TPSC Blog

Why do we not learn from incidents

Posted by Bianca Beentjes on June 8 2017

We try to prevent incidents or calamities by estimating prospective risks. In the case of an adverse event or a near miss, it is important to determine retroactively how an incident of this nature took shape. Various analysis methodologies can be used to facilitate this process, such as the PRISMA and RCA methodology. Everybody can benefit from this kind of incident analysis so that it can be prevented in the future. Yet this is exactly where it often goes wrong…

This blog describes the 3 crucial situations in which learning from incidents can go wrong. Next, the blog shows how to recognise the signals and how to pick them up. 

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Topics: Incident Management

Every mistake is an opportunity to improve healthcare

Posted by Bianca Beentjes on April 11 2017

Systematic incident analysis and classification is a prerequisite to improving healthcare. There are various methodologies available to achieve this objective. One of these methods is the PRISMA methodology. 

This blog describes the characteristics and benefits of incident analysis by using the PRISMA methodology. 

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Topics: Incident Management

Calamity disclosure as a healthcare discussion issue

Posted by Bianca Beentjes on March 28 2017

Did you know that a patient in the midst of a cardiac catheterisation process can be seen by as many as 99 care professionals while in hospital? This considerably increases the risk of incidents, or even worse, calamities.

It is important to report incidents large and small to learn how they originate. Not so much with the intention of pointing the finger (blaming and shaming), but to learn from the incident and prevent it happening again.

This blog describes what is needed to learn from incidents and calamities and how calamitiy and incident disclosure can contribute to healthcare improvement.

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Topics: Incident Management

A cost-effective solution for quality management in nursing homes

Posted by Bianca Beentjes on February 16 2017

There is a tremendous focus on quality and patient safety within hospitals. But if you look at other healthcare institutions such as nursing homes, it is a different story. Naturally nursing homes also want to deliver the very best care for their clients. But they are often more limited because of the lack of laws and funding. Even though nursing homes already made huge strides forward in patient safety, there is still a lot of room for improvement.

This blogs shows how small healthcare providers can afford a sophisticated Quality and Risk Management System and start improving their patient care today!

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The pitfalls of quality registrations on paper or spreadsheets

Posted by Bianca Beentjes on February 2 2017

In our previous blog, we discussed the top 5 quality issues nursing homes are dealing with. One of these issues is that many of them still rely on paper or spreadsheets to register incidents.

Despite the digital age we live in, we see this by many relatively small healthcare providers. Registering quality issues on paper or spreadsheets comes with many disadvantages. Much money, time and effort can be saved by using an online quality and risk management solution.

In this blog, we first describe the disadvantages of quality registrations on paper or spreadsheets. Next we describe the advantages of an online quality and risk management system. We understand that most small healthcare providers do not have the resources to afford and maintain a proper online system. But for that we found a unique solution! 

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Topics: Quality registrations

Top 5 quality issues in nursing homes

Posted by Bianca Beentjes on January 5 2017

The number of older people who are no longer able to look after themselves in developing countries is forecast to quadruple by 2050. Many of the very old lose their ability to live independently and require some form of assisted living. The need for long-term care, including nursing homes, is rising.

Only in Canada there are currently more than 1.360 nursing homes, providing care for approximately 143.000 Canadians. Many of the bigger challenges within nursing homes are quality related. For example, fall incidents, which is a major safety concern for nursing facilities.

Statistics show that a typical 100 beds facility reports up to 200 fall incidents a year. In reality this number is much higher because a lot of fall incidents goes unreported. Up to 20% of the falls result in serious injuries, and sometimes even death. According to the WHO an estimated of 422.000 individuals die from falls globally each year!

The financial costs from fall-related injuries are substantial. Falls were the leading cause of overall injury costs in Canada in 2010, accounting for $8.7 billion. When Canadians aged 85 and over, the per capita costs rise significantly to $1,885.

This blog describes 5 common issues nursing homes have to deal with in order to properly organize quality management. Thereby we provide a practical solution to these challenges, based on a case study of the New Brunswick nursing homes.

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Topics: Nursing homes, Quality issues

Always Events: Make the Patient the Focus

Posted by Bianca Beentjes on November 22 2016

Always Events, developed in the United States by the Picker Institute and currently directed by the Institute for Healthcare Improvement (IHI), is defined by the aspects of care that always should be completed when patients, their family members, and partners come into contact with healthcare professionals and the healthcare institution.

Always Events focus on patient care aspects which are considered important enough by the patient and their family that care providers should always handle them well.

This blog describes what Always Events implies, how to recognize it, how to create it and how it compares to a Just Culture.

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Topics: Patient Safety

The essence of communication in patient safety

Posted by Bianca Beentjes on October 18 2016

In a study from the Joint Commission International (JCI), an American health organisation that provides hospitals with quality and safety certifications, it was determined that 67 percent of medical errors were the result of miscommunication.

How can we prevent miscommunication? What is the role of communication in the learning culture of an organization? And how does communication contribute to a Just Culture?

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Topics: Patient Safety, Culture, Communication

Just Culture: addressing errors in medical care

Posted by Bianca Beentjes on September 27 2016

“The essence of Just Culture lies in that people do not judge based on the result, but based on the behaviour preceding that result. People are inclined to consider the seriousness of the outcome when judging the person who cause the outcome. Driving through a red light is punished more severely if you run someone over”.

Dr. Ian Leistikow
Doctor, senior consultant at the Dutch Health Inspectorate, and member of the advisory commission of the International Forum on Quality and Safety in Healthcare.

In the year 2016, safety is associated with concepts such as ‘strict’ and ‘no nonsense’.  In a Just Culture, the core concepts regarding safety are verifiability and vulnerability. This blog describes two models that explain how to handle human errors in a manner that is in line with a just culture.

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Topics: human error, Culture

Human error: Retributive culture versus Just Culture

Posted by Bianca Beentjes on September 15 2016

From a black-and-white perspective, there are two cultures that can be distinguished with regard to their approach towards ‘human error’ within an organisation. On one side you have a retributive culture, based on rules, breaking these rules, and how that is punished. On the other side you have a restorative culture, a Just Culture. In a restorative culture, openly and honestly sharing mistakes made comes first and foremost.

In this blog post we describe how these two cultures handle human error. What are the consequences of a retributive culture? And what are the conditions to realise a Just Culture? 

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Topics: Culture