Dynamic monitoring of green credit risk using a hybrid gray correlation degree-TOPSIS method

Under the background of the new development pattern, the green credit market has ushered in a huge space for development. The monitoring and control of green credit risk is conducive to solving the negative impact of green credit risk and promoting the healthy development and smooth operation of the green credit market. This study first takes different provinces in China as samples; takes the data of government departments, financial institutions, enterprises, and other stakeholders as the monitoring content; and then uses the hybrid gray correlation degree-TOPSIS method to analyze. Next, this paper compares the green credit risk monitoring values of different regions at the same time and the same regions at different times. And it compares the green credit risk monitoring values of green finance pilot cities before and after the pilot. The research results show that there are obvious differences in eastern, central, and western regions in different time periods, and the green credit risk is also different in green finance pilot cities before and after the pilot. Stakeholders such as government departments, financial institutions, and enterprises need to take active measures to improve the efficiency of green credit risk management and achieve the sustainability of green credit development.

Occupational Exposure to Incidental Nanomaterials in Metal Additive Manufacturing: An Innovative Approach for Risk Management

The benefits of metal 3D printing seem unquestionable. However, this additive manufacturing technology brings concerns to occupational safety and health professionals, since recent studies show the existence of airborne nanomaterials in these workplaces. This article explores different approaches to manage the risk of exposure to these incidental nanomaterials, on a case study conducted in a Portuguese organization using Selective Laser Melting (SLM) technology. A monitoring campaign was performed using a condensation particle counter, a canning mobility particle sizer and air sampling for later scanning electron microscopy and energy dispersive X-ray analysis, proving the emission of nano-scale particles and providing insights on number particle concentration, size, shape and chemical composition of airborne matter. Additionally, Control Banding Nanotool v2.0 and Stoffenmanager Nano v1.0 were applied in this case study as qualitative tools, although designed for engineered nanomaterials. This article highlights the limitations of using these quantitative and qualitative approaches when studying metal 3D Printing workstations. As a result, this article proposes the IN Nanotool, a risk management method for incidental nanomaterials designed to overcome the limitations of other existing approaches and to allow non-experts to manage this risk and act preventively to guarantee the safety and health conditions of exposed workers.

A Classification System for the Sustainable Management of Contaminated Sites Coupled with Risk Identification and Value Accounting

Currently, site contamination is considered to be a sustained, international environmental challenge, and there is an urgent practical need to build a core theoretical system and technical methodology for the sustainable risk management of soil contamination, together with its prevention and control. We aim to improve the risk management of contaminated sites in the post-remediation era, in line with the current trend of sustainable development. The work is based on the theory of sustainability science and the eco-environmental zoning system., In this study, we build a conceptual model that can be used to classify the sustainable performance of contaminated sites in terms of risk management in line with the existing environmental management system for contaminated sites in China. To provide a scientific decision-making basis and technical support for the refined classification management of soil environments in China during the 14th Five-Year Plan period, five typical contaminated sites were selected for a quantitative evaluation by applying multi-technical approaches, including sociological, economic and statistical methods. The results showed that the sustainable performance of contaminated sites with regard to management was affected not only by pollution risk factors but also by potential utility benefits. Specified management strategies should be developed according to different levels of sustainability so as to achieve the goals of improving land use efficiency and enhancing urban functions.

Polychlorinated dibenzo-p-dioxins (PCDDs) and dibenzofurans (PCDFs) soil contamination in Lausanne, Switzerland: Combining pollution mapping and human exposure assessment for targeted risk management

In December 2020, high soil concentrations of polychlorinated dibenzo-p-dioxins (PCDDs) and dibenzofurans (PCDFs) were discovered across large parts of Lausanne, Switzerland. Concentrations reached up to 640 ng TEQ_WHO-2005/kg dry weight. The most likely source was a former municipal waste incinerator. A three-step, multidisciplinary approach to human health risk assessment was conducted to determine the potential population exposure to PCDD/Fs and identify appropriate preventive measures. First, exposure scenarios were developed based on contaminated land uses. Second, the toxicological risks of different scenarios were evaluated using a toxicokinetic model estimating increases in blood serum PCDD/F concentrations over background concentrations from the general population's food consumption. Third, a detailed geostatistical mapping of PCDD/F soil contamination was performed. Stochastic simulations with an external drift and an anisotropic model of the variogram were generated to incorporate the effects of distance from emission source, topography, and main wind directions on the spatial distribution of PCDD/Fs in topsoil. Three main scenarios were assessed: i) direct ingestion of soil by children in playgrounds; ii) consumption of vegetables from private gardens by children and adults; and iii) consumption of food from livestock and poultry raised on contaminated soil. The worst exposure scenario involved the consumption of eggs from private hen houses, resulting in PCDD/F concentrations in serum an order of magnitude higher than might normally be expected. No relevant increases in serum concentrations were calculated for direct soil ingestion and vegetable consumption, except for cucurbitaceous vegetables. Combining mapping and exposure scenario assessment resulted in targeted protective measures for land users, especially concerning food consumption. The results also raised concerns about the potential unsafe consumption of products derived from animals raised on land with PCDD/F concentrations only moderately over environmental background levels.

Perioperative corneal abrasions: A report of 42 cases from the webAIRS database

Corneal abrasions are an uncommon complication of anaesthesia. The aim of this study was to identify potential risk factors, treatment and outcomes associated with corneal abrasions reported to the web-based anaesthesia incident reporting system (webAIRS), a voluntary de-identified anaesthesia incident reporting system in Australia and New Zealand, from 2009 to 2021. There were 43 such cases of corneal abrasions reported to webAIRS over this period. The most common postoperative finding was a painful eye. Common features included older patients, individuals with pre-existing eye conditions, general anaesthesia and procedures longer than 60 minutes. Most cases were treated with a combination of lubricating eye drops or aqueous antibiotic eye drops. The findings indicate that patients who sustain a perioperative corneal abrasion can be reassured that in many cases it will heal within 48 hours, but they should seek earlier review if symptoms persist or deteriorate. None of the cases in this series resulted in permanent harm. Well established eye protective measures are important to utilise throughout the perioperative period, including the time until the patient has recovered in the post-anaesthesia care unit.

