Health and Medical Administration Commons^™

Management Of Inappropriate Behaviors By Healthcare Risk Managers, Sahar Ebrahim Zadeh

Walden Dissertations and Doctoral Studies

Medical errors are the 3rd leading cause of death in the U.S.. The problem is timely recognition and management of inappropriate healthcare worker behaviors that lead to intimidation and loss of staff focus, eventually leading to errors. The purpose of this qualitative modified Delphi study was to seek consensus among a panel of experts in hospital risk management practices on the practical methods for early detection of inappropriate behaviors among hospital staff, which may be used by hospital managers to considerably mitigate the risk of medical mishaps. High reliability theory guided the research process, utilizing the conceptual framework of fair …

Determining Perceived Barriers Affecting Physicians' Readiness To Disclose Major Medical Errors, Jean-Pierre K. Folligah

Walden Dissertations and Doctoral Studies

Medical errors have been detrimental in the field of medicine. They have impacted both patients and doctors. While physicians recognized that error disclosure was an ethical and professional obligation, most remained silent when mistakes happened for different reasons. Guided by the theory of planned behavior and Kant's deontological theory, the purpose of this quantitative study was to investigate the perceived barriers affecting physicians' willingness to report major medical errors. An association was tested between the independent variables physician fear of disclosure of errors, organizational culture toward patient safety, physician apology, professional ethics and transparency, physician education, and the dependent variable …

Patient Safety: Just Ask. Patients As Reporters Of Real-Time Safety Data; A Pilot Project To Improve Patient Safety In Secondary Care, Thomas A. Cairns Dr, Iain Mccallum Mr

Patient Experience Journal

The Berwick review into patient safety recommended ‘involving patients in the healthcare organisation and seeking out the patient voice as an essential asset to monitor safety.’ (1) However routine data collection from patients in our institution is retrospective and doesn't focus on safety. Our objective was to create a patient-centred mechanism to monitor patient-perceived safety concerns and provide immediate resolution of highlighted issues. A pragmatic 6-question questionnaire was developed containing 4 scored and 2 free text questions. This questionnaire was piloted and adjusted before being administered to all inpatients meeting the inclusion criteria in our institution on one day. Safety …

Quality? Safety? Stop Being Naïve., Rana K. Zaban Do, Steven Istephan, Jonathan Serman Md

Clinical Research in Practice: The Journal of Team Hippocrates

The first day of our inpatient medicine rotation, the Emergency Department (ED) admitted a patient to a general medical floor without notifying our rounding team. We used the institution’s system improvement tracking software to draw attention to communication breakdown in the interest of patient safety. This piece illustrates how there is a prominent hierarchy in medicine; it is inherent to the framework of the way in which hospitals function. A discussion ensues with our attending physician supervisor on our patient medicine service. During this discussion, we ponder whether it is possible to impact quality and safety from our position as …

Implementation Of A Standardized Handoff During Transition Of Care From The Emergency Department To The Intensive Care Unit, Melinda Abbring

Evidence-Based Practice Project Reports

Patient safety and nursing communication are crucial to the nursing handoff during transition of care from the emergency department (ED) to the intensive care unit (ICU). The Institute of Medicine published To Err is Human: Building a Safer Health System (1999) and Crossing the Quality Chasm (2001) highlighting ED handoffs as a safety measure. In 2006, the Joint Commission recognized handoffs with the National Patient Safety Goal 2E. The purpose of this evidence-based practice project was to determine if implementation of a standardized handoff would improve nursing communication and patient safety during transition of care from the ED to the …

Analisis Tatakelola Sasaran Keselamatan Pasien Pada Alur Pelayanan Penyakit Sepsis Di Rumah Sakit Tebet 2015, Rianayanti Asmira Rasam

Jurnal ARSI : Administrasi Rumah Sakit Indonesia

In the context of modern medicine, complexity hospital’s management is regarded as the primary cause of medical error (ME). The new healthcare paradigm of “Patient-Focused Care”, patient’s right to receive safe healthcare treatment is considered as main indicator in Standar Akreditasi Rumah Sakit of 2012 (SARS 2012) in Indonesia, through the implementation of 6 Patient Safety (KP) standards. In the category of emergency medical treatment, Sepsis is considered as a disease with high mortality and morbidity rate. The use of The International Classification of Diseases, based on Ninth Revision (ICD-9), have caused terminological confusion and contribute to the increase of …

