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| title | chunk | source | category | tags | date_saved | instance |
|---|---|---|---|---|---|---|
| Patient safety | 4/10 | https://en.wikipedia.org/wiki/Patient_safety | reference | science, encyclopedia | 2026-05-05T04:26:13.019610+00:00 | kb-cron |
=== Aviation safety === In the United States, two organizations contribute to one of the world's lowest aviation accident rates. Mandatory accident investigation is carried out by the National Transportation Safety Board, while the Aviation Safety Reporting System receives voluntary reports to identify deficiencies and provide data for planning improvements. The latter system is confidential and provides reports back to stakeholders without regulatory action. Similarities and contrasts have been noted between the "cultures of safety" in medicine and aviation. Pilots and medical personnel operate in complex environments, interact with technology, and are subject to fatigue, stress, danger, and loss of life and prestige as a consequence of error. Given the enviable record of aviation in accident prevention, a similar medical adverse event system would include both mandatory (for severe incidents) and voluntary non-punitive reporting, teamwork training, feedback on performance and an institutional commitment to data collection and analysis. The Patient Safety Reporting System (PSRS) is a program modeled upon the Aviation Safety Reporting System and developed by the Department of Veterans Affairs (VA) and the National Aeronautics and Space Administration (NASA) to monitor patient safety through voluntary, confidential reports. Required training in crew resource management (CRM), which focused on team dynamics both inside the cockpit and outside was introduced in the early 1980s after the tragic mishap of United Airlines 173. CRM is considered an effective means of improving safety in aviation and is utilized by the DoD, NASA, and almost all commercial airlines. Many of the tenets of this training have been incorporated into medicine under the guise of Team Stepps, which was introduced by the Agency for Healthcare Research and Quality (AHRQ). The AHRQ calls this program "an evidence-based teamwork system to improve communication and teamwork skills among health care professionals."
=== Near-miss reporting === A near miss is an unplanned event that did not result in injury, illness, or damage - but had the potential to do so. Reporting of near misses by observers is an established error reduction technique in aviation, and has been extended to private industry, traffic safety, and fire-rescue services with reductions in accidents and injury. AORN, a US-based professional organization of perioperative registered nurses, has put in effect a voluntary near-miss reporting system (SafetyNet), covering medication or transfusion reactions, communication or consent issues, wrong patient or procedures, communication breakdown or technology malfunctions. An analysis of incidents allows safety alerts to be issued to AORN members. AlmostME is another commercially offered solution for near miss reporting in healthcare.
=== Limits of the Industrial Safety Model === Unintended consequences may occur as improvements in safety are undertaken. It may not be possible to attain maximum safety goals in healthcare without adversely affecting patient care in other ways. An example is blood transfusion; in recent years, to reduce the risk of transmissible infection in the blood supply, donors with only a small probability of infection have been excluded. The result has been a critical shortage of blood for other lifesaving purposes, with a broad impact on patient care. Application of high-reliability theory and normal accident theory can help predict the organizational consequences of implementing safety measures.
== Technology in healthcare ==
=== Overview === According to a study by RAND Health, the U.S. healthcare system could save more than $81 billion annually, reduce adverse healthcare events, and improve the quality of care if health information technology (HIT) is widely adopted. The most immediate barrier to widespread adoption of technology is cost despite the patient benefit from better health, and payer benefit from lower costs. However, hospitals pay both higher costs for implementation and potentially lower revenues (depending on reimbursement scheme) due to reduced patient length of stay. The benefits provided by technological innovations also give rise to serious issues with the introduction of new and previously unseen error types.
=== Types of healthcare technology === Handwritten reports or notes, manual order entry, non-standard abbreviations, and poor legibility lead to substantial errors and injuries, according to the IOM (2000) report. The follow-up IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century, advised rapid adoption of electronic patient records, and electronic medication ordering, with computer- and internet-based information systems to support clinical decisions. This section contains only the patient safety related aspects of HIT.
=== Electronic health record (EHR) === The electronic health record (EHR), previously known as the electronic medical record (EMR), reduces several types of errors, including those related to prescription drugs, emergency and preventive care, and to tests and procedures. Important features of modern EHR include automated drug-drug/drug-food interaction checks and allergy checks, standard drug dosages and patient education information. Drug Information at the point-of-care and drug dispensing points helps in reducing errors. Example: India, MedCLIK. Also, these systems provide recurring alerts to remind clinicians of intervals for preventive care and to track referrals and test results. Clinical guidelines for disease management have a demonstrated benefit when accessible within the electronic record during the process of treating the patient. Advances in health informatics and widespread adoption of interoperable electronic health records promise access to a patient's records at any health care site. Still, there may be a weak link because of physicians' deficiencies in understanding the patient safety features of e.g. government-approved software. Errors associated with patient misidentification may be exacerbated by EHR use, but inclusion of a prominently displayed patient photograph in the EHR can reduce errors and near misses. Portable offline emergency medical record devices have been developed to provide access to health records during widespread or extended infrastructure failure, such as in natural disasters or regional conflicts.
=== Active RFID platform === These systems' basic security measures are based on sound identifying electronic tags to ensure that the patient details provided in different situations are always reliable. These systems offer three differently qualified options: