RESUMO
BACKGROUND: Simulation-based medical education is a widely recognised tool to improve patient safety culture and outcomes. Many preventable clinic errors are specific to the unit where they occur. We planned and conducted an interprofessional in situ simulation program aligned with unit-specific errors and report its design, implementation and evaluation. APPROACH: This prospective, survey-based study was conducted at a paediatric tertiary care centre on a medical-surgical inpatient ward. Incident and accident reports were reviewed; the most frequent and/or severe events were identified. Eight in situ simulations were implemented over 8 months. Participants, including residents, medical students, nurses, pharmacists and physicians completed a survey exploring perceptions of the program's ability to improve patient safety. EVALUATION: Incident reports over 12 months were reviewed (n = 329). Four most frequent and serious errors were identified: intravenous solutions selection, enteral feeding rate or type selection, medication transcription and IV infiltration. Simulation participation rate was 86%; survey response rate was 65%. We evaluated the program using Kirkpatrick's model of educational training, assessing reaction through self-reported surveys and results through changes in incident report frequency. Overall, 86% of participants responded positively regarding the program's potential impact to enhance patient safety. This is supported by an increase in incident reporting the year following program implementation and a decrease in each simulation-targeted medical error, albeit not statistically significant. IMPLICATIONS: Our experience in creating an in situ simulation program that aligns with unit-specific needs and addresses implementation challenges may provide valuable insights for other centres seeking enhance patient safety.
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Relações Interprofissionais , Segurança do Paciente , Pediatria , Treinamento por Simulação , Humanos , Estudos Prospectivos , Pediatria/educação , Treinamento por Simulação/organização & administração , Erros Médicos/prevenção & controle , Inquéritos e Questionários , Centros de Atenção TerciáriaRESUMO
PURPOSE: In high-risk specialties such as oncology, errors in clinical documentation can have severe consequences, highlighting a need for enhanced safety checks. We therefore aimed to evaluate the capability of frontier large language models (LLMs) to identify and correct errors in complex clinical documentation in oncology. METHODS: We conducted a two-phase evaluation. First, we assessed LLMs (GPT o4-mini and Gemini 2.5 Pro) on 1,000 synthetic clinical hematology/oncology vignettes with controlled errors, benchmarking against human expert data for error flag detection and sentence localization. Second, we evaluated advanced LLMs and a local LLM (Gemma 3 27B) against six clinicians in detecting single, predefined, and clinically relevant errors, such as wrong risk classifications or omission of critical medication within 90 synthetic discharge summaries from oncologic patients. RESULTS: LLMs outperformed human benchmark in error flag and sentence localization tasks, with Gemini 2.5 Pro achieving top accuracies of 0.928 and 0.915, respectively. Results were robust across subgroups and scalable, with simultaneous processing of up to 50 vignettes. Within complex discharge summaries, Gemini 2.5 Pro and GPT o4-mini-high identified 97.8% and 87.8% of injected errors, respectively, substantially exceeding the 47.8% average detection rate of human specialists. Gemma 3 27B detected 35.6% of errors. Analysis of error detection overlap revealed a synergistic potential for hybrid human-artificial intelligence (AI) systems. CONCLUSION: Frontier LLMs exhibit superior error-detection capabilities and speed compared with both local models and human specialists, who are inherently time-constrained. Although synthetic data provide a controlled testbed, real-world evaluation across diverse errors and documentation styles remains critical. Advanced LLMs can serve as powerful assistants for clinical documentation reviews, substantially reducing the risk of oversight and clinician workload. Integrating LLM-driven error flagging into electronic health record workflows offers a promising strategy for enhancing documentation accuracy, treatment quality, and patient safety in oncology.
