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Strategies for Patient Safety

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Abstract

The labor and delivery unit was unusually busy, and the resident was especially concerned about two of the patients he was watching closely. Patient A with a vertex/vertex twin pregnancy at 37 weeks of gestation had been in labor for 26 h. Patient B was full term with a Category 2 fetal heart tracing and intermittent decelerations. The resident consulted his attending physician about Patient B’s fetal heart tracing, and it was decided that Patient B could be allowed to continue to labor with very close surveillance.

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References

  • AHRQ (2008) Becoming a high reliability organization: operational advice for hospital leaders. AHRQ publication no. 08-0022. Agency for Healthcare Research and Quality, Rockville

    Google Scholar 

  • Amalberti R, Auroy Y, Berwick D, Barach P (2005) Five system barriers to achieving ultrasafe health care. Ann Intern Med 142(9):756–764

    Article  PubMed  Google Scholar 

  • Argyris C, Schön DA (1995) Organizational learning II: theory, method, and practice. Addison-Wesley, Reading

    Google Scholar 

  • ASHRM (American Society for Healthcare Risk Management) and Carroll R (eds) (2010) Risk management handbook, 6th edn. Jossey Bass, San Francisco

    Google Scholar 

  • Bagnara S, Parlangeli O, Tartaglia R (2010) Are hospitals becoming high reliability organizations? Appl Ergon 41(5):713–718

    Article  PubMed  Google Scholar 

  • Bali R, Dwivedi A (2006) Healthcare knowledge management. Issues, advances and successes. Springer, Berlin/Heidelberg/New York

    Google Scholar 

  • Birnbach D, Nevo I, Scheinman S, Fitzpatrick M, Shekhter I, Lombard J (2010) Patient safety begins with proper planning: a quantitative method to improve hospital design. Qual Saf Health Care 19(5):462–465

    CAS  PubMed  Google Scholar 

  • Bosk CL, Dixon-Woods M, Coeschel CA, Pronovost PJ (2009) Reality check for checklists. Lancet 374:444–445

    Article  PubMed  Google Scholar 

  • Brumby DP, Cox AL, Back J, Gould SJJ (2013) Recovering from an interruption: Investigating speed-accuracy trade-offs in task resumption behavior. J Exp Psychol Appl 19:95–107

    Article  PubMed  Google Scholar 

  • Carayon P, Alyousef B, Xie A (2012) Human factors and ergonomics in health care. In: Salvendy G (Hrsg) Handbook of human factors and ergonomics, 4th edn. Wiley, Hoboken. pp 1574–1595

    Google Scholar 

  • Cohen MD, Hilligoss B, Amaral ACK (2012) A handoff is not a telegram: an understanding of the patient is co-constructed. Crit Care 16:303–308

    Article  PubMed  PubMed Central  Google Scholar 

  • Conell L (1996) Pilot and controller issues. In: Kanki B, Prinzo VO (eds) Methods and metrics of voice communication. DOT/FAA/AM-96/10. FAA Civil Aeromedical Institute, Oklahoma City

    Google Scholar 

  • Cooper JB, Cullen DJ, Eichhorn JH, Philip JH, Holzman RS (1993) Administrative guidelines for response to an adverse anesthesia event. J Clin Anesth 5:79–84

    Article  CAS  PubMed  Google Scholar 

  • Dawson S, King L, Grantham H (2013) Review article: improving the hospital clinical handover between paramedics and emergency department staff in the deteriorating patient. Emerg Med Australas 25(5):393–405

    Article  PubMed  Google Scholar 

  • Degani A, Wiener EL (1993) Cockpit checklists: concepts, design, and use. Hum Factors 35:345–359

    Google Scholar 

  • DeVries EN, Prins HA, Crolla RM, den Outer A, van Andel G, van Helden SH, Schlack WS, van Putten MA, Gouma DJ, Dijkgraaf MG, Smorenburg SM, Boermeester MA, Surpass Collaborative Group (2010) Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 363:1928–1937

    Article  CAS  Google Scholar 

  • Edwards JS, Hall MJ, Shaw D (2005) Proposing a systems vision of knowledge management in emergency care. J Oper Res Soc 56:180–192

