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Säker Vårdpatientskador, rapporteringoch prevention
Nordic Council of Ministers, Nordic School of Public Health NHV.
2006 (Swedish)Doctoral thesis, comprehensive summary (Other academic)
Abstract [sv]

Syfte. Avhandlingen syftar till att bidra med ökad kunskap om faktorer som kan antas påverka patientsäkerheten dels på system-, dels på individnivå. Metod.Det nationella rapporteringssystemet Lex Maria analyserades före och efter Socialstyrelsens regionalisering av tillsynsorganisationen 1990/91. I en av de två studierna analyserades särskilt ärenden som överförts till HSAN för prövning av disciplinär påföljd. I tre empiriska studier analyserades kompletterande metoder till rapportering för att få information om risker i hälso- och sjukvården. Personal har intervjuats om deras uppfattning av potentiella risker som skulle kunna hota patienternas säkerhet. Vårdbiträdens och undersköterskors kunskaper om diabetes undersöktes i en enkätstudie. Eventuella samband mellan vårdbiträdens och undersköterskors kunskapsnivå och medicinskt ansvariga sjuksköterskors uppfattning om säkerhetsrelaterade frågor undersöktes i en uppföljande enkätstudie. I en kvalitativ studie undersöktes flygets metoder för säkerhetsrelaterat arbete vilket jämfördes med motsvarande arbete inom hälso- och sjukvården. Resultat.Lex Maria-rapporteringen ökade efter regionaliseringen av tillsyns-verksamheten och en minskad andel ärenden överfördes till HSAN för disciplinär prövning. De kompletterande metoder för att identifiera risker som undersökts visade sig vara värdefulla tillägg till traditionell rapportering. Intervjuerna inom barnsjukvården uppvisade en annan riskbild än den som fås genom rapporteringssystemet Lex Maria. Enkäten till vårdbiträden och undersköterskor visade ett tydligt samband mellan bristande kunskap om diabetes och en ökad risk att vidta en riskfylld åtgärd. Studien indikerade brister på systemnivå, vilket bekräftades av resultaten från enkätstudien till medicinskt ansvariga sjuksköterskor i motsvarande kommuner. Studien visade på behovet av ökad uppmärksamhet på hur sjukvårdens stödsystem påverkar yrkesutövarna i frontlinjen. Jämförelsen mellan flyget och hälso- och sjukvården visade att flyget hade ett mera proaktivt och bredare förhållningssätt till säkerhet än vad hälso- och sjukvården uppvisade. Slutsatser. Studien har visat att yrkesutövare som befinner sig i frontlinjen och möter den enskilde vårdtagaren är särskilt sårbara när hälso- och sjukvårdens stödsystem uppvisar brister. Förebyggande säkerhetsanalyser som komplement till rapportering visade sig ge värdefull information för det förebyggande säkerhetsarbetet. En sammanhållen strategi baserad på aktuell säkerhetsforskning kan bidra till att utveckla hälso- och sjukvårdens säkerhetsarbete. Nyckelord: Patientsäkerhet, rapportering, prevention, händelseanalys, säkerhetsanalys, Lex Maria, ansvarsärenden, disciplinära åtgärder

Place, publisher, year, edition, pages
Göteborg: Nordic School of Public Health NHV Göteborg, Sweden , 2006. , 83 p.
Series
NHV Reports and Doctor of Public Health-Theses, ISSN 0283-1961 ; Report 2006:1
Keyword [sv]
Patientsäkerhet, Rapportering, Prevention, Händelseanalys, Säkerhetsanalys, Lex Maria, Ansvarsärenden, Disciplinära Åtgärder
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:norden:org:diva-3408ISBN: 91-7997-131-8 (print)OAI: oai:DiVA.org:norden-3408DiVA: diva2:748278
Public defence
2006-04-19, Nordic School of Public Health NHV, Göteborg, Sweden, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2014-09-18 Created: 2014-09-18 Last updated: 2014-09-18Bibliographically approved
List of papers
1. Insulin treatment as a tracer for identifying latent patient safety risks in home-based diabetes care.
Open this publication in new window or tab >>Insulin treatment as a tracer for identifying latent patient safety risks in home-based diabetes care.
2006 (English)In: Journal of Nursing Management, ISSN 0966-0429, E-ISSN 1365-2834, Vol. 14, no 2, 116-27 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To explore whether attitudes and opinions in areas of importance to patient safety expressed by nurses with medical responsibility were related to the knowledge of diabetes among home care personnel.

DESIGN: A questionnaire survey was used to evaluate the knowledge of diabetes among 3144 nurses' aides' and assistant nurses working in 15 municipalities in Sweden. In each municipality a nurse with medical responsibility answered another questionnaire dealing with patient safety matters in general and diabetes in particular.

RESULTS: There were large differences in the knowledge of diabetes among home care personnel on the municipality level. Attitudes and opinions of the nurses with medical responsibility in the areas of leadership, guidance and continuing education were significantly related to the knowledge of diabetes among nurses' aides' and assistant nurses.

