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2023 | OriginalPaper | Hoofdstuk

16. Strategieën voor bevordering van patiëntveiligheid

Auteurs : Dr. Marieke Zegers, Dr. Gijs Hesselink, Dr. Hub Wollersheim

Uitgeverij: Bohn Stafleu van Loghum

Samenvatting

Er is van oudsher veel aandacht voor het voorkomen van schade aan patiënten door toedoen van de zorgverlening. Het meten en verbeteren van patiëntveiligheid heeft zich in de afgelopen jaren sterk ontwikkeld. Het risico op schade is hoger bepaalde patiënten, interventies, geneesmiddelen en omstandigheden. Voor het bereiken van verbetering wordt onder meer ingezet op scholing van zorgverleners, verbetering van samenwerking in teams, werkprocessen en van de organisatie van zorg. Concrete thema’s zijn bijvoorbeeld het voorkomen van ziekenhuisinfecties, decubitus en vallen. Het bewijs voor de effectiviteit van veiligheidsbevorderende interventies is over het algemeen beperkt.

vorige hoofdstuk Organisatorische implementatiestrategieën

volgende hoofdstuk Beleidsmatige implementatiestrategieën

Agency for Healthcare Research and Quality. Report. Surveys on Patient Safety Culture User Network. 2009;1:1–6.

Al-Babtain B, Cheema E, Hadi MA. Impact of community-pharmacist-led medication review programmes on patient outcomes: A systematic review and meta-analysis of randomised controlled trials. Res Social Adm Pharm. 2022;18(4):2559–68.

Alkhenizan A, Shaw C. Impact of accreditation on the quality of healthcare services: a systematic review of the literature. Ann Saudi Med. 2011;31:407.CrossRef

Benn J, Koutantji M, Wallace L, et al. Feedback from incident reporting: information and action to improve patient safety. Qual Saf Health Care. 2009;18:11–21.CrossRef

Bergs J, Hellings J, Cleemput I, et al. Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications. Br J Surg. 2014;101:150–8.CrossRef

Boet S, Bould MD, Fung L, et al. Transfer of learning and patient outcome in simulated crisis resource management: a systematic review. Can J Anaesth. 2014;61:571–82.CrossRef

Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ. Reality check for checklists. Lancet. 2009;374:444–5.CrossRef

Braithwaite J, Wears RL, Hollnagel E. Resilient health care: turning patient safety on its head. Int J Qual Health Care. 2015;27(5):418–20.CrossRef

Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results from the Harvard medical practice study I. N Engl J Med. 1991;324:370–6.CrossRef

Brubakk K, Vist GE, Bukholm G, Barach P, Tjomsland O. A systematic review of hospital accreditation: the challenges of measuring complex intervention effects. BMC Health Serv Res. 2015;15:280.CrossRef

Cameron ID, Dyer SM, Panagoda CE, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2018;(9):CD005465.

Chiozza ML, Ponzetti C. FMEA: a model for reducing medical errors. Clin Chim Acta. 2009;404:75–8.CrossRef

Christensen M, Lundh A. Medication review in hospitalised patients to reduce morbidity and mortality. Cochrane Database Syst Rev. 2016;(2):CD008986.

Colla JB, Bracken AC, Kinney LM, Weeks WB. Measuring patients safety climate: a review of surveys. Qual Saf Health Care. 2005;14:364–6.CrossRef

Cooperrider DL, Whitney D. A positive revolution in change: Appreciative inquiry. In: Cooperrider DL, Sorensen PF, Whitney D, Yaeger T, editors. Appreciative inquiry: rethinking human organization toward a positive theory of change. Champaign, Illinois: Stypes Publishing LLC; 2000. p. 3–28.

Czarniawska-Joerges B. Exploring Complex Organizations: a Cultural Perspective. Newbury Park (CA): Sage Publications; 1992.

Damiani E, Donati A, Serafini G, et al. Effect of performance improvement programs on compliance with sepsis bundles and mortality: a systematic review and meta-analysis of observational studies. PLoS ONE. 2015;10:e0125827.CrossRef

Davey P, Marwick CA, Scott CL, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2013;(4):CD003543.

Davies H, Nutley S, Mannion M. Organisational Culture and Quality of Health Care. Qual Health Care. 2000;9:111–9.CrossRef

De Blok C, Koster E, Schilp J, Wagner C. Implementatie VMS veiligheidsprogramma. Evaluatieonderzoek in Nederlandse ziekenhuizen. Utrecht/Amsterdan: Nivel/EMGO; 2013.