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Inteligência Artificial , Documentação , Erros Médicos , Oncologia , Neoplasias , Segurança do Paciente , Humanos , Segurança do Paciente/normas , Oncologia/métodos , Oncologia/normas , Documentação/normas , Documentação/métodos , Registros Eletrônicos de Saúde , Erros Médicos/prevenção & controle , Neoplasias/terapia , Modelos de Linguagem de Grande EscalaRESUMO
Our Canadian multi-site academic health sciences centre uses a standardized process to review critical patient safety incidents and develop recommendations to prevent incident reoccurrence. We recognized an opportunity to enhance recommendation development by integrating the Hierarchy of Intervention Effectiveness (HIE), a human factors framework, into the incident review process. This project aimed to increase the proportion of system-focused recommendations from critical incident reviews from 16 to 30% over 16 months. A multi-intervention strategy included (1) standardizing the incident analysis review template; (2) earmarking time for recommendation development during reviews; (3) providing participants with just-in-time education and tools; and (4) initiating HIE-based recommendation classification during incident reviews. Statistical process control p-Chart analysis showed an increase in system-focused recommendations from 16 to 30% over 16 months. The HIE promotes system-level change to prevent critical incidents, which other organizations may benefit from incorporating in their patient safety reviews.
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Erros Médicos , Segurança do Paciente , Melhoria de Qualidade , Gestão de Riscos , Gestão da Segurança , Humanos , Canadá , Melhoria de Qualidade/organização & administração , Erros Médicos/prevenção & controle , Gestão de Riscos/métodos , Centros Médicos AcadêmicosRESUMO
OBJECTIVES: The aim of this study was to explore contributing factors identified in serious incident investigations conducted by internal, independent multidisciplinary teams. METHODS: A total of 166 serious incident investigation reports, conducted between 2018 and 2023 in 11 integrated social and health care organizations in Finland, were analyzed. The reports were classified by incident type and contributing factor, which were analyzed using the WHO's Conceptual Framework for the International Classification for Patient Safety. RESULTS: The results indicate considerable variation in the structure and content of serious incident investigation reports, with none specifying the investigation method used. The investigation reports of serious incidents revealed that in 79 (47.6%) cases, the consequences for the client or patient were fatal. The highest number of contributing factors was identified in investigations related to medication errors and errors related to treatment or monitoring. The number of contributing factors per investigation ranged from 1 to 16, with an average of 4.6. Most of the contributing factors were organizational or staff factors. CONCLUSIONS: Investigating serious safety incidents provides valuable insights into event chains and helps organizations learn from past damages. Effectively promoting client and patient safety requires standardized methods and practices for examining adverse events. This requires a shared perspective and clear definitions of best practices. Consistent and effective investigation processes demand national and international collaboration to enhance safety and strengthen organizational learning.
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Erros Médicos , Segurança do Paciente , Gestão de Riscos , Gestão da Segurança , Finlândia , Humanos , Segurança do Paciente/estatística & dados numéricos , Gestão de Riscos/estatística & dados numéricos , Gestão de Riscos/métodos , Erros Médicos/estatística & dados numéricos , Erros Médicos/prevenção & controle , Erros de Medicação/estatística & dados numéricosRESUMO
OBJECTIVE: Clinicians are encouraged to report all health care incidents, but only those causing serious harm are routinely reviewed to improve patient care. There is no consensus on the best method of confirming ongoing nasogastric tube (NGT) position, leading to variation in practice. The aim of this study is to evaluate the clinical contexts of incidents related to ongoing NGT position testing and assess the efficacy of current clinical practices. METHOD: Incident databases in Queensland Health, Australia and NHS England were searched by data custodians for incidents mentioning NGTs. A multidisciplinary team compared the extracted incidents to the inclusion and exclusion criteria. Qualitative content analysis (where incidents were coded into themes) was used to evaluate the incidents. RESULTS: Five of 27 Queensland incidents, 24 of 412 English incidents, and 2 of 26 English Never Events met the inclusion criteria. No incidents in Queensland resulted in harm. The 2 Never Events resulted from a displaced NGT being used. Three of the 24 incidents in England resulted in low-level harm, but were not related to NGT displacement. The themes identified: (1) outcomes related to ongoing NGT position testing, such as missing medications due to inconclusive pH testing, (2) staff interpersonal relationships impacting their ability to follow local procedures, (3) nonadherence to local procedures, and (4) poor quality of incident reports. CONCLUSIONS: Qualitative content analysis successfully identified themes relevant to clinical practice, despite the low quality of individual incident reports. Harm from displaced NGTs was rare but delays from procedural inconsistencies warrant review of current practices, particularly the reliance on pH testing.
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Intubação Gastrointestinal , Erros Médicos , Segurança do Paciente , Gestão de Riscos , Humanos , Intubação Gastrointestinal/efeitos adversos , Intubação Gastrointestinal/métodos , Intubação Gastrointestinal/normas , Erros Médicos/estatística & dados numéricos , Erros Médicos/prevenção & controle , Pesquisa Qualitativa , Queensland , InglaterraRESUMO
OBJECTIVE: With limited evidence to date about the application of Statutory Duty of Candour, we sought to synthesize evidence of the application of this legislation in health service organisations and determine its impacts on patients, families and staff. METHODS: A search strategy was developed and applied to 6 electronic databases, along with relevant websites, to identify evidence in published and gray literature. Eligible articles were published from 2010 onwards, reported primary or secondary analysis of data of the application of the Statutory Duty of Candour in relation to patient safety events in countries that have enacted the Duty. Two reviewers independently extracted data and assessed the risk of bias. Narrative synthesis was conducted using the Synthesis Without Meta-Analysis (SWiM) guideline. The certainty of evidence was rated by the Grading of Recommendations Assessment and Evaluation (GRADE) approach. RESULTS: Included articles (n=15) originated from the United Kingdom (n=14) and Ireland (n=1); 9 were retrieved from the electronic and 6 from the gray literature search. Findings predominantly focused on the implementation of duty of candour, including understanding requirements and thresholds for use (12 articles), with limited evidence of staff (2 articles), health service (2 articles), and particularly patient and carer outcomes (1 article). CONCLUSIONS: Limited evidence is available about the use and impacts of the duty of candour despite 10 years passing since its initial implementation in the United Kingdom. Few peer-reviewed studies have captured primary evaluative data, none of the scale and breadth in terms of health care providers required to draw conclusions about the use or effectiveness of the duty of candour for achieving open and honest communication about health care incidents.
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Erros Médicos , Segurança do Paciente , Gestão da Segurança , Humanos , Segurança do Paciente/legislação & jurisprudência , Erros Médicos/prevenção & controle , Erros Médicos/legislação & jurisprudência , Reino Unido , Gestão da Segurança/legislação & jurisprudência , IrlandaRESUMO
BACKGROUND: In Japan, a significant number of ventilator-related medical accidents continue to be reported, with causes frequently linked to both equipment malfunctions and human errors. Conventional analytical methods often lack the methodological rigor needed for comprehensive safety analysis. OBJECTIVES: This study explores the application of System-Theoretic Process Analysis (STPA) as a novel approach to ventilator safety analysis. The goal is to identify potential hazards arising from human errors and device failures and to establish system-level safety constraints. METHODS: STPA is employed to construct a control structure diagram of a ventilator system, offering a system-wide perspective to identify Unsafe Control Actions (UCAs) and resulting hazardous scenarios. This approach provides a structured analysis of system interactions to derive safety constraints aimed at reducing risks. RESULTS: STPA successfully identified UCAs and system-level interactions that could lead to hazardous outcomes. Compared with the Critical Incident Report (CIR) by the Japan Council for Quality Health Care (JCQHC), which provides retrospective insights into ventilator-related incidents, STPA demonstrates a systematic and comprehensive methodology. It analyzed the mechanisms by which incidents could arise within the system, considering both human and technical factors. The analysis identified hazardous interactions and provided a foundation for implementing preventive measures. CONCLUSIONS: STPA offers a holistic framework for ventilator safety, surpassing traditional analysis methods by addressing complex human-technical interactions. The results contribute to enhanced ventilator safety, improved risk management, and a stronger safety culture across medical devices.
