This document outlines global priorities for patient safety research as identified by a WHO expert group. The group found common priorities across developing, transitional, and developed countries including inadequate training and skills, lack of communication, and healthcare-associated infections. They developed a table of the top six priorities for each setting and identified over 50 priority research topics and questions. The document calls for more applied, evaluative research to develop effective and affordable solutions to improve patient safety worldwide.
Presentation between innovation and precaution ESHRE 2019Verna Jans
At the ESHRE conference in Vienna in 2019, I presented my article on offspring safety considerations in strategies of introducing new reproductive techniques.
Evidence-Informed Public Health Decisions Made Easier: Take it one Step at a ...Health Evidence™
An afternoon workshop - held in partnership with the National Collaborating Centre for Methods and Tools - at the Ontario Public Health Convention April 7, 2011
This final webinar will emphasise the importance of understanding the problem before brainstorming solutions to better ensure a match between barriers and the solutions.
MORE INFO: http://bit.ly/2KctiLH
Presentation between innovation and precaution ESHRE 2019Verna Jans
At the ESHRE conference in Vienna in 2019, I presented my article on offspring safety considerations in strategies of introducing new reproductive techniques.
Evidence-Informed Public Health Decisions Made Easier: Take it one Step at a ...Health Evidence™
An afternoon workshop - held in partnership with the National Collaborating Centre for Methods and Tools - at the Ontario Public Health Convention April 7, 2011
This final webinar will emphasise the importance of understanding the problem before brainstorming solutions to better ensure a match between barriers and the solutions.
MORE INFO: http://bit.ly/2KctiLH
Professor Cindy Farquhar
Cochrane Menstrual Disorders & Subfertility Group
NZ Cochrane Branch of the Australasian Cochrane Centre
New Zealand Guidelines Group
National Women’s Health
University of Auckland
A document prepared by Dr. Mustafa Salih, the former director of the Directorate General of Health Policy, planning and research at the Federal ministry of Health in Sudan.
Journal Club - Mortality after Fluid Bolus in African Children with Severe In...Farooq Khan
Critical Appraisal of:
Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med 2011;364:2483-95
Research in International Emergency Medicine: Scope, Impact and Challenges
EBM Topic: Subgroup Analysis
A presentation, describes basics of Clinical Governance
What do we have in common
as Medical Doctors/Medical
Practitioners?
1. We are technical experts in our fields
2. We are leaders
3. We are managers
4. We are accountable for the patient care and health services
5. We are change agents
6. We are respected highly in the community
7. We are responsive
8. We are good communicators and negotiators
9. We are kind and empathic
10. We are decent and disciplined
Clinical Governance is a strategic framework for the development of high quality healthcare
"A framework through which organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish" – NHS, UK
“clinical governance is a way of making sure that everyone who passes through health system is well cared for”
or
System that enable staff to work in the best possible way
+
Staff performing to the highest possible standards
Seven pillars of Clinical Governance
Patient and public involvement (PPI)
Risk management
Staffing and staff management
Education and training
Clinical effectiveness & Research
Using clinical information & IT
Clinical audit
Patient and public involvement
Ensuring services meet the need of the patients
Patient and public feedback is used to improve services
Patients and the public are involved in the development of services and the monitoring of treatment outcomes
Risk management
Complying with protocols
Learning from mistakes and near-misses
Reporting adverse events
Assessing the risks – probability of occurrence, impact
Promoting blame free culture
Staffing and staff management
Appropriate recruitment and management of staff
Ensuring that underperformance is identified and addressed
Encouraging staff retention by motivating and developing staff
Providing good working conditions
Education and Training
Providing appropriate support available to enable staff to be competent in doing their jobs and to develop their skills so that they are up to date
Professional development needs to continue through lifelong learning
Clinical effectiveness & Research
Clinical effectiveness implies ensuring that everything we do is designed to provide the best outcomes for patients
Clinical audit
Clinical audit is a quality improvement cycle that involves measurement of the effectiveness of healthcare against agreed and proven standards for high quality, and taking action to bring practice in line with these standards so as to improve the quality of care and health outcomes
Clinical audit is a systematic process of looking at your practice and asking:
What should we be doing?
