Analysis of patient safety event report categories at one large academic hospital
Given the persistent safety incidents in operating rooms (ORs) nationwide (approx. 4,000 preventable harmful surgical errors per year), there is a need to better analyze and understand reported patient safety events. This study describes the results of applying the Team Strategies and Tools to Enhan...
| Main Authors: | , , , , , , , , |
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| Format: | Article |
| Language: | English |
| Published: |
Frontiers Media S.A.
2024-04-01
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| Series: | Frontiers in Health Services |
| Subjects: | |
| Online Access: | https://www.frontiersin.org/articles/10.3389/frhs.2024.1337840/full |
| _version_ | 1797230450801901568 |
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| author | Cody Mitchell Logan Butler Alexa D. Holloway Jin H. Ra Karthik Adapa Caprice Greenberg Lawrence B. Marks Lawrence B. Marks Thomas Ivester Lukasz Mazur Lukasz Mazur |
| author_facet | Cody Mitchell Logan Butler Alexa D. Holloway Jin H. Ra Karthik Adapa Caprice Greenberg Lawrence B. Marks Lawrence B. Marks Thomas Ivester Lukasz Mazur Lukasz Mazur |
| author_sort | Cody Mitchell |
| collection | DOAJ |
| description | Given the persistent safety incidents in operating rooms (ORs) nationwide (approx. 4,000 preventable harmful surgical errors per year), there is a need to better analyze and understand reported patient safety events. This study describes the results of applying the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) supported by the Teamwork Evaluation of Non-Technical Skills (TENTS) instrument to analyze patient safety event reports at one large academic medical center. Results suggest that suboptimal behaviors stemming from poor communication, lack of situation monitoring, and inappropriate task prioritization and execution were implicated in most reported events. Our proposed methodology offers an effective way of programmatically sorting and prioritizing patient safety improvement efforts. |
| first_indexed | 2024-04-24T15:28:41Z |
| format | Article |
| id | doaj.art-559ef9d41cee424f8a5b4647375bcfeb |
| institution | Directory Open Access Journal |
| issn | 2813-0146 |
| language | English |
| last_indexed | 2024-04-24T15:28:41Z |
| publishDate | 2024-04-01 |
| publisher | Frontiers Media S.A. |
| record_format | Article |
| series | Frontiers in Health Services |
| spelling | doaj.art-559ef9d41cee424f8a5b4647375bcfeb2024-04-02T04:59:53ZengFrontiers Media S.A.Frontiers in Health Services2813-01462024-04-01410.3389/frhs.2024.13378401337840Analysis of patient safety event report categories at one large academic hospitalCody Mitchell0Logan Butler1Alexa D. Holloway2Jin H. Ra3Karthik Adapa4Caprice Greenberg5Lawrence B. Marks6Lawrence B. Marks7Thomas Ivester8Lukasz Mazur9Lukasz Mazur10Division of Healthcare Engineering, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United StatesDivision of Healthcare Engineering, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United StatesDivision of Healthcare Engineering, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United StatesDivision of Acute Care Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United StatesDivision of Healthcare Engineering, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United StatesDepartment of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United StatesDepartment of Radiation Oncology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United StatesUNC Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United StatesUNC Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United StatesDivision of Healthcare Engineering, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United StatesSchool of Information and Library Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, United StatesGiven the persistent safety incidents in operating rooms (ORs) nationwide (approx. 4,000 preventable harmful surgical errors per year), there is a need to better analyze and understand reported patient safety events. This study describes the results of applying the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) supported by the Teamwork Evaluation of Non-Technical Skills (TENTS) instrument to analyze patient safety event reports at one large academic medical center. Results suggest that suboptimal behaviors stemming from poor communication, lack of situation monitoring, and inappropriate task prioritization and execution were implicated in most reported events. Our proposed methodology offers an effective way of programmatically sorting and prioritizing patient safety improvement efforts.https://www.frontiersin.org/articles/10.3389/frhs.2024.1337840/fullpatient safetysafety eventevent reportingTeamSTEPPPSoperating roomsurgical error |
| spellingShingle | Cody Mitchell Logan Butler Alexa D. Holloway Jin H. Ra Karthik Adapa Caprice Greenberg Lawrence B. Marks Lawrence B. Marks Thomas Ivester Lukasz Mazur Lukasz Mazur Analysis of patient safety event report categories at one large academic hospital Frontiers in Health Services patient safety safety event event reporting TeamSTEPPPS operating room surgical error |
| title | Analysis of patient safety event report categories at one large academic hospital |
| title_full | Analysis of patient safety event report categories at one large academic hospital |
| title_fullStr | Analysis of patient safety event report categories at one large academic hospital |
| title_full_unstemmed | Analysis of patient safety event report categories at one large academic hospital |
| title_short | Analysis of patient safety event report categories at one large academic hospital |
| title_sort | analysis of patient safety event report categories at one large academic hospital |
| topic | patient safety safety event event reporting TeamSTEPPPS operating room surgical error |
| url | https://www.frontiersin.org/articles/10.3389/frhs.2024.1337840/full |
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