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Segurança do Paciente , Gestão da Segurança , Análise de Sistemas , Teoria de Sistemas , Ventiladores Mecânicos , Humanos , Ventiladores Mecânicos/normas , Japão , Erros Médicos/prevenção & controle , Gestão da Segurança/métodosRESUMO
BACKGROUND: Patient safety event reporting systems are essential for identifying potential risks and improving patient outcomes. However, traditional systems frequently face issues of under-reporting, particularly concerning near-miss and no-harm events, thereby limiting opportunities for organizational learning and harm prevention. This initiative used quality improvement principles to design a new reporting system at our institution to enhance safety culture. METHODS: Following extensive stakeholder feedback and multidisciplinary collaboration, a new system was implemented on July 22, 2022. Key features included streamlined reporting, centralized data analysis, and enhanced transparency. RESULTS: Overall event reporting as well as proportional reporting of near-miss and no-harm events increased significantly from around 60% preimplementation to 80% after implementation. Staff engagement also improved, as shown by a steady rise in the number of unique event reporters and reviewers. CONCLUSIONS: The new reporting system has improved reporting overall, with increases in near-miss and no-harm events, along with increased staff engagement with the reporting and review process. Our experience offers practical lessons for institutions seeking to strengthen the learning value of event reporting systems. The principles we identified with simplifying ease of use, integrating into the EHR, improving data transparency, and encouraging greater involvement with event review, along with clear oversight protocols, apply beyond our institution and are not limited to a specific PSRS product or system. These initial outcomes support a culture of safety and bolster organizational learning, with future study needed on long-term effects on patient safety outcomes, staff involvement, and increased trust.
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Erros Médicos , Near Miss , Cultura Organizacional , Segurança do Paciente , Melhoria de Qualidade , Gestão de Riscos , Gestão da Segurança , Humanos , Segurança do Paciente/normas , Melhoria de Qualidade/organização & administração , Gestão da Segurança/organização & administração , Gestão de Riscos/métodos , Near Miss/estatística & dados numéricos , Erros Médicos/prevenção & controle , AprendizagemRESUMO
OBJECTIVES: Effective critical care communication is vital for patient safety, yet the risks of ambiguous abbreviations and acronyms or initialisms in clinical communication remain understudied. This narrative review aims to identify potentially ambiguous abbreviations and acronyms in critical care and evaluate their potential implications for clinical safety and communication quality. From this, educational interventions and standardized protocols could be devised to optimize communication. METHODS: PubMed and Embase databases were used to identify studies and reports on the use of abbreviations and acronyms in medical care and references of identified publications were screened. Additionally, the large language model "Chat Generative Pre-Trained Transformer-4omni" was used to generate a list of ambiguous terms used in critical care. RESULTS: We identified 52 ambiguous acronyms and initialisms, and 24 abbreviations used in critical care with multiple meanings, risking critical errors during communication and ward transfers. These ambiguities stem from specialty, context, or institutional differences. The literature discusses optimization of communication in critical care during hand-offs or more complex solutions including auto-expansion software or protocols. Only few studies discussed the dangers of medication errors or misunderstandings due to abbreviation use. Abbreviations contribute to as much as 13 % of medication errors. Strategies are proposed to reduce abbreviation-related errors including spelling out terms initially, using closed-loop communication, standardized unit-approved lists, regular education, and avoiding jargon. CONCLUSIONS: Ambiguous abbreviations and acronyms pose a significant threat to safe and effective communication in critical care. Standardized terminology, education, and clear documentation practices are urgently needed to mitigate these risks and improve patient safety.