Are we doing it?
If not, how can we improve?
> Why HEOR?
> Costs, Consequences and Perspectives
> Key Stakeholders in HEOR
> What is Health Economics and Pharmaco-economic Research?
> Economic Evaluations
> Incremental Cost Effectiveness Ratio (ICER)
> Concept of HRQoL
> Comparative Effectiveness Research (CER)
> Pragmatic Clinical Trials
> Observational Studies
> Systematic Reviews and Meta-Analysis
> Application of CER
> Health Technology Assessment (HTA)
> Real World Evidence (RWE)
> Patient Reported Outcomes (PROs)
> Patient Focused Drug Development (PFDD)
> Application of Health Economic Evaluations
> Challenges and Barriers
Early child development: Report on case studiesDRIVERS
Case study produced as part of the DRIVERS project. The objective of case studies in areas that are key drivers of health inequities is to identify services, policies or practices that are already in place that have the potential to reduce inequalities in health and its social determinants.
This report highlights the main findings from the EIU assessment of value-based healthcare (VBHC) alignment in 25 countries. The study was commissioned by Medtronic, a global technology and medical devices company. As VBHC is an early-stage concept and model, this study was an effort to establish a standard of evaluation of value-based healthcare alignment and establish the core components of the enabling environment for VBHC.
What is possible in a hospital getting to zero harm cincinati childrens story...Proqualis
Apresentação de Stephen Muething durante o SIMPÓSIO EINSTEIN-IHI: Implantação e Disseminação de Programas de Segurança do Paciente aconteceu de 3 a 5 de novembro de 2013, em São Paulo - Brasil.
Professor Cindy Farquhar
Cochrane Menstrual Disorders & Subfertility Group
NZ Cochrane Branch of the Australasian Cochrane Centre
New Zealand Guidelines Group
National Women’s Health
University of Auckland
A document prepared by Dr. Mustafa Salih, the former director of the Directorate General of Health Policy, planning and research at the Federal ministry of Health in Sudan.
Journal Club - Mortality after Fluid Bolus in African Children with Severe In...Farooq Khan
Critical Appraisal of:
Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med 2011;364:2483-95
Research in International Emergency Medicine: Scope, Impact and Challenges
EBM Topic: Subgroup Analysis
A presentation, describes basics of Clinical Governance
What do we have in common
as Medical Doctors/Medical
Practitioners?
1. We are technical experts in our fields
2. We are leaders
3. We are managers
4. We are accountable for the patient care and health services
5. We are change agents
6. We are respected highly in the community
7. We are responsive
8. We are good communicators and negotiators
9. We are kind and empathic
10. We are decent and disciplined
Clinical Governance is a strategic framework for the development of high quality healthcare
"A framework through which organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish" – NHS, UK
“clinical governance is a way of making sure that everyone who passes through health system is well cared for”
or
System that enable staff to work in the best possible way
+
Staff performing to the highest possible standards
Seven pillars of Clinical Governance
Patient and public involvement (PPI)
Risk management
Staffing and staff management
Education and training
Clinical effectiveness & Research
Using clinical information & IT
Clinical audit
Patient and public involvement
Ensuring services meet the need of the patients
Patient and public feedback is used to improve services
Patients and the public are involved in the development of services and the monitoring of treatment outcomes
Risk management
Complying with protocols
Learning from mistakes and near-misses
Reporting adverse events
Assessing the risks – probability of occurrence, impact
Promoting blame free culture
Staffing and staff management
Appropriate recruitment and management of staff
Ensuring that underperformance is identified and addressed
Encouraging staff retention by motivating and developing staff
Providing good working conditions
Education and Training
Providing appropriate support available to enable staff to be competent in doing their jobs and to develop their skills so that they are up to date
Professional development needs to continue through lifelong learning
Clinical effectiveness & Research
Clinical effectiveness implies ensuring that everything we do is designed to provide the best outcomes for patients
Clinical audit
Clinical audit is a quality improvement cycle that involves measurement of the effectiveness of healthcare against agreed and proven standards for high quality, and taking action to bring practice in line with these standards so as to improve the quality of care and health outcomes
Clinical audit is a systematic process of looking at your practice and asking:
What should we be doing?
