Improved Safety Culture and Teamwork Climate Are Associated With Decreases in Patient Harm and Hospital Mortality Across a Hospital System.

Abstract:

OBJECTIVES:Improved safety and teamwork culture has been associated with decreased patient harm within specific units in hospitals or hospital groups. Most studies have focused on a specific harm type. This study's objective was to document such an association across an entire hospital system and across multiple harm types. METHODS:The Safety Attitudes Questionnaire (SAQ) was administered to all clinical personnel (including physicians) before, 2 years after, and 4 years after establishing a comprehensive patient safety/high-reliability program at a major children's hospital. Resultant data were analyzed hospital-wide as well as by individual units, medical sections, and professional groups. RESULTS:Safety attitude scores improved over the 3 surveys (P < 0.05) as did teamwork attitude scores (P = nonsignificant). These increases were accompanied by contemporaneous statistically significant decreases in all-hospital harm (P < 0.01), serious safety events (P < 0.001), and severity-adjusted hospital mortality (P < 0.001). Differences were noted between physicians' and nurses' views on specific safety and teamwork items within individual units, with nursing scores often lower. These discipline-specific differences decreased with time. CONCLUSIONS:Improved safety and teamwork climate as measured by SAQ are associated with decreased patient harm and severity-adjusted mortality. Discrepancies in SAQ scores exist between different professional groups but decreased over time.

journal_name

J Patient Saf

authors

Berry JC,Davis JT,Bartman T,Hafer CC,Lieb LM,Khan N,Brilli RJ

doi

10.1097/PTS.0000000000000251

subject

Has Abstract

pub_date

2020-06-01 00:00:00

pages

130-136

issue

2

eissn

1549-8417

issn

1549-8425

pii

01209203-202006000-00003

journal_volume

16

pub_type

杂志文章
  • An NTSB for health care: learning from innovation: debate and innovate or capitulate.

    abstract:INTRODUCTION:Economic and medical risks threaten the national security of America. The spiraling costs of United States' avoidable healthcare harm and waste far exceed those of any other nation. This 2-part paper, written by a group of aviators, is a national call to action to adopt readily available and transferable s...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e3182446c51

    authors: Denham CR,Sullenberger CB 3rd,Quaid DW,Nance JJ

    更新日期:2012-03-01 00:00:00

  • Is Communication Improved With the Implementation of an Obstetrical Version of the World Health Organization Safe Surgery Checklist?

    abstract:OBJECTIVE:Communication failures are consistently seen as a root cause of preventable adverse outcomes in obstetrics. We assessed whether use of an Obstetric Safe Surgery Checklist for cesarean deliveries (CDs), based on the WHO Safe Surgery Checklist, can improve communication; reduce team member confusion about urgen...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000327

    authors: Govindappagari S,Guardado A,Goffman D,Bernstein J,Lee C,Schonfeld S,Angert R,McGowan A,Bernstein PS

    更新日期:2020-12-01 00:00:00

  • 30-Day Potentially Avoidable Readmissions Due to Adverse Drug Events.

    abstract:OBJECTIVE:To analyze the patterns of potentially avoidable readmissions due to adverse drug events (ADEs) to identify the most appropriate risk reduction interventions. METHODS:In this observational study, we analyzed a random sample of 534 potentially avoidable 30-day readmissions from 10,275 consecutive discharges f...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000346

    authors: Dalleur O,Beeler PE,Schnipper JL,Donzé J

    更新日期:2017-03-17 00:00:00

  • Give Intravenous Bolus Overdose a Brake: User Experience and Perception of Safety Device.

    abstract:OBJECTIVES:Drugs can come in concentrated solutions that require dilution before intravenous bolus administration. Upon dilution, the syringe can contain more than the required amount of drug. The user may mistakenly administer the full contents of the syringe, resulting in an overdose. In this cross-sectional study, w...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000770

    authors: Ng YYY,Wan PW,Chan KP,Sim GG

    更新日期:2020-09-08 00:00:00

  • Evaluation of a Computer Application for Retrospective Detection of Vitamin K Antagonist Treatment Imbalance.

    abstract:OBJECTIVE:Management of vitamin K antagonists (VKAs) is difficult, and overdoses can have dramatic hemorrhagic consequences. The adverse drug event (ADE) scorecards is a tool intended for the detection and description of adverse drug reaction/ADE developed during a European computerized medical data processing project....

