only clinical factors (clinical significance, scope of practice), but also supervisor factors (availability, approachability), and trainee factors (expertise, desire for independence, evaluation). Trainees perceived that requesting frequent/inappropriate clinical support threatens credibility. The pressure on trainees to act independently was explored in light of educational and organizational theory, resulting in a new practical approach to patient safety during clinical training.
Conclusions. This study offers an important theoretical advancement from the traditional conceptualization of the inverse relationship between safety and education in clinical training. Exposure and examination of the complexities involved in the constant trainee-supervisor negotiations about clinical independence provides a framework for changes that could simultaneously advance the patient care and educational agendas of medical education.
Indexing (document details)
School:
University of Toronto (Canada)
School Location:
Canada
Keyword(s):
Patient safety, Trainee education, Clinical teaching teams
A multivariate analysis of the effects of CPOE on hospital quality and patient safety
Mayfield, Stephen R.. Proquest Dissertations And Theses 2008. Section 1335, Part 0769 237 pages; [D.H.A. dissertation].United States -- South Carolina: Medical University of South Carolina - College of Health Professions; 2008. Publication Number: AAT 3319767.
Abstract (Summary)
Healthcare Information Technology (H.I.T.) solutions are increasingly recommended as a means to improve hospital performance. This study evaluated the performance of 143 hospitals in the state of Georgia. The hospitals were classified as either having computerized provider order entry (8.3%), a culture of safety (12.6%) or having neither (79%). Hospital performance was evaluated along three domains: process compliance, overall quality of care and medication safety.
The major findings include: (a) hospitals with CPOE performed better than those without in all three areas; (b) hospitals with a culture of safety performed better than those without in the areas of process compliance and overall quality of care but not in terms of medication safety. The results have important practice and policy implications. Hospital leaders should be encouraged to adopt a systems approach to process excellence, including health information technology solutions as well as cultures that reflect an emphasis on reliability and teamwork.
Indexing (document details)
Advisor:
Wager, Karen A.
School:
Medical University of South Carolina - College of Health Professions
School Location:
United States -- South Carolina
Keyword(s):
Hospital quality, Patient safety, Computerized provider order entry, Health care information, Process improvement
Communication and cultural issues in medication error reports
Friesen, Mary Ann. Proquest Dissertations And Theses 2008. Section 0883, Part 0569 306 pages; [Ph.D. dissertation].United States -- Virginia: George Mason University; 2008. Publication Number: AAT 3323707.
Abstract (Summary)
Because medication errors pose a major threat to patient safety, it is essential that their causes be studied and addressed in order to identify strategies to decrease the incidence of medication errors and encourage a culture of safety. Communication issues, in particular, have been implicated as a cause of medication errors. This research explored communication and cultural issues within a sample of medication errors involving nurses reported between 2002 and 2005 to the Medication Errors Reporting Program operated by the United States Pharmacopeia in cooperation with the Institute for Safe Medication Practices. Qualitative content analysis and quantitative descriptive methods were used to study the reported medication errors in order to identify categories and themes. A total of 322 errors were analyzed with 21 patient deaths reported. Fifteen categories and 65 subcategories were identified. An additional group of errors related to labeling issues were analyzed separately. Five themes emerged from the analysis: Risking patient safety through behaviors and systems that breach defenses, standing watch for errors, stepping in to prevent harm, experiencing the human impact of medication errors and seeking to prevent reoccurrence of medication errors.
The findings indicated many communication causes and contributors to medication errors. However, medication errors were deflected when effective "open communication processes among healthcare providers were utilized. The findings suggest there are numerous implications for practice, education, policy, and research.
Development of an automated professional shift-exchange template for critical hospital communication
Olson, Nancy Ann. Proquest Dissertations And Theses 2008. Section 1443, Part 0769 179 pages; [Ph.D. dissertation].United States -- Arizona: Northcentral University; 2008. Publication Number: AAT 3316913.
Abstract (Summary)
Communication problems have been the leading cause of hospital sentinel events, that is, events causing patient harm or death over the past decade. In 2006, improving and standardizing the communication handoff of patient care was identified as a national patient safety goal due to the linkage between this problem-prone process and sentinel events. Analysis of previous research identified five communication breakdown categories linked to medical errors or dissatisfaction for the clinical team. Collectively, past research recommended change-of-shift handoff improvements for patient information content, time duration, consistency, dataset grouping, and supplemental hospital updates. Research findings were utilized to develop an innovative new solution adopting 'information age' technology in order to improve critical hospital communication between clinical team members. The process prototype developed in this study automates and standardizes change-of-shift handoff and has been named the professional shift-exchange template (PRO SET). The methodology was quasi-experimental and collected change-of-shift samples from two hospitals and three clinical departments. The 82 patient handoff samples documented the current information exchange process that is incomplete and highly variable. The findings demonstrated that use of the change-of-shift template yielded statistically significant improvements for each of the five process problems. Analysis of the full study results demonstrated the template solution exceeded the 2006 national safety goal mandate to standardize the handoff process and add critical information content with an evidence-based design. Future researchers will have the opportunity to expand the evaluation of the professional shift exchange template prototype or explore other automation solutions to improve the communication handoff process. Reduction in critical communication problems between clinical team members supports safe, high quality care for each patient. Resolving each process flaw through targeted research will enable healthcare administrators to reduce medical errors and dissatisfaction with services.