Perlukah Keselamatan Pasien Menjadi Indikator Kinerja Rs Blu?, Masyitoh Basabih

Jurnal ARSI : Administrasi Rumah Sakit Indonesia

The government which is the Ministry of Health through its regulations mandates the importance of patient safety. This can be seen from the mention of patient safety in the four articles in Undang-Undang Number 44 Year 2009 about Hospital and specifically in the Minister of Health Regulation. The importance of patient safety issues in hos pitals is not directly proportional to the performance indicators of the BLU Hospital written inPeraturan Direktur Jenderal Pembendaharaan Number 34 Year 2014 about the Guidelines for Performance Appraisal of Public Ser vice Bodies for Health Services. In this regulation, it can be seen that the …

Impact Of A Localized Lean Six Sigma Implementation On Overall Patient Safety And Process Efficiency, Luvianca Gil, Pilar Pazos, Mamadou Seck, Rolando Delaguila

Engineering Management & Systems Engineering Faculty Publications

Continuous quality improvement tools have caught the attention of the Health Care Industry as a solution to process efficiency, patient safety and cost reduction. This research explores the impact of a Lean Six Sigma (LSS) process improvement initiative in overall process efficiency and patient safety in two Labor and Delivery (L+D) units of two large hospital providers. This study focuses on the application of modeling and simulation methodology to investigate the influence of a localized process improvement intervention on the overall L+D unit output, by considering patient flow, system capacity and unit performance. The simulation models capacity profiles and patient …

Experiences And Barriers For Patient Safety Officers Conducting Root Cause Analysis, Cynthia Lightner

Walden Dissertations and Doctoral Studies

Research shows that, when unintentional harm to patients in outpatient and hospital settings occurs, root cause analysis (RCA) investigations should be conducted to identify and implement corrective actions to prevent future patient harm. Executives at a small healthcare consulting company that employs patient safety officers (PSOs) responsible for conducting RCAs were concerned with the low quality of RCA outcomes, prompting this postinvestigation assessment of PSOs' RCA training and experiences. Guided by adult learning theory, the purpose of this study was to assess PSOs' RCA training and investigation experiences by examining self-reported benefits, attitudes, barriers, and time since training, and the …

Implementing A Good Catch Program In Nursing Homes, Leigh Raposo

Muskie School Capstones and Dissertations

Rationale and processes for reporting near misses and evidence-based tools were collected by a literature search, seminal works by Sidney Dekker and James Reason, and websites for the Agency for Healthcare Research and Quality (AHRQ), the Institute for Healthcare Improvement (IHI), and the Centers for Medicare and Medicaid Services (CMS). Tools, information, and strategies found in this research were evaluated for implementation in Maine nursing homes. The tools provide a communication vehicle for nursing home staff to safely report to management near misses, or mistakes that do not harm residents. To emphasize a positive approach, the project replaces the term …

Handoffs, Safety Culture, And Practices: Evidence From The Hospital Survey On Patient Safety Culture, Soo-Hoon Lee, Phillip H. Phan, Todd Dorman, Sallie J. Weaver, Peter J. Pronovost

Management Faculty Publications

Background: The context of the study is the Agency for Healthcare Research and Quality’s Hospital Survey on Patient Safety Culture (HSOPSC). The purpose of the study is to analyze how different elements of patient safety culture are associated with clinical handoffs and perceptions of patient safety.

Methods: The study was performed with hierarchical multiple linear regression on data from the 2010 Survey. We examine the statistical relationships between perceptions of handoffs and transitions practices, patient safety culture, and patient safety. We statistically controlled for the systematic effects of hospital size, type, ownership, and staffing levels on perceptions of patient safety. …

A Vision For Using Online Portals For Surveillance Of Patient-Centered Communication In Cancer Care, Hardeep Singh, Neeraj K. Arora, Kathleen M. Mazor, Richard L. Street Jr

Patient Experience Journal

The Veterans Health Administration (VHA) is charged with providing high-quality health care, not only in terms of technical competence but also with regard to patient-centered care experiences. Patient-centered coordination of care and communication are especially important in cancer care, as deficiencies in these areas have been implicated in many cases of delayed cancer diagnosis and treatment. Additionally, because cancer care facilities are concentrated within the VHA system, geographical and system-level barriers may present prominent obstacles to quality care. Systematic assessment of patient-centered communication (PCC) may help identify both individual veterans who are at risk of suboptimal care and opportunities for …

Cancer Patients’ Experiences Of Error And Consequences During Diagnosis And Treatment, Henriette Lipczak, Liv H. Dørflinger, Christine Enevoldsen, Mette M. Vinter, Jeanne L. Knudsen

Patient Experience Journal

The study objective was to investigate patient experienced error during diagnosis and treatment of cancer. The design included a nationwide patient survey on quality and safety in Danish cancer care. Responses regarding patient experienced error were separately analyzed, quantitative responses using descriptive statistics and qualitative responses using systematic text analysis. Study participants included 6,720 adult patients with a first time diagnosis of cancer registered between May 1st and August 31st 2010. The patients received a questionnaire concerning their experiences of care received by general practitioners, specialist practitioners and at the hospital. A response rate of 65% was achieved. 10 – …