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000182

    authors: Ferret L,Luyckx M,Ficheur G,Chazard E,Beuscart R

    更新日期:2018-06-01 00:00:00

  • Identification and description of randomized controlled trials and systematic reviews on patient safety published in medical journals.

    abstract:OBJECTIVE:To identify and describe randomized controlled trials (RCTs) and systematic reviews (SRs) on patient safety published from 1973 onward. MATERIALS AND METHODS:We handsearched a total of 12 medical journals published in English with contents related to patient safety to identify RCTs and SRs published between ...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e31827cda38

    authors: Barajas-Nava LA,Calvache JA,López-Alcalde J,Solà I,Cosp XB

    更新日期:2013-06-01 00:00:00

  • Shoulder dystocia documentation: an evaluation of a documentation training intervention.

    abstract:OBJECTIVE:To evaluate the quality and content of nurse and physician shoulder dystocia delivery documentation before and after MORE training in shoulder dystocia management skills and documentation. METHODS:Approximately 384 charts at the Ottawa Hospital General Campus involving a diagnosis of shoulder dystocia betwee...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e3182948a51

    authors: LeRiche T,Oppenheimer L,Caughey S,Fell D,Walker M

    更新日期:2015-03-01 00:00:00

  • The Patient Safety Culture Scale for Chinese Primary Health Care Institutions: Development, Validity and Reliability.

    abstract:BACKGROUND:Existing patient safety culture assessment tools are mostly developed in western countries and may not be suitable for Chinese primary health care institutions. Primary care plays an important role in China's medical system, and a targeted tool for its patient safety culture is urgently needed. OBJECTIVE:Th...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000733

    authors: Cheng S,Hu Y,Pfaff H,Lu C,Fu Q,Wang L,Li D,Xia S

    更新日期:2020-05-13 00:00:00

  • An exploration of safety climate in nursing homes.

    abstract:OBJECTIVES:Although nursing homes provide complex care requiring attention to safety, research on safety climate in nursing homes is limited. Our study assessed differences in attitudes about safety among nursing home personnel and piloted a new survey, specifically designed for the nursing home context. METHODS:Drawi...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e31824badce

    authors: Singer S,Kitch BT,Rao SR,Bonner A,Gaudet J,Bates DW,Field TS,Gurwitz JH,Keohane C,Campbell EG

    更新日期:2012-09-01 00:00:00

  • A Systematic Review of Methods for Medical Record Analysis to Detect Adverse Events in Hospitalized Patients.

    abstract:OBJECTIVE:In this systematic review, we evaluate 2 of the most used trigger tools according to the criteria of the World Health Organization for evaluating methods. METHODS:We searched Embase, PubMed, and Cochrane databases for studies (2000-2017). Studies were included if medical record review (MRR) was performed wit...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000670

    authors: Klein DO,Rennenberg RJMW,Koopmans RP,Prins MH

    更新日期:2020-03-11 00:00:00

  • A Study of Rate and Predictors of Fall Among Elderly Patients in a University Hospital.

    abstract:INTRODUCTION:Falls represent a serious problem facing hospital-admitted patients, and the severity of fall-related complications rises steadily after the age of 65 years. OBJECTIVES:The aims of this study were (a) to calculate the rate of falls among elderly patients in the internal medicine departments in Ain Shams U...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000117

    authors: al Tehewy MM,Amin GE,Nassar NW

    更新日期:2015-12-01 00:00:00

  • Prevalence of Implanted Medical Devices in Medicine Inpatients.

    abstract::Implanted medical devices (IMDs) are extremely common, yet they are not systematically documented on hospital admission. Through structured patient interviews, we determined the prevalence of IMDs in hospital inpatients. Using medical record review, we evaluated the sensitivity of the medical record reporting of IMDs ...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000187

    authors: Kuder M,Gelman A,Zenilman JM

    更新日期:2018-09-01 00:00:00

  • Frequency and Severity of Adverse Drug Events by Medication Classes: The JADE Study.

    abstract:OBJECTIVE:Adverse drug events (ADEs) are a significant concern in daily practice; however, the profile of high-risk drugs remains unclear. Our objective was to categorize high-risk medication classes according to frequency and severity of ADEs. METHODS:The JADE study is a prospective cohort study of 3459 hospitalized ...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000235

    authors: Sakuma M,Kanemoto Y,Furuse A,Bates DW,Morimoto T

    更新日期:2020-03-01 00:00:00

  • Next of Kin Involvement in Regulatory Investigations of Adverse Events That Caused Patient Death: A Process Evaluation (Part I - The Next of Kin's Perspective).