Indexing (document details)
Advisor:
Ferencak, Rita
School:
Northcentral University
School Location:
United States -- Arizona
Keyword(s):
Hospital communication, Shift changes, Patient handoff, Patient safety, Medical errors
Healing the effects of medical errors: A vision of justice as wholeness
Schubert, Christiane Catharine. Proquest Dissertations And Theses 2008. Section 0106, Part 0769 347 pages; [Ph.D. dissertation].United States -- California: Loma Linda University; 2008. Publication Number: AAT 3319718.
Abstract (Summary)
Medical errors cannot be avoided completely even when employing the greatest care and applying the most sophisticated medical technologies. They occur when organizational, human, technical, or environmental factors lead to unintentional failures which result in recognizable physical, mental, spiritual, or social harm to patients. Until recently, the medical profession has responded with silence while patients remained uncompensated or resorted to the legal system. Professional distancing undermines transparency and patient safety while medical malpractice litigation ruptures the fragile relationships between patients and healthcare providers in whom patients trust. Philosophically, these responses draw on the framework of deontological liberalism, promoting notions of just deserts and conceptions of freedom that, either when regarded from a Kantian perspective of autonomy or considered as freedom from non-interference, highlight individualism. Metaphors of this paradigm are expressed in a language of rights, which have limited potential to restore personal and social well-being. Drawing on both, the biblical tradition and republican political theory, this dissertation develops a culturally situated principled consequentialist approach, called justice as wholeness. Justice as wholeness responds to the multidimensional effects of medical errors by promoting wholeness as the theory of value. Deeply rooted in the biblical notion of human dignity, it distinguishes between the eschatological meaning of wholeness as a vision and its relative experience in a broken world. The function of justice is to restore the relative experience of the physical, mental, spiritual, and social dimensions of wholeness. A mixed approach to normative ethics, justice as wholeness has two principles that exclude unjust pursuits of its value-goal: a civic republican conceptualization of freedom and a biblical notion of equality. Justice as wholeness is a comprehensive and integrative framework that serves as a philosophical foundation for medical error policies and processes that resonate with the mission and values of faith-based hospitals. Loma Linda University Medical Center serves as a test case for incorporating the vision into policy. Justice as wholeness informs mission integration, the disclosure of medical errors to patients, and processes of restoration while encouraging transparent autonomy in peer review and compassion in hospital culture.
Indexing (document details)
Advisor:
Winslow, Gerald
School:
Loma Linda University
School Location:
United States -- California
Keyword(s):
Medical errors, Justice, Wholeness, Patient safety, Medical malpractice
How to say I'm sorry: A study of the Veterans Administration Hospital Association's Apology and Disclosure Program
Carmack, Heather J.. Proquest Dissertations And Theses 2008. Section 0167, Part 0459 402 pages; [Ph.D. dissertation].United States -- Ohio: Ohio University; 2008. Publication Number: AAT 3319022.
Abstract (Summary)
Medical mistakes are the "hidden epidemic" of medical care. The number of medical mistakes continues to rise, but patients, medical providers, and hospitals remain silent about mistakes. I join the scholarly and practical discussion about medical mistakes through a case study of the Veterans Administration Hospital Association's Apology and Disclosure Program. This program, created 21 years ago at the VAMC in Lexington, Kentucky, was the first program in the country to remove the secrecy and silence surrounding medical mistake experiences. At the VAMC, physicians openly disclose bad outcomes and potential mistakes to patients, and the hospital issues an apology and offers compensation when a mistake does happen. In this dissertation, I provide the first in-depth communicative analysis of the program and offer an interpretation of how multiple medical and hospital stakeholders make sense of organizational policies and external exigencies that enable and constrain the practice of medicine. Using narrative and structuration frameworks, I employ three methodologies to collect discourse related to the VAMC program and medical mistakes: in-depth interviews, participant observation, and document analysis.
The results are encapsulated in five themes which include discussions of issues related to the bureaucratic organizational structuring of hospital policy, narrative expressions of mistakes, the discursive and material consequences of mistakes, the emotional redemptive journey through mistakes, and the question of ethical action in health care. Woven throughout these five major themes are issues of co-ownership of mistake experiences, control and authority, and ideological and ontological questioning about the role of professionalism in medicine.
The results of the data collection and interpretation are used to answer four research questions. Ultimately, I argue that the VAMC disclosure and apology program attempts to re-envision medical mistake narratives, providing multiple stakeholders new scripts through which to interact with patients and practice medicine. The analysis attempts to enlarge the societal scripts about medical mistakes and the cultural practice of medicine. I underscore the complexity of practicing "socially responsible" medicine in the face of inevitable mistakes, managed care, and the bureaucratic organizing of medicine. Theoretical and practical implications for the VAMC program, limitations of the study, and directions for future research are also discussed.
Indexing (document details)
Advisor:
Harter, Lynn M.
