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Berdida DJE, Grande RAN. Nurses' safety climate, quality of care, and standard precautions adherence and compliance: A cross-sectional study. J Nurs Scholarsh 2024; 56:442-454. [PMID: 38284297 DOI: 10.1111/jnu.12960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 01/08/2024] [Accepted: 01/15/2024] [Indexed: 01/30/2024]
Abstract
INTRODUCTION Investigations about the interrelationships of nurses' safety climate, quality of care, and standard precautions (SP) adherence and compliance remain particularly scarce in the literature. Thus, we tested a model of the associations between nurses' safety climate, quality of care, and the factors influencing adherence and compliance with SPs utilizing the structural equation modeling (SEM) approach. DESIGN Cross-sectional design complying with STROBE guidelines. METHODS Using convenience sampling, nurses (n = 730) from the Philippines were recruited. Data were collected between April and September 2022 using four validated self-report measures. Spearman Rho, mediation and path analyses, and SEM were employed for data analysis. RESULTS Acceptable model fit indices were shown by the emerging model. The safety climate is positively associated with quality of care and factors influencing adherence to and compliance with SPs. Quality of care directly affected factors influencing adherence to SPs. The factors influencing adherence to SPs directly affected SP compliance. Quality of care mediated between safety climate and the factors influencing adherence to SPs. Factors influencing adherence to SPs mediated between safety climate, quality of care, and SP compliance. CONCLUSIONS The study's variables are not distinct but overlapping nursing concepts that must be examined collectively. Nurse administrators can utilize the emerging model to formulate strategies and regulations for evaluating and enhancing nurses' safety climate, quality of care, and SP adherence and compliance. CLINICAL RELEVANCE Our findings may impact policymaking, organizational, and individual levels to improve nurses' clinical practice. PATIENT OR PUBLIC CONTRIBUTION This study had no patient contribution or public funding.
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Affiliation(s)
- Daniel Joseph E Berdida
- Faculty, College of Nursing, University of Santo Tomas, Manila, Philippines
- Northern College of Nursing, Arar, Northern Borders, Saudi Arabia
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Rasmussen K, Sollid SJM, Kvangarsnes M. Sky-High Safety? A Qualitative Study of Physicians' Experiences of Patient Safety in Norwegian Helicopter Emergency Services. J Patient Saf 2024; 20:1-6. [PMID: 37883061 PMCID: PMC11809709 DOI: 10.1097/pts.0000000000001172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
BACKGROUND Patients treated and transported by Helicopter Emergency Medical Services (HEMS) are prone to both flight and medical hazards, but incident reporting differs substantially between flight organizations and health care, and the extent of patient safety incidents is still unclear. METHODS A qualitative descriptive study based on in-depth interviews with 8 experienced Norwegian HEMS physicians from 4 different bases from February to July 2020 using inductive qualitative content analysis. The study objectives were to explore the physicians' experience with incident reporting and their perceived areas of risk in HEMS. RESULTS/FINDINGS The HEMS physicians stated that the limited number of formal incident reports was due to the "nature of the HEMS missions" and because reports were mainly relevant when deviating from procedures, which are sparse in HEMS. The physicians preferred informal rather than formal incident reporting systems and reporting to a colleague rather than a superior. The reasons were ease of use, better feedback, and less fear of consequences. Their perceived areas of risk were related to all the phases of a HEMS mission: the physician as the team leader, medication errors, the handover process, and the helicopter as a work platform. CONCLUSIONS The sparse, informal, and fragmented incident reporting provides a poor overview of patient safety risks in HEMS. Focusing on organizational factors and system responsibility and research on environmental and contextual factors are needed to further improve patient safety in HEMS.
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Affiliation(s)
- Kristen Rasmussen
- From the SHARE–Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger
- 2 Norwegian Air Ambulance Foundation, Oslo
- Department of Anesthesiology, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund
| | - Stephen JM Sollid
- From the SHARE–Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger
- 2 Norwegian Air Ambulance Foundation, Oslo
- Prehospital Division, Oslo University Hospital, Oslo
| | - Marit Kvangarsnes
- Department of Health Sciences in Ålesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU)
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
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Dadiz R, Bender J, Robin B. Simulation-based operations testing in new neonatal healthcare environments. Semin Perinatol 2023; 47:151828. [PMID: 37775365 DOI: 10.1016/j.semperi.2023.151828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
In situ simulations, those conducted in the actual clinical environment, confer a high level of contextual fidelity and have been applied to the operations testing of new healthcare environments (HCE) to identify potential threats to patient, family and staff safety. By conducting simulation-based operations testing, these latent safety threats (LSTs) - which are weaknesses in communications, human factors, system process and technologies, and the way they are linked together - can be identified and corrected prior to moving patients into the new HCE. Simulation-based operations testing has extended to the neonatal HCE, as neonatal intensive care units (NICUs) transition from open-bay to single-family room design. In this section, we define LSTs, review simulation-based operations testing in new neonatal and perinatal HCEs, review challenges associated with conducting simulation-based operations testing, and briefly review pre-construction simulation-based user-centered design of new HCEs.
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Affiliation(s)
- Rita Dadiz
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA.
| | - Jesse Bender
- Department of Pediatrics, Virginia Tech Carillon School of Medicine, Roanoke, VA, USA
| | - Beverley Robin
- Department of Pediatrics, Rush University Medical Center, Chicago, IL, USA
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Boet S, Burns JK, Brehaut J, Britton M, Grantcharov T, Grimshaw J, McConnell M, Posner G, Raiche I, Singh S, Trbovich P, Etherington C. Analyzing interprofessional teamwork in the operating room: An exploratory observational study using conventional and alternative approaches. J Interprof Care 2023; 37:715-724. [PMID: 36739535 DOI: 10.1080/13561820.2023.2171373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/26/2022] [Accepted: 01/07/2023] [Indexed: 02/06/2023]
Abstract
Intraoperative teamwork is vital for patient safety. Conventional tools for studying intraoperative teamwork typically rely on behaviorally anchored rating scales applied at the individual or team level, while others capture narrative information across several units of analysis. This prospective observational study characterizes teamwork using two conventional tools (Operating Theatre Team Non-Technical Skills Assessment Tool [NOTECHS]; Team Emergency Assessment Measure [TEAM]), and one alternative approach (modified-Systems Engineering Initiative for Patient Safety [SEIPS] model). We aimed to explore the advantages and disadvantages of each for providing feedback to improve teamwork practice. Fifty consecutive surgical cases at a Canadian academic hospital were recorded with the OR Black Box®, analyzed by trained raters, and summarized descriptively. Teamwork performance was consistently high within and across cases rated with NOTECHS and TEAMS. For cases analyzed with the modified-SEIPS tool, both optimal and suboptimal teamwork behaviors were identified, and team resilience was frequently observed. NOTECHS and TEAM provided summative assessments and overall pattern descriptions, while SEIPS facilitated a deeper understanding of teamwork processes. As healthcare organizations continue to prioritize teamwork improvement, SEIPS may provide valuable insights regarding teamwork behavior and the broader context influencing performance. This may ultimately enhance the development and effectiveness of multi-level teamwork interventions.
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Affiliation(s)
- Sylvain Boet
- Department of Anesthesiology & Pain Medicine, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Innovation in Medical Education, Faculty of Medicine, University of Ottawa, Ottawa, Canada
- Institut du Savoir Montfort, Montfort Hospital & Faculty of Education, University of Ottawa, Ottawa, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Joseph K Burns
- Department of Anesthesiology & Pain Medicine, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jamie Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Meghan Britton
- Main Operating Room, The Ottawa Hospital (General Campus), Ottawa, Canada
| | - Teodor Grantcharov
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Department of General Surgery, University of Toronto, Toronto, Canada
| | - Jeremy Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Meghan McConnell
- Department of Anesthesiology & Pain Medicine, University of Ottawa, Ottawa, Canada
- Department of Innovation in Medical Education, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Glenn Posner
- Department of Innovation in Medical Education, Faculty of Medicine, University of Ottawa, Ottawa, Canada
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada
| | - Isabelle Raiche
- Department of General Surgery, University of Ottawa, Ottawa, Canada
| | - Sukhbir Singh
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada
| | - Patricia Trbovich
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Cole Etherington
- Department of Anesthesiology & Pain Medicine, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
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Immonen H, Raekallio M, Holmström AR. Promoting veterinary medication safety - Exploring the competencies of community pharmacy professionals in veterinary pharmacotherapy. Vet Anim Sci 2023; 21:100310. [PMID: 37664413 PMCID: PMC10468355 DOI: 10.1016/j.vas.2023.100310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023] Open
Abstract
The science of veterinary medicine is currently lacking studies on medication safety, although its importance in protecting animals from medication errors is central. Pharmacy professionals have an important role in ensuring medication safety of both prescription and over-the-counter medications of animals. However, this requires adequate competencies of pharmacy professionals in veterinary pharmacotherapy. The present study aimed to explore the competencies of pharmaceutical staff in community pharmacies in veterinary pharmacotherapy, which factors influence these competencies and what kind of information sources they typically use on veterinary pharmacotherapy. The study was conducted as a cross-sectional online survey targeted to pharmacy professionals in the Finnish community pharmacies, providing 596 responses. Less than half of the respondents (41%, n = 246) are considered to possess good competencies in veterinary pharmacotherapy. A third of the respondents (35%, n = 211) would dispense an anti-inflammatory drug for an animal off-label, whereas 24% (n = 145) would not interview the pet owner to discover the need for internal parasite medication before dispensing the drug. A small proportion (<1%, n = 5) would have dispensed a broad-spectrum internal parasite medication. Approximately a quarter of the respondents (27%, n = 159) stated that they acquired information on pharmacotherapy only from the material produced by the manufacturers of veterinary drugs. The competencies of pharmacy professionals in veterinary pharmacotherapy need to be strengthened in many areas to better promote veterinary medication safety. It should also be ensured that pharmacy professionals can access and use independent, high-quality information on veterinary pharmacotherapy.
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Affiliation(s)
- H. Immonen
- Faculty of Pharmacy, Division of pharmacology and pharmacotherapy, University of Helsinki, Viikinkaari 5 E, 00014, Finland
| | - M.R. Raekallio
- Faculty of Veterinary Medicine, Department of Equine and Small Animal Medicine, University of Helsinki, Koetilantie 2, 00014, Finland
| | - A-R. Holmström
- Faculty of Pharmacy, Division of pharmacology and pharmacotherapy, University of Helsinki, Viikinkaari 5 E, 00014, Finland
- Faculty of Veterinary Medicine, Department of Equine and Small Animal Medicine, University of Helsinki, Koetilantie 2, 00014, Finland
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Hillen F, Henderson T, White K. A case of carrier gas confusion: Unintentional use of carbogen. Vet Anaesth Analg 2023; 50:197-198. [PMID: 36646609 DOI: 10.1016/j.vaa.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/04/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022]
Affiliation(s)
- Florence Hillen
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington, UK
| | - Tracy Henderson
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington, UK
| | - Kate White
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington, UK.