    Article  Google Scholar 

  • Eichhorn S (1995) Risk management, quality assurance, and patient safety. In: Gravenstein N, Kirbi RR (eds) Complications in anesthesiology. Lippincott-Raven, Philadelphia, pp 1–15

    Google Scholar 

  • Goldhaber-Fiebert SN, Howard SK (2013) Implementing emergency manuals: can cognitive aids help translate best practices for patient care during acute events? Anesth Analg 117(5):1149–1161

    Article  PubMed  Google Scholar 

  • Grote G (2015) Promoting safety by increasing uncertainty – Implications for risk management. Safety Sci 71:71–79

    Article  Google Scholar 

  • Hales BM, Pronovost PJ (2006) The checklist – A tool for error management and performance improvement. J Crit Care 21:231–235

    Article  PubMed  Google Scholar 

  • Handler JA, Feied CF, Coonan K, Vozenilek J, Gillam M, Peacock PR Jr, Sinert R, Smith MS (2004) Computerized physician order entry and online decision support. Acad Emerg Med 11:1135–1141

    Article  PubMed  Google Scholar 

  • Harrison TK, Manser T, Howard SK, Gaba DM (2006) Use of cognitive aids in a simulated crisis. Anesth Analg 103(3):551–556

    Article  PubMed  Google Scholar 

  • Hart EM, Owen H (2005) Errors and omissions in anesthesia: a pilot study using a pilot’s checklist. Anesth Analg 101:246–250

    Article  PubMed  Google Scholar 

  • Hasibeder WR (2010) Does standardization of critical care work? Curr Opin Crit Care 16:493–498

    Article  PubMed  Google Scholar 

  • Hayashi I, Wakisaka M, Ookata N, Fujiwara M, Odashiro M (2007) Actual conditions of the check system for the anesthesia machine before anesthesia. Do you really check? Masui 56:1182–1185

    PubMed  Google Scholar 

  • Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA, Safe Surgery Saves Lives Study, Group (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360(5):491–499

    Article  CAS  PubMed  Google Scholar 

  • Helmreich RL (2000) On error management. Lessons learned from aviation. BMJ 320:781–785

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Hilligoss B, Moffatt-Bruce SD (2014) The limits of checklists: handoff and narrative thinking. BMJ Qual Saf 23(7):527–533. doi:10.1136/bmjqs-2013-002705

    Article  Google Scholar 

  • Hollnagel E, Woods DD, Leveson N (eds) (2006) Resilience engineering. Concepts and precepts. Ashgate, Aldershot

    Google Scholar 

  • Klopfenstein CE, Van Gessel E, Forster A (1998) Checking the anaesthetic machine: self-reported assessment in a university hospital. Eur J Anaesthesiol 15:314–319

    Article  CAS  PubMed  Google Scholar 

  • Laboutique X, Benhamou D (1997) Evaluation of a checklist for anesthetic equipment before use. Ann Fr Anesth Reanim 16:19–24

    Article  CAS  PubMed  Google Scholar 

  • Langford R, Gale TC, Mayor AH (2007) Anesthesia machine checking guidelines: have we improved our practice? Eur J Anaesthesiol 30:1–5

    Google Scholar 

  • Leotsakos A, Zheng H, Croteau R, Loeb JM, Sherman H, Hoffman C, Morganstein L, O’Leary D, Bruneau C, Lee P, Duguid M, Thomeczek C, van der Schrieck-De Loos E, Munier B (2014) Standardization in patient safety: the WHO High 5s project. Int J Qual Health Care 26(2):109–116

    Article  PubMed  Google Scholar 

  • Lyons VE, Popejov LL (2014) Meta-analysis of surgical safety checklist effect on teamwork, communication, morbidity, mortality, and safety. West J Nurs Res 36(2):245–261

    Article  PubMed  Google Scholar 

  • March MG, Crowley JJ (1991) An evaluation of anesthesiologists’ present checkout methods and the validity of the FDA checklist. Anesthesiology 75:724–729

    Article  CAS  PubMed  Google Scholar 

  • Marshall S (2013) The use of cognitive aids during emergencies in anesthesia: review of the literature. Anesth Analg 117:1162–1171