Are we doing it?
If not, how can we improve?
> Why HEOR?
> Costs, Consequences and Perspectives
> Key Stakeholders in HEOR
> What is Health Economics and Pharmaco-economic Research?
> Economic Evaluations
> Incremental Cost Effectiveness Ratio (ICER)
> Concept of HRQoL
> Comparative Effectiveness Research (CER)
> Pragmatic Clinical Trials
> Observational Studies
> Systematic Reviews and Meta-Analysis
> Application of CER
> Health Technology Assessment (HTA)
> Real World Evidence (RWE)
> Patient Reported Outcomes (PROs)
> Patient Focused Drug Development (PFDD)
> Application of Health Economic Evaluations
> Challenges and Barriers
Early child development: Report on case studiesDRIVERS
Case study produced as part of the DRIVERS project. The objective of case studies in areas that are key drivers of health inequities is to identify services, policies or practices that are already in place that have the potential to reduce inequalities in health and its social determinants.
This report highlights the main findings from the EIU assessment of value-based healthcare (VBHC) alignment in 25 countries. The study was commissioned by Medtronic, a global technology and medical devices company. As VBHC is an early-stage concept and model, this study was an effort to establish a standard of evaluation of value-based healthcare alignment and establish the core components of the enabling environment for VBHC.
What is possible in a hospital getting to zero harm cincinati childrens story...Proqualis
Apresentação de Stephen Muething durante o SIMPÓSIO EINSTEIN-IHI: Implantação e Disseminação de Programas de Segurança do Paciente aconteceu de 3 a 5 de novembro de 2013, em São Paulo - Brasil.
1EU HCM505 - 146Research Methodology in Health CriAnastaciaShadelb
1
EU HCM505 - 146
Research Methodology in Health
Critical Thinking Assignment: Research Paper_ Module 12
130 Points
/
Saami Comment by Dale Gooden: Hello Saleh,
Thank you for the hard work on this submission. I enjoyed reading it and have provided my feedback below.
Warmly,
Dr. Gooden
November 26, 2021
Patient Safety Culture in hospitals.
Introduction. Comment by Dale Gooden: You provided a solid introduction, background, and overview of the central theme of your research.
Patient safety is an issue of global public health concern. It refers to preventing patients from harm by implementing a care system that contains errors and learns from medical errors to build a safety culture involving healthcare workers, patients, and healthcare organizations. The safety of patients is critical in care quality. Many patients worldwide have suffered injuries, disabilities, and death due to medical errors or unsafe care. Patient safety culture can be defined as healthcare organizations' values about what is essential and how to operate to protect patients. To achieve a safety culture, organizations and their members need to understand the values, norms and beliefs about the essential attitudes and behaviors associated with patient safety (Ali et al., 2018).
To achieve a culture of safety, organizations should emphasize addressing disparities in the quality of care because the current challenges may worsen the efforts to narrow the gap. Quality and safety are key issues in establishing and delivering accessible, responsive and effective healthcare systems. Poor quality and unsafe patient care increase mortality and morbidity rates throughout the world. About 75% of the healthcare delivery gaps are preventable, and approximately 10% of inpatient admission result from preventable patient harm (Amiri et al., 2018).
Patient safety cultures with strong collaboration and leadership drive and prioritize safety (Wu et al., 2019). Strong leadership and commitment from manger are essential because their attitudes and actions influence the wider workforce's behaviors, perceptions, and attitudes. Other important aspects of the patient safety culture are; effective communication, mutual trust, shared views on the importance of patient safety, engaging the healthcare workforce, acknowledging mistakes, and having a system that recognizes, responds, and gives feedback on adverse events (Alquwez et al., 2018). Patient safety culture is influenced by burnouts, hospital characteristics, communication, position, work area, commitment to the patient safety program, leadership, and patient safety resources and management.