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Diamant A, Shevchenko A, Johnston D, Quereshy F. Consecutive surgeries with complications: the impact of scheduling decisions. INTERNATIONAL JOURNAL OF OPERATIONS & PRODUCTION MANAGEMENT 2023. [DOI: 10.1108/ijopm-07-2022-0460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
PurposeThe authors determine how the scheduling and sequencing of surgeries by surgeons impacts the rate of post-surgical complications and patient length-of-stay in the hospital.Design/methodology/approachLeveraging a dataset of 29,169 surgeries performed by 111 surgeons from a large hospital network in Ontario, Canada, the authors perform a matched case-control regression analysis. The empirical findings are contextualized by interviews with surgeons from the authors’ dataset.FindingsSurgical complications and longer hospital stays are more likely to occur in technically complex surgeries that follow a similarly complex surgery. The increased complication risk and length-of-hospital-stay is not mitigated by scheduling greater slack time between surgeries nor is it isolated to a few problematic surgery types, surgeons, surgical team configurations or temporal factors such as the timing of surgery within an operating day.Research limitations/implicationsThere are four major limitations: (1) the inability to access data that reveals the cognition behind the behavior of the task performer and then directly links this behavior to quality outcomes; (2) the authors’ definition of task complexity may be too simplistic; (3) the authors’ analysis is predicated on the fact that surgeons in the study are independent contractors with hospital privileges and are responsible for scheduling the patients they operate on rather than outsourcing this responsibility to a scheduler (i.e. either a software system or an administrative professional); (4) although the empirical strategy attempts to control for confounding factors and selection bias in the estimate of the treatment effects, the authors cannot rule out that an unobserved confounder may be driving the results.Practical implicationsThe study demonstrates that the scheduling and sequencing of patients can affect service quality outcomes (i.e. post-surgical complications) and investigates the effect that two operational levers have on performance. In particular, the authors find that introducing additional slack time between surgeries does not reduce the odds of back-to-back complications. This result runs counter to the traditional operations management perspective, which suggests scheduling more slack time between tasks may prevent or mitigate issues as they arise. However, the authors do find evidence suggesting that the risk of back-to-back complications may be reduced when surgical pairings are less complex and when the method involved in performing consecutive surgeries varies. Thus, interspersing procedures of different complexity levels may help to prevent poor quality outcomes.Originality/valueThe authors empirically connect choices made in scheduling work that varies in task complexity and to patient-centric health outcomes. The results have implications for achieving high-quality outcomes in settings where professionals deliver a variety of technically complex services.
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Ismail A, Khalid SNM. Patient safety culture and its determinants among healthcare professionals at a cluster hospital in Malaysia: a cross-sectional study. BMJ Open 2022; 12:e060546. [PMID: 35995542 PMCID: PMC9403112 DOI: 10.1136/bmjopen-2021-060546] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess the baseline level and mean score of every domain of patient safety culture among healthcare professionals at a cluster hospital and identify the determinants associated with patient safety culture. METHODS This cross-sectional study was conducted at a cluster hospital comprising one state and two district hospitals in Malaysia. The safety culture was assessed using the Safety Attitude Questionnaire (SAQ), which is a validated questionnaire. Using proportionate stratified random sampling, 1814 respondents were recruited, and we used the independent t-test, Pearson's χ2 test and multiple logistic regression analysis for data assessment. RESULTS Only 23.9% of the respondents had positive patient safety culture levels (SAQ score ≥75%); the overall mean score was 67.82±10.53. The job satisfaction dimension had the highest percentage of positive responses (67.0%), with a mean score of 76.54±17.77. The factors associated with positive patient safety culture were age (OR 1.03, p<0.001), gender (OR 1.67, p=0.001), education level (OR 2.51, p<0.001), work station (OR 2.02, p<0.001), participation in patient safety training (OR 1.64, p=0.007), good perception of the incident reporting system (OR 1.71, p=0.038) and a non-blaming (OR 1.36, p=0.013) and instructive (OR 3.31, p=0.007) incident reporting system. CONCLUSIONS Healthcare professionals at the cluster hospital showed unsatisfactory patient safety culture levels. Most of the respondents appreciated their jobs, despite experiencing dissatisfaction with their working conditions. The priority for changes should involve systematic interventions to focus on patient safety training, address the blame culture, improve communication, exchange information about errors and improve working conditions.
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Affiliation(s)
- Aniza Ismail
- Community Health Department, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Malaysia
| | - Siti Norhani Mazrah Khalid
- Community Health Department, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Malaysia
- Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia
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Neo HJ, Sim MA, Ti LK, Ang SBL. Evaluation of the Efficiency and Safety of a Safe Label System: A Prospective Simulation Study. J Patient Saf 2022; 18:e568-e572. [PMID: 35188941 DOI: 10.1097/pts.0000000000000875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Our study aims to investigate the safety and efficiency of the Codonics Safe Label System (SLS) in a prospective simulation study. METHODS Three sets of simulated experiments involving 82 anesthetists were carried out on patient simulator mannequins. The primary outcome assessed through the simulated experiments was the effectiveness of the SLS in avoiding vial swap errors. Secondary outcomes analyzed included the efficacy of the SLS in preventing syringe swap and the difference in time taken to prepare standardized drugs as compared with conventional methods. RESULTS The SLS was associated with a significant reduction in all 4 stages of vial swap error. The incidence of wrong ampoule breakage was significantly lower in the SLS group compared with the conventional group (12.1% versus 38.5%, P = 0.007). The number of staff who drew the wrong ampoule was similarly lower in the SLS group compared with the conventional group (4.9% versus 33.3%, P = 0.001). The proportions of staff who eventually wrongly labeled the loaded syringe were 0% in the SLS group and 17.9% in the conventional group (P = 0.005).Drug preparation time was longer for the SLS group than for the conventional group (239.6 ± 45.9 versus 160.3 ± 46.5 seconds, P < 0.001).There was no significant difference in the incidence of syringe swap with the use of the SLS. CONCLUSIONS The use of the SLS is effective in reducing vial swap error, but not syringe swap errors, and is associated with increased time taken for anesthetic drug preparation.
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Affiliation(s)
- Hong Jye Neo
- From the Department of Anaesthesia, National University Hospital
| | - Ming Ann Sim
- From the Department of Anaesthesia, National University Hospital
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Long JA, Webster CS, Holliday T, Torrie J, Weller JM. Latent Safety Threats and Countermeasures in the Operating Theater: A National In Situ Simulation-Based Observational Study. Simul Healthc 2022; 17:e38-e44. [PMID: 35104831 PMCID: PMC8812409 DOI: 10.1097/sih.0000000000000547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION In situ simulation provides a valuable opportunity to identify latent safety threats (LSTs) in real clinical environments. Using a national simulation program, we explored latent safety threats (LSTs) identified during in situ multidisciplinary simulation-based training in operating theaters in hospitals across New Zealand. METHOD Surgical simulations lasting between 15 and 45 minutes each were run as part of a team training course delivered in 21 hospitals in New Zealand. After surgical in situ simulations, instructors used a template to record identified LSTs in a postcourse report. We analyzed these reports using the contributory factors framework from the London Protocol to categorize LSTs. RESULTS Of 103 postcourse reports across 21 hospitals, 77 contained LSTs ranging across all factors in the London Protocol. Common threats included staff knowledge and skills in emergencies, team factors, factors related to task or technology, and work environment threats. Team factors were also commonly reported as protecting against adverse events, in particular, creating a shared mental model. Examples of actions taken to address threats included replacing or repairing faulty equipment, clarifying emergency processes, correcting written information, and staff training for clinical emergencies. CONCLUSIONS The pervasiveness of LSTs suggests that our results have widespread relevance to surgical departments throughout New Zealand and elsewhere and that collective solutions would be valuable. In situ simulation is an effective mechanism both for identifying threats to patient safety and to prompt initiatives for improvement, supporting the use of in situ simulation in the quality improvement cycle in healthcare.
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Eiding H, Røise O, Kongsgaard UE. Potentially Severe Incidents During Interhospital Transport of Critically Ill Patients, Frequently Occurring But Rarely Reported: A Prospective Study. J Patient Saf 2022; 18:e315-e319. [PMID: 32910036 PMCID: PMC8719502 DOI: 10.1097/pts.0000000000000769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The out-of-hospital environment can pose significant challenges to the quality and safety of interhospital transport of critically ill patients. Because we lack knowledge of the occurrence of incidents, their potential consequences, and whether they are actually reported, this study was initiated. METHODS Two different services in Norway were asked to self-report incidents after every interhospital transport of critically ill patients. Sampling lasted for 12 and 8 months, respectively. An expert group evaluated each incident for severity and demand for reporting into the hospital's electronic incident reporting system. One year later, the hospital's reporting system was scrutinized to determine the number of incidents actually reported. RESULTS A total of 455 transports of critically ill patients were performed, resulting in 294 unique incidents reported: medical (15%), technical (25%), missing equipment (17%), and personal failures and communication difficulties (42%). Only 3 (1%) of the 294 unique incidents were actually reported in the hospital's electronic incident reporting system. The experts were inconsistent in which incidents should have been reported and to what degree checklists, standard operating procedures, simulation, and training could have prevented the incidents. CONCLUSIONS This study of interhospital transports of critically ill patients reveals a very high number of incidents. Despite this fact, these incidents are severely underreported in the hospital's electronic incident reporting system. This suggests that learning is lost and errors with predominant probability are repeated. These results emphasize the existing challenges in regard to the quality and safety of interhospital transport of critically ill patients.