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Abreviaturas como Assunto , Comunicação , Cuidados Críticos , Segurança do Paciente , Humanos , Cuidados Críticos/normas , Erros Médicos/prevenção & controleRESUMO
Preventable medical error is a leading cause of death in the United States. While high-reliability organization (HRO) implementation efforts have become widespread, they often lack integration across culture, learning systems, and ambulatory care. A large health system launched a systemwide HRO improvement effort to drive reductions in serious safety events (SSEs), improve safety reporting culture, and align executive leadership with frontline safety practice. This is a retrospective observational study conducted between January 2019 and June 2025 across 12 hospitals and over 90 ambulatory clinics. The systemwide HRO intervention included leadership development, a unified safety reporting system, tiered safety huddles, and structured root cause analysis feedback. Safety culture scores were measured using Agency for Healthcare Research and Quality surveys in 2021 and 2024. SSEs were standardized as serious safety event reports (SSERs) per 10,000 patient-days. Hospital SSERs decreased significantly by 71% ( P < 0.001 for trend). Ambulatory SSERs increased due to enhanced harm detection efforts, but not significantly ( P = 0.356 for trend). Safety culture composite scores improved in 11 of 13 individual domains, with the largest percentage improvements in scores for leadership support and communication. A systemwide, unified HRO approach that holistically incorporates HRO-aligned standard work, executive leadership alignment, and proactive systems design can result in lasting preventable harm reductions and cultural transformation.
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Erros Médicos , Cultura Organizacional , Segurança do Paciente , Melhoria de Qualidade , Gestão da Segurança , Humanos , Estudos Retrospectivos , Gestão da Segurança/organização & administração , Erros Médicos/prevenção & controle , Segurança do Paciente/normas , Liderança , Estados Unidos , Melhoria de Qualidade/organização & administração , Análise de Causa FundamentalRESUMO
Simulation courses develop both technical and non-technical skills. The latter are the most important skills for preventing errors resulting from communication or awareness. The error room methodology involves setting up spaces that match the work environments of the professionals being trained, within which training programs are offered that adhere to the most effective andragogical techniques. This training project involved 280 nurses with an average age of 39.7 years. A total of 1,560 hours of simulation training were provided in the error room. This paper demonstrated that the Error Room certainly represents an opportunity for technical and non-technical skills, but above all, it allows multidisciplinary teams to practice innovative organizational models together.
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Erros Médicos , Segurança do Paciente , Treinamento por Simulação , Humanos , Itália , Adulto , Erros Médicos/prevenção & controle , Pessoa de Meia-Idade , Feminino , MasculinoRESUMO
Background Transitions in care between resident physician teams represent a vulnerable time for hospitalized patients and are prone to increased adverse patient outcomes. Objective This prospective study evaluated whether a pragmatic, time-efficient intervention could decrease adverse patient outcomes during end-of-week transitions of care between inpatient resident teams. Methods From September 2022 to May 2024, following their first week of inpatient service, resident teams performed an unstructured written handoff to the next team (control group). At the end of their second inpatient week, the team performed a structured verbal handoff utilizing the I-PASS system (intervention group). Two days prior to their verbal handoff, residents received a 5- to 10-minute teaching session on the appropriate use of the I-PASS system. On switch days, 4 adverse patient events (primary composite endpoint) were collected including delays in patient discharge, delays in scheduled procedures, incomplete patient-to-physician communications, and major adverse patient events. Results A total of 3744 patients were evaluated: 2000 in the control group and 1744 in the intervention group. The composite endpoint incidence was 6.35% (127 of 2000) in the control group and 3.61% (63 of 1744) in the intervention group (X2=13.9, P=.002). This represented an absolute risk reduction of 2.74% (95% CI, 1.3-4.1) and a number needed to treat of 37 (95% CI, 24-75). Conclusions The implementation of a time-efficient structured verbal I-PASS handoff, when compared to an unstructured handoff, was associated with a decrease in number of adverse patient outcomes during end-of-week transitions of care.
