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Archive for the ‘BEST.ARTICLE.EVER.’ Category

Infectious moments

In BEST.ARTICLE.EVER. on July 19, 2014 at 8:38 am

My favorite article about preventing patient harm through infection prevention. Filed under BEST> ARTICLE>EVER>

Infectious Risk Moments: A Novel, Human Factors–Informed Approach to Infection Prevention. Clark et all (2014)
http://www.jstor.org/discover/10.1086/677166?uid=3739696&uid=2&uid=4&uid=3739256&sid=21104507319963

We pilot tested a novel human factors–informed concept to identify
infectious risk moments (IRMs) that occur with high frequency
during routine intensive care. Following 30 observation-hours, 28
potential IRMs related to hand hygiene, gloves, and objects were
expert rated. A comprehensive IRM inventory may provide valuable
taxonomy for research, training, and intervention.
Infect Control Hosp Epidemiol 2014;35(8):000-000

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Story telling to change safety culture

In Behavior change, BEST.ARTICLE.EVER., Patient Safety, Safety climate on May 26, 2014 at 5:04 pm

While this study is about the workplace and not patient safety in particular, it shows the importance of story telling on culture.
Workplace culture influences patient safety.

The researchers identified several forms and functions of these stories:

To control behavior: These forms of stories serve as lessons, and indoctrination to the behaviors that are either encouraged or discouraged by the moral. Themes of punishment or reward are common.
Oppositional stories: These stories provide an outlet for expressing frustration with the company. Researchers suggested that even these types of stories can be used strategically, if key leaders in the organization are aware of them.
Differentiation/integration: This type of story serves to answer the question, “Who are we as a group?” These stories establish the unique identity of the company, and make a distinction between the organization and its competitors. These tales shape impressions of the organization, and the employees’ place within it.
Preparation for the future and change: These stories can be used to provide stability and a road map during times of difficulty or change by setting examples for solving problems.

Read more

New feature: BEST.ARTICLE.EVER

In BEST.ARTICLE.EVER. on May 9, 2013 at 7:39 am

As I new feature I decided to add the category BEST.ARTICLE.EVER. to posts where I utilize information that I feel is from a patient-safety game-changing article. If you look at the word cloud at the bottom of this blog and click on BEST.ARTICLE.EVER. you will get a list of posts containing this designation. If you only have time to read select articles, these are the ones I would recommend.

the first ever BEST.ARTICLE.EVER. designation goes to :
http://www.longwoods.com/content/22845
Cafazzo & St-Cyr (2012). This article and its incredible graphic “The Hierachy of Intervention EFfectiveness” are truly game changers. READ this ASAP. Then read it again and again and again especially when you are trying to address a patient safety issue.

Wrong side wrong system?

In BEST.ARTICLE.EVER., Checklists, Force function, Human Factors on May 9, 2013 at 7:28 am

Another article about a recent wrong side surgery: http://www.stltoday.com/business/local/ssm-health-care-apologizes-for-brain-surgery-error/article_05e1c0fa-fd7c-5aa0-a30f-1784edfd7d39.html

SSM Health Care acknowledged Tuesday that its neurosurgeon and medical staff recently operated on the wrong side of a St. Louis-area woman’s brain and skull.
The admission — and a lengthy public apology — followed a Post-Dispatch story in Tuesday’s paper about a lawsuit filed Friday on behalf of Regina Turner of St. Ann.
“SSM Health Care and SSM St. Clare Health Center sincerely apologize for the wrong-site surgery in our operating room,” Chris Howard, president and chief executive of SSM Health Care-St. Louis, said in a written statement. As a result of the mistaken surgery on April 4, Turner, 53, now needs 24-hour nursing care for her basic needs and cannot speak intelligibly, said Alvin Wolff Jr., her Clayton-based attorney.
According to the lawsuit filed in circuit court in Clayton, the former paralegal “will also continue to suffer from emotional distress, anxiety, disfigurement and depression.”

“This was a breakdown in our procedures, and it absolutely should not have happened,” Howard wrote in his statement. “We apologized to the patient and continue to work with the patient and family to resolve this issue with fairness and compassion. We immediately began an investigation.”

Time outs and checklists have reduced the incident of wrong side surgery but not eliminated the problem. Let’s analyze this from the human factors/risk management Hierarchy of Intervention Effectiveness (see graphic below). Capture
While checklists and standard time-outs are better than education, they do not reach the level of automation or force function.

In the words of Cafazzo & St-Cyr (2012,http://www.longwoods.com/content/22845)
“Although checklist use has recently made headlines in its ability to reduce adverse events in settings such as the operating room and intensive care (Haynes et al. 2009; Pronovost 2006), it remains unclear that an intervention so fundamentally reliant on human behaviour will be sustainable in the long term without constant enforcement (Bosk et al. 2009). Are all healthcare organizations able to create a culture for the sustained use of checklists? If this solution applies only to organizations that have the leadership and resources to maintain such a culture, checklists – and other solutions reliant on human behaviour – cannot be considered a systemic solution. Given how rare serious adverse events are to the total volume of healthcare encounters, a solution that applies to only a fraction of organizations cannot address this safety issue fully.”

My thoughts: why can’t we ace wrap the WRONG side…with a distinctive sterile wrap designed like yellow police tape (DO NOT CROSS!).. it can be removed once the first cut is made into the appropriate surgical site.
Simple, but it would provide some force function as the team would literally have to remove a wrapping that said “WRONG SIDE” in order to make a mistake!

Graphic: Cafazzo and St-Cyr, 2012
http://www.longwoods.com/content/22845
A safetydog: BEST.ARTICLE.EVER.

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