Advancing Patient Safety Science While Not Losing Focus of the Big Picture: Improving Patient Care

Susan Khalil; Charles Ascher-Walsh

doi:10.1016/j.jmig.2022.03.003

Advancing Patient Safety Science While Not Losing Focus of the Big Picture: Improving Patient Care

Research output: Contribution to journal › Editorial

Original language	English
Pages (from-to)	581-582
Number of pages	2
Journal	Journal of Minimally Invasive Gynecology
Volume	29
Issue number	5
DOIs	https://doi.org/10.1016/j.jmig.2022.03.003
State	Published - May 2022

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10.1016/j.jmig.2022.03.003

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@article{dd7ea807bf58477f96d872084ebeda40,

title = "Advancing Patient Safety Science While Not Losing Focus of the Big Picture: Improving Patient Care",

author = "Susan Khalil and Charles Ascher-Walsh",

note = "Funding Information: The findings of Cohen et al included that retained foreign objects were most common in patients who underwent labor and vaginal delivery (n = 20, 44%), and the objects found were sponges or other items for absorbing bodily fluids (n = 23, 53%), followed by broken instruments. Their study identified 75 contributing factors in the 45 events (1.6 factors per case, SD = 1.7) that were largely categorized under preconditions for unsafe acts (n = 37, 49.3%) and unsafe acts (n = 34, 45.3%) tiers. The authors cite skill-based errors, as an occurrence under unsafe acts, referencing cognitive load during procedures, using a dataset over 19 years from the period of 2000 through 2019. This spanned a time that just started the patient safety movement, with “to Err is Human” statement in 1999 from the Institute of Medicine, and then David Marx's Just Culture framework in 2001, supported by a grant from the National Heart, Lung, and Blood Institute of the National Institutes of Health [ 4 , 5 ]. This sets the stage as tools for error management have evolved from use of TeamSTEPPS (AHRQ, Rockville, MD) to applying Crew Resource Management [6] in healthcare and applying them to the unique teams in healthcare that function in the operating room setting or labor and delivery or areas of high intensity with critical outcomes, such as lifesaving procedures or processes on a daily basis. ",

year = "2022",

month = may,

doi = "10.1016/j.jmig.2022.03.003",

language = "English",

volume = "29",

pages = "581--582",

journal = "Journal of Minimally Invasive Gynecology",

issn = "1553-4650",

publisher = "Elsevier B.V.",

number = "5",

}

TY - JOUR

T1 - Advancing Patient Safety Science While Not Losing Focus of the Big Picture

T2 - Improving Patient Care

AU - Khalil, Susan

AU - Ascher-Walsh, Charles

N1 - Funding Information: The findings of Cohen et al included that retained foreign objects were most common in patients who underwent labor and vaginal delivery (n = 20, 44%), and the objects found were sponges or other items for absorbing bodily fluids (n = 23, 53%), followed by broken instruments. Their study identified 75 contributing factors in the 45 events (1.6 factors per case, SD = 1.7) that were largely categorized under preconditions for unsafe acts (n = 37, 49.3%) and unsafe acts (n = 34, 45.3%) tiers. The authors cite skill-based errors, as an occurrence under unsafe acts, referencing cognitive load during procedures, using a dataset over 19 years from the period of 2000 through 2019. This spanned a time that just started the patient safety movement, with “to Err is Human” statement in 1999 from the Institute of Medicine, and then David Marx's Just Culture framework in 2001, supported by a grant from the National Heart, Lung, and Blood Institute of the National Institutes of Health [ 4 , 5 ]. This sets the stage as tools for error management have evolved from use of TeamSTEPPS (AHRQ, Rockville, MD) to applying Crew Resource Management [6] in healthcare and applying them to the unique teams in healthcare that function in the operating room setting or labor and delivery or areas of high intensity with critical outcomes, such as lifesaving procedures or processes on a daily basis.

PY - 2022/5

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DO - 10.1016/j.jmig.2022.03.003

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AN - SCOPUS:85127627388

SN - 1553-4650

VL - 29

SP - 581

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JO - Journal of Minimally Invasive Gynecology

JF - Journal of Minimally Invasive Gynecology

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