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Affiliation(s)
- Helge Eiding
- From the Division of Emergencies and Critical Care, Oslo University Hospital
- The Norwegian Air Ambulance Foundation
- Institute of Clinical Medicine, Medical Faculty, University of Oslo
| | - Olav Røise
- Institute of Clinical Medicine, Medical Faculty, University of Oslo
- Division of Orthopedic Surgery, Oslo University Hospital, Oslo
- Faculty of Health Sciences, SHARE—Centre for Resilience in Healthcare, University of Stavanger, Stavanger, Norway
| | - Ulf E. Kongsgaard
- From the Division of Emergencies and Critical Care, Oslo University Hospital
- Institute of Clinical Medicine, Medical Faculty, University of Oslo
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Tartaglia R, Prineas S, Poli D, Albolino S, Bellandi T, Biancofiore G, Bertolini G, Toccafondi G. Safety Analysis of 13 Suspicious Deaths in Intensive Care: Ergonomics and Forensic Approach Compared. J Patient Saf 2021; 17:e1774-e1778. [PMID: 32168278 DOI: 10.1097/pts.0000000000000666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Thirteen suspicious deaths occurred in an intensive care unit of Tuscany, Italy, in 2015. All patients developed sudden unexplained coagulopathy leading to severe bleeding. None of them had been prescribed heparin, but supertherapeutic concentrations of heparin were found. After a nurse was arrested on suspicion of murdering Human Factor and Ergonomics (HF/E) experts received a mandate to identify system failures. According to the judgment of the Court of First Instance on April 2019, the nurse was found guilty. METHODS The HF/E group used a two-pronged safety analysis: understanding the conditions in which the healthcare practitioners were working in the period when the suspicious deaths emerged and reviewing the clinical records. RESULTS Fourteen patients admitted to the intensive care unit in 2014 and 2015 were selected on the basis of markedly abnormal coagulation tests (n = 13) or a family member's complaint (n = 1). In 13 cases, a massive, abrupt hemorrhage in the presence of an unexpected abnormality of coagulation tests occurred, whereas the fourteenth patient had the only prolongation of coagulation markers without bleeding. All cases examined classified as adverse events related to a coagulation disorder. Human factor and ergonomics analysis identified a number of latent and active failures that contributed to the event and provided a set of important recommendations for safety improvement. CONCLUSIONS When presented with a manifest, albeit suspected, wrongdoing with lethal consequences for patients, forensic investigators and safety investigators have distinctly different goals and methods. We believe that a memorandum of understanding between HF/E and forensic investigative teams provides an operative framework for allowing co-existence and fosters collaboration. The pursuit of safe care as a new emerging right for patients and balancing the right to legal justice with the right to safer healthcare merit further investigation and discussion.
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Affiliation(s)
- Riccardo Tartaglia
- From the Center For Clinical Risk Management and Patient Safety, Tuscany Region
| | | | - Daniela Poli
- Thrombosis Center of Careggi University Hospital - Florence
| | - Sara Albolino
- From the Center For Clinical Risk Management and Patient Safety, Tuscany Region
| | - Tommaso Bellandi
- Tuscany Northwest Trust, Patient Safety Unit, Regional Health Service of Tuscany, Lucca
| | - Gianni Biancofiore
- Laboratory of Clinical Epidemiology, IRCCS-Mario Negri Institute, Bergamo, Italy
| | - Guido Bertolini
- Department of Transplant Anesthesia and Critical Care, University School of Medicine - Pisa, Pisa
| | - Giulio Toccafondi
- From the Center For Clinical Risk Management and Patient Safety, Tuscany Region
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Simunovic M, Grubac V, Hillis C, Yang I, Eskicioglu C, Bogach J, Kennedy E, Porter G, Fahim C, Wright J, Aziz T, Tsai S, van der Pol CB, Devereaux PJ, Baker GR. Identification and Adjudication of Adverse Events Following Rectal Cancer Surgery: Observational Case Series in a Region of Ontario, Canada. Ann Surg Oncol 2021; 29:1182-1191. [PMID: 34486089 DOI: 10.1245/s10434-021-10651-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/19/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND For patients undergoing rectal cancer surgery, we evaluated whether suboptimal preoperative surgeon evaluation of resection margins is a latent condition factor-a factor that is common, unrecognized, and may increase the risk of certain adverse events, including local tumour recurrence, positive surgical margin, nontherapeutic surgery, and in-hospital mortality. METHODS In this observational case series of patients who underwent rectal cancer surgery during 2016 in Local Health Integrated Network 4 region of Ontario (population 1.4 million), chart review and a trigger tool were used to identify patients who experienced the adverse events. An expert panel adjudicated whether each event was preventable or nonpreventable and identified potential contributing factors to adverse events. RESULTS Among 173 patients, 25 (14.5%) had an adverse event and 13 cases (7.5%) were adjudicated as preventable. Rate of surgeon awareness of preoperative margin status was low at 50% and similar among cases with and without an adverse event (p = 0.29). Suboptimal surgeon preoperative evaluation of surgical margins was adjudicated a contributing factor in all 11 preventable local recurrence, positive margin, and nontherapeutic surgery cases. Failure to rescue was judged a contributing factor in the two cases with preventable in-hospital mortality. CONCLUSIONS Suboptimal surgeon preoperative evaluation of surgical margins in rectal cancer is likely a latent condition factor. Optimizing margin evaluation may be an efficient quality improvement target.
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Affiliation(s)
- Marko Simunovic
- Department of Surgery, McMaster University, Hamilton, ON, Canada. .,Department of Oncology, McMaster University, Hamilton, ON, Canada. .,Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada.
| | - Vanja Grubac
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Ilun Yang
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Cagla Eskicioglu
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jessica Bogach
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Erin Kennedy
- Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Geoff Porter
- Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | | | - James Wright
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Tariq Aziz
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Scott Tsai
- Department of Radiology, McMaster University, Hamilton, ON, Canada
| | | | - P J Devereaux
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - G R Baker
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Carmichael H, Mastoras G, Nolan C, Tan H, Tochkin J, Poulin C, Willmore A, Posner G. Integration of In Situ Simulation Into an Emergency Department Code Orange Exercise in a Tertiary Care Trauma Referral Center. AEM EDUCATION AND TRAINING 2021; 5:e10485. [PMID: 33842806 PMCID: PMC8019225 DOI: 10.1002/aet2.10485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 05/17/2020] [Accepted: 05/25/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Disaster-preparedness and response are a commonly overlooked aspect of hospital policy and can frequently be outdated and undertested. Simulation-based education has become a core education modality within Canadian medical training programs. We hypothesized that integrating in situ simulation (ISS) into a hospital-wide, mass-casualty response exercise would enhance realism and our ability to identify latent safety threats (LSTs). METHODS Using ISS we created a simulated mass shooting scenario with 20 patients, played by actors in full moulage, presenting to a large tertiary care hospital over a 50-minute period. RESULTS Integrating ISS into our exercise created a realistic experience for the participants involved and improved participant education, while imparting enough systemic stress to expose LSTs associated within patient care and hospital policy. CONCLUSION Overall, ISS was successfully used and enhanced a large-scale test of our hospital's mass-casualty response plan.
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Affiliation(s)
- Harrison Carmichael
- From theDepartment of Emergency MedicineUniversity of OttawaOttawaOntarioCanada
| | - George Mastoras
- From theDepartment of Emergency MedicineUniversity of OttawaOttawaOntarioCanada
| | - Caroline Nolan
- theDepartment of Emergency ManagementThe Ottawa HospitalOttawaOntarioCanada
| | - Hung Tan
- theDepartment of Emergency ManagementThe Ottawa HospitalOttawaOntarioCanada
| | - Jeffrey Tochkin
- theDepartment of Emergency ManagementThe Ottawa HospitalOttawaOntarioCanada
| | - Cari Poulin
- From theDepartment of Emergency MedicineUniversity of OttawaOttawaOntarioCanada
| | - Andrew Willmore
- From theDepartment of Emergency MedicineUniversity of OttawaOttawaOntarioCanada
- theDepartment of Emergency ManagementThe Ottawa HospitalOttawaOntarioCanada
| | - Glenn Posner
- and theDepartment of Obstetrics & GynecologyDepartment of Innovation in Medical EducationUniversity of OttawaOttawaOntarioCanada
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15
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Mastoras G, Poulin C, Norman L, Weitzman B, Pozgay A, Frank JR, Posner G. Stress Testing the Resuscitation Room: Latent Threats to Patient Safety Identified During Interprofessional In Situ Simulation in a Canadian Academic Emergency Department. AEM EDUCATION AND TRAINING 2020; 4:254-261. [PMID: 32704595 PMCID: PMC7369481 DOI: 10.1002/aet2.10422] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/18/2019] [Accepted: 11/20/2019] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Emergency department (ED) resuscitation is a complex, high-stakes procedure where positive outcomes depend on effective interactions between the health care team, the patient, and the environment. Resuscitation teams work in dynamic environments and strive to ensure the timely delivery of necessary treatments, equipment, and skill sets when required. However, systemic failures in this environment cannot always be adequately anticipated, which exposes patients to opportunities for harm. METHODS As part of a new interprofessional education and quality improvement initiative, this prospective, observational study sought to characterize latent safety threats (LSTs) identified during the delivery of in situ, simulated resuscitations in our ED. In situ simulation (ISS) sessions were delivered on a monthly basis in the EDs at each campus of a large tertiary care academic hospital system, during which a variety of scenarios were run with teams of ED health care professionals. LSTs were identified by simulation facilitators and participants during the case and debriefing and then grouped thematically for analysis. RESULTS During the study period, 22 ISS sessions were delivered, involving 58 cases and reaching 383 ED health care professionals. 196 latent safety threats were identified through these sessions (mean = 3.4 LSTs per case) of which 110 were determined to be "actionable" at a system level. LSTs identified included system/environmental design flaws, equipment problems, failures in department processes, and knowledge/skill gaps. Corrective mechanisms were initiated in 85% of actionable cases. CONCLUSIONS Effective quality improvement and continuing education programs are essential to translate these findings into more resilient patient care. ISS, beyond its role as a training tool for developing intrinsic and crisis resource management skills, can be effectively used to identify system issues in the ED that could expose critically ill patients to harm.
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Affiliation(s)
- George Mastoras
- Department of Emergency MedicineFaculty of MedicineUniversity of OttawaOttawaOntario
| | - Cari Poulin
- Department of Emergency MedicineFaculty of MedicineUniversity of OttawaOttawaOntario
| | - Larry Norman
- Department of Emergency MedicineFaculty of MedicineUniversity of OttawaOttawaOntario
| | - Brian Weitzman
- Department of Emergency MedicineFaculty of MedicineUniversity of OttawaOttawaOntario
| | - Anita Pozgay
- Department of Emergency MedicineFaculty of MedicineUniversity of OttawaOttawaOntario
| | - Jason R. Frank
- Department of Emergency MedicineFaculty of MedicineUniversity of OttawaOttawaOntario
- Royal College of Physicians and Surgeons of CanadaOttawaOntarioCanada
| | - Glenn Posner
- Department of Obstetrics and GynecologyFaculty of MedicineUniversity of OttawaOttawaOntario
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Doing well by doing good: Evaluating the influence of patient safety performance on hospital financial outcomes. Health Care Manage Rev 2020; 44:2-9. [PMID: 28445325 DOI: 10.1097/hmr.0000000000000163] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND As financial pressures on hospitals increase because of changing reimbursement structures and heightened focus on quality and value, the association between patient safety performance and financial outcomes remains unclear. PURPOSE The purpose of this study is to investigate if hospitals with higher patient safety performance are associated with higher levels of profitability than those with lower safety performance. METHODOLOGY/APPROACH Using multinomial logistic regression, we analyzed data from the spring 2014 Leapfrog Hospital Safety Score and the 2014 American Hospital Association to determine the association between Leapfrog Hospital Safety Score performance and three dimensions of organizational profitability: operating margin, net patient revenue, and operating income. RESULTS Our findings suggest that improved hospital safety scores are associated with a relative risk of being in the top versus bottom quartile of financial performance: 5.41 times greater (p < .001) for operating margin, 10.98 times greater (p < .001) for net patient revenue, and 4.03 times greater (p < .001) for operating income. PRACTICE IMPLICATIONS Our findings suggest that improved patient safety performance, as evaluated within the Leapfrog Hospital Safety Score, is associated with improved financial performance at the hospital level. Targeted focus on patient safety may allow hospitals to improve financial performance, maximize scarce resources, and generate additional capital to continue to positively evolve care.