CONCLUSIONS: Our study shows that factors that are related to attitudes and opinions about patient safety among nurses with medical responsibility can increase the risk of home care personnel to make mistakes in the direct care of patients with diabetes.

Keyword
Home-Based Care, Insuffient Knowledge, Latent Conditions, Medical Error, Patient Safety
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:norden:org:diva-3407 (URN)10.1111/j.1365-2934.2006.00543.x (DOI)16487423 (PubMedID)
Available from: 2014-09-18 Created: 2014-09-18 Last updated: 2014-09-18Bibliographically approved
2. From punishment to prevention: Medical errors reported in Sweden in 1989 and 1993
Open this publication in new window or tab >>From punishment to prevention: Medical errors reported in Sweden in 1989 and 1993
1999 (English)In: Safety Science Monitor, ISSN 1443-8844, Vol. 3Article in journal (Refereed) Published
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:norden:org:diva-3402 (URN)
Available from: 2014-09-18 Created: 2014-09-18 Last updated: 2014-09-18Bibliographically approved
3. Safety management in civil aviation: a useful method for improved safety in medical care?
Open this publication in new window or tab >>Safety management in civil aviation: a useful method for improved safety in medical care?
2000 (English)In: Safety Science Monitor, ISSN 1443-8844, Vol. 4, no 1, 1-12 p.Article in journal (Refereed) Published
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:norden:org:diva-3404 (URN)
Available from: 2014-09-18 Created: 2014-09-18 Last updated: 2014-09-18Bibliographically approved
4. Knowledge of diabetes among personnel in home-based care: how does it relate to medical mishaps?
Open this publication in new window or tab >>Knowledge of diabetes among personnel in home-based care: how does it relate to medical mishaps?
2001 (English)In: Journal of Nursing Management, ISSN 0966-0429, E-ISSN 1365-2834, Vol. 9, no 2, 107-14 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To assess the influence of knowledge about diabetes on the performance of diabetes care for the elderly involving insulin treatment, with special attention to aspects of patient safety in home care.

DESIGN: A questionnaire was administered to nurse's aides and assistant nurses (n = 3144). Answers to questions about knowledge of diabetes were related to "relevant" or "risky measures" as judged from a hypothetical diabetes case. A 94% response rate was obtained. The study took place in January 1997 in 15 of Sweden's 289 municipalities.

RESULTS: Insufficient theoretical knowledge about how the blood sugar is related to an insulin reaction led to an almost threefold increased risk of taking a "risky measure". Insufficient knowledge about reasons for an insulin reaction also resulted in a higher risk, as was the case for personnel working in home based care in contrast to those working solely in Institutional care. In addition, the risk that a nurse's aide would take a "risky measure" was higher than that for an assistant nurse. This may indicate that the basic theoretical knowledge of nurse's aides is inadequate.

CONCLUSION: Deficiencies in basic knowledge of diabetes among nurse's aides and assistant nurses constitute a major cause of potentially serious mishaps in home care of elderly diabetic patients treated with insulin.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:norden:org:diva-3406 (URN)11879453 (PubMedID)
Available from: 2014-09-18 Created: 2014-09-18 Last updated: 2014-09-18Bibliographically approved
5. Reporting system, disciplinary measures and patient safety: a Swedish study
Open this publication in new window or tab >>Reporting system, disciplinary measures and patient safety: a Swedish study
2006 (English)Article in journal (Refereed) Published
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:norden:org:diva-3403 (URN)
Available from: 2014-09-18 Created: 2014-09-18 Last updated: 2015-02-03Bibliographically approved
6. Perceived potential risk factors in child care.
Open this publication in new window or tab >>Perceived potential risk factors in child care.
2004 (English)In: Journal of Health Organisation & Management, ISSN 1477-7266, E-ISSN 1758-7247, Vol. 18, no 1, 38-52 p.Article in journal (Refereed) Published
Abstract [en]

This study is based on semi-structured interviews focusing on staff members' opinions about potential risk factors that could threaten patient safety. The aim was to acquire more in-depth knowledge about the causes of patient injuries. The study, which was conducted at a children's hospital, has a qualitative approach that is influenced by the critical incident technique. A total of 28 persons were interviewed. Analysis of the data resulted in five qualitatively differentiated categories of potential risk factors: a large influx of patients, a lack of professional experience, a lack of inter-professional communication and cooperation, and deficiencies related to work hours and to the physical environment. The results reflect a complex picture where the risks, as described by the informants, can either alone or in concert directly or indirectly affect the individual in the practice of his or her profession or contribute to a mistake.

Keyword
Patient Care, Children, Health and Safety, Risk Assessment
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:norden:org:diva-3405 (URN)10.1108/14777260410532056 (DOI)15133883 (PubMedID)
Available from: 2014-09-18 Created: 2014-09-18 Last updated: 2014-09-18Bibliographically approved

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