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Internato e Residência , Transferência da Responsabilidade pelo Paciente , Transferência de Pacientes , Humanos , Transferência da Responsabilidade pelo Paciente/organização & administração , Internato e Residência/métodos , Estudos Prospectivos , Feminino , Masculino , Comunicação , Pessoa de Meia-Idade , Adulto , Segurança do Paciente , Erros Médicos/prevenção & controleRESUMO
Background Academic institutions in the United States continue to struggle with increasing the rate of patient safety event reporting by trainees. Objective To describe the development and implementation of 2 escape room cases with the goal of improving resident reporting of adverse events, reporting participant teamwork and communication skills, and describing feasibility and acceptability data. Methods We developed 2 high-fidelity medical simulation cases via group consensus from an interprofessional team as part of a required quality improvement curriculum for all graduate medical education learners. Senior residents and fellows from all training programs at a single university were recruited to participate. We utilized the New World Kirkpatrick Model levels 1-2 as our program evaluation framework to analyze data from participants between 2022 and 2023. Surveys were collected via an online survey tool immediately prior to and following the event. Results Over 2 years, 130 learners participated in the escape room event (78 residents [60%] and 52 fellows [40%] across 15 specialties/subspecialties). One hundred twenty-four (95%) completed the post-event survey. Eighty-four percent (104 of 124) reported they had never submitted a patient safety event report prior to this activity. All strongly agreed or agreed this educational activity had clear goals and was organized, 94% (117 of 124) felt the escape error room was relevant to their needs as a physician in training, and 83% (103 of 124) reported greater likelihood of submitting an event report in the future. Cost was $6 per learner. Conclusions This educational modality demonstrated feasibility and acceptability and improved overall willingness to submit future patient safety event reports.
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Educação de Pós-Graduação em Medicina , Internato e Residência , Segurança do Paciente , Treinamento por Simulação , Humanos , Internato e Residência/métodos , Educação de Pós-Graduação em Medicina/métodos , Melhoria de Qualidade , Treinamento por Simulação/métodos , Currículo , Inquéritos e Questionários , Estados Unidos , Erros Médicos/prevenção & controle , ComunicaçãoRESUMO
BACKGROUND: A key part of the patient safety system is how it responds to and learns from safety incidents. To date, there is limited research on understanding system-based approaches to investigating incidents that occur within this complex interacting system. OBJECTIVES: The aims of this study were to qualitatively explore mental health professionals' perceptions of patient safety incident investigations; to understand the impact of the transition to systems-based approaches and to explore the influence of different elements of the system on the goals of patient safety. DESIGN, SETTING AND PARTICIPANTS: The qualitative study involved 19 semi-structured interviews with professionals working within the patient safety system across two mental health National Health Service trusts. The data were analysed using thematic analysis. RESULTS: Those interviewed identified that a change in approach to incident investigation, from root cause analysis to systems-based, would lead to rigorous investigations that are effectively linked to learning. Over time, this was described as a contributory factor to reducing feelings of blame and positively influencing safety culture. There were considerations of potential negative effects from a systems-based approach, such as the shifting rather than elimination of blame, and the possibility of missing individual poor practice. The findings identify the presence of several interdependencies across the system that could have a positive or negative influence on the outcomes of incident responses. CONCLUSIONS: This study demonstrates that the interdependencies within the system and our limited understanding of safety in mental healthcare introduces complexity and uncertainty to incident investigation outcomes. This is likely to impact on safety incident responses and learning, where acknowledging and evaluating this complexity is likely to reduce any potential negative outcomes that exist.