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17
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Vaismoradi M, Tella S, A. Logan P, Khakurel J, Vizcaya-Moreno F. Nurses' Adherence to Patient Safety Principles: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17062028. [PMID: 32204403 PMCID: PMC7142993 DOI: 10.3390/ijerph17062028] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 03/11/2020] [Accepted: 03/16/2020] [Indexed: 12/18/2022]
Abstract
Background: Quality-of-care improvement and prevention of practice errors is dependent on nurses’ adherence to the principles of patient safety. Aims: This paper aims to provide a systematic review of the international literature, to synthesise knowledge and explore factors that influence nurses’ adherence to patient-safety principles. Methods: Electronic databases in English, Norwegian, and Finnish languages were searched, using appropriate keywords to retrieve empirical articles published from 2010–2019. Using the theoretical domains of the Vincent’s framework for analysing risk and safety in clinical practice, we synthesized our findings according to ‘patient’, ‘healthcare provider’, ‘task’, ‘work environment’, and ‘organisation and management’. Findings: Six articles were found that focused on adherence to patient-safety principles during clinical nursing interventions. They focused on the management of peripheral venous catheters, surgical hand rubbing instructions, double-checking policies of medicines management, nursing handover between wards, cardiac monitoring and surveillance, and care-associated infection precautions. Patients’ participation, healthcare providers’ knowledge and attitudes, collaboration by nurses, appropriate equipment and electronic systems, education and regular feedback, and standardization of the care process influenced nurses’ adherence to patient-safety principles. Conclusions: The revelation of individual and systemic factors has implications for nursing care practice, as both influence adherence to patient-safety principles. More studies using qualitative and quantitative methods are required to enhance our knowledge of measures needed to improve nurse’ adherence to patient-safety principles and their effects on patient-safety outcomes.
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Affiliation(s)
- Mojtaba Vaismoradi
- Faculty of Nursing and Health Sciences, Nord University, 8049 Bodø, Norway
- Correspondence: ; Tel.: +47-75517813
| | - Susanna Tella
- Faculty of Health and Social Care, LAB University of Applied Sciences, 53850 Lappeenranta, Finland;
| | - Patricia A. Logan
- Faculty of Science, Charles Sturt University, 2795 Bathurst, Australia;
| | - Jayden Khakurel
- Research Centre for Child Psychiatry, Department of Child Psychiatry, Faculty of Medicine, University of Turku, 20014 Turku, Finland;
| | - Flores Vizcaya-Moreno
- Nursing Department, Faculty of Health Sciences, University of Alicante, 03080 Alicante, Spain;
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18
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Simulation-Based Event Analysis Improves Error Discovery and Generates Improved Strategies for Error Prevention. Simul Healthc 2020; 14:209-216. [PMID: 31135682 DOI: 10.1097/sih.0000000000000372] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION An adverse event (AE) is a negative consequence of health care that results in unintended injury or illness. The study investigates whether simulation-based event analysis is different from traditional event analysis in uncovering root causes and generating recommendations when analyzing AEs in hospitalized children. METHODS Two simulation scenarios were created based on real-life AEs identified through the hospital's Safety Reporting System. Scenario A involved an error of commission (inpatient drug error) and scenario B involved detecting an error that already occurred (drug infusion error). Each scenario was repeated 5 times with different, voluntary clinicians. Content analysis, using deductive and inductive approaches to coding, was used to analyze debriefing data. Causes and recommendations were compiled and compared with the traditional event analysis. RESULTS Errors were reproduced in 60% (3/5) of scenario A. In scenario B, participants identified the error in 100% (5/5) of simulations (average time to error detection = 15 minutes). Debriefings identified reasons for errors including product labeling, memory aid interpretation, and lack of standard work for patient handover. To prevent error, participants suggested improved drug labeling, specialized drug kits, alert signs, and handoff checklists. Compared with traditional event analysis, simulation-based event analysis revealed unique causes for error and new recommendations. CONCLUSIONS Using simulation to analyze AEs increased unique error discovery and generated new recommendations. This method is different from traditional event analysis because of the immediate clinician debriefings in the clinical environment. Hospitals should consider simulation-based event analysis as an important addition to the traditional process.
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19
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Song W, Li J, Li H, Ming X. Human factors risk assessment: An integrated method for improving safety in clinical use of medical devices. Appl Soft Comput 2020. [DOI: 10.1016/j.asoc.2019.105918] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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20
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Liang C, Zhou S, Yao B, Hood D, Gong Y. Toward systems-centered analysis of patient safety events: Improving root cause analysis by optimized incident classification and information presentation. Int J Med Inform 2019; 135:104054. [PMID: 31864129 DOI: 10.1016/j.ijmedinf.2019.104054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/18/2019] [Accepted: 12/11/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Systems-centered root cause analysis (RCA) of patient safety events presents unique advantages as it aims to disclose vulnerabilities of healthcare systems. However, the increasing number of collected events poses the problems of low efficiency and information overload for traditional RCA. OBJECTIVES This study aims to improve systems-centered RCA by developing optimized information extraction and presentation. METHODS We experimented supervised machine-learning methods to extract safety-related information from 3333 de-identified patient safety event reports from two independent sources. Based on the extracted information, we further evaluated how optimized information presentation could help facilitate the disclosure of system vulnerabilities in traditional RCA. RESULTS Multilabel text classification is effective in identifying safety-related information from the narrative description of patient safety events. The Pruned Sets in conjunction with Naïve Bayes are the outperformed algorithm in one dataset, with an overall F score of 60.0 % and the highest F score of 96.0 % for identifying "Adverse Drug Reaction". The Classifier Chains in conjunction with Naïve Bayes are the outperformed algorithm in another dataset, with an overall F score of 43.2 % and the highest F score of 64.0 % for identifying "Medication". During the RCA, human experts applied the optimized presentation of information which showed advantages of identifying system vulnerabilities. CONCLUSION Our study demonstrated the feasibility of using multilabel text classification for identifying safety-related information from the narrative description of patient safety events. The extracted information when grouped by safety-related information can better aid human experts to conduct systems-centered RCA and disclose system vulnerabilities.
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Affiliation(s)
- Chen Liang
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
| | - Sicheng Zhou
- School of Biomedical Informatics, University of Texas Health Science Center, Houston, TX, United States
| | - Bin Yao
- School of Biomedical Informatics, University of Texas Health Science Center, Houston, TX, United States
| | - Donna Hood
- Division of Nursing, Louisiana Tech University, Ruston, LA, United States
| | - Yang Gong
- School of Biomedical Informatics, University of Texas Health Science Center, Houston, TX, United States.
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21
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Tyler N, Wright N, Waring J. Interventions to improve discharge from acute adult mental health inpatient care to the community: systematic review and narrative synthesis. BMC Health Serv Res 2019; 19:883. [PMID: 31760955 PMCID: PMC6876082 DOI: 10.1186/s12913-019-4658-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 10/20/2019] [Indexed: 01/25/2023] Open
Abstract
Background The transition from acute mental health inpatient to community care is often a vulnerable period in the pathway, where people can experience additional risks and anxiety. Researchers globally have developed and tested a number of interventions that aim to improve continuity of care and safety in these transitions. However, there has been little attempt to compare and contrast the interventions and specify the variety of safety threats they attempt to resolve. Methods The study aimed to identify the evidence base for interventions to support continuity of care and safety in the transition from acute mental health inpatient to community services at the point of discharge. Electronic Databases including PsycINFO, MEDLINE, Embase, HMIC, CINAHL, IBSS, Cochrane Library Trials, ASSIA, Web of Science and Scopus, were searched between 2000 and May 2018. Peer reviewed papers were eligible for inclusion if they addressed adults admitted to an acute inpatient mental health ward and reported on health interventions relating to discharge from the acute ward to the community. The results were analysed using a narrative synthesis technique. Results The total number of papers from which data were extracted was 45. The review found various interventions implemented across continents, addressing problems related to different aspects of discharge. Some interventions followed a distinct named approach (i.e. Critical Time Intervention, Transitional Discharge Model), others were grouped based on key components (i.e. peer support, pharmacist involvement). The primary problems interventions looked to address were reducing readmission, improving wellbeing, reducing homelessness, improving treatment adherence, accelerating discharge, reducing suicide. The 69 outcomes reported across studies were heterogeneous, meaning it was difficult to conduct comparative quantitative meta-analysis or synthesis. Conclusions The interventions reviewed are spread across a spectrum ranging from addressing a single problem within a single agency with a single solution, to multiple solutions addressing multi-agency problems. We recommend that future research attempts to improve homogeneity in outcome reporting.
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Affiliation(s)
- Natasha Tyler
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester, UK.
| | - Nicola Wright
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Justin Waring
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester, UK.,Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, UK
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22
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Foster M, Tagg A. A systems-centred approach to reducing medication error: Should pre-hospital providers and emergency departments dose children by age during resuscitation? J Paediatr Child Health 2019; 55:1299-1303. [PMID: 31517422 DOI: 10.1111/jpc.14626] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/14/2019] [Accepted: 08/27/2019] [Indexed: 11/29/2022]
Abstract
The high-risk, high-stress and high-stakes environment of out-of-hospital or emergency department paediatric resuscitation is prone to human error, and medication errors are common. This could be contributing to the difference in survival rate of resuscitation in the out-of-hospital versus inpatient setting. Medication for children during resuscitation requires estimation of the child's weight and calculation of the corresponding drug dose. Whilst both of these steps can lead to error, calculation errors (including 10-fold errors) are much more common and harmful than weight errors. Previous solutions aim to optimise each stage of the medication dosing process. Currently, Australian guidelines suggest using the highly inaccurate original advanced paediatric life support formula, weight = 2 × (age + 4), to dose medications in these settings. This means age is converted to weight, which is then converted to dose. There is no evidence that this is causing harm to patients. Therefore, it could be suggested that age could safely be converted straight to dose according to preset doses. This eliminates the need for any weight estimation or dose calculation, thus reducing the potential for error and harm.
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Affiliation(s)
- Mieke Foster
- Deakin University School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Andrew Tagg
- Sunshine Hospital Emergency Department, Western Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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Boet S, Larrigan S, Martin L, Liu H, Sullivan KJ, Etherington C. Measuring non-technical skills of anaesthesiologists in the operating room: a systematic review of assessment tools and their measurement properties. Br J Anaesth 2018; 121:1218-1226. [PMID: 30442248 PMCID: PMC9520753 DOI: 10.1016/j.bja.2018.07.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 06/25/2018] [Accepted: 07/12/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Non-technical skills, such as communication or leadership, are integral to clinical competence in anaesthesia. There is a need for valid and reliable tools to measure anaesthetists' non-technical performance for both initial and continuing professional development. This systematic review aims to summarise the measurement properties of existing assessment tools to determine which tool is most robust. METHODS Embase (via OVID), Medline and Medline in Process (via OVID), and reference lists of included studies and previously published relevant systematic reviews were searched (through August 2017). Quantitative studies investigating the measurement properties of tools used to assess anaesthetists' intraoperative non-technical skills, either in a clinical or simulated environment, were included. Pairs of independent reviewers determined eligibility and extracted data. Risk of bias was assessed using the COSMIN checklist. RESULTS The search yielded 978 studies, of which 14 studies describing seven tools met the inclusion criteria. Of these, 12 involved simulated crisis settings only. The measurement properties of the Anaesthetists' Non-Technical Skills (ANTS) tool were most commonly assessed (n=9 studies), with studies of two types of validity (content, concurrent) and two types of reliability (internal consistency, interrater). Most of these studies, however, were at serious risk of bias. CONCLUSIONS Though there are seven tools for assessing the non-technical skills of anaesthetists, only ANTS has been extensively investigated with regard to its measurement properties. ANTS appears to have acceptable validity and reliability for assessing non-technical skills of anaesthetists in both simulated and clinical settings. Future research should consider additional clinical contexts and types of measurement properties.
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Affiliation(s)
- S Boet
- Department of Anaesthesiology and Pain Medicine, Ottawa Hospital, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Innovation in Medical Education, University of Ottawa, ON, Canada.
| | - S Larrigan
- Translational and Molecular Medicine Program, ON
| | | | | | - K J Sullivan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Cole Etherington
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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24
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Pearson JD, Maund A, Jones CP, Coley E, Frazer S, Connor D. Defence Anaesthesia transition from the Tri-Service Anaesthetic Apparatus to the Diamedica Portable Anaesthesia Machine 02. J ROY ARMY MED CORPS 2018; 165:351-355. [DOI: 10.1136/jramc-2018-001061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 09/27/2018] [Accepted: 09/29/2018] [Indexed: 11/04/2022]
Abstract
Defence Anaesthesia is changing its draw-over anaesthetic capability from the Tri-Service Anaesthetic Apparatus (TSAA) to the Diamedica Portable Anaesthesia Machine 02 (DPA02). The DPA02 will provide a portable, robust, lightweight and simple method for delivering draw-over volatile anaesthesia with the option of positive pressure ventilation through manual or mechanical operation for paediatric and adult patients. The UK Defence Medical Services uses a modified configuration of the DPA02; this paper seeks to explain the rationale for the differing configurations and illustrates alternative assemblies to support integration with other Defence Anaesthesia equipment. High-fidelity simulation training using the DPA02 will continue to be delivered on the Defence Anaesthesia Simulation Course (DASC). Conformité Européenne accreditation of DPA02 supports future UK live patient training in centres of excellence supervised by subject matter experts; this was not possible with the TSAA. This article is intended to be a key reference for all members of the Defence Anaesthesia team. Alongside other resources, it will be given as precourse learning prior to attending the DASC and the Military Operational Surgical Training. This article will also be issued with all Defence DPA02 units, supporting ease of access for review during future clinical exercises (including validation), prior to supervised live training and on operational deployments.
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25
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van Melle MA, Zwart DLM, Poldervaart JM, Verkerk OJ, Langelaan M, van Stel HF, de Wit NJ. Validity and reliability of a medical record review method identifying transitional patient safety incidents in merged primary and secondary care patients' records. BMJ Open 2018; 8:e018576. [PMID: 30104308 PMCID: PMC6091899 DOI: 10.1136/bmjopen-2017-018576] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 06/20/2018] [Accepted: 07/20/2018] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Inadequate information transfer during transitions in healthcare is a major patient safety issue. Aim of this study was to pilot a review of medical records to identify transitional safety incidents (TSIs) for use in a large intervention study and assess its reliability and validity. DESIGN A retrospective medical record review study. SETTINGS AND PARTICIPANTS Combined primary and secondary care medical records of 301 patients who had visited their general practitioner and the University Medical Center Utrecht, the Netherlands, in 2013 were randomly selected. Six trained reviewers assessed these medical records for presence of TSIs. OUTCOMES To assess inter-rater reliability, 10% of medical records were independently reviewed twice. To assess validity, the identified TSIs were compared with a reference standard of three objectively identifiable TSIs. RESULTS The reviewers identified TSIs in 52 (17.3%) of all transitional medical records. Variation between reviewers was high (range: 3-28 per 50 medical records). Positive agreement for finding a TSI between reviewers was 0%, negative agreement 80% and the Cohen's kappa -0.15. The reviewers identified 43 (22%) of 194 objectively identifiable TSIs. CONCLUSION The reliability of our measurement tool for identifying TSIs in transitional medical record performed by clinicians was low. Although the TSIs that were identified by clinicians were valid, they missed 80% of them. Restructuring the record review procedure is necessary.
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Affiliation(s)
- Marije A van Melle
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Dorien L M Zwart
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| | - Judith M Poldervaart
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| | - Otto Jan Verkerk
- Faculty of Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maaike Langelaan
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Henk F van Stel
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| | - Niek J de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
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26
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Mira JJ, Lorenzo S, Carrillo I, Ferrús L, Silvestre C, Astier P, Iglesias-Alonso F, Maderuelo JA, Pérez-Pérez P, Torijano ML, Zavala E, Scott SD. Lessons learned for reducing the negative impact of adverse events on patients, health professionals and healthcare organizations. Int J Qual Health Care 2018; 29:450-460. [PMID: 28934401 DOI: 10.1093/intqhc/mzx056] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 05/05/2017] [Indexed: 12/21/2022] Open
Abstract
Purpose To summarize the knowledge about the aftermath of adverse events (AEs) and develop a recommendation set to reduce their negative impact in patients, health professionals and organizations in contexts where there is no previous experiences and apology laws are not present. Data sources Review studies published between 2000 and 2015, institutional websites and experts' opinions on patient safety. Study selection Studies published and websites on open disclosure, and the second and third victims' phenomenon. Four Focus Groups participating 27 healthcare professionals. Data extraction Study characteristic and outcome data were abstracted by two authors and reviewed by the research team. Results of data synthesis Fourteen publications and 16 websites were reviewed. The recommendations were structured around eight areas: (i) safety and organizational policies, (ii) patient care, (iii) proactive approach to preventing reoccurrence, (iv) supporting the clinician and healthcare team, (v) activation of resources to provide an appropriate response, (vi) informing patients and/or family members, (vii) incidents' analysis and (viii) protecting the reputation of health professionals and the organization. Conclusion Recommendations preventing aftermath of AEs have been identified. These have been designed for the hospital and the primary care settings; to cope with patient's emotions and for tacking the impact of AE in the second victim's colleagues. Its systematic use should help for the establishment of organizational action plans after an AE.
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Affiliation(s)
- Jose Joaquin Mira
- Alicante-Sant Joan Health Department, Alicante, Spain.,Miguel Hernández University, Elche, Spain
| | | | | | - Lena Ferrús
- Integrated Health Organisation, L'Hospitalet de Llobregat, Spain
| | | | - Pilar Astier
- Family and Community Medicine, Tauste Health District, Aragon Health Service (SALUD), Zaragoza, Spain
| | | | - Jose Angel Maderuelo
- Salamanca Primary Care Management, Castilla y León Health Service (SACYL), Salamanca, Spain
| | - Pastora Pérez-Pérez
- Patient Safety Observatory, Andalusian Agency for Healthcare Quality, Seville, Spain
| | | | | | - Susan D Scott
- University of Missouri Health System, Columbia, MO, USA
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Eltaybani S, Mohamed N, Abdelwareth M. Nature of nursing errors and their contributing factors in intensive care units. Nurs Crit Care 2018; 24:47-54. [PMID: 29701274 DOI: 10.1111/nicc.12350] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 01/03/2018] [Accepted: 02/27/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Errors tend to be multifactorial and so learning from nurses' experiences with them would be a powerful tool toward promoting patient safety. AIM To identify the nature of nursing errors and their contributing factors in intensive care units (ICUs). METHODS A semi-structured interview with 112 critical care nurses to elicit the reports about their encountered errors followed by a content analysis. RESULTS A total of 300 errors were reported. Most of them (94·3%) were classified in more than one error category, e.g. 'lack of intervention', 'lack of attentiveness' and 'documentation errors': these were the most frequently involved error categories. Approximately 40% of reported errors contributed to significant harm or death of the involved patients, with system-related factors being involved in 84·3% of them. More errors occur during the evening shift than the night and morning shifts (42·7% versus 28·7% and 16·7%, respectively). There is a statistically significant relation (p ≤ 0·001) between error disclosure to a nursing supervisor and its impact on the patient. CONCLUSIONS Nurses are more likely to report their errors when they feel safe and when the reporting system is not burdensome, although an internationally standardized language to define and analyse nursing errors is needed. Improving the health care system, particularly the managerial and environmental aspects, might reduce nursing errors in ICUs in terms of their incidence and seriousness. RELEVANCE TO CLINICAL PRACTICE Targeting error-liable times in the ICU, such as mid-evening and mid-night shifts, along with improved supervision and adequate staff reallocation, might tackle the incidence and seriousness of nursing errors. Development of individualized nursing interventions for patients with low health literacy and patients in isolation might create more meaningful dialogue for ICU health care safety.
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Affiliation(s)
- Sameh Eltaybani
- Department of Critical Care and Emergency Nursing, Faculty of Nursing, University of Alexandria, Alexandria, Egypt.,Department of Palliative Care Nursing, Division of Health Science and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nadia Mohamed
- Department of Critical Care and Emergency Nursing, Faculty of Nursing, University of Alexandria, Alexandria, Egypt
| | - Mona Abdelwareth
- Department of Critical Care and Emergency Nursing, Faculty of Nursing, University of Alexandria, Alexandria, Egypt
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Chrouser KL, Xu J, Hallbeck S, Weinger MB, Partin MR. The influence of stress responses on surgical performance and outcomes: Literature review and the development of the surgical stress effects (SSE) framework. Am J Surg 2018. [PMID: 29525056 DOI: 10.1016/j.amjsurg.2018.02.017] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Surgical adverse events persist despite several decades of system-based quality improvement efforts, suggesting the need for alternative strategies. Qualitative studies suggest stress-induced negative intraoperative interpersonal dynamics might contribute to performance errors and undesirable patient outcomes. Understanding the impact of intraoperative stressors may be critical to reducing adverse events and improving outcomes. DATA SOURCES We searched MEDLINE, psycINFO, EMBASE, Business Source Premier, and CINAHL databases (1996-2016) to assess the relationship between negative (emotional and behavioral) responses to acute intraoperative stressors and provider performance or patient surgical outcomes. RESULTS/CONCLUSIONS Drawing on theory and evidence from reviewed studies, we present the Surgical Stress Effects (SSE) framework. This illustrates how emotional and behavioral responses to stressors can influence individual surgical provider (e.g. surgeon, nurse) performance, team performance, and patient outcomes. It also demonstrates how uncompensated intraoperative threats and errors can lead to adverse events, highlighting evidence gaps for future research efforts.
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Affiliation(s)
- Kristin L Chrouser
- Minneapolis VA Health Care Center, 1 Veterans Dr, Minneapolis, MN 55417, USA; The University of Minnesota, Dept of Urology, 420 Delaware St SE, Minneapolis, MN 55455, USA.
| | - Jie Xu
- Center for Psychological Science, Zhejiang University, China; Vanderbilt University School of Medicine, Dept of Anesthesiology, 1121 21st Avenue S., MAB Suite 732, Nashville, TN 37212, USA.
| | - Susan Hallbeck
- Mayo Clinic Health Sciences Research Department, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
| | - Matthew B Weinger
- Vanderbilt University School of Medicine, Dept of Anesthesiology, 1121 21st Avenue S., MAB Suite 732, Nashville, TN 37212, USA.
| | - Melissa R Partin
- Minneapolis VA Health Care Center, Center for Chronic Disease Outcomes Research, 1 Veterans Dr (152/Bldg 9), Minneapolis, MN 55417, USA.
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Seshia SS, Bryan Young G, Makhinson M, Smith PA, Stobart K, Croskerry P. Gating the holes in the Swiss cheese (part I): Expanding professor Reason's model for patient safety. J Eval Clin Pract 2018; 24:187-197. [PMID: 29168290 PMCID: PMC5901035 DOI: 10.1111/jep.12847] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 09/28/2017] [Accepted: 10/02/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Although patient safety has improved steadily, harm remains a substantial global challenge. Additionally, safety needs to be ensured not only in hospitals but also across the continuum of care. Better understanding of the complex cognitive factors influencing health care-related decisions and organizational cultures could lead to more rational approaches, and thereby to further improvement. HYPOTHESIS A model integrating the concepts underlying Reason's Swiss cheese theory and the cognitive-affective biases plus cascade could advance the understanding of cognitive-affective processes that underlie decisions and organizational cultures across the continuum of care. METHODS Thematic analysis, qualitative information from several sources being used to support argumentation. DISCUSSION Complex covert cognitive phenomena underlie decisions influencing health care. In the integrated model, the Swiss cheese slices represent dynamic cognitive-affective (mental) gates: Reason's successive layers of defence. Like firewalls and antivirus programs, cognitive-affective gates normally allow the passage of rational decisions but block or counter unsounds ones. Gates can be breached (ie, holes created) at one or more levels of organizations, teams, and individuals, by (1) any element of cognitive-affective biases plus (conflicts of interest and cognitive biases being the best studied) and (2) other potential error-provoking factors. Conversely, flawed decisions can be blocked and consequences minimized; for example, by addressing cognitive biases plus and error-provoking factors, and being constantly mindful. Informed shared decision making is a neglected but critical layer of defence (cognitive-affective gate). The integrated model can be custom tailored to specific situations, and the underlying principles applied to all methods for improving safety. The model may also provide a framework for developing and evaluating strategies to optimize organizational cultures and decisions. LIMITATIONS The concept is abstract, the model is virtual, and the best supportive evidence is qualitative and indirect. CONCLUSIONS The proposed model may help enhance rational decision making across the continuum of care, thereby improving patient safety globally.
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Affiliation(s)
- Shashi S Seshia
- Department of Pediatrics, University of Saskatchewan, Saskatoon, Canada
| | - G Bryan Young
- Clinical Neurological Sciences and Medicine (Critical Care), Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada, Grey Bruce Health Services, Owen Sound, Canada
| | - Michael Makhinson
- Department of Psychiatry and Biobehavioral Science, David Geffen School of Medicine at the University of California, Los Angeles, USA.,Department of Psychiatry, Harbor-UCLA Medical Center, Torrance, USA
| | - Preston A Smith
- College of Medicine, University of Saskatchewan, Health Sciences Building, Saskatoon, Canada
| | - Kent Stobart
- College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Pat Croskerry
- Critical Thinking Program, Division of Medical Education, Dalhousie University Medical School, Halifax, Canada
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Jones CPL, Fawker-Corbett J, Groom P, Morton B, Lister C, Mercer SJ. Human factors in preventing complications in anaesthesia: a systematic review. Anaesthesia 2018; 73 Suppl 1:12-24. [DOI: 10.1111/anae.14136] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 12/17/2022]
Affiliation(s)
- C. P. L. Jones
- Aintree University Hospital NHS Foundation Trust; Longmoor Lane, Aintree; Liverpool UK
- Defence Medical Services; Royal Centre for Defence Medicine; Queen Elizabeth Hospital Birmingham; Mindelsohn Way, Edgbaston; Birmingham UK
| | - J. Fawker-Corbett
- Aintree University Hospital NHS Foundation Trust; Longmoor Lane, Aintree; Liverpool UK
| | - P. Groom
- Aintree University Hospital NHS Foundation Trust; Longmoor Lane, Aintree; Liverpool UK
| | - B. Morton
- Aintree University Hospital NHS Foundation Trust; Longmoor Lane, Aintree; Liverpool UK
- Liverpool School of Tropical Medicine; Pembroke Place; Liverpool UK
| | - C. Lister
- Aintree University Hospital NHS Foundation Trust; Longmoor Lane, Aintree; Liverpool UK
| | - S. J. Mercer
- Aintree University Hospital NHS Foundation Trust; Longmoor Lane, Aintree; Liverpool UK
- Defence Medical Services; Royal Centre for Defence Medicine; Queen Elizabeth Hospital Birmingham; Mindelsohn Way, Edgbaston; Birmingham UK
- Postgraduate School of Medicine; University of Liverpool; Cedar House, Ashton Street; Liverpool UK
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Posner GD, Clark ML, Grant VJ. Simulation in the clinical setting: towards a standard lexicon. Adv Simul (Lond) 2017; 2:15. [PMID: 29450016 PMCID: PMC5806315 DOI: 10.1186/s41077-017-0050-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 09/11/2017] [Indexed: 11/10/2022] Open
Abstract
Simulation-based educational activities are happening in the clinical environment but are not all uniform in terms of their objectives, delivery, or outputs. While these activities all provide an opportunity for individual and team training, nuances in the location, timing, notification, and participants impact the potential outcomes of these sessions and objectives achieved. In light of this, there are actually many different types of simulation-based activity that occur in the clinical environment, which has previously all been grouped together as “in situ” simulation. However, what truly defines in situ simulation is how the clinical environment responds in its’ natural state, including the personnel, equipment, and systems responsible for care in that environment. Beyond individual and team skill sets, there are threats to patient safety or quality patient care that result from challenges with equipment, processes, or system breakdowns. These have been labeled “latent safety threats.” We submit that the opportunity for discovery of latent safety threats is what defines in situ simulation and truly differentiates it from what would be more rightfully called “on-site” simulation. The distinction between the two is highlighted in this article, as well as some of the various sub-types of in situ simulation.
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Affiliation(s)
- Glenn D Posner
- 1Department of Innovation in Medical Education, University of Ottawa, Ottawa, Ontario Canada.,2Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario Canada.,3University of Ottawa Skills and Simulation Centre and The Ottawa Hospital Simulation Patient Safety Program, Ottawa, Ontario Canada
| | - Marcia L Clark
- 4Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada.,Advanced Technical and Simulation Skills Lab (ATSSL), Calgary, Alberta Canada
| | - Vincent J Grant
- 6Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada.,7Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada.,8KidSIM Simulation Program, Alberta Children's Hospital, Calgary, Alberta Canada
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33
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Murray M, Sundin D, Cope V. New graduate registered nurses’ knowledge of patient safety and practice: A literature review. J Clin Nurs 2017; 27:31-47. [DOI: 10.1111/jocn.13785] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2017] [Indexed: 12/30/2022]
Affiliation(s)
- Melanie Murray
- School of Nursing and Midwifery; Edith Cowan University; Joondalup WA Australia
| | - Deborah Sundin
- School of Nursing and Midwifery; Edith Cowan University; Joondalup WA Australia
| | - Vicki Cope
- School of Health Professions; Murdoch University; Murdoch WA Australia
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Jylhä V, Mikkonen S, Saranto K, Bates DW. The Impact of Information Culture on Patient Safety Outcomes. Development of a Structural Equation Model. Methods Inf Med 2017; 56:e30-e38. [PMID: 28272647 PMCID: PMC5388883 DOI: 10.3414/me16-01-0075] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 01/25/2017] [Indexed: 12/20/2022]
Abstract
Background An organization’s information culture and information management practices create conditions for processing patient information in hospitals. Information management incidents are failures that could lead to adverse events for the patient if they are not detected. Objectives To test a theoretical model that links information culture in acute care hospitals to information management incidents and patient safety outcomes. Methods Reason’s model for the stages of development of organizational accidents was applied. Study data were collected from a cross-sectional survey of 909 RNs who work in medical or surgical units at 32 acute care hospitals in Finland. Structural equation modeling was used to assess how well the hypothesized model fit the study data. Results Fit indices indicated a good fit for the model. In total, 18 of the 32 paths tested were statistically significant. Documentation errors had the strongest total effect on patient safety outcomes. Organizational guidance positively affected information availability and utilization of electronic patient records, whereas the latter had the strongest total effect on the reduction of information delays. Conclusions Patient safety outcomes are associated with information management incidents and information culture. Further, the dimensions of the information culture create work conditions that generate errors in hospitals.
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Affiliation(s)
- Virpi Jylhä
- Virpi Jylhä, PhD, Department of Health and Social Management, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland, E-mail:
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35
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Medical Device Guidebook: A browser information resource for medical device users. Med Eng Phys 2017; 41:97-102. [PMID: 28159447 DOI: 10.1016/j.medengphy.2017.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 12/16/2016] [Accepted: 01/08/2017] [Indexed: 11/23/2022]
Abstract
A web based information resource - the 'Medical Device Guidebook' - for the enabling of safe use of medical devices is described. Medical devices are described within a 'catalogue' of specific models and information on a specific model is provided within a consistent set of information 'keys'. These include 'user manuals', 'points of caution', 'clinical use framework', 'training/assessment material', 'frequently asked questions', 'authorised user comments' and 'consumables'. The system allows identification of known risk/hazards associated with specific devices, triggered, for example, by national alerts or locally raised safety observations. This provides a mechanism for more effective briefing of equipment users on the associated hazards of equipment. A feature of the system is the inclusion of a specific 'Operational Procedure' for each device, where the lack of this focus is shown in the literature to often be a key factor in equipment misuse and associated patient injury. The 'Guidebook' provides a mechanism for the development of an information resource developed within local clinical networks and encourages a consistent approach to medical device use.