School:
Ohio University
School Location:
United States -- Ohio
Keyword(s):
Medical mistakes, Health communication, Apology, Patient safety, Veterans Administration Hospital Association, Apology and Disclosure Program
Improving communication within the members of the interdisciplinary team in residential care
Pannun, Parmjit Kaur. Proquest Dissertations And Theses 2008. Section 1313, Part 0459 84 pages; [M.A. dissertation].Canada: Royal Roads University (Canada); 2008. Publication Number: AAT MR35403.
Abstract (Summary)
This action research study explored current interdisciplinary communication practices in residential care and considered communication strategies that may improve ineffective practices. A literature review indicated that communication breakdowns between health care providers are a consistent feature in critical incidents and compromise patient safety. The Situational Briefing model or SBAR (Situation, Background, Assessment, and Recommendation), a communication framework that has been successful in improving nurse-physician communication was explored as one communication strategy for use in residential care. Participants included all interdisciplinary team members as all health professionals interact to provide care in residential settings. Qualitative data collected through a literature review, open-ended questionnaires, and a World Café highlighted findings similar to the literature review: Role clarity, use of a common language, trust and respect, and teamwork. Recommendations addressed these findings and suggested creating a community of practice to address this ongoing issue.
Optimization of hospital design: A matter of patient safety and efficiency
Gandhi, Tejas Rajendra. Proquest Dissertations And Theses 2008. Section 1335, Part 0769 140 pages; [D.H.A. dissertation].United States -- South Carolina: Medical University of South Carolina - College of Health Professions; 2008. Publication Number: AAT 3304581.
Abstract (Summary)
The healthcare industry is expected to double its spending towards hospital construction in the next decade. Chasing the Quality Chasm [Institute of Medicine, 1999] emphasized the need to look at healthcare as a system and that errors resulted due to the failure of systems. Conventional architecture techniques are insufficient for accurately factoring these system failures into consideration. A comprehensive, quantitative and qualitative design process is required if organizations are to build facilities that enhance patient safety and create a patient-safe culture. This study identifies a new quantitative design approach to the hospital design process. Information extracted from 'quality function deployment' and 'critical clinical pathway' methods was translated by the architects into multiple design options. These in turn were modeled in a simulation package. Simulation was performed to identify a best-suited design that would minimize the total travel distances and handoffs for patients, staffs and families.
Indexing (document details)
Advisor:
Simpson, Kit
School:
Medical University of South Carolina - College of Health Professions
Patient safety and legal challenges: Disclosure of medical error, class actions, and reporting systems
Woffen, Tim. Proquest Dissertations And Theses 2008. Section 0779, Part 0398 72 pages; [LL.M. dissertation].Canada: University of Toronto (Canada); 2008. Publication Number: AAT MR45094.
Abstract (Summary)
This paper explores some of the recent legal developments in Canada and the United States with respect to patient safety. It starts off with a critique of the current "patient safety approach" or "systems approach" to medical error which is the theoretical basis for many reform efforts. A critique of the tort system follows. Within the adversarial tort system, the disclosure of errors to patients remains difficult and requires substantial legal changes. A promising development is the increased use of class actions in Canada to address systemic errors. The patient safety movement has also led to the development of a variety of reporting systems. As a means of safety-research and quality-management, it is their goal is to detect unsafe conditions, preferably before harmful medical errors occur. In the United States, legal protections are increasingly used to create trust in confidential reporting and to uncouple reporting systems from other procedures.
Preventing patient harm: The role of nurse competency
Kendall-Gallagher, Deborah Leslie. Proquest Dissertations And Theses 2008. Section 0831, Part 0569 197 pages; [Ph.D. dissertation].United States -- Colorado: University of Colorado Health Sciences Center; 2008. Publication Number: AAT 3316521.
Abstract (Summary)
Registered Nurses (RNs) are in a position to prevent and mitigate risk of patient harm in the hospital setting but little is known regarding effective strategies for achieving that goal. Patient safety research suggests that nurse-related adverse events result from an interaction among multiple factors rather than a single phenomenon. RN workforce competence is a known, but relatively understudied, factor in patient safety. This study explored the relationship between RN certification and rates of adverse events in intensive care (ICU) and non-intensive care (NonICU) settings. Unit proportion of certified staff RNs, representing RN workgroup competence, provided conceptual and methodological links for demonstrating an empirical relationship between nursing actions and patient safety.
A correlational, linear mixed model design was used to examine the relationship among unit proportion of RN certification, covariates (RN experience, RN education, RN mix, total nursing care hours per day, Medicare casemix index, and magnet status), and adverse events (medication administration errors, falls, skin breakdown, and hospital-acquired infections). The sample for the secondary data analysis consisted of 168 patient care units nested within 33 hospitals derived from data collected in 2000 in a retrospective, cross-sectional study that examined the relationship between nurse staffing patterns and quality of care in a randomly selected, nationwide sample of community hospitals. Hierarchical linear modeling regression was used to identify significant predictors. The hypothesis was that an inverse relationship existed between unit proportion of certified staff RNs and unit rates of adverse events.
Significant or close to significant relationships were found between unit proportion of certified staff RNs and rates of falls, bloodstream infections, and urinary tract infections. RN certification and rates of falls and urinary tract infections were inversely related in the ICU setting and positively related in the NonICU setting. The small sample size required that caution be exercised when interpreting study findings. Knowledge gained from this study provides preliminary guidance for policymakers, payers, and educators regarding content development and structure of RN core competencies needed to reduce risk of patient harm.