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Atitude do Pessoal de Saúde , Erros Médicos , Serviços de Saúde Mental , Segurança do Paciente , Gestão de Riscos , Gestão da Segurança , Humanos , Segurança do Paciente/normas , Pesquisa Qualitativa , Serviços de Saúde Mental/normas , Erros Médicos/prevenção & controle , Entrevistas como Assunto , Medicina Estatal , Feminino , Reino Unido , MasculinoRESUMO
PURPOSE OF REVIEW: In the quarter of a century since the release of the report To Err is Human, current progress in patient safety is at best inconsistent, and at worst, has outright stalled. To resume the speed of progress made at the start of the patient safety movement, we will need to approach patient safety in a different way. RECENT FINDINGS: The lack of progress in patient safety has increased enthusiasm for different paradigms of understanding patient safety. Rather than focusing on deficit-based models of patient safety, newer approaches focus on complementary methods that attempt to understand the essential underpinnings of work that is safe. SUMMARY: Weick describes the story of wildland firefighters who failed to drop their tools when they were no longer useful, resulting in their deaths. While the tools used by patient safety professionals are not physical implements, a similar phenomenon exists. In this review, the commonly used patient safety tools which are impeding progress are discussed. Alternative views to citing human error as a cause, ruthlessly targeting unachievable goals, and approaching the complex environment of healthcare as a linear system are presented.
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Erros Médicos , Segurança do Paciente , Assistência Perioperatória , Gestão da Segurança , Humanos , Segurança do Paciente/normas , Erros Médicos/prevenção & controle , Assistência Perioperatória/normas , Assistência Perioperatória/métodos , Gestão da Segurança/métodosRESUMO
PURPOSE OF REVIEW: Although effective patient safety education is critical to reducing medical errors, little guidance exists on best practices for patient safety curricula. This review explores the current state of patient safety education in anesthesiology and highlights emerging technologies as tools to enhance and personalize education. RECENT FINDINGS: Despite formal mandates from accrediting bodies, patient safety education in anesthesiology lacks standardization in content, delivery, and assessment. Structured clinical training, simulation, and quality improvement projects are common teaching strategies, but novel approaches such as immersive reality (IR), artificial intelligence (AI)-powered agents, gamification, and mobile platforms are gaining traction. AI shows promise in tailoring instruction and identifying high-risk learners, and IR offers tools for both technical and nontechnical skills training. SUMMARY: Patient safety education in anesthesiology is evolving with technology. AI and digital tools provide adaptive and interactive learning experiences that may help address current limitations in fixed, generalized curriculum structure and accessibility. However, these innovations require robust validation and thoughtful integration into educational frameworks to realize their full potential.
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Anestesiologia , Segurança do Paciente , Humanos , Anestesiologia/educação , Anestesiologia/tendências , Segurança do Paciente/normas , Inteligência Artificial , Currículo , Competência Clínica , Erros Médicos/prevenção & controle , Melhoria de Qualidade , Treinamento por Simulação/métodos , Tecnologia Educacional/tendênciasRESUMO
PURPOSE OF REVIEW: This review provides clinicians with an introduction to the theories underlying safety-I, II, and III. These are concepts that have recently been adapted to healthcare and are growing in popularity among patient safety experts. Clinicians will be encountering patient safety interventions and analyses rooted in these theories, making an understanding of the safety science behind them important. RECENT FINDINGS: There is a growing body of literature analyzing safety-I, II, and III in healthcare as well as multiple recently published applied case studies. SUMMARY: Safety-I, II, and III are complementary ways of considering how accidents occur and how systems can build safety. Safety-I assumes that accidents occur through linear chains of events, prompting searches for root causes of accidents. Safety-II is grounded in resilience engineering and posits that accidents occur due to variability, but variability can also be protective as people prevent harm from reaching patients. Safety-III assumes that safety emerges from the interactions of the people, software, and hardware in the system as they work to control their behavior within safe bounds. These three unique lenses on safety offer different lessons learned from accidents and different strategies to promote patient safety.