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36
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Deutsch ES, Dong Y, Halamek LP, Rosen MA, Taekman JM, Rice J. Leveraging Health Care Simulation Technology for Human Factors Research: Closing the Gap Between Lab and Bedside. HUMAN FACTORS 2016; 58:1082-1095. [PMID: 27268996 DOI: 10.1177/0018720816650781] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 04/24/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE We describe health care simulation, designed primarily for training, and provide examples of how human factors experts can collaborate with health care professionals and simulationists-experts in the design and implementation of simulation-to use contemporary simulation to improve health care delivery. BACKGROUND The need-and the opportunity-to apply human factors expertise in efforts to achieve improved health outcomes has never been greater. Health care is a complex adaptive system, and simulation is an effective and flexible tool that can be used by human factors experts to better understand and improve individual, team, and system performance within health care. METHOD Expert opinion is presented, based on a panel delivered during the 2014 Human Factors and Ergonomics Society Health Care Symposium. RESULTS Diverse simulators, physically or virtually representing humans or human organs, and simulation applications in education, research, and systems analysis that may be of use to human factors experts are presented. Examples of simulation designed to improve individual, team, and system performance are provided, as are applications in computational modeling, research, and lifelong learning. CONCLUSION The adoption or adaptation of current and future training and assessment simulation technologies and facilities provides opportunities for human factors research and engineering, with benefits for health care safety, quality, resilience, and efficiency. APPLICATION Human factors experts, health care providers, and simulationists can use contemporary simulation equipment and techniques to study and improve health care delivery.
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Affiliation(s)
| | - Yue Dong
- Mayo Clinic, Rochester, Minnesota
| | | | | | | | - John Rice
- Children's Hospital of Philadelphia, PennsylvaniaMayo Clinic, Rochester, MinnesotaStanford University, Palo Alto, CaliforniaJohns Hopkins University, Baltimore, MarylandDuke University, Durham, North CarolinaSociety for Simulation in Healthcare, Norfolk, Virginia
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37
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Crema M, Verbano C. Safety improvements from health lean management implementation. INTERNATIONAL JOURNAL OF QUALITY & RELIABILITY MANAGEMENT 2016. [DOI: 10.1108/ijqrm-11-2014-0179] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
In a context where healthcare systems have to face multiple challenges, the development of a methodology that combines new managerial approaches could contribute to pursue and achieve multiple objectives. Inside the research stream that intends to combine health lean management (HLM) and clinical risk management (CRM), the purpose of this paper is to study the significant features that characterize HLM projects obtaining patient safety improvements (L&S projects).
Design/methodology/approach
The novelty of the research implies to adopt qualitative research methodology, analyzing in-depth case studies. L&S projects at different organizational levels have been selected from the same hospital. Following a research protocol, data have been collected through semi-structured interviews and they have been triangulated studying reports and archival documentation.
Findings
Comparing the three cases, it emerges that HLM can be a support for CRM since safety improvements can be achieved solving organizational issues. Analyzing the significant features of the three cases, relevant differences have been highlighted among them. At the end, first indications useful for achieving safety improvements from lean project implementation have been grasped.
Originality/value
This research provides a preliminary contribution to a new research stream that aims to develop a synergic methodology combining HLM and CRM. The first provided indications can be followed by hospital managers who wish to learn how to implement projects achieving patient safety improvements besides efficiency enhancement. After testing and exploiting the obtained results, a new methodology should be developed moving toward a safer and more sustainable healthcare system.
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Mota Martínez J, Facal de Castro F, Mirón Mombiela R. Diagnostic errors in examinations of the spine. RADIOLOGIA 2016; 58 Suppl 1:2-12. [PMID: 26775011 DOI: 10.1016/j.rx.2015.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 10/28/2015] [Accepted: 11/04/2015] [Indexed: 11/16/2022]
Abstract
The most common radiological error in examinations of the spine is the failure to diagnose fractures. This is the third most frequent reason for lawsuits brought against radiologists for negligence, after the failure to diagnose breast cancer and the failure to diagnose lung cancer. The thousands of radiological reports of spinal examinations done every year affect not only patients' health, but also their permission to be off work and their compensation. For this reason, it is our responsibility to know why errors are committed and how to detect them in order to avoid their repetition. In this article, we show the spectrum of the most common errors in our experience in double reading spinal examinations, and we try to determine what causes these errors.
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Affiliation(s)
| | - F Facal de Castro
- IberoRAD Teleradiología, Barcelona, España; Hospital General Universitario de Valencia, Valencia, España
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Kapur N, Parand A, Soukup T, Reader T, Sevdalis N. Aviation and healthcare: a comparative review with implications for patient safety. JRSM Open 2016; 7:2054270415616548. [PMID: 26770817 PMCID: PMC4710114 DOI: 10.1177/2054270415616548] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Safety in aviation has often been compared with safety in healthcare. Following a recent article in this journal, the UK government set up an Independent Patient Safety Investigation Service, to emulate a similar well-established body in aviation. On the basis of a detailed review of relevant publications that examine patient safety in the context of aviation practice, we have drawn up a table of comparative features and a conceptual framework for patient safety. Convergence and divergence of safety-related behaviours across aviation and healthcare were derived and documented. Key safety-related domains that emerged included Checklists, Training, Crew Resource Management, Sterile Cockpit, Investigation and Reporting of Incidents and Organisational Culture. We conclude that whilst healthcare has much to learn from aviation in certain key domains, the transfer of lessons from aviation to healthcare needs to be nuanced, with the specific characteristics and needs of healthcare borne in mind. On the basis of this review, it is recommended that healthcare should emulate aviation in its resourcing of staff who specialise in human factors and related psychological aspects of patient safety and staff wellbeing. Professional and post-qualification staff training could specifically include Cognitive Bias Avoidance Training, as this appears to play a key part in many errors relating to patient safety and staff wellbeing.
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40
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Abstract
Traditional surgical attitude regarding error and complications has focused on individual failings. Human factors research has brought new and significant insights into the occurrence of error in healthcare, helping us identify systemic problems that injure patients while enhancing individual accountability and teamwork. This article introduces human factors science and its applicability to teamwork, surgical culture, medical error, and individual accountability.
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Affiliation(s)
- James E Stein
- Children's Hospital Los Angeles, 4650 Sunset Blvd, MS 100, Los Angeles, California 90027.
| | - Kurt Heiss
- Children's Hospital Los Angeles, 4650 Sunset Blvd, MS 100, Los Angeles, California 90027
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41
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Zimmermann K, Holzinger IB, Ganassi L, Esslinger P, Pilgrim S, Allen M, Burmester M, Stocker M. Inter-professional in-situ simulated team and resuscitation training for patient safety: Description and impact of a programmatic approach. BMC MEDICAL EDUCATION 2015; 15:189. [PMID: 26511721 PMCID: PMC4625566 DOI: 10.1186/s12909-015-0472-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 10/22/2015] [Indexed: 05/21/2023]
Abstract
BACKGROUND Inter-professional teamwork is key for patient safety and team training is an effective strategy to improve patient outcome. In-situ simulation is a relatively new strategy with emerging efficacy, but best practices for the design, delivery and implementation have yet to be evaluated. Our aim is to describe and evaluate the implementation of an inter-professional in-situ simulated team and resuscitation training in a teaching hospital with a programmatic approach. METHODS We designed and implemented a team and resuscitation training program according to Kern's six steps approach for curriculum development. General and specific needs assessments were conducted as independent cross-sectional surveys. Teamwork, technical skills and detection of latent safety threats were defined as specific objectives. Inter-professional in-situ simulation was used as educational strategy. The training was embedded within the workdays of participants and implemented in our highest acuity wards (emergency department, intensive care unit, intermediate care unit). Self-perceived impact and self-efficacy were sampled with an anonymous evaluation questionnaire after every simulated training session. Assessment of team performance was done with the team-based self-assessment tool TeamMonitor applying Van der Vleuten's conceptual framework of longitudinal evaluation after experienced real events. Latent safety threats were reported during training sessions and after experienced real events. RESULTS The general and specific needs assessments clearly identified the problems, revealed specific training needs and assisted with stakeholder engagement. Ninety-five interdisciplinary staff members of the Children's Hospital participated in 20 in-situ simulated training sessions within 2 years. Participant feedback showed a high effect and acceptance of training with reference to self-perceived impact and self-efficacy. Thirty-five team members experiencing 8 real critical events assessed team performance with TeamMonitor. Team performance assessment with TeamMonitor was feasible and identified specific areas to target future team training sessions. Training sessions as well as experienced real events revealed important latent safety threats that directed system changes. CONCLUSIONS The programmatic approach of Kern's six steps for curriculum development helped to overcome barriers of design, implementation and assessment of an in-situ team and resuscitation training program. This approach may help improve effectiveness and impact of an in-situ simulated training program.
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Affiliation(s)
- Katja Zimmermann
- Department of Paediatrics, Children's Hospital Lucerne, CH-6000, Lucerne 16, Switzerland.
| | | | - Lorena Ganassi
- Department of Paediatrics, Children's Hospital Lucerne, CH-6000, Lucerne 16, Switzerland.
| | - Peter Esslinger
- Department of Paediatrics, Children's Hospital Lucerne, CH-6000, Lucerne 16, Switzerland.
| | - Sina Pilgrim
- University Children's Hospital Berne, Inselspital, CH-3000, Bern, Switzerland.
| | - Meredith Allen
- The Royal Children's Hospital, Flemington Road, Parkville, VIC, 3052, Australia.
| | | | - Martin Stocker
- Department of Paediatrics, Children's Hospital Lucerne, CH-6000, Lucerne 16, Switzerland.
