Safety Huddle: Optimize the risk management process
We know that the Safety Culture is an important pillar in the structural component of the services, which encourages the implementation of safe practices and decreases incidents and adverse events. The term “safety culture” was first used by the International
Disclosure: what is the role of top management in reporting adverse events?
When developing and implementing a disclosure policy or process, it must be understood that each patient and each patient's safety incident are unique. Thus, the disclosure process requires flexibility to ensure it is effective and meets the information needs of
Disclosure: How to report incidents and adverse events to patients and family members
In aiming to achieve a culture of safety, clear, effective, open communication is necessary between healthcare services and patients. Patients have the right to access information on the state of their health and the risks inherent to the care provided. When
Find out more about the WHO Global Patient Safety | Action Plan 2021-2030
1. Background of the WHO’s approach to the topic of “patient safety” In May 2002, the 55th World Health Assembly encouraged member states to be aware of the problem of patient safety, establishing and strengthening the evidence-based systems necessary for improving
How to select tools for investigating adverse events
Much has been said on the topic of the most suitable tools for investigating adverse events in healthcare organizations. A study published in the journal of the School of Nursing of Universidade de São Paulo indicated some pointers that will
Categorizing intervention strength
Full, robust investigation of incidents has several important stages, such as using the WHO conceptual framework, setting up a specialist team, quality tools used in root cause analysis, among others. However, every investigative process results in one, very important stage, which
Are the Root Cause recommendations effective and sustainable?
An observational study Aim of the study To analyze the proportion of sustainability of the Root Cause Analyses (RCA) recommendations based on sentinel events notified in the Australian healthcare system. Results and Discussion The research collected data over five years, from 36 hospitals. The
Root Cause Analysis
Root Cause Analysis (RCA) is a tool that has its origins in Engineering and large industries. The aeronautical and aerospace industries were the first to use it as a strategy to deal with high-risk activities. The term Root Cause Analysis indicates
What causes death in sepsis patients and how to prevent it
Sepsis is the primary individual cause of admission in Intensive Care Units in Brazil. However, it is possible to get a different impression when considering sepsis data separately. On the other hand, we must think that, behind every primary diagnosis of
How to assess ICU efficiency for sepsis patients
Sepsis is one of the main causes of admission in Intensive Care Units in Brazil. When we look at clinical diagnoses, sepsis, regardless of its source, accounts for up to 35% of ICU admissions. We should also consider that