Hospital Quality Systems: unraveling working mechanisms

Wagner, C. [Promotor]Groenewegen, P.P. [Promotor

What Can We Learn from In-Depth Analysis of Human Errors Resulting in Diagnostic Errors in the Emergency Department:An Analysis of Serious Adverse Event Reports

Introduction Human error plays a vital role in diagnostic errors in the emergency department. A thorough analysis of these human errors, using information-rich reports of serious adverse events (SAEs), could help to better study and understand the causes of these errors and formulate more specific recommendations. Methods We studied 23 SAE reports of diagnostic events in emergency departments of Dutch general hospitals and identified human errors. Two researchers independently applied the Safer Dx Instrument, Diagnostic Error Evaluation and Research Taxonomy, and the Model of Unsafe acts to analyze reports. Results Twenty-one reports contained a diagnostic error, in which we identified 73 human errors, which were mainly based on intended actions (n=69) and could be classified as mistakes (n=56) or violations (n=13). Most human errors occurred during the assessment and testing phase of the diagnostic process. Discussion The combination of different instruments and information-rich SAE reports allowed for a deeper understanding of the mechanisms underlying diagnostic error. Results indicated that errors occurred most often during the assessment and the testing phase of the diagnostic process. Most often, the errors could be classified as mistakes and violations, both intended actions. These types of errors are in need of different recommendations for improvement, as mistakes are often knowledge based, whereas violations often happen because of work and time pressure. These analyses provided valuable insights for more overarching recommendations to improve diagnostic safety and would be recommended to use in future research and analysis of (serious) adverse events

Compliance with a time-out procedure intended to prevent wrong surgery in hospitals:results of a national patient safety programme in the Netherlands

OBJECTIVE: To prevent wrong surgery, the WHO 'Safe Surgery Checklist' was introduced in 2008. The checklist comprises a time-out procedure (TOP): the final step before the start of the surgical procedure where the patient, surgical procedure and side/site are reviewed by the surgical team. The aim of this study is to evaluate the extent to which hospitals carry out the TOP before anaesthesia in the operating room, whether compliance has changed over time, and to determine factors that are associated with compliance.DESIGN: Evaluation study involving observations.SETTING: Operating rooms of 2 academic, 4 teaching and 12 general Dutch hospitals.PARTICIPANTS: A random selection was made from all adult patients scheduled for elective surgery on the day of the observation, preferably involving different surgeons and different procedures.RESULTS: Mean compliance with the TOP was 71.3%. Large differences between hospitals were observed. No linear trend was found in compliance during the study period. Compliance at general and teaching hospitals was higher than at academic hospitals. Compliance decreased with the age of the patient, general surgery showed lower compliance in comparison with other specialties and compliance was higher when the team was focused on the TOP.CONCLUSIONS: Large differences in compliance with the TOP were observed between participating hospitals which can be attributed at least in part to the type of hospital, surgical specialty and patient characteristics. Hospitals do not comply consistently with national guidelines to prevent wrong surgery and further implementation as well as further research into non-compliance is needed.</p

Control van financiële derivaten, een empirisch onderzoek in Nederland

Control van financiële derivaten, een empirisch onderzoek in Nederlan

MDW-accountancy: aanbe­ velingen en uitgangspunten in perspectief geplaatst

MDW-accountancy: aanbe­ velingen en uitgangspunten in perspectief geplaats

Monitor Patiëntveiligheid 2019-2022. Vijf onderzoeksprojecten naar patiëntveiligheid in Nederlandse ziekenhuizen.

De onderzoeksgroep Patiëntveiligheid van het Nivel en APH start eind 2019 met vijf nieuwe studies: vier verdiepingsstudies en de vijfde landelijke meting naar potentieel vermijdbare schade en sterfte in ziekenhuizen (als vervolg op die van 2015-2016). In deze folder een overzicht van de vijf projecten en de bijbehorende planningen