Effect of a two-year national quality improvement program on surgical checklist implementation.

Use of the surgical checklist in Switzerland is still incomplete and unsatisfactory. A national improvement program was developed and conducted in Switzerland to implement and improve the use of the surgical safety checklists. The aims of the implementation program were to implement comprehensive and correct checklist use in participating hospitals in every patient and in every surgical procedure; and to improve safety climate and teamwork as important cultural context variables. 10 hospitals were selected for participation in the implementation program. A questionnaire assessing use, knowledge, and attitudes towards the checklist and the Safety Climate Survey were conducted at two measurement occasions each in October/November 2013 and January/February 2015. Significant increases emerged for frequency of checklist use (F(1,1001)=340.9, p<0.001), satisfaction (F(1,1232)=25.6, p<0.001), and knowledge(F(1,1294)=184.5, p<0.001). While significant differences in norms (F(1,1284)=17.9, p<0.001) and intentions (F(1,1284)=7.8, p<0.01) were observed, this was not the case for attitudes (F(1,1283)=.8, n.s.) and acceptance (F(1,1284)=0.1, n.s.). Significant differences for safety climate and teamwork emerged in the present study (F(1,3555)=11.8, p<0.001 and F(1,3554)=24.6, p<0.001, respectively). However, although statistical significance was reached, effects are very small and practical relevance is thus questionable. The results of the present study suggest that the quality improvement program conducted by the Swiss Patient Safety Foundation in 10 hospitals led to successful checklist implementation. The strongest effects were seen in aspects concerning behaviour and knowledge specifically related to checklist use. Less impact was achieved on general cultural variables safety climate and teamwork. However, as a trend was observable, these variables may simply need more time in order to change substantially

Neutral tritium gas reduction in the KATRIN differential pumping sections

The KArlsruhe TRItium Neutrino experiment (KATRIN) aims to measure the effective electron anti-neutrino mass with an unprecedented sensitivity of $0.2\,\mathrm{eV}/\mathrm{c}^2$, using $\beta$-electrons from tritium decay. The electrons are guided magnetically by a system of superconducting magnets through a vacuum beamline from the windowless gaseous tritium source through differential and cryogenic pumping sections to a high resolution spectrometer and a segmented silicon pin detector. At the same time tritium gas has to be prevented from entering the spectrometer. Therefore, the pumping sections have to reduce the tritium flow by more than 14 orders of magnitude. This paper describes the measurement of the reduction factor of the differential pumping section performed with high purity tritium gas during the first measurement campaigns of the KATRIN experiment. The reduction factor results are compared with previously performed simulations, as well as the stringent requirements of the KATRIN experiment.Comment: 19 pages, 4 figures, submitted to Vacuu

Communication barriers in counselling foreign-language patients in public pharmacies: threats to patient safety?

Foreign-language (FL) patients are at increased risk for adverse drug events. Evidence regarding communication barriers and the safety of pharmaceutical care of FL patients in European countries is scarce despite large migrant populations

Mean ratings of potential of patient harm, discomfort to speak up, decision difficulty and likelihood of speaking up for the four clinical frames by managerial function of respondent.

<p>Mean ratings of potential of patient harm, discomfort to speak up, decision difficulty and likelihood of speaking up for the four clinical frames by managerial function of respondent.</p

Example vignette.

<p>Example vignette.</p

Results of multiple regression analysis with reported likelihood of speaking up as outcome.

<p>Results of multiple regression analysis with reported likelihood of speaking up as outcome.</p

Characteristics of survey responders (n = 1013).

<p>Characteristics of survey responders (n = 1013).</p

Mean ratings of harm, discomfort, decision difficulty and likelihood of speaking up across vignettes, by clinical frame.

<p>N = 1013 participants; n = 4052 vignette evaluations;</p>#<p>higher values indicate higher levels of potential for patient harm, feeling less comfortable to speak up, higher decision difficulty, and higher likelihood of speaking up.</p><p>*responders with rating >4; ⁺mean across the 8 vignettes within each frame.</p

Threats to patient safety in the primary care office: concerns of physicians and nurses

Little is known about primary care professionals' concerns about risks to patient safety