Thesis statement. Comment by Dale Gooden: Include a research question supported with peer-reviewed references to improve your grade.
Patient safety culture focuses on safety in health care by emphasizing the prevention, reporting, and investigation of medical errors that may cause patients' adverse effects, thus reducing harm by implementing n ...
Patient Safety: Evolving from Compliance to Cultureclinicalsolutions
Patient Safety, evolving from Compliance to Culture with McKesson http://www.mckesson.com/static_files/McKesson.com/MPT/Documents/PatientSafety_WHT260.pdf
Patient Safety: Evolving from Compliance to Cultureclinicalsolutions
Patient Safety, evolving from Compliance to Culture with McKesson http://www.mckesson.com/static_files/McKesson.com/MPT/Documents/PatientSafety_WHT260.pdf
Running head SKILLS ASSESSMENT PAPER1SKILLS ASSESSMENT PAPE.docxtodd521
Running head: SKILLS ASSESSMENT PAPER
1
SKILLS ASSESSMENT PAPER
4
Skills Assessment Paper
Summary of Skills
For the development of an organization to be successful and effectively achieve set goals and objectives, strong management and organization skills will be required (Bateman & Snell, 2007). Our Team A brings a broad spectrum of skills and talents coming from life, educational and work-related experiences. Each member of the team possesses unique skill sets that will bring fresh ideas, techniques and creative solutions to challenges in the development of our consulting firm.
A thorough evaluation of our team member’s skills, suggests that our key strengths lie within teamwork and dedication, creating presentations, critical thinking, problem-solving techniques, communication, research, and observations. With these skills, this team will be able to successfully achieve most tasks necessary in the development of a consulting firm. This team will need to use these skills to collaborate efforts in a cooperative manner to create, plan, develop and accomplish the goals of the consulting firm. This evaluation also portrays a strong dedication to learning and improving which is beneficial in the development of new skills that may be needed.
Most members of our team currently have educational and professional experience that proves an intense desire to improve and advocate change and educate communities to collaborate an effort enhancing the lives of individuals. This desire will effectively promote positive changes both within communities as well as at a societal level. The team’s overall commitment is to meet basic human needs through education, focusing on identification of challenges and prevention, as well as assist in overcoming personal and organizational obstacles that individuals may face. Our team is committed to improving the overall quality of life through advocacy and action.
The first type of consulting firm that we could possibly work with would be a human services/independent living consulting program. This program would collaborate with a client’s care givers, doctors and independent care organizations to assist in facilitating a client’s independence and improve or maintain health. This consulting firm would collaborate efforts to create an independent, long-term care plan that will enhance the develop of daily living skills, educate on services and programs available, exercise the right to make healthy living choices, and encourage pro-active involvement of all care-giving professionals in the pursuit of personal growth, presence, and participation in the long term care process. This program will improve and emphasis respect and dignity through the promotion of independence.
PLEASE ADD THE OTHER TWO TYPES HERE!
The types of problems these consulting firms might solve.
Inflexible regulatory and legal issues create competitive obstacles human services providers face when offering health services to communities.
Patient Safety: Evolving from Compliance to Cultureclinicalsolutions
Patient Safety, evolving from Compliance to Culture with McKesson http://www.mckesson.com/static_files/McKesson.com/MPT/Documents/PatientSafety_WHT260.pdf
Patient Safety: Evolving from Compliance to Cultureclinicalsolutions
Patient Safety, evolving from Compliance to Culture with McKesson http://www.mckesson.com/static_files/McKesson.com/MPT/Documents/PatientSafety_WHT260.pdf
Patient Safety: Evolving from Compliance to Cultureclinicalsolutions
Patient Safety, evolving from Compliance to Culture with McKesson http://www.mckesson.com/static_files/McKesson.com/MPT/Documents/PatientSafety_WHT260.pdf
Patient Safety: Evolving from Compliance to Cultureclinicalsolutions
Patient Safety, evolving from Compliance to Culture with McKesson http://www.mckesson.com/static_files/McKesson.com/MPT/Documents/PatientSafety_WHT260.pdf
WHO Foresight Approaches in Public Health.pdfWendy Schultz
Suggestions for expanding futures research and foresight capabilities in an organization, with an emphasis on broad participation by stakeholders; includes examples of multiple futures methods and linked processes.
