Fire in the operating room during open heart surgery: a case report.

A patient had a fire in his chest cavity during dissection of the left internal mammary artery before coronary artery bypass graft. The electrosurgical unit indirectly ignited gauze, resulting in a fire. It was determined that oxygen was being entrained into the surgical field through open pulmonary blebs. This case identifies the need for continued fire training and prevention strategies, persistent vigilance, and quick intervention to prevent injury whenever electrosurgical units are used in an oxygen-enriched environment.

A systematic review of the designs of clinical technology: findings and recommendations for future research.

Human factors (HF) studies are increasingly important as technology infuses into clinical settings. No nursing research reviews exist in this area. The authors conducted a systematic review on designs of clinical technology, 34 articles with 50 studies met inclusion criteria. Findings were classified into 3 categories on the basis of HF research goals. The majority of studies evaluated effectiveness of clinical design; efficiency was fewest. Current research ranges across many interface types examined with no apparent pattern or obvious rationale. Future research should expand types, settings, and participants; integrate displays; and expand outcome variables.

A model framework for patient safety training in chiropractic: a literature synthesis.

OBJECTIVE: The objective of this review is to develop an evidence-focused and work-based model framework for patient safety training, that is, reporting and learning from adverse events in chiropractic care. This article will not debate specific issues of adverse events from spinal manipulation. The main focus is on education for patient safety. METHODS: We conducted a systematic search and synthesized 196 articles on patient safety to provide guidance. The review was carried out by the 2 authors independently in 3 ways: research type, relevancy with respect to patient safety, safety culture or climate, and distinct description of one or more of the adapted Bland's characteristics. RESULTS: Fifty-five articles were included. Their review provided knowledge acquisition and practice behavior regarding patient safety issues and excellent baseline data on reporting and learning of adverse events for training purpose. CONCLUSIONS: Leadership, commitment, and communication together with trust and openness to build a culture of patient safety are prerequisites for successful reporting and learning.

Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes.

BACKGROUND: Root cause analysis is a method to examine causes of unintended events. PRISMA (Prevention and Recovery Information System for Monitoring and Analysis: is a root cause analysis tool. With PRISMA, events are described in causal trees and root causes are subsequently classified with the Eindhoven Classification Model (ECM). It is important that root cause analysis tools are reliable, because they form the basis for patient safety interventions. OBJECTIVES: Determining the inter-rater reliability of descriptions, number and classifications of root causes. DESIGN: Totally, 300 unintended event reports were sampled from a database of 2028 events in 30 hospital units. The reports were previously analysed using PRISMA by experienced analysts and were re-analysed to compare descriptions and number of root causes (n = 150) and to determine the inter-rater reliability of classifications (n = 150). MAIN OUTCOME MEASURES: Percentage agreement and Cohen's kappa (kappa). RESULTS: Agreement between descriptions of root causes was satisfactory: 54% agreement, 17% partial agreement and 29% no agreement. Inter-rater reliability of number of root causes was moderate (kappa = 0.46). Inter-rater reliability of classifying root causes with the ECM was substantial from highest category level (kappa = 0.71) to lowest subcategory level (kappa = 0.63). Most discrepancies occurred in classifying external causes. CONCLUSIONS: Results indicate that causal tree analysis with PRISMA is reliable. Analysts formulated similar root causes and agreed considerably on classifications, but showed variation in number of root causes. More training on disclosure of all relevant root causes is recommended as well as adjustment of the model by combining all external causes into one category.

After action reviews: a new model for learning.

University College London Hospitals NHS Foundation Trust is committed to developing a learning culture for its staff and, to achieve this, the organisation recently developed the after action review (AAR) model as a way for people involved in specific incidents to explore what happened and what they have learned. This article explains the concept of AAR and uses case studies to illustrate how it can improve patient care.

Ticket to ride: reducing handoff risk during hospital patient transport.