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Fyhr A, Ternov S, Ek Å. From a reactive to a proactive safety approach. Analysis of medication errors in chemotherapy using general failure types. Eur J Cancer Care (Engl) 2015; 26. [PMID: 26239427 PMCID: PMC5298025 DOI: 10.1111/ecc.12348] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2015] [Indexed: 11/30/2022]
Abstract
A better understanding of why medication errors (MEs) occur will mean that we can work proactively to minimise them. This study developed a proactive tool to identify general failure types (GFTs) in the process of managing cytotoxic drugs in healthcare. The tool is based on Reason's Tripod Delta tool. The GFTs and active failures were identified in 60 cases of MEs reported to the Swedish national authorities. The most frequently encountered GFTs were defences, procedures, organisation and design. Working conditions were often the common denominator underlying the MEs. Among the active failures identified, a majority were classified as slips, one‐third as mistakes, and for a few no active failure or error could be determined. It was found that the tool facilitated the qualitative understanding of how the organisational weaknesses and local characteristics influence the risks. It is recommended that the tool be used regularly. We propose further development of the GFT tool. We also propose a tool to be further developed into a proactive self‐evaluation tool that would work as a complement to already incident reporting and event and risk analyses.
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Affiliation(s)
- A Fyhr
- Ergonomics and Aerosol Technology, Department of Design Sciences, Faculty of Engineering, Lund University, Lund, Sweden
| | | | - Å Ek
- Ergonomics and Aerosol Technology, Department of Design Sciences, Faculty of Engineering, Lund University, Lund, Sweden
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Greig PR, Higham H, Vaux E. Lack of standardisation between specialties for human factors content in postgraduate training: an analysis of specialty curricula in the UK. BMJ Qual Saf 2015; 24:558-60. [PMID: 26041812 DOI: 10.1136/bmjqs-2014-003684] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 05/15/2015] [Indexed: 11/03/2022]
Affiliation(s)
- Paul R Greig
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Helen Higham
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Emma Vaux
- Department of Renal Medicine, Royal Berkshire Hospital NHS Foundation Trust, Reading, UK Royal College of Physicians, London, UK
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Simsekler MCE, Card AJ, Ruggeri K, Ward JR, Clarkson PJ. A comparison of the methods used to support risk identification for patient safety in one UK NHS foundation trust. ACTA ACUST UNITED AC 2015. [DOI: 10.1177/1356262215580224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In healthcare, various methods are available to support risk identification in risk management process. However, there is no clear evidence on their contribution to risk identification. In this study, different methods used to support risk identification were therefore analysed to compare their contribution to overall risk identification. The study was conducted at Cambridge University Hospitals Foundation Trust, UK. Three main methods were selected to compare their support in risk identification: incident reports through their Risk Management Information System, risk registers through their Risk Registers system, and safety walkabouts through their internal patient safety assessment process. Where possible, simple comparison tests were run between the different methods of identifying risks as well as by the type of risks identified. It was found that each method has contributed to the risk identification by adding different sets of risk sources despite some overlaps. However, they produced discrete assessments from different aspects and none of them, on its own, could produce adequate results for effective risk identification. In any healthcare setting, having a system to put all risk information in one picture would help maximise the contribution of each method within the scope risk management process. Future studies may benefit from broader use of multiple and system-based risk identification approaches, and coding methods for more powerful analytical test.
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Affiliation(s)
- MC Emre Simsekler
- Department of Management Science and Innovation, University College London, London, UK
| | - Alan J Card
- Evidence-Based Health Solutions, LLC, Notre Dame, IN, USA
| | - Kai Ruggeri
- Engineering Department, Engineering Design Centre, University of Cambridge, Cambridge, UK
| | - James R Ward
- Engineering Department, Engineering Design Centre, University of Cambridge, Cambridge, UK
| | - P John Clarkson
- Engineering Department, Engineering Design Centre, University of Cambridge, Cambridge, UK
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45
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McKinley J, Dempster M, Gormley GJ. 'Sorry, I meant the patient's left side': impact of distraction on left-right discrimination. MEDICAL EDUCATION 2015; 49:427-435. [PMID: 25800303 DOI: 10.1111/medu.12658] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 07/11/2014] [Accepted: 10/21/2014] [Indexed: 06/04/2023]
Abstract
CONTEXT Medical students can have difficulty in distinguishing left from right. Many infamous medical errors have occurred when a procedure has been performed on the wrong side, such as in the removal of the wrong kidney. Clinicians encounter many distractions during their work. There is limited information on how these affect performance. OBJECTIVES Using a neuropsychological paradigm, we aim to elucidate the impacts of different types of distraction on left-right (LR) discrimination ability. METHODS Medical students were recruited to a study with four arms: (i) control arm (no distraction); (ii) auditory distraction arm (continuous ambient ward noise); (iii) cognitive distraction arm (interruptions with clinical cognitive tasks), and (iv) auditory and cognitive distraction arm. Participants' LR discrimination ability was measured using the validated Bergen Left-Right Discrimination Test (BLRDT). Multivariate analysis of variance was used to analyse the impacts of the different forms of distraction on participants' performance on the BLRDT. Additional analyses looked at effects of demographics on performance and correlated participants' self-perceived LR discrimination ability and their actual performance. RESULTS A total of 234 students were recruited. Cognitive distraction had a greater negative impact on BLRDT performance than auditory distraction. Combined auditory and cognitive distraction had a negative impact on performance, but only in the most difficult LR task was this negative impact found to be significantly greater than that of cognitive distraction alone. There was a significant medium-sized correlation between perceived LR discrimination ability and actual overall BLRDT performance. CONCLUSIONS Distraction has a significant impact on performance and multifaceted approaches are required to reduce LR errors. Educationally, greater emphasis on the linking of theory and clinical application is required to support patient safety and human factor training in medical school curricula. Distraction has the potential to impair an individual's ability to make accurate LR decisions and students should be trained from undergraduate level to be mindful of this.
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Affiliation(s)
- John McKinley
- Department of Neurology, Royal Victoria Hospital, Belfast, UK
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Johnston MJ, Arora S, King D, Bouras G, Almoudaris AM, Davis R, Darzi A. A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery. Surgery 2015; 157:752-63. [DOI: 10.1016/j.surg.2014.10.017] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/22/2014] [Accepted: 10/31/2014] [Indexed: 10/23/2022]
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Jenkins A, Wilkinson JV, Akeroyd MA, Broom MA. Distractions during critical phases of anaesthesia for caesarean section: an observational study. Anaesthesia 2014; 70:543-8. [DOI: 10.1111/anae.12979] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2014] [Indexed: 11/29/2022]
Affiliation(s)
- A. Jenkins
- Department of Anaesthesia; Princess Royal Maternity Hospital; Glasgow Royal Infirmary; Glasgow UK
| | - J. V. Wilkinson
- Department of Anaesthesia; Princess Royal Maternity Hospital; Glasgow Royal Infirmary; Glasgow UK
| | - M. A. Akeroyd
- MRC Institute of Hearing Research (Scottish Section); Glasgow Royal Infirmary; Glasgow UK
| | - M. A. Broom
- Department of Anaesthesia; Princess Royal Maternity Hospital; Glasgow Royal Infirmary; Glasgow UK
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48
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van Schoten SM, Baines RJ, Spreeuwenberg P, de Bruijne MC, Groenewegen PP, Groeneweg J, Wagner C. The ecometric properties of a measurement instrument for prospective risk analysis in hospital departments. BMC Health Serv Res 2014; 14:103. [PMID: 24589240 PMCID: PMC4233624 DOI: 10.1186/1472-6963-14-103] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 02/07/2014] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Safety management systems have been set up in healthcare institutions to reduce the number of adverse events. Safety management systems use a combination of activities, such as identifying and assessing safety risks in the organizational processes through retrospective and prospective risk assessments. A complementary method to already existing prospective risk analysis methods is Tripod, which measures latent risk factors in organizations through staff questionnaires. The purpose of this study is to investigate whether Tripod can be used as a method for prospective risk analysis in hospitals and whether it can assess differences in risk factors between hospital departments. METHODS Tripod measures risk factors in five organizational domains: (1) Procedures, (2) Training, (3) Communication, (4) Incompatible Goals and (5) Organization. Each domain is covered by 15 items in the questionnaire. A total of thirteen departments from two hospitals participated in this study. All healthcare staff working in the participating departments were approached. The multilevel method ecometrics was used to evaluate the validity and reliability of Tripod. Ecometrics was needed to ensure that the differences between departments were attributable to differences in risk at the departmental level and not to differences between individual perceptions of the healthcare staff. RESULTS A total of 626 healthcare staff completed the questionnaire, resulting in a response rate of 61.7%. Reliability coefficients were calculated for the individual level and department level. At the individual level, reliability coefficients ranged from 0.78 to 0.87, at the departmental level they ranged from 0.55 to 0.73. Intraclass correlations at the departmental level ranged from 3.7% to 8.5%, which indicate sufficient clustering of answers within departments. At both levels the domains from the questionnaire were positively interrelated and all significant. CONCLUSIONS The results of this study show that Tripod can be used as a method for prospective risk analysis in hospitals. Results of the questionnaire provide information about latent risk factors in hospital departments. However, this study also shows that there are indications that the method is not sensitive enough to detect differences between hospital departments. Therefore, it is important to be careful when interpreting differences in potential risks between departments when using Tripod.
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Affiliation(s)
- Steffie M van Schoten
- NIVEL – Netherlands Institute for Health Services Research, Otterstraat 118-124, PO Box 1568, Utrecht 3500 BN, Netherlands
| | - Rebecca J Baines
- Department of Public and Occupational Health & EMGO Institute for Health and Care Research, Vrije Universiteit Medical Center (VUmc), Amsterdam, The Netherlands
| | - Peter Spreeuwenberg
- NIVEL – Netherlands Institute for Health Services Research, Otterstraat 118-124, PO Box 1568, Utrecht 3500 BN, Netherlands
| | - Martine C de Bruijne
- Department of Public and Occupational Health & EMGO Institute for Health and Care Research, Vrije Universiteit Medical Center (VUmc), Amsterdam, The Netherlands
| | - Peter P Groenewegen
- NIVEL – Netherlands Institute for Health Services Research, Otterstraat 118-124, PO Box 1568, Utrecht 3500 BN, Netherlands
- Department of Sociology, Department of Human Geography, Utrecht University, Utrecht, Netherlands
| | - Jop Groeneweg
- Faculty of Social and Behavioural Sciences, Cognitive Psychology, Leiden University, Leiden, Netherlands
- TNO, Hoofddorp, Netherlands
| | - Cordula Wagner
- NIVEL – Netherlands Institute for Health Services Research, Otterstraat 118-124, PO Box 1568, Utrecht 3500 BN, Netherlands
- Department of Public and Occupational Health & EMGO Institute for Health and Care Research, Vrije Universiteit Medical Center (VUmc), Amsterdam, The Netherlands
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Reid JH. Violations and migrations perioperative practice: how organisational drift puts patients at risk. J Perioper Pract 2014; 24:45-49. [PMID: 24720056 DOI: 10.1177/175045891602400303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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50
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Chandran R, DeSousa KA. Human factors in anaesthetic crisis. World J Anesthesiol 2014; 3:203. [DOI: 10.5313/wja.v3.i3.203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Revised: 04/14/2014] [Accepted: 07/17/2014] [Indexed: 02/06/2023] Open
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