Validation of the Algorithmic Prediction of Failure Modes in Health Care Methodology: Applied to the Department of Sterile Supply and Equipment

Failure mode and effect analysis (FMEA) is a leading tool for risk management in health care. The term "blanket" approach FMEA describes a comprehensive simultaneous look at the variety of interrelated factors that may directly and indirectly affect patient safety. Applying FMEA with the "blanket" approach is not common, due to FMEA's limitations. Algorithmic prediction of failure modes in health care (APFMH) is leaner and enables the application of the "blanket" approach, but, like FMEA, it lacks formal validation. The authors set out to validate the APFMH method while applying a "blanket" approach. They analyzed the sterile supply handling at a 1900-bed academic medical center. The study's first step took place in the operating room (OR) aspect of the process. An APFMH analysis was performed using the "blanket" approach, to identify the hazards and define the common root causes for predicted hazards. The second step took place a year later at the sterile supply and equipment department (SSED) and aimed to validate these root causes, thus validating the reliability of APFMH. The "blanket" approach analysis with the APFMH method consisted of categorization into 3 risk-dimensions: patient safety, equipment damage, and time management. Root causes were defined for 8 high-ranking hazards. All the root causes for failures, identified by APFMH at the OR department, were revealed as actual hazards in the processes of the SSED. The independent findings at the SSED level validated the list of identified hazards that was formed at the target department (ie, the OR). APFMH methodology is a lean in time and human resources process that ensures comprehensive hazard analysis, which can include the "blanket" approach, and which was validated in this study. The authors suggest using the APFMH methodology for any organizational analysis method that requires the inclusion of "blanket" approaches.

Patient safety incidents in dentomaxillofacial imaging: reported adverse events from Hospital District Helsinki and Uusimaa and the City of Helsinki during 2012-2017

OBJECTIVES

Our study aimed to reveal the frequency of patient safety incidents (PSI) in dentomaxillofacial radiology (DMFR), including their mitigating and contributing factors, to help recognize and thus better prevent these adverse events (AE) in the future.

METHODS

Hospital District Helsinki and Uusimaa (HUS) and the City of Helsinki (HKI) use HaiPro, an anonymous web-based tool, for healthcare professionals to report PSI. Dentistry-related PSIs were evaluated individually to find any DMFR-related reports. Additionally, we searched the HaiPro-data using multiple dentistry- and DMFR-related keywords. We compartmentalized all DMFR-related PSI by their type and assessed their contributing factors, as well as their risk classification, severity, outcome, and possible corrective actions.

RESULTS

In HUS and HKI, 43 of the 195,589 HaiPro-reports filed during 2012-2017 were DMFR-related. The most prevalent event type of DMFR-related PSIs was laboratory-, medical imaging-, or other patient examination-related events (33%). The second most common event type was defined as being related to flow or control of information (26%). For both of these event types, the most common contributing factors were shortcomings of communication and flow of information. Risk classification showed only one AE to be of moderate risk, and all others were perceived as irrelevant or minor.

CONCLUSIONS

PSI in DMFR are only rarely reported, and mostly, they are perceived of causing little or no harm. We detected a great difference in reporting activity between primary and secondary healthcare workers, but the underlaying causes remain unclear.

Using Fish as a Sentinel in Risk Management of Contaminated Sediments

Sediments polluted by historical emissions from anthropogenic point sources are common in industrialized parts of the world and pose a potential threat to the function of aquatic ecosystems. Gradient studies using fish as a bioindicator are an option to assess the ecological impact of locally polluted areas. This study investigates the remaining effects of historical emissions on sediments outside ten Swedish pulp and paper mills using perch (Perca fluviatilis). The aim has been to obtain a general picture of the impact area of local deposits of cellulose fiber-rich sediments containing elevated levels of trace metals, e.g., Hg, and organochlorines, e.g., dioxins. In addition to analyzing contaminant levels in muscle and liver tissue, morphological measures in the fish that constitute biomarkers for health and reproductivity were measured. Another aim was to augment existing historical data sets to observe possible signs of environmental recovery. Overall, the results indicate only a minor elevation in contaminant levels and a minor impact on the fish health status in the polluted areas, which in several cases is an improvement from historical conditions. However, exceptions exist. Differences in the ecosystems' responses to pollution loads are primarily explained by abiotic factors such as water turnover rate, bottom dynamic conditions, and water chemistry. Weaknesses in the sampling methodology and processing of data were identified. After minor modifications, the applied survey strategy has the potential to be a management tool for decision-makers working on the remediation of contaminated areas.

Risk perception in the construction industry: A literature review and future research directions

BACKGROUND

Risk perception is an intuitive risk about hazards to which people are exposed daily and is related to several factors. In the construction context, there is a need to identify and understand how risk perception is related to these factors; construction companies can implement this information to develop measures for effective risk management.

OBJECTIVE

This literature review aims to identify recommendations for future research about factors that may be related to risk perception in construction workers.

METHODS

We used the SPIDER tool and searched available electronic databases for the most recent research articles published on risk perception in the construction area.

RESULTS

We identified main recommendations for future research: Behavior, environment and working conditions, risk assessment methods, culture, individual and demographic factors, and knowledge.

CONCLUSION

Safety behavior is the primary variable of concern in studies related to risk perception in the construction area. Therefore, further research is needed to identify the factors that intervene and impact risk perception to reduce accident rates among construction industry workers.

Gender Bias in Risk Management Reports Involving Physicians in Training - A Retrospective Qualitative Study

OBJECTIVE

Gender bias, which contributes to burnout and attrition of female medical trainees, may manifest as disparate workplace evaluations. Here, we explore gender-based differences in perceived competence and professionalism as described in an institutional electronic risk management reporting system.

DESIGN

In this retrospective qualitative study, recurring themes were identified from anonymous entries reported to an electronic institutional risk management database from July 2014 to July 2015, and from July 2019 to July 2020 using inductive methods. This electronic system is often used by hospital staff to document complaints against physicians under the pretext of poor patient care, regardless of whether an adverse event occurred. Two individuals independently coded entries. Themes were determined from event indicator codes (EIC) using Delphi methodology and compared between gender and specialty using bivariate statistics.

