Evaluating the effect of safety culture on error reporting: a comparison of managerial and staff perspectives

December 23, 2015

Source:  American Journal of Medical Quality 30/6 pp. 550-8

Follow this link for abstract

Date of publication:  November 2015

Publication type:  Journal article

In a nutshell:  Although medical error reporting has been studied, under-reporting remains pervasive. The study aims were to identify the organisational factors with the greatest perceived effect on error reporting and to determine whether associations differ for management and clinical staff.

Error feedback was perceived as the most significant predictor, while organisational learning was another significant factor. It also was found that although management support for patient safety was significantly related to error reporting among clinical staff, this association was not significant among management. This difference is relevant because managers may not be aware that their failure to demonstrate support for safety leads to underreporting by frontline clinical staff. Findings from this study can inform hospitals’ efforts to increase error reporting.

Length of publication:  9 pages

Advertisements

Infections and interaction rituals in the organisation: clinician accounts of speaking up or remaining silent in the face of threats to patient safety

November 25, 2015

Source:  Sociology of Health and Illness [Epub ahead of print]

Follow this link for abstract

Date of publication: November 2015

Publication type:  Journal article

In a nutshell:  Drawing on 103 interviews with clinicians at one hospital in the United States this article examines how clinicians talk about speaking up or not in the face of breaches in infection prevention technique. Accounts are analysed using a microsociological lens as stories of interaction, through which respondents appeal to situational and organisational realities of medical work that serve to justify speaking up or remaining silent. Analysis of these accounts reveals three influences on the decision to speak up, shaped by background conditions in the organisation; mutual focus of attention, interactional path dependence and the presence of an audience.

Length of Publication: Unspecified

Some important notes:  Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library


Developing person-centred analysis of harm in a paediatric hospital: a quality improvement report

May 22, 2015

Source:  BMJ Quality & Safety 24/5 pp. 337-44

Follow this link for item

Date of publicationMay 2015

Publication type:  Journal article

In a nutshell: Staff at Great Ormond Street Hospital developed and tested a tool specifically designed for patients and families to report harm. Processes to report harm were developed over a 10-month period. The tool was tested in different formats and it moved from a provider centric to a person-centred tool analysed in real time. Feedback to staff provided learning opportunities. Improvements in culture climate and staff reporting were noted in the short term. The integration of patient involvement in safety monitoring systems is vital to achieve safety. The testing and introduction of a self-reporting, real-time bedside tool has led to active engagement with families and patients and raised awareness.

Length of Publication:  8 pages


Our approach to changing the culture of caring for the acutely unwell patient at a large UK teaching hospital: A service improvement focus on Early Warning Scoring tools

May 22, 2015

Source: Intensive & Critical Care Nursing 31/2 pp. 106-15

Follow this link for abstract

Date of publication:  April 2015

Publication type:  Journal article

In a nutshell:  Early Warning Scoring tools have been in place in Nottingham University Hospitals NHS Trust for over five years but compliance has been low. A service improvement project commenced across all admission wards in 2013. Prior to the project, only one out of five clinical care targets set were achieved. An established framework for service improvement was used to guide delivery. Since introduction of the service improvement team, consistent signs of improvement have been visible across the admission areas in four out of five of the clinical care targets. The first 12 months of the project has seen benefits in patient care and staff experience.

Length of Publication:  10 pages

Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library


Junior doctors’ views on reporting concerns about patient safety: a qualitative study

May 22, 2015

Source:  Postgraduate Medical Journal [Epub ahead of print]

Follow this link for abstract

Date of publication:  April 2015

Publication type:  Journal article

In a nutshell:  This study set out to explore the attitudes and barriers to junior doctors formally reporting concerns about patient safety to the organisations in which they are training. A qualitative study was conducted, comprising three focus groups with 10 junior doctors at an Acute Teaching Hospital Trust in the Midlands in 2013. Participants identified that existing incident reporting systems could frustrate efforts to report concerns. They described barriers to reporting, a culture within medicine that was not conducive to reporting concerns, and a lack of feedback providing evidence that formal reporting was worthwhile. They reported a tendency to rely on informal ways of dealing with concerns as an alternative to engaging with formal reporting systems. Attention needs to be paid to the features of reporting systems, the implications of hierarchies and the wider cultural context in which junior doctors work.

Length of Publication:  1 web page

Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library


Safety culture and the 5 steps to safer surgery: an intervention study

April 29, 2015

Source:  British Journal of Anaesthesia pii: aev063. [Epub ahead of print]

Follow this link for abstract

Date of publication:  March 2015

Publication type:  Journal article

In a nutshell:  The 5 Steps to Safer Surgery (5SSS) incorporates pre-list briefings, the three steps of the WHO Surgical Safety Checklist (SSC) and post-list debriefings in one framework. This study aimed to identify any changes in safety culture associated with the introduction of the 5SSS in orthopaedic operating theatres. The authors assessed the safety culture in the elective orthopaedic theatres of a large UK teaching hospital before and after introduction of the 5SSS using a modified version of the Safety Attitude Questionnaire – Operating Room (SAQ-OR). They also analysed changes in responses to two items regarding perioperative briefings. The authors conclude that implementation of the 5SSS was associated with a significant improvement in the safety culture of elective orthopaedic operating theatres.

Length of Publication:  1 web page

Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library


Do large-scale hospital- and system-wide interventions improve patient outcomes: a systematic review

October 29, 2014

Source:  BMC Health Services Research 14/1 pp.369

Follow this link for item

Date of publication:  September 2014

Publication type:  Journal article

In a nutshell: The authors of this review assessed the impact of hospital and system-wide interventions to improve patient safety. Studies which measured outcomes two years after implementation or more were more likely to show improved outcomes. It was difficult to assess the impact of organisational culture or other determinants. Effective leadership and clinical champions, adequate financial and educational resources and dedicated promotional activities may have a significant impact.

Length of Publication:  1 web page