The effect of pediatric hospital specialization on patient safety and effectiveness of care
Harris, James Mitchell, II. Proquest Dissertations And Theses 2007. Section 2383, Part 0769 187 pages; [Ph.D. dissertation].United States -- Virginia: Virginia Commonwealth University; 2007. Publication Number: AAT 3294833.
Abstract (Summary)
Provider specialization is an area of interest in health care as patients, payers and policy makers are now demanding better performance and demonstrated proof of the benefits of specialization. While previously ignored in the specialization debate, now even the hospitals focusing on pediatric care (i.e. children's hospitals) are experiencing pressure to demonstrate their value. The current study attempts to answer the questions: do hospitals specializing in pediatric care provide better quality pediatric inpatient care; and do they do so for differing types of patient outcomes and across different levels of care complexity?
Contingency Theory is used to develop and assess a theoretical framework to see if pediatric hospital specialization is associated with improved outcomes for pediatric inpatient care. The theory suggests that not all ways of organizing are equally effective, and that organizational performance is maximized when there is alignment between organizational structure (specialization) and external contingencies (care complexity).
A sample of 1,317 U.S. hospitals was included in the study. Data from two sources--the 2003 Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) and the American Hospital Association's (AHA) Annual Survey Database for fiscal year 2003--was used in a factor analysis to generate a measure of hospital pediatric specialization. The results of the factor analysis were then used in regression models to examine the effect hospital pediatric specialization had on patient safety and effectiveness of care at multiple levels of care complexity.
Results suggest that there are two dimensions of hospital pediatric specialization--a pediatric focused element and a complex pediatric care element--and that these dimensions appear to have opposing influences on measures of inpatient care quality. Focusing primarily on the treatment of pediatric patients seems to improve the level of care provided, but specializing in the care of complex pediatric conditions has a small but significant association with higher patient safety event rates and longer than expected lengths of stay.
Indexing (document details)
Advisor:
Ozcan, Yasar A.
School:
Virginia Commonwealth University
School Location:
United States -- Virginia
Keyword(s):
Children hospitals, Hospital specialization, Contingency theory, Patient safety, Effectiveness of care
The relationship of hospital systems and utilization of patient safety practices to patient outcomes
Thornlow, Deirdre Kling. Proquest Dissertations And Theses 2007. Section 0246, Part 0569 238 pages; [Ph.D. dissertation].United States -- Virginia: University of Virginia; 2007. Publication Number: AAT 3239960.
Abstract (Summary)
Determining the factors that are associated with the provision of safe patient care is crucial for today's healthcare environment. Such efforts are necessary, as research demonstrates that the majority of medical errors, or adverse events, are preventable. This correlational study provided evidence regarding the types of acute care hospitals that are likely to utilize patient safety practices and whether this composite of patient safety practices is associated with patient safety outcomes.
The Quality Health Outcomes Model and Learning Organization Theory guided hypothesis development. Secondary data were used to evaluate hospital systems, patient safety practices, and patient outcomes on a stratified probability sample of acute care hospitals. JCAHO accreditation performance areas were reduced into sub-component scores to measure the utilization of patient safety practices. Patient safety outcome rates were calculated using the AHRQ Patient Safety Indicator software; hypotheses were tested using multiple regression analysis.
Findings indicate that acute care hospitals with higher levels of nurse staffing were more likely to utilize patient safety practices, as measured by the broader overall JCAHO score, than hospitals with poorer levels of nurse staffing. When the overall performance areas were reduced into sub-component scores, nurse staffing was not consistently associated with the utilization of patient safety practices. Although teaching status and nurse staffing did not affect patient safety outcomes, larger hospitals had higher rates of 'infections due to medical care' than smaller hospitals. Although not hypothesized a priori, larger hospitals also demonstrated higher rates of 'post-operative respiratory failure' than smaller hospitals. Additionally, for-profit hospitals displayed higher rates of 'decubitus ulcer' and 'post-operative respiratory failure' than non-profit and non-federal government hospitals. And finally, the effect of implementing various patient safety practices, and most specifically the resultant impact on patient outcomes, also appears dependent upon the outcome measured. Hospitals utilizing fewer patient safety practices demonstrated higher rates of 'infections due to medical care' and higher rates of 'decubitus ulcers,' but no differences were noted in rates of 'post-operative respiratory failure' or 'failure to rescue.' Some adverse events, such as infection, may be more amenable to the development of policies and procedures designed to prevent occurrence.
Indexing (document details)
Advisor:
Merwin, Elizabeth
School:
University of Virginia
School Location:
United States -- Virginia
Keyword(s):
Acute care, Hospital, Patient safety, Patient outcomes
Error and reporting in surgery: Exploring team and patient perceptions
Espin, Sherry. Proquest Dissertations And Theses 2006. Section 0779, Part 0564 178 pages; [Ph.D. dissertation].Canada: University of Toronto (Canada); 2006. Publication Number: AAT NR15871.
