Annotated Bibliographies

Patient Safety: Fatigue Among Clinicians and the Safety of Patients

Published on by Jared Padgett

The levels of continuous duty and work hours for health care personnel are much greater than those allowed in the transportation and nuclear-power industries.

In this article, the authors describe fatigue as a risk factor for impaired performance in healthcare. Residents often work long shifts back to back, with little to no sleep. The effects of fatigue have been covered in other industries, but is slow to catch on in healthcare. Limiting hours for on-duty and on-call shifts may be helpful in reducing errors, but these limits will address a symptom, not the problem. A culture change is needed that encourages physicians to get proper rest, with support from organizational policies and procedures. When the definition of a dedicated physician is based on rest rather than working long hours, the system may begin to improve.

Gaba, D. M., & Howard, S. K. (January 01, 2002). Patient safety: fatigue among clinicians and the safety of patients. The New England Journal of Medicine, 347, 16, 1249-55. doi:10.1056/NEJMsa020846

Emotional Impact of Patient Safety Incidents on Family Physicians and Their Office Staff

Published on by Jared Padgett

This study was designed to determine the emotional effect of patient safety errors on the physician and office staff. To avoid burnout and other problems, an outlet should be chosen to deal with psychological distress following an incident. The results of the study indicated that the level of emotional response was related to the duration of the trauma rather than the event itself (O’Bierne, Sterling, Palacios-Derflingher, Hohman, & Zwicker, 2012). This article is useful for this researcher’s study as it will help in presenting the background of patient safety culture, and why it is applicable to business and healthcare organizations.

Notes:

A lack of support after a crisis hinders organizational learning.

Physicians suffer emotional distress, sleeplessness, and other effects after an incident in which a patient suffered unnecessary harm.

O’Bierne, M., Sterling, P., Palacios-Derflingher, L., Hohman, S., & Zwicker, K. (2012). Emotional impact of patient safety incidents on family physicians and their office staff. Jabfm, 25, 2, 179-185. doi: 10.3122/jabfm.2012.02.110166

Enhancing Patient Safety through Organizational Learning: Are Patient Safety Indicators a Step in the Right Direction?

Published on by Jared Padgett

The authors noted increasing use of Patient Safety Indicators (PSIs), and evaluated whether analysis of PSIs contributes to improved patient safety. PSIs are calculated through administrative data, and the authors suggested that without organizational learning, PSIs and other measurements may not be as effective. They describe a process for using PSIs to improve organizational learning.

The authors also discuss the distinction between process measures and outcome measures. Process measures may be more effective for long-term improvement, yet may not be as reliable or valid as outcome measures. A combination of multiple sources of data might be more valuable to an organization.

Rivard, P. E., Rosen, A. K., & Carroll, J. S. (2006). Enhancing patient safety through organizational learning: Are patient safety indicators a step in the right direction? Health Services Research, 41(4p2), 1633–1653. doi:10.1111/j.1475-6773.2006.00569.x

Creating High Reliability in Health Care Organizations

Published on by Jared Padgett

This article describes the creation of a patient safety model, and the results of the model’s test in intensive care units. The model was developed using elements of HRO theory, including development of standard processes, and improved communication. Emphasis was placed on improving organizational learning through application of lessons learned, so that future errors could be prevented.

Implementation of the model described in the study contributed to a reduction of catheter-related blood stream infection rates in Michigan ICUs. Changing culture is a key step in improving patient safety, and is facilitated through intentional and sustainable implementation of HRO theory.

Pronovost, P. J., Berenholtz, S. M., Goeschel, C. A., Needham, D. M., Sexton, J. B., Thompson, D. A., Lubomski, L. H., et al. (2006). Creating high reliability in health care organizations. Health Services Research, 41(4p2), 1599–1617. doi:10.1111/j.1475-6773.2006.00567.x

Assessing NASA’s Safety Culture: The Limits and Possibilities of High‐Reliability Theory

Published on by Jared Padgett

This article provides alternative viewpoints for what an HRO should look like. It contrasts normal accident theory with High Reliability Theory (HRT). It also shows how some organizations cannot become HROs, though they should continue striving to do so. HRO is a process, not an achievement. The authors suggest that NASA cannot become an HRO, though specific departments within NASA might demonstrate successful integration of HRO principles in their daily practice.

Boin, A., & Schulman, P. (2008). Assessing NASA’s safety culture: The limits and possibilities of high‐reliability theory. Public Administration Review, 68(6), 1050–1062. doi:10.1111/j.1540-6210.2008.00954.x