SUMMARY OF THE EVIDENCE ON PATIENT SAFETY: IMPLICATIONS FOR RESEARCH
The Research Priority Setting Working Group of the World
World Health Organization 2008
Available online PDF file [136p.] at:
‘…..This publication of the World Health Organization aims to outline the future direction of patient safety research across the globe.
Patient safety research does not have the benefit of the well-established approaches available to other fields of medical study. Multiple hurdles and challenges will need to be faced when designing trials, conducting audits and making use of novel techniques, such as those that directly involve the patient as a partner in risk identification and problem resolution. This is partly related to the fact that patient safety research is a new field of study and that traditional research methods may therefore need to be suitably adapted.
We must develop a better understanding of adverse events in health care: their causes, how they are reported, how to learn from them and prevent them. Setting nationally and internationally recognized research priorities enables the selection of areas for research that are not only important for individual countries, but also allow collaboration and sharing of findings across geographical borders.
This publication outlines the areas that the World Alliance for Patient Safety recommends for urgent attention, through a rigorous consensus process by international experts. Priorities should then be set by researchers and research leaders, according to the preference of countries….” Sir Liam Donaldson
Chair, WHO World
Content:
Executive summary
Section I Background and main findings
Section II Outcomes of unsafe medical care
1 Adverse events due to drug treatment
2 Adverse events and injuries due to medical devices
3 Injuries due to surgical and anaesthesia errors
4 Health care-associated infections
5 Unsafe injection practices
6 Unsafe blood products
7 Safety of pregnant women and newborns
8 Safety of the elderly
9 Injuries due to falls in hospitals
10 Decubitus ulcers
Section III Structural factors that contribute to unsafe care
11 Organizational determinants and latent failures
12 Structural accountability: use of accreditation and regulation to ensure patient safety
13 Safety culture
14 Training, education and human resources
15 Stress and fatigue
16 Production pressure
17 Lack of appropriate knowledge and its transfer
18 Devices and procedures with no human factors
Section IV Processes that contribute to unsafe care
19 Misdiagnosis
20 Poor test follow-up
21 Counterfeit and substandard drugs
22 Inadequate measures of patient safety
23 Lack of involvement of patients in patient safety
Section V Discussion, recommendations and conclusions
References
WHO website: http://www.who.int/patientsafety/research/grants/en/index.html
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