    abstract:OBJECTIVE:The aim of the study was to explore experiences from the next of kin's perspective of a new involvement method in the regulatory investigation process of adverse events causing patient death. METHODS:The study design was a qualitative process evaluation of the new involvement method in two Norwegian counties...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000630

    authors: Wiig S,Haraldseid-Driftland C,Tvete Zachrisen R,Hannisdal E,Schibevaag L

    更新日期:2019-10-22 00:00:00

  • Merits of using color and shape differentiation to improve the speed and accuracy of drug strength identification on over-the-counter medicines by laypeople.

    abstract:OBJECTIVE:This study aimed to examine the utility of using color and shape to differentiate drug strength information on over-the-counter medicine packages. Medication errors are an important threat to patient safety, and confusions between drug strengths are a significant source of medication error. METHOD:A visual s...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/pts.0b013e3181eee157

    authors: Hellier E,Tucker M,Kenny N,Rowntree A,Edworthy J

    更新日期:2010-09-01 00:00:00

  • High-Alert Medication Stratification Tool-Revised: An Exploratory Study of an Objective, Standardized Medication Safety Tool.

    abstract:OBJECTIVE:To develop an objective tool designed to standardize the identification of high-alert medications (HAMs) according to patient safety risk. METHODS:Medications were evaluated using the High-Alert Medication Stratification Tool (HAMST). Tool revision occurred through assessing medications on an organization-ap...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000445

    authors: Washburn NC,Dossett HA,Fritschle AC,Degenkolb KE,Macik MR,Walroth TA

    更新日期:2017-12-12 00:00:00

  • A new leadership role for pharmacists: a prescription for change.

    abstract:OBJECTIVE:Pharmacists can play an important role as leaders to reduce patient safety risks, optimize the safe function of medication management systems, and align pharmacy services with national initiatives that measure and reward quality performance. The objective of this article is to determine the actions that pharm...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e3181d108cb

    authors: Burgess LH,Cohen MR,Denham CR

    更新日期:2010-03-01 00:00:00

  • Development of a Trigger Tool to Identify Adverse Drug Events in Elderly Patients With Multimorbidity.

    abstract:PURPOSE:Elderly patients with multimorbidity are especially vulnerable to adverse drug events (ADEs) and had high prevalence rates. Identifying ADEs is essential for enabling timely interventions that can mitigate the adverse events detected and for developing targeted strategies to prevent their occurrence as well as ...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000389

    authors: Toscano Guzmán MD,Galván Banqueri M,Otero MJ,Alfaro Lara ER,Casajus Lagranja P,Santos Ramos B

    更新日期:2017-06-14 00:00:00

  • Does Free-Text Information in Falls Incident Reports Assist to Explain How and Why the Falls Occurred in a Hospital Setting?

    abstract:OBJECTIVE:The aim of this study was to explore whether information captured in falls reports in incident management systems could be used to explain how and why the falls occurred, with a view to identifying whether such reports can be a source of subsequent learnings that inform practice change. METHODS:An analysis o...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000533

    authors: de Jong LD,Francis-Coad J,Waldron N,Ingram K,McPhail SM,Etherton-Beer C,Haines TP,Flicker L,Weselman T,Hill AM

    更新日期:2018-09-05 00:00:00

  • Evaluation of time- and cost-saving modifications of HFMEA: an experimental approach in radiotherapy.

    abstract:OBJECTIVE:: This study aimed to evaluate different shortcuts of Healthcare Failure Mode and Effects Analysis (HFMEA) in a radiotherapy setting. DESIGN:: A 2 × 2 study design was set up, in which 4 similar groups analyzed separately the possible risks of the same process by using different versions of HFMEA. SETTING::...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e31822b07ee

    authors: Vlayen A

    更新日期:2011-09-01 00:00:00

  • Evaluation of a Program for Improving Advanced Imaging Interpretation.

    abstract:OBJECTIVES:Self-referred imaging has grown rapidly, raising concerns about increased costs and compromised quality of care. A quality improvement program using imaging interpretation criteria was designed by a national payer to ensure that noninvasive diagnostic images are interpreted by appropriately trained physician...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000345

    authors: Powell AC,Long JW,Kren EM,Gupta AK,Levin DC

    更新日期:2019-03-01 00:00:00

  • UDI2Claims: Planning a Pilot Project to Transmit Identifiers for Implanted Devices to the Insurance Claim.

    abstract:BACKGROUND:In response to problems with the current postmarket surveillance of medical devices, the U.S. Food and Drug Administration mandated device labelers to include a unique device identifier (UDI), composed of a device identifier (DI) and production identifier. Including the DI in insurance claims could be a pote...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000543

    authors: Zerhouni YA,Krupka DC,Graham J,Landman A,Li A,Bhatt DL,Nguyen LL,Capatch K,Concheri K,Reich AJ,Wilson N,Weissman JS