SETTING

A multi-center integrated healthcare delivery system.

PARTICIPANTS

Risk management entries pertaining to physician trainees by hospital staff as written submissions to the institution's electronic risk management reporting system. Main outcomes included themes defined as: (1) lack of professionalism (i.e., delay in response, attitude, lack of communication), (2) perceived medical error, (3) breach of institutional protocol.

RESULTS

Of the 207 entries included for analysis, 52 entries identified men (25%) and 31 entries identified women (15%). The gender was not available in 124 entries and, therefore, categorized as ambiguous. The most common complaint about men involved a physician-related EIC (n = 12, 23%, EIC TX39) and the most common complaint about women involved a communication-related EIC (n = 7, 23%, EIC TX55). Eighty-eight (43%) entries involved medical trainees; 82 (40%) involved surgical trainees. Women were more often identified by their name only (n = 8, 26% vs. n = 3, 6%; p < 0.001). This finding was consistent in both medical (n = 0, 0% vs. n = 5, 31%; p < 0.001) and surgical (n = 2, 7% vs. n = 3, 25%; p = 0.006) specialties. In entries involving women, a lack of professionalism was most frequently cited (n = 29, 94%). Entries identifying medical errors more frequently involved men (n = 25, 48% vs. n = 7, 23%; p = 0.02).

CONCLUSIONS

Gender-based differences exist in how hospital staff interpret trainees' actions and attitudes. These differences have consequences for training paradigms, perceptions of clinical competence, physician burnout, and ultimately, patient outcomes.

Characteristics, risk management and GMP standards of pharmaceutical companies in China

The Good Manufacturing Practice (GMP) is one of the gold standards by which governments worldwide judge modern pharmaceutical companies' production processes and product-safety standards. However, in all the nations, it is difficult to obtain real data about GMP inspection results, so conducting the related research is impossible. Taking advantage of a rare chance to obtain the on-site GMP inspection results in China, we have been able to initiate an empirical analysis of how company characteristics and risk management affect the GMP inspection results of certain pharmaceutical companies. The 2SLS method regression was employed in this study. Our four main findings are as follows. First, compared with Chinese state-owned companies, foreign commercial and private enterprises are held to higher standards. Second, the GMP inspection results tend to be better for those enterprises whose main sources of capital are not dependent on bank loans. Third, enterprises with higher fixed assets tend to receive the better GMP inspection results. Fourth, the longer the quality authorized staff has worked in a company, the better the GMP inspection results expected of that enterprise. These findings offer insights into inspections and production improvements in China and other GMP-compliant countries.

Preoperative Risk Management Programs at the Top 50 Orthopaedic Institutions Frequently Enforce Strict Cutoffs for BMI and Hemoglobin A1c Which May Limit Access to Total Joint Arthroplasty and Provide Limited Resources for Smoking Cessation and Dental Care

BACKGROUND

Performing elective orthopaedic surgery on patients with high BMI, poorly controlled hyperglycemia, and who use tobacco can lead to serious complications. Some surgeons use cutoffs for BMI, hemoglobin A1c, and cigarette smoking to limit surgery to patients with lower risk profiles rather than engaging in shared decision-making with patients about those factors. Other studies have suggested this practice may discriminate against people of lower income levels and women. However, the extent to which this practice approach is used by orthopaedic surgeons at leading hospitals is unknown.

QUESTIONS/PURPOSES

(1) How often are preoperative cutoffs for hemoglobin A1c and BMI used at the top US orthopaedic institutions? (2) What services are available at the top orthopaedic institutions for weight loss, smoking cessation, and dental care? (3) What proportion of hospital-provided weight loss clinics, smoking cessation programs, and dental care clinics accept Medicaid insurance?

METHODS

To investigate preoperative cutoffs for hemoglobin A1c and BMI and patient access to nonorthopaedic specialists at the top orthopaedic hospitals in the United States, we collected data on the top 50 orthopaedic hospitals in the United States as ranked by the 2020 US News and World Report 's "Best Hospitals for Orthopedics" list. We used a surgeon-targeted email survey to ascertain information regarding the use of preoperative cutoffs for hemoglobin A1c and BMI and availability and insurance acceptance policies of weight loss and dental clinics. Surgeons were informed that the survey was designed to assess how their institution manages preoperative risk management. The survey was sent to one practicing arthroplasty surgeon, the chair of the arthroplasty service, or department chair, whenever possible, at the top 50 orthopaedic institutions. Reminder emails were sent periodically to encourage participation from nonresponding institutions. We received survey responses from 70% (35 of 50) of hospitals regarding the use of preoperative hemoglobin A1c and BMI cutoffs. There was no difference in the response rate based on hospital ranking or hospital region. Fewer responses were received regarding the availability and Medicaid acceptance of weight loss and dental clinics. We used a "secret shopper" methodology (defined as when a researcher calls a facility pretending to be a patient seeking care) to gather information from hospitals directly. The use of deception in this study was approved by our institution's institutional review board. We called the main telephone line at each institution and spoke with the telephone operator at each hospital asking standardized questions regarding the availability of medical or surgical weight loss clinics, smoking cessation programs, and dental clinics. When possible, researchers were referred directly to the relevant departments and asked phone receptionists if the clinic accepted Medicaid. We were able to contact every hospital using the main telephone number. Our first research question was answered using solely the surgeon survey responses. Our second and third research questions were addressed using a combination of the responses to the surgeon surveys and specific hospital telephone calls.

RESULTS

Preoperative hemoglobin A1c cutoffs were used at 77% (27 of 35) of responding institutions and preoperative BMI cutoffs were used at 54% (19 of 35) of responding institutions. In the secret shopper portion of our study, we found that almost all the institutions (98% [49 of 50]) had a medical weight loss clinic, surgical weight loss clinic, or combined program. Regarding smoking cessation, 52% (26 of 50) referred patients to a specific department in their institution and 18% (9 of 50) referred to a state-run smoking cessation hotline. Thirty percent (15 of 50) did not offer any internal resource or external referral for smoking cessation. Regarding dental care, 48% (24 of 50) of institutions had a dental clinic that performed presurgical check-ups and 46% (23 of 50) did not offer any internal resource or external referral for dental care. In the secret shopper portion of our study, for institutions that had internal resources, we found that 86% (42 of 49) of weight loss clinics, 88% (23 of 26) of smoking cessation programs, and 58% (14 of 24) of dental clinics accepted Medicaid insurance.

CONCLUSION

Proceeding with TJA may not be the best option for all patients; however, surgeons and patients should come to this consensus together after a thoughtful discussion of the risks and benefits for that particular patient. Future research should focus on how shared decision-making may influence patient satisfaction and a patient's ability to meet preoperative goals related to weight loss, glycemic control, smoking cessation, and dental care. Decision analyses or time trade-off analyses could be implemented in these studies to assess patients' tolerance for risk.

CLINICAL RELEVANCE

Orthopaedic surgeons should engage in shared decision-making with patients to develop realistic goals for weight loss, glycemic control, smoking cessation, and dental care that consider patient access to these services as well as the difficulties patients experience in losing weight, controlling blood glucose, and stopping smoking.

Cybersecurity Risk Management Framework for Blockchain Identity Management Systems in Health IoT

Blockchain (BC) has recently paved the way for developing Decentralized Identity Management (IdM) systems for different information systems. Researchers widely use it to develop decentralized IdM systems for the Health Internet of Things (HIoT). HIoT is considered a vulnerable system that produces and processes sensitive data. BC-based IdM systems have the potential to be more secure and privacy-aware than centralized IdM systems. However, many studies have shown potential security risks to using BC. A Systematic Literature Review (SLR) conducted by the authors on BC-based IdM systems in HIoT systems showed a lack of comprehensive security and risk management frameworks for BC-based IdM systems in HIoT. Conducting a further SLR focusing on risk management and supplemented by Grey Literature (GL), in this paper, a security taxonomy, security framework, and cybersecurity risk management framework for the HIoT BC-IdM systems are identified and proposed. The cybersecurity risk management framework will significantly assist developers, researchers, and organizations in developing a secure BC-based IdM to ensure HIoT users' data privacy and security.

Proactive Risk Assessment through Failure Mode and Effect Analysis (FMEA) for Perioperative Management Model of Oral Anticoagulant Therapy: A Pilot Project

INTRODUCTION

Correct perioperative management of anticoagulant therapy is essential to prevent thromboembolic events and reduce the risk of bleeding. The lack of universally accepted guidelines makes perioperative anticoagulant therapy management difficult. The present study aims to identify the perioperative risks of oral anticoagulant therapy and to reduce adverse events through Failure Mode and Effect Analysis (FMEA).

MATERIALS AND METHODS

A multidisciplinary working group was set up, and four main phases of the process were identified. Each of these phases was divided into micro-activities to identify the related possible failure modes and their potential consequences. The Risk Priority Number was calculated for each failure mode.

RESULTS AND DISCUSSION

Seventeen failure modes were identified in the entire perioperative period; those with a higher priority of intervention concern the incorrect timing between therapy suspension and surgery, and the incorrect assessment of the bleeding risk related to the invasive procedure.

CONCLUSION

The FMEA method can help identify anticoagulant therapy perioperative failures and implement the management and patient safety of surgical procedures.

Urban Flood Risk Assessment Based on Dynamic Population Distribution and Fuzzy Comprehensive Evaluation

Floods are one of the most common natural disasters that can cause considerable economic damage and loss of life in many regions of the world. Urban flood risk assessment is important for urban flood control, disaster reduction, and risk management. In this study, a novel approach for assessing urban flood risk was proposed based on the dynamic population distribution, improved entropy weight method, fuzzy comprehensive evaluation method, and the principle of maximum membership, and the spatial distribution of flood risk in four different sessions or daily time segments (TS1-TS4) in the northern part of the Shenzhen River Basin (China) was assessed using geographic information system technology. Results indicated that risk levels varied with population movement. The areas of highest risk were largest in TS1 and TS3, accounting for 7.03% and 7.07% of the total area, respectively. The areas of higher risk were largest in TS2 and TS4, accounting for 4.54% and 4.64% of the total area, respectively. The findings of this study could provide a theoretical basis for assessing urban flood risk management measures in Shenzhen (and even throughout China), and a scientific basis for development of disaster prevention and reduction strategies by flood control departments.

Companion Rescue and Risk Management of Trekkers on the Everest Trek, Solo Khumbu Region, Nepal

BACKGROUND

Trekking to high-altitude locations presents inherent health-related hazards, many of which can managed with specific first aid (FA) training. This study evaluates the trip preparation, FA knowledge, and FA self-assessment of trekkers (organized by tour operators vs. individually planned tours). Data obtained shall be used for specific FA trip preparation and management of emergencies en route for this population.

METHODS

A total of 366 trekkers on the Everest Base Camp Trek, Nepal, were interviewed using a questionnaire specifically designed to evaluate their FA knowledge and management of emergencies. Data evaluation was performed using descriptive statistics.

RESULTS

A total of 40.5% of trekkers experienced at least one medical incident during their trip, of which almost 50% were due to acute mountain sickness (AMS). There was more AMS in commercially organized groups than in individually planned ones (55% vs. 40%). For more than 50%, no medical care was available during their trip. A total of 80% could answer only 3/21 FA questions completely correctly. Only 1% showed adequate knowledge concerning FA strategies. A total of 70% were willing to enroll in an FA class specialized towards the needs of trekkers.

CONCLUSIONS

The importance of high-altitude FA knowledge and trip preparation is widely underestimated. There is an unmet demand amongst trekkers for specific wilderness FA classes.

Malpractice Claims and Incident Reporting: Two Faces of the Same Coin?

Incident reporting is an important method to identify risks because learning from the reports is crucial in developing and implementing effective improvements. A medical malpractice claims analysis is an important tool in any case. Both incident reports and claims show cases of damage caused to patients, despite incident reporting comprising near misses, cases where no event occurred and no-harm events. We therefore compare the two worlds to assess whether they are similar or definitively different. From 1 January 2014 to 31 December 2021, the claims database of Policlinico Universitario A. Gemelli IRCCS collected 843 claims. From 1 January 2020 to 31 December 2021, the incident-reporting database collected 1919 events. In order to compare the two, we used IBNR calculation, usually adopted by the insurance industry to determine loss to a company and to evaluate the real number of adverse events that occurred. Indeed, the number of reported adverse events almost overlapped with the total number of events, which is indicative that incurred-but-not-reported events are practically irrelevant. The distribution of damage events reported as claims in the period from 1 January 2020 to 31 December 2021 and related to incidents that occurred in the months of the same period, grouped by quarter, was then compared with the distribution of damage events reported as adverse events and sentinel events in the same period, grouped by quarter. The analysis of the claims database showed that the claims trend is slightly decreasing. However, the analysis of the reports database showed that, in the period 2020-2021, the reports trend was increasing. In our study, the comparison of the two, malpractice claims and incident reporting, documented many differences and weak areas of overlap. Nevertheless, this contribution represents the first attempt to compare the two and new studies focusing on single types of adverse events are, therefore, desirable.

Primary healthcare providers challenged during the COVID-19 pandemic: a qualitative study

BACKGROUND

Primary healthcare (PHC) providers are widely acknowledged for putting the most efficient and long-lasting efforts for addressing community health issues and promoting health equity. This study aimed to explore PHC providers' experiences with coronavirus pandemic preparedness and response in Armenia.

METHODS

We applied a qualitative study design using semi-structured in-depth interviews and structured observation checklists. Study participants were recruited using theoretical and convenience sampling techniques throughout Armenia. Inductive conventional content analysis was utilized to analyze the in-depth interviews. Nineteen in-depth interviews were conducted with 21 participants. Observations took place in 35 PHC facilities. The data collected during the observations was analyzed using the "SPSS22.0.0.0" software.

RESULTS

Five main themes of primary healthcare providers' experiences were drawn out based on the study findings: 1) the gap in providers' risk communication skills; 2) uneven supply distributions; 3) difficulties in specimen collection and testing processes; 4) providers challenged by home visits; 5) poor patient-provider relationships. The results revealed that primary care providers were affected by uneven supply distribution throughout the country. The lack of proper laboratory settings and issues with specimen collection were challenges shaping the providers' experiences during the pandemic. The study highlighted the health systems' unpreparedness to engage providers in home visits for COVID-19 patients. The findings suggested that it was more challenging for healthcare providers to gain the trust of their patients during the pandemic. The study results also underlined the need for trainings to help primary care providers enhance their risk communication expertise or assign other responsible bodies to carry out risk communication on PHC providers' behalf.

CONCLUSION

The study discovered that PHC providers have a very important role in healthcare system's preparedness and response to handle public health emergencies such as the COVID-19 pandemic. Based on the findings the study team recommends prioritizing rural PHC development, ensuring appropriate supply distributions, developing comprehensive protocols on safe home visits and specimen collection and testing processes, and trainings PHC providers on risk communication, patient-centeredness, as well as proper use of personal protective equipment.

The Effect of a System-Level Tiered Huddle System on Reporting Patient Safety Events: An Interrupted Time Series Analysis

BACKGROUND

The objective of this research was to evaluate the effect of implementing a system-level tiered huddle system (THS) on the reporting of patient safety events into the official event reporting system.

METHODS

A quasi-experimental study using interrupted time series was conducted to assess the impact and changes to trends in the reporting of patient safety events pre- (February-July 2020; six months) and post- (September 2020-February 2021; six months) THS implementation within one health care system (238 clinics and 4 hospitals). The severity of harm was analyzed in July 2021 using a modified Agency for Healthcare Research and Quality (AHRQ) harm score classification. The primary outcome measure was the number of patient safety events reported per month. Secondary outcomes included the number of patient safety events reported per month by each AHRQ harm score classification.

RESULTS

The system-level THS implementation led to a significant and immediate increase in the total number of patient safety events reported per month (777.73, 95% confidence interval [CI] 310.78-1,244.68, p = 0.004). Similar significant increases were seen for reported numbers of unsafe conditions, near misses, no-harm events that reached patients, and temporary harm (p < 0.05 for each). Reporting of events with permanent harm and deaths also increased but was not statistically significant, likely due to the small number of reported events involving actual harm.

CONCLUSION

These findings suggest that system-level THS implementation may increase reporting of patient safety events in the official event reporting system.

Navigating Pregnancy for Employees in Civilian Rotary-Wing Aeromedicine

INTRODUCTION: Women of child-bearing age make up an ever-increasing element of the aeromedical workforce in Australia and the UK. However, policy relating to the management of risk for pregnant employees in this sector is often missing or inadequate, with many women facing detrimental impacts on their career progression and financial well-being. For women who choose to continue flying, there is a lack of transparent guidance about the risks of flying within a helicopter in an aeromedical role. While grounding pregnant employees removes some risks, it is at the cost of autonomy and brings other adverse effects for the employee and employer. Updated reflections on this important topic will empower the audience to make informed discussions around pregnancy in aeromedical roles.TOPIC: Applying principles from literature surrounding commercial, military, and medical aviation, the risks to pregnant employees and the fetus are reviewed. These risks are complex and dynamic depending on gestation and underlying medical problems; thus, individualization of risk management is of key importance. In low-risk pregnancies, incapacitation risk is below the usual threshold adopted for safety-sensitive aviation activities. Based on available evidence we have quantified risks where possible and provide guidance on the relevant factors to consider in creating a holistic risk-management framework. The greatest unknown surrounds the risk from vibration, noise, and winching. These are reviewed and suggestions given for discussing this risk. We also highlight the need for policy providing acceptable nonflying options to remove the pressure to continue flying in pregnancy.APPLICATION: Based on a literature review we have generated a framework for understanding and assessing risk relating to pregnant employees in the aeromedical sector. This is intended for use by aeromedical organizations, pregnant employees, and their treating medical practitioners to provide rational and sensible policy and guidance.Storey HM, Austin J, Davies-White NL, Ransley DG, Hodkinson PD. Navigating pregnancy for employees in civilian rotary-wing aeromedicine. Aerosp Med Hum Perform. 2022; 93(12):866-876.

