A systematic proactive risk assessment of hazards in surgical wards: A quantitative study

Annals of Surgery

Volumn 255, Issue 6, 2012, Pages 1086-1092

  Anderson, Oliver ^a,b   Brodie, Andrea ^a   Vincent, Charles A ^a   Hanna, George B ^b  

^a Centre for Patient Safety and Service Quality   (United Kingdom)

^b IMPERIAL COLLEGE LONDON   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; DISEASE SEVERITY; HAZARD ASSESSMENT; HEALTH CARE AVAILABILITY; HEALTH CARE SURVEY; HEALTH HAZARD; HOSPITAL HYGIENE; HUMAN; INFECTION CONTROL; MAJOR CLINICAL STUDY; MORBIDITY; NURSING STAFF; PATIENT SAFETY; POSTOPERATIVE COMPLICATION; PRIORITY JOURNAL; QUANTITATIVE STUDY; RISK ASSESSMENT; SURGICAL WARD; VITAL SIGN;

GENERAL SURGERY; HEALTH CARE SURVEYS; HOSPITAL UNITS; HUMANS; MEDICAL ERRORS; PATIENT SAFETY; PROCESS ASSESSMENT (HEALTH CARE); RISK ASSESSMENT; ROOT CAUSE ANALYSIS;

EID: 84861339160     PISSN: 00034932     EISSN: 15281140     Source Type: Journal    
DOI: 10.1097/SLA.0b013e31824f5f36     Document Type: Article

References (37)

1. de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17:216-223.
2. Smith IJ. Failure Mode and Effects Analysis in Health Care. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2005.
3. Nagpal K, Vats A, Ahmed K, et al. A systematic quantitative assessment of risks associated with poor communication in surgical care. Arch Surg. 2010;145:582-588.
4. National Patient Safety Agency. A risk matrix for risk managers 2008. Available at: http://www.nrls.npsa.nhs.uk/resources/patient-safety-topics/risk- assessment-management. Accessed June 28, 2011.
5. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316:1154-1157. (Pubitemid 28156466)
6. DeRosier J, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. Jt Comm J Qual Improv. 2002;28:248-267, 209.
7. WHO Guidelines on Hand Hygiene in Healthcare. First Global Patient Safety Challenge Clean Care is Safer Care. Geneva, Switzerland: World Health Organization; 2009.
8. Swedberg C. RFID-based hand-hygiene system prevents health-care acquired infections [RFID JournalWeb site]. 2010. Available at: http://www.rfidjournal. com/article/view/7660/2. Accessed June 28, 2011.
9. Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect. 2009;73:305-315.
10. Pittet D, Dharan S, Touveneau S, et al. Bacterial contamination of the hands of hospital staff during routine patient care. Arch Intern Med. 1999;159:821-826. (Pubitemid 29200308)
11. Boyce J, Pittet D. Healthcare Infection control Practices Advisory Committee, HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force CDC guideline for hand hygiene in health-care settings. MMWR. 2002.
12. Collins J. Hospitals get a healthy dose of RFID [RFID JournalWeb site]. 2004. Available at: http://www.rfidjournal.com/article/view/920. Accessed June 28, 2011.
13. Hailey D, Jacobs PD, Ries NM, et al. Reuse of single use medical devices in Canada: clinical and economic outcomes, legal and ethical issues, and current hospital practice. Int J Technol Assess Health Care. 2008;24:430-436.
14. Rutala W, Weber D. Healthcare Infection Control Practices Advisory Committee (HICPAC): Guideline for disinfection and sterilization in healthcare facilities, 2008. 2008. Available at: http://www.cdc.gov/hicpac/Disinfection Sterilization/14 00ReuseMedicalDevices.html. Accessed June 28, 2011.
15. Hogan J.Why don't nurses monitor the respiratory rates of patients? Br J Nurs. 2006;15:489-492.
16. NCEPOD. An acute problem? 2005 report. Available at: http://www.ncepod. org.uk/2005report/index.html. Accessed June 28, 2011.
17. Prytherch DR, Smith GB, Schmidt P, et al. Calculating early warning scores-a classroom comparison of pen and paper and hand-held computer methods. Resuscitation. 2006;70:173-178. (Pubitemid 44219006)
18. Prytherch DR, Smith GB, Schmidt PE, et al. ViEWS-towards a national early warning score for detecting adult inpatient deterioration. Resuscitation. 2010;81:932-937.
19. Green CJ, Du-Pre P, Elahi N, et al. Omission after admission: failure in prescribed medications being given to inpatients. Clin Med. 2009;9:515-518.
20. Agrawal A, Aronson JK, Britten N, et al. Medication errors: problems and recommendations from a consensus meeting. Br J Clin Pharmacol. 2009;67:592-598.
21. Solet DJ, Norvell JM, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80:1094-1099. (Pubitemid 44366105)
22. Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34:563-570.
23. Riesenberg LA, Leisch J, Cunningham JM. Nursing handoffs: a systematic review of the literature. Am J Nurs. 2010;110:24-34; quiz 35-36.
24. Riesenberg LA, Leitzsch J,Massucci JL, et al. Residents' and attending physicians' handoffs: a systematic reviewof the literature. Acad Med. 2009;84:1775-1787.
25. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet. 2000;356:1307-1312.
26. Kampf G, Loffler H, Gastmeier P. Hand hygiene for the prevention of nosocomial infections. Dtsch Arztebl Int. 2009;106:649-655.
27. Moore G, Ali S, FitzGerald G, et al. Ward assessment of Smart Ideas Project: bringing source isolation to the patient. J Hosp Infect. 2010;76:103-107.
28. Mangini E, Segal-Maurer S, Burns J, et al. Impact of contact and droplet precautions on the incidence of hospital-acquired methicillin-resistant Staphylococcus aureus infection. Infect Control Hosp Epidemiol. 2007;28:1261-1266. (Pubitemid 47596565)
29. Cretikos MA, Bellomo R, Hillman K, et al. Respiratory rate: the neglected vital sign. Med J Aust. 2008;188:657-659.
30. McGain F, Cretikos MA, Jones D, et al. Documentation of clinical review and vital signs after major surgery. Med J Aust. 2008;189:380-383.
31. Buist MD, Jarmolowski E, Burton PR, et al. Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. A pilot study in a tertiary-care hospital. Med J Aust. 1999;171:22-25. (Pubitemid 29342243)
32. McGloin H, Adam SK, SingerM. Unexpected deaths and referrals to intensive care of patients on general wards. Are some cases potentially avoidable? J R Coll Physicians Lond. 1999;33:255-259.
33. Moon A, Cosgrove JF, Lea D, et al. An eight-year audit before and after the introduction of modified early warning score (MEWS) charts, of patients admitted to a tertiary referral intensive care unit after CPR. Resuscitation. 2011;82:150-154.
34. Virtanen M, Kurvinen T, Terho K, et al. Work hours, work stress, and collaboration among ward staff in relation to risk of hospital-associated infection among patients. Med Care. 2009;47:310-318.
35. Akbari A, Mayhew A, Al-AlawiMA, et al. Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev. 2008;(4):CD005471.
36. Amato-Vealey EJ, Barba MP, Vealey RJ. Hand-off communication: a requisite for perioperative patient safety. AORN J. 2008;88:763-770; quiz 771-774.
37. Shebl NA, Franklin BD, Barber N. Is failure mode and effect analysis reliable? J Patient Saf. 2009;5:86-94.