A significant number of medical errors occur during patient handoffs, leading to less than optimal care, patient harm, and even death. The Joint Commission National Patient Safety Goals require hospitals to implement a standardized approach to "handoff" communications. The authors describe an initiative that focuses on standardization of the physical and informational handoff during hospital transport; outcomes are promising in terms of both patient safety and patient satisfaction.

Leveraging safer nursing care by conceptualizing near misses as recovery processes.

The purpose of this study was to elicit perceptions and experiences of nurses associated with a recovery process (near miss) intervention (wound care management). From the content analysis of interview data involving 12 registered nurses, 2 key themes emerged. Both themes illuminated the links among pattern recognition, alignment of care processes and practice guidelines, and nurses' accountability for safe pressure ulcer care.

Missed nursing care: errors of omission.

This study examines what and why nursing care is missed. A sample of 459 nurses in 3 hospitals completed the Missed Nursing Care (MISSCARE) Survey. Assessment was reported to be missed by 44% of respondents while interventions, basic care, and planning were reported to be missed by > 70% of the survey respondents. Reasons for missed care were labor resources (85%), material resources (56%), and communication (38%). A comparison of the hospitals showed consistency across all 3 hospitals. Associate degree nurses reported more missed care than baccalaureate-prepared and diploma-educated nurses. The results of this study lead to the conclusion that a large proportion of all hospitalized patients are being placed in jeopardy because of missed nursing care or errors of omission. Furthermore, changes in Center for Medicare and Medicaid Services (CMS) regulations which will eliminate payment for acute care services when any one of a common set of complications occurs, such as pressure ulcers and patient falls, point to serious cost implications for hospitals.

Improving communication among healthcare providers: preparing student nurses for practice.

Communication errors are identified by the Joint Commission as the primary root cause of sentinel events across all categories. In addition, improving the effectiveness of communication among healthcare providers is listed as one of the Joint Commission's 2008 National Patient Safety Goals. Nursing programs are expected to graduate practice-ready nurses who demonstrate quality and safety in patient care, which includes interdisciplinary communication. Through objectively structured clinical assessment simulations, faculty evaluate each nursing student's ability to perform many aspects of care, including the ability to communicate effectively with physicians via telephone in an emergent situation. This quality improvement project reports the results of a three-year review of undergraduate student nurse performance (n = 285) related to effective clinical communication. Changes in teaching-learning strategies, implementation of a standardized communication tool, and clinical enhancements which resulted in improved student competency, will be presented.

From blaming to proactively changing the future: the leader's safety challenge.

Simplifying to the point of blaming limits learning and the ability to prevent similar occurrences in the future. Often, the characteristics of the blame culture are very subtle and what appears to be valuable work is actually a subtle sign of the blame game. Leaders must change the language to a proactive, future preventative state rather than focusing on the past and looking for single causes of events. Many nurses have left their positions because they have chosen not to work in a culture of blame. Eliminating all forms of blame is essential for excellence in patient care outcomes and loyalty of staff.

Patient misidentification in oncology care.

Patients with cancer are at risk for patient misidentification, or "wrong patient" incidents. Patient misidentification can result in medication and transfusion errors, unnecessary testing or procedures, and, in some cases, death. Patients may be misidentified when nurses mispronounce their names, refer to them by their first or last names only, are complacent and fail to check armbands, or encounter language or communication barriers. Errors caused by patient misidentification can be prevented when healthcare providers consistently use two unique patient identifiers (other than the patient's room, examination, or chair number) to verify identities.

Peer case review sharpens event analysis.

This manuscript describes a scholarly approach to peer case review that identifies and analyzes quality-of-care issues in response to a question about nursing care of a specific patient. The comprehensive method provides a structured format that critically examines untoward patient events, generates an awareness of gaps in care from a systems perspective, ensures action planning focused on legitimate root causes, stimulates performance improvement initiatives, and provides a forum to share learning throughout the organization.

Enteral feeding misconnections: a consortium position statement.

A consortium of organization identified solutions to the problem of enteral feeding misconnections in three areas: (1) education, awareness, and human factors; (2) purchasing strategies; and (3) design changes.