Effect-based monitoring to integrate the mixture hazards of chemicals into water safety plans

Water safety plans (WSPs) are intended to assure safe drinking water (DW). WSPs involve assessing and managing risks associated with microbial, chemical, physical and radiological hazards from the catchment to the consumer. Currently, chemical hazards in WSPs are assessed by targeted chemical analysis, but this approach fails to account for the mixture effects of the many chemicals potentially present in water supplies and omits the possible effects of non-targeted chemicals. Consequently, effect-based monitoring (EBM) using in vitro bioassays and well plate-based in vivo assays are proposed as a complementary tool to targeted chemical analysis to support risk analysis, risk management and water quality verification within the WSP framework. EBM is frequently applied to DW and surface water and can be utilised in all defined monitoring categories within the WSP framework (including 'system assessment', 'validation', 'operational' and 'verification'). Examples of how EBM can be applied within the different WSP modules are provided, along with guidance on where to apply EBM and how frequently. Since this is a new area, guidance documents, standard operating procedures (SOPs) and decision-making frameworks are required for both bioassay operators and WSP teams to facilitate the integration of EBM into WSPs, with these resources being developed currently.

Safety culture in French nursing homes: A randomised controlled study to evaluate the effectiveness of a risk management intervention associated with care

BACKGROUND

French Nursing Homes (NHs) are in the early stages of implementing their Risk Management (RM) approach. A regional structure, which was mandated to provide independent support in RM, designed a training package.

OBJECTIVE

To study the impact of the RM training package on safety culture (SC) in NHs and drivers for improvement in SC scores.

METHOD AND ANALYSIS

This randomised controlled study targeted French NHs. Inclusion criteria were voluntary participation, no external support provided on the topic of adverse incidents upstream of the project, and the commitment of top management to its implementation. The 61 NHs were randomly allocated to one of two groups: the first benefited from a training package; support was given to the second after the impact measurement. Seven dimensions of SC were measured, at an 18-month interval, using the validated Nursing Home Survey on Patient Safety Culture questionnaire (22 items), which was administered to all of the professionals working in NHs. Eleven variables were captured, relating to the structural profile of the NH, the choices of top management in terms of healthcare safety, and the implementation of the system. Further modelling identified predictive factors for changes in SC scores.

RESULTS

95% of NHs completed both rounds of the questionnaire. The dimension Feedback and communication about incidents (SC = 85.4% before the intervention) significantly improved (+2.8%; p = 0.044). Improvement in the dimension Overall perceptions of resident safety-organizational learning was close to significant (+3.1%; p = 0.075). Drivers for improvement in scores were a pre-existing quality improvement approach, and a steering group that showed RM leadership.

CONCLUSIONS

The system appears to have improved several dimensions of SC. Our findings are all the more important given the current crisis in the healthcare sector.

TRIAL REGISTRATION

Retrospectively registered as NCT02908373 (September 21, 2016).

Nationwide survey on Japanese residents' experience with and barriers to incident reporting

The ability of any incident reporting system to improve patient care is dependent upon robust reporting practices. However, under-reporting is still a problem worldwide. We aimed to reveal the barriers experienced while reporting an incident through a nationwide survey in Japan. We conducted a cross-sectional survey. All first- and second-year residents who took the General Medicine In-Training Examination (GM-ITE) from February to March 2021 in Japan were selected for the study. The voluntary questionnaire asked participants regarding the number of safety incidents encountered and reported within the previous year and the barriers to reporting incidents. Demographics were obtained from the GM-ITE. The answers of respondents who indicated they had never previously reported an incident (non-reporting group) were compared to those of respondents who had reported at least one incident in the previous year (reporting group). Of 5810 respondents, the vast majority indicated they had encountered at least one safety incident in the past year (n = 4449, 76.5%). However, only 2724 (46.9%) had submitted an incident report. Under-reporting (more safety incidents compared to the number of reports) was evident in 1523 (26.2%) respondents. The most frequently mentioned barrier to reporting an incident was the time required to file the report (n = 2622, 45.1%). The barriers to incident reporting were significantly different between resident physicians who had previously reported and those who had never previously reported an incident. Our study revealed that resident physicians in Japan commonly encounter patient safety incidents but under-report them. Numerous perceived and experienced barriers to reporting remain, which should be addressed if incident reporting systems are to have an optimal impact on improving patient safety. Incident reporting is essential for improving patient safety in an institution, and this study recommends establishing appropriate interventions according to each learner's barriers for reporting.

Research on Risk and Resilience Evaluation of Urban Underground Public Space

High urban density, land scarcity, rapid population growth, and traffic congestion have restricted urban development. In response, selected multiple functions have increasingly been integrated into the underground public space (UPS) to maximize the 3D utilization of precious urban space. The accelerated intensity of UPS use has alerted safety concerns. UPS with enclosed and confined natures, complex building structures, locations usually in cramped areas, and limited emergency exits are potentially more prone to heavy casualties and losses in natural or human-made disasters. As research on UPS safety is limited and focused on single risks, we attempted to fill the knowledge gap by developing an integrated risk analysis of UPS to understand risk resilience and improve risk management. From the perspective of the UPS system, four latent factors were identified: natural environment, economic environment, facilities and equipment, and physical structure. Seventeen resilience indicators subsumed under the factors were selected based on resilience concepts. A questionnaire was designed to gather opinions on the relative importance rating of the resilience indicators. SPSS and AMOS software were enlisted to build a structural equation model (SEM), validate the data and model, and calculate the path coefficients and index weights to test four hypotheses. The SEM model results were employed to develop a holistic resilience enhancement strategy under a four-phase framework: before, during, after, and long-term, and under four latent factors. The resilience enhancements can optimize UPS disaster prevention, rescue and evacuation, mitigation, and response management.