De Bruijne MC, Zegers M, Hoonhout LHF, Wagner C. Onbedoelde schade in Nederlandse ziekenhuizen. Amsterdam, Utrecht: EMGO-NIVEL; 2007.

De Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17:216–23.CrossRef

De Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363(20):1928–37.CrossRef

Dy SM, Taylor SL, Carr LH, et al. A framework for classifying patient safety practices: results from an expert consensus process. BMJ Qual Saf. 2011;20:618–24.

Erlenwein J, Koschwitz R, Pauli-Magnus D, et al. A follow-up on Acute Pain Services in Germany compared to international survey data. Eur J Pain. 2016;20:874–83.CrossRef

Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc. 2007;2:115–25.CrossRef

Flin R, Burns C, Mearns K, et al. Measuring safety climate in health care. Qual Saf Health Care. 2006;15:109–15.CrossRef

Fung L, Boet S, Bould MD, et al. Impact of crisis resource management simulation-based training for interprofessional and interdisciplinary teams: A systematic review. J Interprof Care. 2015;29:433–44.CrossRef

Gaal S, van Laarhoven E, Wolters R, et al. Patient safety in primary care has many aspects: an interview study in primary care physicians and nurses. J Eval Clin Pract. 2010a;16(3):639–43.

Gaal S, Verstappen W, Wensing M. Patient safety in primary care: a survey of general practitioners in the Netherlands. BMC Health Serv Res. 2010b;10(1):21.CrossRef

Gaal S, Verstappen W, Wolters R, Lankveld H, van Weel C, Wensing M. Prevalence and consequences of patient safety incidents in general practice in The Netherlands: a retrospective medical record review study. Implem Sci. 2011;6:37.CrossRef

Gillespie BM, Marshall A. Implementation of safety checklists in surgery: a realist synthesis of evidence. Implem Sci. 2015;10:137.CrossRef

Gould DJ, Moralejo D, Drey N, Chudleigh JH, Taljaard M. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev. 2017;(9):CD005186.

Grayson ML, Stewardson AJ, Russo PL, et al. Effects of the Australian National Hand Hygiene Initiative after 8 years on infection control practices, health-care worker education, and clinical outcomes: a longitudinal study. Lancet Infect Dis. 2018;18:1269–77.CrossRef

Hanskamp-Sebregts M, Zegers M, Boeijen W, Wollersheim H, van Gurp PJ, Westert GP. Process evaluation of the effects of patient safety auditing in hospital care (part 2). Int J Qual Health Care. 2019 Jul 1; 31(6): 433–441.

Hanskamp-Sebregts M, Zegers M, Boeijen W, et al. Effects of auditing patient safety in hospital care: design of a mixed-method evaluation. BMC Health Serv Res. 2013;13:226.

Haynes AB, Weiser TG, Berry WR, et al. Safe surgery saves lives study group: a surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491–9.CrossRef

Hesselink G, Berben S, Beune T, et al. Improving the governance of patient safety in emergency care: a systematic review of interventions. BMJ Open. 2016;6:e009837.CrossRef

Herling SF, Greve IE, Vasilevskis EE, et al. Interventions for preventing intensive care unit delirium in adults. Cochrane Database Syst Rev. 2018;(11):CD00978.

Hollnagel E. FRAM: the functional resonance analysis method. Farnham, UK: Ashgate; 2012.

Hollnagel E, Wears R, Braithwaite J. From safety I to safety II: a white paper. 2015.

Johnson TR, Tang X, Graham MJ, et al. Attitudes toward medical device use errors and the prevention of adverse events. Jt Comm J Qual Patient Saf. 2007;33:689–94.

Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158:397–403.CrossRef

Lainer M, Vögele A, Wensing M, Sönnichsen A. Improving medication safety in primary care. A review and consensus procedure by the LINNEAUS collaboration on patient safety in primary care. Eur J Gen Pract. 2015;21 Suppl:14–18.

Leape LL. Reporting of adverse events. N Engl J Med. 2002;347:1633–8.CrossRef

Leistikow IP, Den Ridder K, De Vries B, De Vries B. Patient safety. Systematic incident reconstruction and evaluation, 3th edition. Houten: Bohn Stafleu van Loghum; 2016.

Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. BMJ Qual Saf. 2004;13(suppl 1):i85–90.CrossRef

Luangasanatip N, Hongsuwan M, Limmathurotsakul D, et al. Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis. BMJ. 2015;351: h3728.CrossRef

MacDonald RD. Articles that may change your practice: crew resource management. Air Med J. 2016;35:65–6.CrossRef

Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care. 2015;19:254.CrossRef

Mann S, Marcus R, Sachs B. Lessons from the cockpit: how teamtraining can reduce errors on L&D. Contemp Obst Gyn. 2006;51:1–6.

Martinez F, Tobar C, Hill N. Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and meta-analysis of the literature. Age Ageing. 2014;44:196–204.CrossRef

McGaughey J, O’Halloran P, Porter S, Blackwood B. Early warning systems and rapid response to the deteriorating patient in hospital: A systematic realist review. J Adv Nurs. 2017;73:2877–91.CrossRef

McInnes E, Jammali-Blasi A, Bell-Syer SE, Dumville JC, Middleton V, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2015;(9);CD001735.

Meddings J, Rogers MA, Krein SL, et al. Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Qual Saf. 2014;23:277–89.CrossRef

Meissner W, Coluzzi F, Fletcher D, et al. Improving the management of post-operative acute pain: priorities for change. Curr Med Res Opin. 2015;31:2131–43.CrossRef

Meissner W, Huygen F, Neugebauer EAM, et al. Management of acute pain in the postoperative setting: the importance of quality indicators. Curr Med Res Opin. 2018;34:187–96.CrossRef

Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158:390–6.CrossRef

Mishra A, Catchpole K, McCulloch P. The Oxford NOTECHS system: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre. Qual Saf Health Care. 2009;18:104–8.CrossRef

Mohr BJ, Watkins JM. The Essentials of Appreciative inquiry: a Roadmap for Creating Positive Futures. Williston, Vt: Pegasus Communications; 2002.

Øvretveit J. Improvement leaders: what do they and should they do? A summary of a review of research. Qual Saf Health Care. 2010;19:490–2.

Parand A, Dopson S, Renz A, Vincent C. The role of hospital managers in quality and patient safety: a systematic review. BMJ Open. 2014;4:e005055.CrossRef

Prgomet M, Li L, Niazkhani Z, Georgiou A, Westbrook JI. Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis. J Am Med Inform Assoc. 2017;24:413–22.

Reason JT. Human error. Cambridge: Cambridge University Press; 1990.CrossRef

Rennke S, Nguyen OK, Shoeb MH. Hospital-initiated translational care interventions as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158:433–40.CrossRef

Reston JT, Schoelles KM. In-facility delirium prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158:375–80.CrossRef

Runciman W, Hibbert P, Thomson R, et al. Towards an international classification for patient safety: key concepts and terms. Int J Qual Health Care. 2009;21:18–26.CrossRef

Schmidt E, Goldhaber-Fiebert SN, Ho LA, et al. Simulation exercises as a patient safety strategy: a review. Ann Intern Med. 2013;158:426–32.CrossRef

Schmutz J, Manser T. Do team processes really have an effect on clinical performance? A systematic literature review. Br J Anaesth. 2013;110:529–34.CrossRef

Scott T, Mannion R, Davies H, Marshall M. The quantitative measurement of organisational culture in health care: a review of the available instruments. Health Serv Res. 2003a;38:923–45.CrossRef

Scott T, Mannion R, Marshall M, Davies H. Does organisational culture influence health care performance? A review of the evidence. J Health Serv Res. 2003b;8:105–17.CrossRef

Selvadis N, Lyons M, Healey AN, et al. Observational teamwork assessment for Surgery: construct validation with expert versus novice raters. Ann Surg. 2009;249:1047–51.CrossRef

Sexton JB, Adair KC, Leonard MW, Frankel TC, Proulx J, Watson SR. Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout. BMJ Qual Saf. 2018;27:261–70.CrossRef

Shaw KN, Lavelle JL, Crescenzo K, Noll J, Bonalumi N, Baren J. Creating unit-based patient safety walk-rounds in a pediatric emergency department. Clin Pediatr Emerg Med. 2006;7:231–7.CrossRef

Shebl NA, Franklin BD, Barber N. Is failure mode and effect analysis reliable? J Pat Saf. 2009;5:86–94.CrossRef

Siddiqi N, Harrison JK, Clegg A, et al. Interventions for preventing delirium in hospitalised non‐ICU patients. Cochrane Database Syst Rev. 2016;(3):CD005563.