4. Foreword
Research is vitally important to
increase the world’s body of knowledge
about patient safety. How research
is conducted, what priorities are
determined, and how the results are
disseminated can have significant
impact on government health policies,
the introduction of improved health-care
practices and as a result better patient care.
The work commissioned by WHO Patient Safety that underpins the dialogue in this
publication, represents the opinions of patient safety experts worldwide. In their deliberations,
they analysed results from developing, transitional and developed countries and while there
were exceptional differences across the three areas, there were also commonalities.
The priorities outlined in the following pages become even more important when we consider
how funding is prioritized for research globally, and how much and to what extent we can
influence decision makers at all levels, whether they are involved in policy, administration or
are clinicians working at the coal face.
There is no doubt, that the changes required to improve safer care for patients everywhere
will come about through the positive energies channelled and endorsed by governments,
International organizations or other agencies to support greater levels of research.
I endorse the opinions of the research team that undertook the original study and identified the
global priorities for patient safety. How we advocate for greater funding is now our big challenge.
Sir Liam Donaldson
Chair, WHO Patient Safety
(refer http://www.who.int/patientsafety/research/priorities/global_priorities_patient_safety_research.pdf
1
3
5. Introduction
Patient safety is a global issue affecting
countries at all levels of development.
Although estimates of the size of the
problem are scarce, particularly in
developing and transitional countries,
it is likely that millions of patients
worldwide suffer disabilities, injuries
or death every year due to unsafe
medical care. Health care-associated
infections, misdiagnosis, delays in
treatment, injury due to the inadequate
use of medical devices, and, adverse
events due to medication errors, are
common causes of preventable harm
to patients. Reducing the incidence of
patient harm is a matter for everyone
in health care and there is much
to be learned and shared between
developed nations, developing
countries and countries in transition.
4
6. Understanding the magnitude of the problem and the
main contributing factors is essential in order to devise
appropriate solutions. New research will be key to improving
safety in health care, and setting global priorities to focus on
the most critical aspects of patient safety is essential to yield
the maximum possible benefit especially when research
funds are limited. This will contribute to improving patient
safety and reducing harm.
Most research has been done on hospital (secondary) care
in developed countries and these studies show an adverse
event rate of about 10%, this is to say, one in every ten
patients admitted to hospital suffers an adverse event. Little
research has been done in other settings such as primary
care, long term care and mental health care. However, the
available evidence indicates patient safety in these settings
may be as great a problem as in secondary care.
Research Initiative
WHO Patient Safety brought together a working group
of research experts from around the world to focus on
identifying research priorities in developing, transitional
and developed countries. This work, published in May
2009, provides a crucial focus and starting point for global
research into patient safety.
The identification of these priorities enables a more
collaborative global approach, finding solutions that can be
applied in different countries and thus avoiding duplication
of research. Although priorities differ in different parts of the
world, there is considerable overlap in priorities between
developing countries and countries in transition.
Ranking the issues identifies the stark fact that
organizational behaviour is as important as clinical practice
and as such should be of interest to researchers in the field
of psychology and management.
5
7. Priority Table
There must be a strong emphasis on applied and evaluative research leading to developing or
locally adapting effective, appropriate and affordable solutions. Experience shows that while
many solutions exist for certain patient safety hazards, many countries cannot apply them as
they are costly or inappropriate to the local context and circumstance.
The following table shows the top six research priorities across developing countries, countries
in transition and developed countries. It highlights where there are similarities. As such, this is
an important starting point, providing a focus where research funds are limited. The WHO Patient
Safety expert group is currently developing a method for countries to identify their own priorities.
