Bad stars or guiding lights? Learning from disasters to improve patient safety

C Hughes1, J F Travaglia, J Braithwaite

  • 1Centre for Clinical Governance Research in Health, Institute of Health Innovation, Faculty of Medicine, University of New South Wales, 10 Arthur Street, Randwick, NSW 2052, Australia.

Abstract

Related Concept Videos

Healthcare Associated Infections II: Preventive Measures01:22

Healthcare Associated Infections II: Preventive Measures

Essential infection prevention measures are based on the knowledge of the infection chain, the modes of transmission in healthcare settings, and the use of the best practices in all healthcare settings. Compulsory public reporting of healthcare-associated infection rates is needed to allow individuals and the community to make informed choices regarding selecting a healthcare facility.
The best practices for preventing healthcare-associated infections include hand hygiene, patient risk...
Obedience01:08

Obedience

According to obedience research, we may harm others under the forceful pressures of an authority figure (Milgram, 1974). How about if the inappropriate orders were delivered with less force? The increasing interdependence between nurses and physicians compelled Hofling and his colleagues to explore nurses’ reactions to a potentially harmful medical request made by the perceived authority figure, the doctor (Hofling, Brotzman, Dalrymple, Graves, & Pierce, 1966). In this situation, obedience...
SBAR I: Understanding the Concept01:29

SBAR I: Understanding the Concept

Effective communication among healthcare professionals during hand-off reporting is essential to delivering safe and continuous patient care. Common professional interactions include reports to healthcare team members, hand-off, and transfer reports. Nurses routinely report information to other healthcare team members and also urgently contact healthcare providers to report changes in patient status.
Standardized methods of communication have been developed to ensure that information is...
Guidelines and Strategies for Safe Computer Charting01:18

Guidelines and Strategies for Safe Computer Charting

The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ensuring safe and secure computer charting systems in healthcare settings. Let's break down each recommendation:
Maintain Confidentiality and Security:
Patient-centered Care01:13

Patient-centered Care

Patient-centered care involves delivering care beyond inpatient hospitalization. Reflective practice can enhance a patient-centered approach. Reflective practice is a process of reasoning that considers all aspects of the present situation, including practicalities, learning from personal practice, and consideration of patient needs. Patients appreciate care decisions made while considering their input. Involving the patient in their care provides the patient with a sense of contribution rather...
Accountability and Responsibility of a Nurse I01:30

Accountability and Responsibility of a Nurse I

Accountability in nursing is a fundamental principle that underscores the obligation of nurses to take responsibility for their actions and answer for any errors or omissions in patient care. This principle is grounded in the professional, legal, and ethical frameworks that shape nursing practice. For instance, nurses must adhere to all relevant laws, regulations, and practice standards, including guidelines set forth by nursing boards and professional bodies, to ensure their actions comply...