Abstract (Summary)
This thesis presents a research study, conducted for my PhD. This research used mixed qualitative and quantitative methods to address four central questions: How do interdisciplinary team members perceive error and error reporting? How do patients perceive error and error reporting? What are the areas of congruence and conflict between different healthcare professionals' approaches to error and patients' needs and perspectives? Why are certain events not described as errors and not addressed in a systematic fashion that would improve patient safety? This study was conducted in the grounded theory tradition and included two phases. The first phase investigated the perceptions of OR team members and patients regarding error definition and error reporting; the second phase sought to elaborate two of the dominant themes from the first phase.
The first three chapters of this thesis provide background information about the context, theoretical foundation, and design of the research. The following three chapters present the results of the study in the form of three self-contained articles that have been published or submitted to academic journals. The first of these articles describes and compares surgical team members' and patients' perceptions of error, its reporting, and its disclosure from the first phase of the study. It is published in the journal Surgery . The second article explores operating room (OR) nurses' error reporting preferences from the second phase of the study. This article has been submitted to an applied nursing research journal. The third article sought to probe the factors influencing whether team members saw error events in everyday work as problematic or whether they rationalized such occurrences to support the status quo. The analysis draws on three concepts from organizational and psychological theory to explore team members' responses to these error scenarios. This article has been submitted to the journal Quality and Safety in Healthcare . The final chapter draws the three papers together into an extended discussion about the significance and future implications of this work.
Indexing (document details)
School:
University of Toronto (Canada)
School Location:
Canada
Keyword(s):
Surgery, Medical errors, Error reporting
Source:
DAI-B 67/07, Jan 2007
Source type:
Dissertation
Subjects:
Surgery, Health care, Medical errors, Teams, Perceptions, Patient safety, Studies
Patient safety and disclosure of medical error: The legal and ethical implications of human error in medicine
Waite, Michael Allen. Proquest Dissertations And Theses 2006. Section 0351, Part 0398 155 pages; [LL.M. dissertation].Canada: University of Alberta (Canada); 2006. Publication Number: AAT MR13723.
Abstract (Summary)
Physicians have both an ethical and legal duty to disclose medical errors to patients. Although no Canadian court has held that nurses or hospitals have a corresponding legal duty to disclose medical error to patients, it is likely that such a duty exists. To facilitate increased disclosure, significant cultural and educational changes to hospitals and the health professions are required. Health administrators must recognize that most errors are systemic (not individual) errors and must foster a system of just responses to error. To promote the disclosure of medical error, there must also be legal reform to remove barriers to disclosure and to improve the efficacy of the medical liability system. Once these steps have been taken, a full discussion and investigation of every medical error and near miss is more likely to occur, thereby allowing the health system to act to prevent similar errors from occurring in the future.
Indexing (document details)
School:
University of Alberta (Canada)
School Location:
Canada
Source:
MAI 44/05, Oct 2006
Source type:
Dissertation
Subjects:
Law, Surgery, Health care, Patient safety, Medical errors, Ethics, Medicine
Pediatric patient safety: Factors pediatric nurses identify as contributing to medication administration errors
Hogan, Catherine Ann. Proquest Dissertations And Theses 2006. Section 0112, Part 0569 232 pages; [Ph.D. dissertation].United States -- Illinois: Loyola University Chicago; 2006. Publication Number: AAT 3229785.
Abstract (Summary)
Patient safety is the number one goal of every health care organization. One of the major threats to patient safety in the acute care environment is medication error. Nursing is involved in all aspects of the medication-use process. Medication administration is a significant responsibility for nurses in the pediatric acute care setting owing to complex drug calculations and weight based dosing. To date, little research has focused on nurses who transcribe, prepare, administer and monitor drug effects in the pediatric acute care environment. The purpose of this study was to establish factors that pediatric nurses identify and describe as contributing to medication errors in the pediatric acute care setting.
A descriptive, cross-sectional design was used with a nonprobability purposive sample of 326 pediatric nurses. Data were collected using an electronic mail survey using the medication Administration Error survey (Wakefield et al. 1996). The factor analysis of responses to the MAE survey revealed the following five factors as reasons why medication administration errors occur in the pediatric acute care setting: physician, systems, pharmacy, industry, and knowledge. Additionally, factor analysis of responses to section B of the MAE survey indicated that the following three factors as reasons why medication administration errors are not reported: fear, disagreement over error and administrative response. Analysis of variance was conducted to evaluate the relationship between the responses to the survey, demographic and personal characteristics. Significant differences were found. When respondents were grouped by medical, surgical and critical care nursing groups, significant differences were found on the responses to the physician, systems, disagreement over error and administrative response factors.
Study findings provide information that may be used in the development of error reduction programs and to foster increased medication error reporting within the acute care pediatrics setting. Additionally, this study meets one of the JCAHO's (2006) goals for healthcare providers by identifying potential strategies to prevent medication errors by identifying factors that may be used in improving the safety of medications in hospitals.
Indexing (document details)
Advisor:
Haas, Sheila
School:
Loyola University Chicago
School Location:
United States -- Illinois
Keyword(s):
Pediatric, Patient safety, Pediatric nurses, Medication, Medical errors
Second, do less harm: The state of states' medical error reporting programs
Rasmus, Monica Lynn. Proquest Dissertations And Theses 2006. Section 0219, Part 0564 71 pages; [Dr.P.H. dissertation].United States -- Texas: The University of Texas School of Public Health; 2006. Publication Number: AAT 3241400.