Use of Failure Mode and Effects Analysis (FMEA) for Risk Analysis of Drug Use in Patients with Lung Cancer

It is crucial to investigate the risk factors inherent in the medication process for cancer patients since improper antineoplastic drug use frequently has serious consequences. As a result, the Severity, Occurrence, and Detection rate of each potential failure mode in the drug administration process for patients with lung cancer were scored using the Failure Mode and Effect Analysis (FMEA) model in this study. Then, the risk level of each failure mode and the direction of improvement were investigated using the Slacks-based measure data envelopment analysis (SBM-DEA) model. According to the findings, the medicine administration process for lung cancer patients could be classified into five links, with a total of 60 failure modes. The risk of failure modes for patient medication and post-medication monitoring ranked highly, with unauthorized use of traditional Chinese medicine and folk prescription and unauthorized drug addition (incorrect self-medication) ranking first (1/60); doctor prescription was also prone to errors. The study advises actively looking at ways to decrease the occurrence and difficulty of failure mode detection to continually enhance patient safety when using medications.

Assessment of Glucose Lowering Medications' Effectiveness for Cardiovascular Clinical Risk Management of Real-World Patients with Type 2 Diabetes: Targeted Maximum Likelihood Estimation under Model Misspecification and Missing Outcomes

The results from many cardiovascular (CV) outcome trials suggest that glucose lowering medications (GLMs) are effective for the CV clinical risk management of type 2 diabetes (T2D) patients. The aim of this study is to compare the effectiveness of two GLMs (SGLT2i and GLP-1RA) for the CV clinical risk management of T2D patients in a real-world setting, by simultaneously reducing glycated hemoglobin, body weight, and systolic blood pressure. Data from the real-world Italian multicenter retrospective study Dapagliflozin Real World evideNce in Type 2 Diabetes (DARWINT 2D) are analyzed. Different statistical approaches are compared to deal with the real-world-associated issues, which can arise from model misspecification, nonrandomized treatment assignment, and a high percentage of missingness in the outcome, and can potentially bias the marginal treatment effect (MTE) estimate and thus have an influence on the clinical risk management of patients. We compare the logistic regression (LR), propensity score (PS)-based methods, and the targeted maximum likelihood estimator (TMLE), which allows for the use of machine learning (ML) models. Furthermore, a simulation study is performed, resembling the structure of the conditional dependencies among the main variables in DARWIN-T2D. LR and PS methods do not underline any difference in the effectiveness regarding the attainment of combined CV risk factor goals between the two treatments. TMLE suggests instead that dapagliflozin is significantly more effective than GLP-1RA for the CV risk management of T2D patients. The results from the simulation study suggest that TMLE has the lowest bias and SE for the estimate of the MTE.

Using Grounded Theory to Identify Online Public Opinion in China to Improve Risk Management-The Case of COVID-19

BACKGROUND

During the outbreak of COVID-19, online public opinion related to the epidemic was rapidly generated and developed rapidly. If some online public opinions cannot be effectively responded to and guided, it will bring risks to social order. The government should understand how to use information on social media to grasp public demands, provide useful information in a timely manner and take countermeasures. Studying the formation mechanism of online public opinion during the outbreak can help the government make scientific decisions and improve risk management capabilities.

METHODS

The research selects the public opinion information of online platforms represented by WeChat, online communities, Sina Weibo and search engines, involving 75 relevant texts (1 January to 31 March 2022). According to the grounded theory method, using the QSR NVivo12 qualitative research software, the collected network texts were successively researched using open coding, axial coding and theoretical coding.

RESULTS

The structure of online public opinion during the COVID-19 epidemic was obtained. The operation mechanism of the online public opinion system about COVID-19 was mainly affected by the interaction of online public opinion objects, online public opinion subjects, online public opinion intermediaries and government forces. It was based on social facts and citizens' appeals as the starting point, subject behaviors and prevention and control measures as the focus, government's governance as macro-control and citizens' evaluation as the guide.

CONCLUSIONS

Scientific analysis of online public opinion is an important tool to identify and manage risks and improve the quality of government activities. Online public opinion has the function of assisting government decision-making, and the government can identify the important information reflected in it, especially the mainstream public opinion, as a reference for decision-making. By taking effective measures and properly responding to citizens' reasonable demands, the government can prevent social risks and avoid new negative public opinions. Contributions: According to the characteristics of the basic model of online public opinion, this study provides risk mitigation suggestions for Chinese public sectors to use online public opinion, optimize epidemic prevention policies and formulate strategic measures.

[Risk assessment and management: between epidemiology and social acceptability]

Risk is a well-known concept in medicine and in epidemiology and its approach intend to be rational and measurable. Risk measurement makes it possible to communicate with a patient or a population the risk of occurrence of an event. However, it is often difficult to estimate accurately the probability of occurrence of an adverse event and there is therefore uncertainty. In addition, the notion of risk is not easy to grasp for most people. The same risk can be perceived very differently from one individual to another and this perception and understanding depends on psychological, social, cultural, historical and political factors. Understanding this social dimension of risk in clinical practice or in public health is essential to implement efficient risk management.

[Implications for risk management of foodborne pathogens in China from the outbreak of monophasic salmonella enterica serovar Typhimurium contaminated chocolate products]

Outbreaks caused by highly industrialized food companies are characterized by cross-border, trans-regional, rapid and unpredictable, related to serious disease and economic burden. A cluster of cases with monophasic salmonella enterica serovar Typhimurium ST34 infection suspected to be associated with consumption of contaminated chocolate products have been reported in several Europe countries since December 2021. After retrospective investigations, the buttermilk circuit in the Belgian factory was suspected to be the point of origin of the contamination. This outbreak could provide a reference for the risk management of foodborne pathogens contamination in China. The objective of this paper was to summarize the process and characteristics of the outbreak of monophasic S. Typhimurium caused by contaminated chocolate products, analyze the characteristics of ST34 monophasic S. Typhimurium and the microbial management measures in the process of chocolate products, and systematically discuss the suggestions for the risk management of foodborne pathogens contamination and countermeasures for the rapid development of industrialization of food enterprises in China, in order to provide scientific and technological support for the prevention and control, prediction and early warning of sudden cases in China.