Patient Complaints As Predictors Of Patient Safety Incidents, Helen L. Kroening, Bronwyn Kerr, James Bruce, Iain Yardley

Patient Experience Journal

Patients remain an underused resource in efforts to improve quality and safety in healthcare, despite evidence that they can provide valuable insights into the care they receive. This study aimed to establish whether high-level patient safety incidents (HLIs) were predictable from preceding complaints, enabling complaints to be used to prevent HLIs. For this study complaints received from November 2011 through June 2012 and HLI incident reports from April through September 2012 were examined. Complaints and HLIs were categorised according to location or specialty and the themes they included. Data were analysed to look for correlations between number of complaints and …

The Effect Of A Culture Of Safety On Patient Throughput, Laurie Lee Dawn Dillon

Walden Dissertations and Doctoral Studies

There is a national movement to create improvements in patient safety and outcomes due to evolutionary changes in the healthcare. Many health care organizations are using the framework of a culture of safety in order to create a reliable and stable work environment that emphasizes safety and improves patient outcomes. Patient throughput, defined as the active management of the supply of patient beds (rooms for occupation) to the demand of patients to beds and the length of time it takes for this action to occur, has been identified as one of the areas in need of improvement. This study considered …

Book Review: Questioning Protocol, Barbara Lewis Mba

Patient Experience Journal

In her review of Questioning Protocol by Randi Redmond Oster, Barbara Lewis shares how this new and award winning book takes the reader on Randi Oster's harrowing journey of navigating the healthcare system while helping her teenage son’s battle with Crohn’s disease. Seventeen chapters build a chronological story of success, frustration and failure in dealing with modern medicine and a healthcare industry that may appear foreign to the outsider.

Einstein's Comprehensive Unit-Based Safety Program, Beth Lapiene Msph

Population Health Matters (Formerly Health Policy Newsletter)

No abstract provided.

Healthcare-Associated Infections-Is Targeting Zero A Global Reality?, Mary Lou Manning Phd, Crnp, Cic, Faan, Denise Murphy Rn, Mph, Cic, Faan

Population Health Matters (Formerly Health Policy Newsletter)

No abstract provided.

Perceptions Of Hospital Patient Safety Culture In Department Of Veterans Affairs Station 593 Southern Nevada, Kimberly Falco

UNLV Theses, Dissertations, Professional Papers, and Capstones

Opportunities for error exist, adverse events occur, and challenges endure. However, patients will continue to experience preventable adverse events unless steps are taken. Efforts to improve patient safety are critical to today's healthcare environment. The Department of Veterans Affairs (VA) believes that the identification of adverse events allows for creation of system improvements to increase patient safety.

Implementing safety culture requires a proper assessment of existing barriers and potential challenges. Patient safety culture assessments start by evaluating the current patient care environment. This assists the organization in identifying barriers to patient safety and in working toward creating a culture of …

Impact Of Culture And A Performance Improvement Framework On The "Superior Care Experience" At Main Line Health System, Denise M. Murphy Rn, Mph, Cic, Jessica Lampley Mha

Population Health Matters (Formerly Health Policy Newsletter)

No abstract provided.

Policies In Hospital Social Work, Jolene L. Reisdorfer

All Graduate Theses, Dissertations, and Other Capstone Projects

The goal of this project was to create an environment that provides a professional standard of care to ensure patient safety. This project will address the absence of policies in the Social Service Department at Mayo Clinic Health System, Southwest Region. A standard of care is a detailed standardized model of an intervention process that discusses the goals, objectives, settings, process, procedures and interventions (Gayle, 2005). Policy development must occur to assure that patients with social service needs are being identified appropriately and are being provided necessary interventions to meet their needs (Gordon & Rehrs, 1969). The project also identified …

The Effect Of Pediatric Hospital Specialization On Patient Safety And Effectiveness Of Care, James Mitchell Harris Ii

Theses and Dissertations

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 …

Doctors At Risk: A Problem As Viewed By Decision Analysis, Leonard P. Caccamo, Kimbroe J. Carter, Barbara A. Erickson, William R. Johnson, Edward Kessler

RISK: Health, Safety & Environment (1990-2002)

The authors closely analyze a case in which a Peer Review Organization cited a physician for treatment with potential for significant adverse effect. They also critique the regulatory scheme under which peer review occurs and conclude that such regulation interferes with physicians' primary obligations, fails to encourage cost-effective behavior and may decrease the quality of medical care.