Abstract (Summary)
Statement of the problem and public health significance. Hospitals were designed to be a safe haven and respite from disease and illness. However, a large body of evidence points to preventable errors in hospitals as the eighth leading cause of death among Americans. Twelve percent of Americans, or over 33.8 million people, are hospitalized each year. This population represents a significant portion of at risk citizens exposed to hospital medical errors. Since the number of annual deaths due to hospital medical errors is estimated to exceed 44,000, the magnitude of this tragedy makes it a significant public health problem.
Specific aims. The specific aims of this study were threefold. First, this study aimed to analyze the state of the states' mandatory hospital medical error reporting six years after the release of the influential IOM report, "To Err is Human." The second aim was to identify barriers to reporting of medical errors by hospital personnel. The third aim was to identify hospital safety measures implemented to reduce medical errors and enhance patient safety.
Methods. A descriptive, longitudinal, retrospective design was used to address the first stated objective. The study data came from the twenty-one states with mandatory hospital reporting programs which report aggregate hospital error data that is accessible to the public by way of states' websites. The data analysis included calculations of expected number of medical errors for each state according to IOM rates. Where possible, a comparison was made between state reported data and the calculated IOM expected number of errors. A literature review was performed to achieve the second study aim, identifying barriers to reporting medical errors. The final aim was accomplished by telephone interviews of principal patient safety/quality officers from five Texas hospitals with more than 700 beds.
Results. The state medical error data suggests vast underreporting of hospital medical errors to the states. The telephone interviews suggest that hospitals are working at reducing medical errors and creating safer environments for patients. The literature review suggests the underreporting of medical errors at the state level stems from underreporting of errors at the delivery level.
Balancing patient safety
Lam, Brian B. L.. Proquest Dissertations And Theses 2005. Section 1313, Part 0769 127 pages; [M.A. dissertation].Canada: Royal Roads University (Canada); 2005. Publication Number: AAT MR09466.
Abstract (Summary)
Organizational leaders are responsible for achieving strategic priorities and operational efficiencies. Healthcare leaders have an added responsibility of ensuring that their customer or patient's well-being is protected.
These responsibilities become increasingly challenging during organizational change. Widespread organizational change frequently leads to an initial state of organizational chaos and confusion that results in a variety of undesirable consequences.
Vancouver Coastal Health (VCH) has been in a constant state of change and development. Misunderstandings and errors have developed throughout the system, thus impacting upon the consistent delivery of quality patient care and hence, potentially impacting patient safety.
This paper examines VCH's capacity and ability to balance its leadership responsibilities of leading organizational change while ensuring safe, consistent patient care. The results show that safe-quality care needs to be firmly rooted in VCH. Several suggestions from the findings and the literature are proposed.
Indexing (document details)
School:
Royal Roads University (Canada)
School Location:
Canada
Source:
MAI 44/03, Jun 2006
Source type:
Dissertation
Subjects:
Health care, Patient safety, Health facilities, Organizational change, Leadership, Strategic management, Studies
Development and testing of an automated Fall-Injury Risk Assessment Instrument
Currie, Leanne Marie. Proquest Dissertations And Theses 2004. Section 0054, Part 0569 196 pages; [D.N.Sc. dissertation].United States -- New York: Columbia University; 2004. Publication Number: AAT 3147223.
Abstract (Summary)
Falls in the inpatient environment continue to be a frequent occurrence and are one of the highest causes of mortality and subsequent morbidity in the acute care setting. The overarching goal of the study was to develop an automated Fall-Injury Risk Assessment Instrument that would be perceived by end-users to be usable, easy to use and useful. Automation of the instrument seeks to support care processes toward a goal of improving patient safety. Methods . This study consisted of five sub-studies: (1) A case-control study to identify instrument items; (2) A quasi-experimental study to pilot test and refine the instrument; (3) Descriptive studies evaluating the representation of associated concepts in standardized terminologies and in the local data dictionary; and Qualitative studies, including (4) focus groups to identify requirements and (5) usability testing with usability experts and end-users to inform design decisions. Results . The case-control study identified a five-factor model; sensitivity 67.4% and specificity 60%. The five factors include: (1) Use of sedatives, (2) History of falling, (3) Male gender, (4) Impaired cognition, and (5) Unsteady gait and not using an assistive device, an interaction variable. Pilot testing revealed an inverse correlation between instrument and policy use and fall rates; the unit with the best adherence to using the instrument had a decrease in falls from a mean of 9.1 to 5.1 over a three-month period (p = 0.12). The concepts were well represented by the UMLS (100%) and LOINC semantic structure, but were less well-represented by ICD9-CM (66%). Requirements specified by key decision makers and end-users included alignment with the hospital policy, pre-population with patient data and colors for visual cues. Usability studies revealed that the automated instrument was perceived to be usable, easy to use and useful. Discussion . Automation of a Fall-Injury Risk Assessment Instrument promotes a culture of safety and provides a method to systematically evaluate adult inpatients' risk of falling. A comprehensive terminology model ensures that data are non-ambiguous and can be re-used for clinical and administrative purposes. Involving key decision makers and end-users in the development was critical to create a useful, usable and easy to use instrument.
