References
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2. Institute of Medicine. To Err is Human: Building a Safer Health Care System. 1999; Washington, DC: National Academies Press.
3. Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, Whittington JC, Frankel A, Seger A, James BC: 'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs 2011;30(4):581-589.
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Additional Reading
Huskins WC et al., Intervention to reduce transmission of resistant bacteria in intensive care. New England Journal of Medicine 2011;364:1407-18
Jain R et al., , Veterans Affairs initiative to prevent MRSA infections. New England Journal of Medicine 2011;364:1419-30.
Platt R. Time for a culture change? New England Journal of Medicine 2011;364:1464-65.
In 2011, the New England Journal of Medicine published two articles on efforts to reduce MRSA infections. Efforts were unsuccessful in a group of intensive care units (Huskins et al) and successful in a group of Veterans Affairs Hospitals (Jain et al). The issue's editorial, written by a prominent infectious disease specialist (Platt), suggests that social culture may be what differentiates these two groups.
Curry LA, et al. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study. Annals of Internal Medicine 2011;154:384-90.
High-performing hospitals are characterized by an organizational culture that supports efforts to improve acute myocardial infarction care hospital-wide. Evidence-based protocols and processes, although important, may be insufficient to achieve high hospital performance in care for patients with acute myocardial infarction.
Hansen LO, Williams MV, Singer SJ. Perceptions of hospital safety climate and incidence of readmission. Health Services Research 2011;46(2):596-616.
There is a significant positive association between lower safety climate and higher readmission rates for acute myocardial infarction and heart failure.
Singer S, Lin S, Falwell A, Gaba D, Bake L. Relationship of safety climate and safety performance in hospitals. Health Services Research 2009;44(2 Pt 1):399-421.
Hospitals with better safety climates overall had a lower incidence of Patient Safety Indicators, as did hospitals with better scores measuring personal beliefs about shame and blame. The results link hospital safety climate to indicators of potential safety events.
Pettker CM, Thung SF, Norwitz ER, Buhimschi CS, Raab C, Copel J, et al. Impact of a comprehensive patient safety strategy on obstetric adverse events. American Journal of Obstetrics and Gynecology 2009;200:492.e1-492.e8.
Patient safety interventions significantly reduced the Adverse Outcome Index. Concurrent with these improvements, the authors saw clinically significant improvements in safety climate as measured by validated safety attitude surveys.
Vogus, TJ, Sutcliffe KM, Weick KE. Doing no harm: enabling , enacting, and elaborating a culture of safety in health care. Academy of Management Perspectives 2010;24(4): 60-77.
This paper consolidates management research into a comprehensive and integrative framework that shows how patient safety is realized and sustained through safety culture.
Frankel AS, Leonard MW, Denham, CR. Fair and just culture, team behavior, and leadership engagement: The tools to achieve high reliability. Health Services Research (2006);41(4 Pt 2):1690-709.
Just culture principles, teamwork training, and leadership walkrounds stand out as worthy initiatives to improve interpersonal relationships and apply provider concerns to shape operational change. To achieve reliability, organizations need to begin thinking about the relationship between these principles and efforts and find ways to link them conceptually.
Hofmann D, Mark B. An Investigation of the relationship between safety climate and medication errors as well as other nurse and patient outcomes. Personnel Psychology 2006;59(4):847-869.
Results reveal that safety climate predicted medication errors, nurse back injuries, urinary tract infections, patient satisfaction, patient perceptions of nurse responsiveness, and nurse satisfaction.
Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J, et al. The Safety Attitudes Questionnaire : psychometric properties , benchmarking data , and emerging research. BMC Health Services Research 2006;10:1-10.
Multilevel factor analysis shows that the Safety Attitudes Questionnaire demonstrates good psychometric properties. Healthcare organizations can use the survey to measure caregiver attitudes about six patient safety-related domains, to compare themselves with other organizations, to prompt interventions to improve safety attitudes, and to measure the effectiveness of these interventions.
Leonard M. The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care 2004;13(1): i85-i90.
High reliability domains, such as commercial aviation, have shown that adopting standardized tools and behaviors enhances teamwork and reduces risk. This paper describes ongoing patient safety implementation using this approach within Kaiser Permanente.