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Erros Médicos , Segurança do Paciente , Gestão da Segurança , Segurança do Paciente/normas , Humanos , Erros Médicos/prevenção & controle , Gestão da Segurança/métodosRESUMO
PURPOSE OF REVIEW: This review provides an overview of the concept of transparency, focusing on the various ways that adverse events are shared within and across departments in a single institution, across different institutions, and with national organizations. RECENT FINDINGS: Within a department, strategies to promote transparency from frontline clinicians to department leadership (bottom-up transparency) include easy-to-use reporting systems and maintaining a robust safety culture. Top-down transparency can be facilitated with the timely sharing of systemic changes made because of reported events and the continued cultivation of a psychologically safe learning environment. Daily safety huddles, leadership walkrounds, and shared case conferences that break down barriers in communication can encourage interdepartmental transparency. Sharing events across institutions remains challenging. In addition, while reporting events to national registries and databases does occur, top-down transparency back to hospitals and departments remains unsystematic. Finally, there exist several legal challenges to advancing transparency. SUMMARY: There has been much progress nationally in enhancing the transparency of adverse events. Future areas of improvement include cross-institutional transparency and facilitating the timely sharing of repeat concerns and lessons learned from national registries back with participating institutions and departments. Concerns about legal consequences when discussing adverse events may prohibit expanded transparency.
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Anestesiologia , Disseminação de Informação , Erros Médicos , Segurança do Paciente , Humanos , Erros Médicos/prevenção & controle , Erros Médicos/legislação & jurisprudência , Segurança do Paciente/legislação & jurisprudência , Comunicação , Liderança , Gestão de Riscos , Cultura Organizacional , Anestesiologia/legislação & jurisprudência , Anestesiologia/normas , Sistema de RegistrosRESUMO
OBJECTIVE: To identify cognitive biases and heuristics experienced by surgeons in operative settings and the impact these biases and heuristics have on patient care. BACKGROUND: Cognitive biases and heuristics are systematic errors in thinking that can affect clinical decisions. Both are noted in surgical settings and are a risk to patient safety. METHODS: This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and PROSPERO registered (CRD42023432099). Five major databases were searched from inception to August 28, 2022, with an updated search on January 27, 2024. Original primary research studies in English were included, with relevant risk of bias tools employed for each study. RESULTS: Twenty-one papers were included. Thirty-eight biases were identified across 6 experiments, 5 analyses, and 10 survey studies. Confirmation bias, anchoring, risk aversion, and overconfidence bias were the most represented. Risk of bias was moderate across most studies. Cognitive biases and heuristics were found to influence surgical outcomes and 6 studies cited a negative impact on patient care, with one associating biases with fatal outcomes. CONCLUSIONS: Biases and heuristics contribute to surgical errors and never events, and will continue to do so until they are recognised and addressed. Implementing debiasing strategies, such as mindfulness training and deliberate reflection, was found to reduce surgical errors in 2 studies. This review highlights the need for experimental studies, which are essential for understanding how and why biases lead to negative outcomes and for evaluating further debiasing interventions. We propose directions for future research and system changes.
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Tomada de Decisão Clínica , Cognição , Heurística , Erros Médicos , Cirurgiões , Procedimentos Cirúrgicos Operatórios , Humanos , Viés , Erros Médicos/prevenção & controle , Cirurgiões/psicologiaRESUMO
Adverse events in healthcare continue to challenge hospital management practices, often resulting in avoidable patient harm and substantial financial costs. Despite technological progress and the availability of risk management tools, healthcare institutions still struggle to systematically monitor and evaluate risk dynamics over time. This study proposes a multi-criteria decision analysis framework based on the ELECTRE Tri-nC method to assess the evolution of clinical and non-clinical risks at Hospital da Luz Lisboa, a private Portuguese hospital. A panel of risk management experts evaluated twelve criteria across five years (2018-2022), enabling the classification of each quarter into one of five predefined risk categories. The model accommodates the non-compensatory nature of risk indicators and integrates expert-defined thresholds. Results reveal critical periods of heightened risk, underscoring the importance of analysing risk trends over time rather than focusing on isolated incidents. A stability analysis confirms the robustness of the weight structure and highlights the model's sensitivity to changes in the credibility threshold. Overall, the proposed approach provides healthcare decision-makers with a transparent and structured framework for retrospective risk analysis and supports the design of timely, targeted mitigation strategies. The methodology is adaptable to other hospital settings.