    更新日期:2018-11-21 00:00:00

  • In-Hospital Fall and Fracture Risk With Conditions in the Elixhauser Comorbidity Index: An Analysis of State Inpatient Data.

    abstract:OBJECTIVE:In-hospital falls (IHFs) are a significant burden to the healthcare industry and patients seeking inpatient care. Many falls lead to injuries that could be considered a hospital-acquired condition (HAC). We demonstrated how administrative data can be used to quantify how many IHFs occur and identify what cond...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000637

    authors: Davis J,Casteel C,Peek-Asa C

    更新日期:2020-03-11 00:00:00

  • Pursuing Patient Safety at the Intersection of Design, Systems Engineering, and Health Care Delivery Research: An Ongoing Assessment.

    abstract:OBJECTIVES:Despite endorsements for greater use of systems approaches and reports from national consensus bodies calling for closer engineering/health care partnerships to improve care delivery, there has been a scarcity of effort of actually engaging the design and engineering disciplines in patient safety projects. T...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000577

    authors: Henriksen K,Rodrick D,Grace EN,Shofer M,Jeffrey Brady P

    更新日期:2019-02-09 00:00:00

  • A public health approach to patient safety reporting systems is urgently needed.

    abstract::Patient safety reporting systems (PSRSs) currently operate at local, regional, and national levels within health care. This article analyzes 6 different PSRSs using a World Health Organization and public health classification system. Patient safety incidents (PSIs) are reported, analyzed, mitigated, and evaluated in a...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e31821b8a6c

    authors: Noble DJ,Panesar SS,Pronovost PJ

    更新日期:2011-06-01 00:00:00

  • The effect of hospital organizational characteristics on postoperative complications.

    abstract:OBJECTIVES:To determine if there is a relationship between the risk of postoperative complications and the nonclinical hospital characteristics of bed size, ownership structure, relative urbanicity, regional location, teaching status, and area income status. METHODS:This study involved a secondary analysis of 2006 adm...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e3182995e5b

    authors: Knight M

    更新日期:2013-12-01 00:00:00

  • A Study on the Status and Contributory Factors of Adverse Events Due to Negligence in Nursing Care.

    abstract:BACKGROUND:Patient safety issues in medical institutions have received worldwide attention. Nurses play a pivotal role in providing health care at the bedside and the interception of adverse events (AEs). A knowledge of contributory factors for these AEs is vital to individuals, institutional procedures, and also natio...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000791

    authors: Kim MJ,Jang SG,Kim IS,Lee W

    更新日期:2020-10-01 00:00:00

  • Prescriber Compliance With Liver Monitoring Guidelines for Pazopanib in the Postapproval Setting: Results From a Distributed Research Network.

    abstract:OBJECTIVES:Pazopanib received US Food and Drug Administration approval in 2009 for advanced renal cell carcinoma. During clinical development, liver chemistry abnormalities and adverse hepatic events were observed, leading to a boxed warning for hepatotoxicity and detailed label prescriber guidelines for liver monitori...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000332

    authors: Shantakumar S,Nordstrom BL,Hall SA,Djousse L,van Herk-Sukel MPP,Fraeman KH,Gagnon DR,Chagin K,Nelson JJ

    更新日期:2019-03-01 00:00:00

  • Outpatient adverse drug events identified by screening electronic health records.

    abstract:OBJECTIVES:Relatively little is known about rates of outpatient adverse drug events (ADEs), and most health systems do not routinely identify them. We developed a computerized ADE measurement process and used it to detect ADEs from electronic health records and then categorized them according to type, preventability, a...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e3181dcae06

    authors: Gandhi TK,Seger AC,Overhage JM,Murray MD,Hope C,Fiskio J,Teal E,Bates DW

    更新日期:2010-06-01 00:00:00

  • Perception Gaps of Disclosure of Patient Safety Incidents Between Nurses and the General Public in Korea.

    abstract:OBJECTIVES:This study aimed to explore nurses' perceptions regarding disclosure of patient safety incidents. METHODS:An anonymous online survey was conducted, and results were compared with those of the general public using the same questionnaire in a previous study. RESULTS:Among 689 nurses, 96.8% of nurses felt maj...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000781

    authors: Choi EY,Pyo J,Lee W,Jang SG,Park YK,Ock M,Lee H

    更新日期:2020-09-08 00:00:00