Errors and failures in complex health-care systems: Individual, team, system and cultural contributors
Scott, Kathy A.. Proquest Dissertations And Theses 2004. Section 1414, Part 0769 227 pages; [Ph.D. dissertation].United States -- Ohio: Union Institute and University; 2004. Publication Number: AAT 3162990.
Abstract (Summary)
This study examined three error-events in two community hospitals in the Northwest and Midwest United States which resulted in patient harm and/or potential patient harm. This study sought to answer the following questions: "What are the individual, team, and system characteristics and behaviors that contribute to error in community hospitals?" and "How does organizational culture contribute to error in health-care organizations?" Two sets of data were collected--(1) root-cause analyses, medical records, and staffing schedules from the two respective databases of the two hospitals; and (2) interview data from the persons who were identified as contributors to errors in the three error-events selected for study. The Taxonomy of Error Root Cause Analysis Protocol (TERCAP) tool, which was created by the National Council of State Boards of Nursing Practice Breakdown Research Advisory Council (2002) for retrospective error-categorization of nursing errors, was adapted by the researcher to categorize and analyze the individual errors of nurses and other health-care professionals and workers. The interdisciplinary team dynamics within the system and organizational culture were analyzed after an extensive review of the related research and literature. Findings revealed that multiple people in multiple professions and positions committed a variety of errors during the course of routine and emergent work that resulted in patient harm. Four patterns of behavior were identified involving individuals, team, systems, and cultures which contributed to six categories of error across the three error-events. The four patterns of behavior were: cultures of blame, fear, self protection and a hierarchical status-consciousness; difficult interpersonal relations; difficulty managing conflict, coping with stress, and confronting ones weaknesses; and feedback delays related to error discovery and reporting. The four patterns of behavior led to the following six categories of error that resulted in patient harm: (1) Failure to anticipate and be attentive secondary to unclear expectations and distractions; (2) Inappropriate judgment secondary to simplification and/or self aggrandizement; (3) Ineffective teamwork related to status consciousness and conflict; (4) Lack of agency/fiduciary responsibility in cultures that normalize intimidation and blame; (5) Inadequate system controls for critical operations; and (6) Inadequate and delayed feedback for learning.
Indexing (document details)
Advisor:
Prewitt, Lena B.
School:
Union Institute and University
School Location:
United States -- Ohio
Keyword(s):
Health care, Hospitals, Medical errors
Source:
DAI-B 66/02, p. 792, Aug 2005
Source type:
Dissertation
Subjects:
Health care, Management, Patient safety, Errors, Culture
The occurrence of medical errors: Assessing error detection, correction, and prevention within acute care hospitals in Pennsylvania
Atkin, Monica L.. Proquest Dissertations And Theses 2004. Section 0176, Part 0769 256 pages; [Ph.D. dissertation].United States -- Pennsylvania: The Pennsylvania State University; 2004. Publication Number: AAT 3139987.
Abstract (Summary)
The ultimate goal of this study was to help providers of healthcare within Pennsylvania acute care hospitals find solutions to the ever-present problem of the occurrence of medical errors. Scholarly literature states that the majority of medical errors occur due to systems that breakdown and fail healthcare workers. However, there was a stated gap within cited literature in regard to "where" systems breakdown. This study sought to provide new knowledge in regard to where one particular system may be breaking down, specifically the error reporting system. The purpose of this study was twofold; (1) to develop two structured interview questionnaires, and (2) to conduct structured interviews as a means to collect data that focused on the occurrence of medical errors; specifically through assessing the error reporting systems within a sample of Pennsylvania acute care hospitals. Conclusions in this study included perceived areas of potential breakdowns of error reporting systems. Most notably, it was found that a significant breakdown may exist at the correction stage within sampled error reporting systems. The overwhelming majority of research participants stated that corrective actions, once an error was detected, focused upon various training interventions. However, scholarly literature states that the majority of medical errors do not occur due to the lack of competence, skills, or knowledge of healthcare professionals. Thus, using training interventions to solve non-training problems may not prove effective. Using a qualitative methodology, perceptions of twenty-two healthcare professionals and fifteen patients were collected through structured interviews. More specifically, twelve patient safety officers, ten nurses, and fifteen patients were interviewed. Interviews averaged forty-three minutes in length. Five research questions provided the framework for data organization and for interpreting the perceptions of the research participants. Eighty-eight categories emerged from the data and nineteen themes emerged from the categories of information. A detailed discussion of the categories and themes was discussed, as well as the conclusions found in this study. Recommendations for both healthcare professionals and patients were offered. Lastly, further research was suggested as it relates to patient safety and the reduction of medical errors.
Indexing (document details)
Advisor:
Rothwell, William
School:
The Pennsylvania State University
School Location:
United States -- Pennsylvania
Keyword(s):
Medical errors, Error detection, Acute care hospitals, Pennsylvania, Performance improvements
Source:
DAI-B 65/07, p. 3364, Jan 2005
Source type:
Dissertation
Subjects:
Health care, Medical errors, Critical care, Hospitals
Epidemiology of medical errors
Johnson, Trista Wendy. Proquest Dissertations And Theses 2003. Section 0130, Part 0573 216 pages; [Ph.D. dissertation].United States -- Minnesota: University of Minnesota; 2003. Publication Number: AAT 3076323.
Abstract (Summary)
First, a methodological study examined the application of epidemiology to the study of medical errors. This study proposed that epidemiologic methods would be useful as a tool to determine rates, risks, prevalence, or incidence of adverse health outcomes as a result of medical care. The study examined a definition in measurement of patient safety events, data collection methods, and the study designs that may be useful for studying medical errors.
The second study explored variables associated with increased reporting of safety events, a key factor associated with improved safety in other industries. This study examined the association between data from a survey of employees on the culture of safety and actual reporting rates of errors at a group of hospitals. The results indicated that reporting of near misses (errors caught before they reach the patient) was important in driving the overall culture for reporting of safety events. Departments that responded in the survey that they often report near misses also had higher overall reporting of safety events.
The third study examined risk factors for insulin medication errors using a cohort study and a nested case-control study. The source population was all inpatients with orders for insulin at four Twin Cities hospitals from 2000-2001. Cases were patients with insulin errors and controls were patients without errors. For the nested case-control study, controls were matched in a 1:1 ratio to cases on hospital, age, gender, diagnosis, and severity of illness. There were 404 cases and 404 matched controls. Results of the case-control study indicated several modifiable risk factors, such as insulin order complexity, and results of the cohort study indicated several non-modifiable risk factors, such as gender or diagnosis, were significantly associated with insulin errors.
Indexing (document details)
Advisor:
Anderson, Kristin Ellen
School:
University of Minnesota
School Location:
United States -- Minnesota
Keyword(s):
Epidemiology, Medical errors, Patient safety, Insulin
Exploring pediatric patient safety
Woods, Donna. Proquest Dissertations And Theses 2003. Section 0541, Part 0769 194 pages; [Ph.D. dissertation].United States -- Massachusetts: Brandeis University, The Heller School for Social Policy and Management; 2003. Publication Number: AAT 3090049.
Abstract (Summary)
Patient safety and the prevention of medical injuries are important issues in the health care system. Relatively little information is available about the nature and type of problems that occur in pediatric medical care. This investigation explores pediatric patient safety using a three part methodology: (1) a literature based review of pediatric specific vulnerabilities identifiable through the pediatric and patient safety literature; (2) an epidemiologic exploration using the Colorado and Utah Medical Practice Study population database of adverse medical events to estimate the rates of occurrence of adverse events and preventable adverse events in children, and in comparison with adults; (3) a qualitative critical incident analysis reviewing clinician descriptions of the circumstances of problems that occur in children's medical care.
This investigation identified several key findings: (1) Children experience medical errors and adverse events, but appear less likely than adults to experience adverse events. Once a medical injury has been sustained, there is no significant difference in the extent of harm experienced by children and adults. (2) Adverse events and related injuries in children are most common in the context of birth. This high frequency is related to the proportion of hospital admissions of children for birth. However, adolescents have the highest rate of adverse events and preventable adverse events. (3) Child specific factors contributed to nearly half of the problems described. (4) The area of diagnostics is the only aspect of medicine that carries a higher risk of preventable adverse events to children than to adults.
This study provides the first typology of pediatric safety-related problems. Children present specific characteristics that must be taken into account in the design of strategies to improve patient safety. A three pronged approach for improvement is recommended: (1) As medical care systems are reorganized and re-tooled, patient safety principles and pediatric specific design features are recommended, (2) coordination of oversight efforts is needed to focus attention and resources toward these changes, and (3) there is need for continued study to increase understanding and effectively target priorities.
Indexing (document details)
Advisor:
Altman, Stuart
School:
Brandeis University, The Heller School for Social Policy and Management
School Location:
United States -- Massachusetts
Keyword(s):
Patient safety, Pediatrics, Children, Health care
Source:
DAI-B 64/05, p. 2113, Nov 2003
Source type:
Dissertation
Subjects:
Health care, Surgery, Public health, Pediatrics, Patients, Safety
Factors contributing to medication errors
Mutsch, Karen. Proquest Dissertations And Theses 2000. Section 1259, Part 0569 47 pages; [M.S. dissertation].United States -- Kentucky: Northern Kentucky University; 2000. Publication Number: AAT EP25673.
Abstract (Summary)
Medication errors are a primary concern in today's healthcare environment. Over six of every 100 patients admitted to the hospital suffer a drug-related injury (Bates and all, 1999). In order to improve patient safety, medication systems have to improve. The purpose of this study is to determine that factors contribute to medication errors. This was a non-experimental, descriptive study focusing on the ways in which medication errors can occur. The Quality Assurance Model Using Research is the conceptual framework used for this quantitative study. This study was conducted in the Risk Management Department office in a mid-west hospital. Approximately 820 incident reports from two quarters in 2000 were reviewed. The sample size was 109 occurrence report forms involving 132 medications from ten different patient service areas. Data was collected using a researcher created data collection form that included patient service area, drug class, and administration errors. The data collection tool also identified the medication process area in which the medication error was made. The data was described using descriptive statistics. The completion of this project provided current data and information that will be useful in identifying those factors contributing to medication errors. Practical implications were identified to aid in the prevention of related medication system errors.