    Article  PubMed  Google Scholar 

  • Marshall S (2015) The effect of cognitive aids on formation and functioning of teams in medical emergencies. PhD-Thesis; Dpt. of Psychology, University of Queensland, Queensland

    Google Scholar 

  • Nonaka I, Takeuchi H (1995) The knowledge-creating company: how Japanese companies create the dynamics of innovation. Oxford University Press, Oxford

    Google Scholar 

  • O’Connor RE, Slovis CM, Hunt RC, Pirrallo RG, Sayre MR (2002) Eliminating errors in emergency medical services: realities and recommendations. Prehosp Emerg Care 6:107–113

    Article  PubMed  Google Scholar 

  • Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C (2006) An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006(355):2725–2732

    Article  Google Scholar 

  • Reason J (1990) Human error. Cambridge University Press, Cambridge

    Book  Google Scholar 

  • Resar RK (2006) Making noncatastrophic health care processes reliable: learning to walk before running in creating high-reliability organizations. Health Serv Res 41(4):1677–1689

    Article  PubMed  PubMed Central  Google Scholar 

  • Riesenberg LA, Leitzsch J, Little BW (2009) Systematic review of handoff mnemonics literature. Am J Med Qual 24:196–204

    Article  PubMed  Google Scholar 

  • Robson M (1989) Quality circles: a practical guide. Gower, Aldershot

    Google Scholar 

  • Runciman WB, Merry AF (2005) Crises in clinical care: an approach to management. Qual Saf Health Care 14:156–163

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Russ S, Rout S, Sevdalis N, Moorthy K, Darzi A, Vincent C (2013) Do safety checklists improve teamwork and communication in the operating room? A systematic review. Ann Surg 258:856–871

    Article  PubMed  Google Scholar 

  • Sawa T, Ohno–Machado L (2001) Generation of dynamically configured check lists for intra-operative problems using a set of covering algorithms. Proc AMIA Symp 2001:593–597

    Google Scholar 

  • Segall N, Bonifacio A, Schroeder R, Barbeito A, Rogers D, Thornlow D, Emery J, Kellum S, Wright MC, Mark JB (2012) Can we make postoperative patient handovers safer? A systematic review of the literature. Anesth Analg 115(1):102–115

    Article  PubMed  Google Scholar 

  • Senge PM (1990) The fifth discipline. Doubleday Business, New York

    Google Scholar 

  • Sutcliffe KM, Vogus TJ (2003) Organizing for resilience. In: Cameron KS, Dutton JE, Quinn RE (eds) Positive organizational scholarship: foundations of a new discipline. Berett-Koehler Publishers, San Francisco, pp 94–110

    Google Scholar 

  • Stefanelli M (2004) Knowledge and process management in health care organizations. Methods Inf Med 43:525–535

    CAS  PubMed  Google Scholar 

  • Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN (2014) Introduction of surgical safety checklists in Ontario. Canada. N Engl J Med 370(11):1029–1038

    Article  CAS  PubMed  Google Scholar 

  • Vincent C (1996) Clinical risk management. BMJ Books, London

    Google Scholar 

  • Vincent C, Blandford A, Li Y (2014) Integration of human factors and ergonomics during medical device design and development: It’s all about communication. Appl Ergon 45(3):413–419. doi:10.1016/j.apergo.2013.05.009

    Article  PubMed  Google Scholar 

  • Weiser TG, Haynes AB, Dziekan G, Berry WR, Lipsitz SR, Gawande AA, Safe Surgery Safes Lives Investigator Study Group (2010) Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg 251(5):976–980

    Article  PubMed  Google Scholar 

  • Werner E (1989) Vulnerable, but Invincible. Adams, Bannister and Cox, New York

    Google Scholar 

  • Winters BD, Gurses AP, Lehmann H, Sexton JB, Rampersad CJ, Pronovost PJ (2009) Clinical review: checklists – translating evidence into practice. Crit Care 13:210. doi:10.1186/cc7792

    Article  PubMed  PubMed Central  Google Scholar 

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St.Pierre, M., Hofinger, G., Simon, R. (2016). Strategies for Patient Safety. In: Crisis Management in Acute Care Settings. Springer, Cham. https://doi.org/10.1007/978-3-319-41427-0_15

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  • DOI: https://doi.org/10.1007/978-3-319-41427-0_15

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