The full list of 50 priorities and research questions is available at http://www.who.int/patientsafety/
research/priorities/global_priorities_patient_safety_research.pdf
Table 1 Six ranked research priorities
Developing Countries Countries with Economies Developed Countries
in Transition
1. Counterfeit & substandard Inadequate competence Lack of communication
drugs & training skills & coordination (including
coordination across
organizations, discontinuity
& handovers)
2. Inadequate competence Lack of appropriate Latent organizational
training & skills knowledge & transfer failures
3. Maternal & newborn care Lack of communication Poor safety culture &
& coordination (including blame-oriented processes
coordination across
organizations, discontinuity
& handovers)
4. Health care-associated Health care-associated Inadequate safety
infections infections indicators
5. Unsafe injection practices Maternal & newborn care Adverse drug events due to
drugs & medication errors
6. Unsafe blood practices Adverse drug events due to Care of the frail & elderly
drugs & medication errors
6
8. Research Questions
Standardized methods for research will be used to answer questions formulated around the
identified priorities. This will ensure the validity of the solutions suggested as a result
of research.
Table 2 outlines some of the priority topics and potential research questions. The complete
list is available for download on the WHO Patient Safety website.
Table 2 Research topics and research questions
Topic Research questions
Extent & nature of the What are the incidence and prevalence of patient safety problems
problem of patient safety in various health-care settings?
What is the burden of unsafe care on the general population in
terms of morbidity and mortality?
What is the burden of unsafe care on special populations, such as
the elderly, minorities and children?
Maternal & newborn care What are costs and benefits of adapting already established
Identification design & guidelines as opposed to designing new solutions?
testing of locally effective
and affordable solutions What mechanisms are needed to ensure specific solutions are valid,
effective and responsive to changing needs and sustainable and
measurable over time?
What solutions for preventing common adverse events are effective
in low resource situations?
Counterfeit and How effective are regulatory actions and interventions in addressing
substandard drugs this issue?
How much do counterfeit and substandard drugs contribute to the
problems of patient safety?
What are the factors that lead to the use of counterfeit and
substandard drugs?
Inadequate competence Are health-care professionals adequately trained in assessing and
training and skills dealing with patients with reported adverse events or medical errors?
Is patient safety a specific topic in the core curricula of physicians,
nurses and health managers?
What kind of continuing medical education programmes are most
effective for ensuring that physicians and nurses retain competency
in patient safety?
7
9. Topic Research questions
Maternal What are the main safety issues in maternal and newborn care?
and newborn care
What is the burden of unsafe maternal and newborn care?
What are the most cost-effective strategies for improving the safety
of maternal and newborn care?
What resources and systems are needed to implement
recommended maternal and newborn care interventions effectively?
Health care-associated What are the epidemiology of and risk factors for health care-associated
infections infections in hospitals?
What is the availability and cost of commercial handrub products and
how does that affect hand hygiene promotion strategies?
What strategies are effective in optimizing participation in infection
control practices?
Are there effective plans in place for the control of epidemic outbreaks
of health care-associated infections?
Does use of new practices (e.g. silver-coated catheters) reduce the
incidence of health care-associated infections?
8
10. ‘With so many unanswered questions on patient safety, it is
(often) difficult for researchers to know where to begin.’
(Bates BMJ 2009; 338:b1775)
However, WHO Patient Safety through its research
programme, since its establishment in 2005, has
developed a growing network of experts worldwide who
can contribute to this important work. WHO provides the
facility for research to take place to meet the strategic
priorities it sets. It works on concepts and definitions
and guidelines to give guidance on the best approaches
and methods for researchers to adopt when undertaking
studies and surveys. In addition, it has set up a small
grants initiative to which researchers can apply on an
annual basis for funding to undertake smaller research in
topics that are aligned to the priorities identified. While the
emphasis must be on developing countries and countries
in transition, it is important to appreciate the global learning
that can be harnessed from quality, well researched and
resourced findings.
Greater understanding of patient safety issues and the
spread of knowledge based on solid evidence will contribute
to reducing the incidences of harm and death to the world’s
patient population.
Research requires funding and commitment from
organizations and individuals who are in positions where they
can allocate the required resources. WHO Patient Safety
extends an invitation to participate and advocate in its quest
to reduce the continuing global incidents of patient harm
and death by supporting the call for greater research to be
undertaken on patient safety.
9