Smits M. Unintended events in hospitals: causes and the role of patient safety culture. Proefschrift. Amsterdam: Vrije Universiteit; 2009.

Smits M, Janssen JCJA, De Vet HCW, et al. Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes. Int J Qual Health Care. 2009;21(4):292–300.CrossRef

Snijders C, Van der Schaaf TW, Klip H, et al. Feasibility and reliability of PRISMA-Medical for specialty-based incident analysis. Qual Saf Health Care. 2009;18:486–91.CrossRef

Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158:410–6.

Tricco AC, Thomas SM, Veroniki AA, et al. Comparisons of interventions for preventing falls in older adults: a systematic review and meta-analysis. JAMA. 2017;318:1687–99.CrossRef

Tuijn SM, Robben PB, Janssens FJ, Van den Bergh H. Evaluating instruments for regulation of health care in the Netherlands. J Eval Clin Pract. 2011;17:411–9.CrossRef

Van Gelderen SC, Zegers M, Boeijen W, et al. Evaluation of the organisation and effectiveness of internal audits to govern patient safety in hospitals: a mixed-methods study. BMJ Open. 2017;7:e015506.CrossRef

Van Schoten S, Van Eikenhorst L, Schouten B, Baartmans M, De Bruijne MC, De Jong L, Waals M, Asscheman H, Wagner C. Monitor Zorggerelateerde schade 2019: dossieronderzoek bij overleden patiënten in Nederlandse ziekenhuizen. NIVEL/APH, Utrecht/Amsterdam; 2022.

Verleysen B, Lambrechts F, Van Acker F. Building psychological capital with appreciative inquiry: Investigating the mediating role of basic psychological need satisfaction. J Appl Behav Sci. 2015;51(1):10–35.CrossRef

Verstappen W, Gaal S, Esmail A, Wensing M. Patient safety improvement programs for primary care. Review of a delphi procedure and pilot studies by the LINNEAUS collaboration on patient safety in primary care. Eur J Gen Pract. 2015;21:S50–5.

Vincent C. Understanding and responding to adverse events. N Engl J Med. 2003;348:1051–6.CrossRef

Wagner C, Van der Wal G. Voor een goed begrip. Bevordering patiëntveiligheid vraagt om heldere definities. Med Contact. 2005;47:1888–90.

Wang T, Benedict N, Olsen KM, et al. Effect of critical care pharmacists intervention on medication errors: a systematic review and meta-analysis of observational studies. J Crit Care. 2015;30:1101–6.CrossRef

Wears RL, Hollnagel E, Braithwaite J. Resilient health care, volume 2: the resilience of everyday clinical work. Abingdon, Oxon: Routledge; 2015.

Weaver SJ, Lubokomski LH, Wilson RF, et al. Promoting a culture of safety as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158:369–74.CrossRef

Wells N, Pasero C, McCaffery M. Improving the quality of care through pain assessment and management. In: Hughes RG (ed.), Patient safety and quality: an evidence-based handbook for nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008.

Wilf-Miron R, Lewenhoff I, Benyamini Z, Aviram A. From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care. Qual Saf Health Care. 2003;12:35–9.CrossRef

Winters BD, Weaver SJ, Pfoh ER, et al. Rapid-response systems as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158:417–25.CrossRef

World Alliance for Patient Safety. The research priority setting working group. Summary of the evidence on patient safety: implications for research. Geneva: WHO; 2008.

World Health Organization Alliance for Patient Safety. The conceptual framework of an international patient safety event classification: executive summary. Geneva: WHO; 2009.

Zegers M, De Bruijne MC, Wagner C, et al. Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual Saf Health Care. 2009;18:297–302.CrossRef

Zegers M, Hesselink G, Geense W, Vincent C, Wollersheim H. Evidence based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews. BMJ Open. 2016 Sep 29;6(9):e012555.CrossRef

Titel: Strategieën voor bevordering van patiëntveiligheid
Auteurs: Dr. Marieke Zegers
Dr. Gijs Hesselink
Dr. Hub Wollersheim
Uitgeverij: Bohn Stafleu van Loghum
Boek: Implementatie
Print ISBN: 978-90-368-2908-3

Elektronisch ISBN: 978-90-368-2909-0

Copyright: 2023
DOI: https://doi.org/10.1007/978-90-368-2909-0_16

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