Medication safety in the perioperative setting: A comparison of methods for detecting medication errors and adverse medication events

The purpose of this study was to evaluate perioperative medication-related incidents (medication errors (MEs) and/or adverse medication events (AMEs)) identified by 2 different reporting methods (self-report and direct observation), and to compare the types and severity of incidents identified by each method. We compared perioperative medication-related incidents identified by direct observation in Nanji et al's 2016 study[1] to those identified by self-report via a facilitated incident reporting system at the same 1046-bed tertiary care academic medical center during the same 8-month period. Incidents, including MEs and AMEs were classified by type and severity. In 277 operations involving 3671 medication administrations, 193 MEs and/or AMEs were observed (5.3% incident rate). While none of the observed incidents were self-reported, 10 separate medication-related incidents were self-reported from different (unobserved) operations that occurred during the same time period, which involved a total of 21,576 operations and approximately 280,488 medication administrations (0.004% self-reported incident rate). The distribution of incidents (ME, AME, or both) did not differ by direct observation versus self-report methodology. The types of MEs identified by direct observation differed from those identified by self-report (P = .005). Specifically, the most frequent types of MEs identified by direct observation were labeling errors (N = 37; 24.2%), wrong dose errors (N = 35; 22.9%) and errors of omission (N = 27; 17.6%). The most frequent types of MEs identified by self-report were wrong dose (N = 5; 50%) and wrong medication (N = 4; 40%). The severity of incidents identified by direct observation and self-report differed, with self-reported incidents having a higher average severity (P < .001). The procedure types associated with medication-related incidents did not differ by direct observation versus self-report methodology. Direct observation captured many more perioperative medication-related incidents than self-report. The ME types identified and their severity differed between the 2 methods, with a higher average incident severity in the self-reported data.

Approaches to managing work-related fatigue to meet the needs of American workers and employers

On September 13-14, 2019, the National Institute for Occupational Safety and Health (NIOSH) hosted a national forum entitled "Working hours, sleep and fatigue: Meeting the needs of American workers and employers." The purpose of this inaugural meeting was to discuss current evidence about the broad-based risks and effective countermeasures related to working hours, sleep, and fatigue, with further considerations to tailor solutions for specific industries and worker populations. We aimed to identify the knowledge gaps and needs in this area and future directions for research. We also sought to identify similarities across industries with the goal of sharing lessons learned and successful mitigation strategies across sectors. Participants included an international representation of academics, scientists, government representatives, policymakers, industry leaders, occupational health and safety professionals, and labor representatives. A total of eight manuscripts were developed following stakeholder comments and forum discussions. Six focused on sector-specific approaches (i.e., Agriculture, Forestry & Fishing; Healthcare & Social Assistance; Mining; Oil and Gas Extraction; Public Safety; Transportation, Warehousing & Utilities) to identify unique factors for fatigue-risk and effective countermeasures. Two additional manuscripts addressed topic areas that cut across all industries (disproportionate risks, and economic evaluation). Findings from the Forum highlight that the identification of common risk factors across sectors allows for transfer of information, such as evidence for effective mitigation strategies, from sectors where fatigue risk has been more widely studied to those sectors where it has been less so. Further considerations should be made to improve knowledge translation activities by incorporating different languages and modes of dissemination such that information is accessible for all workers. Additionally, while economic evaluation can be an important decision-making tool for organizational- and policy-level activities, multi-disciplinary approaches combining epidemiology and economics are needed to provide a more balanced approach to economic evaluation with considerations for societal impacts. Although fatigue risk management must be tailored to fit industries, organizations, and individuals, knowledge gained in this forum can be leveraged, modified, and adapted to address these variabilities. Our hope is to continue sharing lessons learned to encourage future innovative, multi-disciplinary, cross-industry collaborations that will meet the needs of workers and employers to mitigate the risks and losses related to workplace fatigue.

Strategies to be prepared for a risk communication crisis

This introductory article describes a multistep process for communicating complex information from the perspective of the communicator. As part of the introduction to a special issue, it suggests three premises grounded in the literature and practice. One is an organization cannot risk communicate its way out of problems created by poor risk assessment and risk management. Second, poor risk communication can undermine satisfactory risk assessment and management. Third, a proactive plan grounded in risk analysis is essential and implemented with periodic training exercises. The article presents a step-by-step communication planning process that has been used in the field. Much of the special issue is devoted to the experiences of practitioners and communication experts in successfully communicating and listening to government and private organization representatives, media representatives, and the public about complex risk issues, focusing on nuclear-related ones. The goal is to add to our collective experience on practices that work and do not work under the many conditions that involve risk communications. The ground is changing under risk communication because of the rapid expansion of media sources and technologies. What worked a decade ago may no longer be best practice. Common to success across media and audience is the need for a planning process that is adaptable to changing conditions.

How Risk Management During COVID-19 Influences Eldercare Personnel's Perceptions of Their Work Environment

OBJECTIVE

To investigate the association between workplace COVID-19 (coronavirus disease 2019) risk management and eldercare workers' perception of their social environment at work.

METHODS

Cross-sectional questionnaire data from 952 participants were collected by the Danish labor union, FOA, and analyzed using multinomial logistic regression.

RESULTS

Unclear guidelines, insecurity regarding organization of work, lack of attention to vulnerable employees, and lack of instruction in the use of personal protective equipment were associated with perceived negative changes in the social environment at work. Also, higher local incidence rates of SARS-CoV-2 infections were associated with a weaker sense of community (odds ratio, 1.18; 95% confidence interval, 1.04-1.36).

CONCLUSIONS

These findings indicate that risk management is important not only for prevention of infection but also for individual and workplace resilience toward external demands and health threats.

[Impact of the COVID-19 pandemic on patient safety incident and medication error reporting systems]

BACKGROUND AND AIM

To determine the impact of the COVID-19 pandemic on the epidemiology of safety incidents (SI) and medication errors (ME) reported to the CISEMadrid notification system in the hospital and primary care settings of the Madrid Health Service (SERMAS).

MATERIALS AND METHODS

Observational and descriptive study with a retrospective analysis of data including all CISEMadrid notifications from 01-Jan-2018 to 31-Dec-2020, from 33 hospitals and 262 health care centres of the SERMAS. The two periods in 2020 with the greatest increase in COVID-19 cases were identified to compare incidents reported in the pre-pandemic and pandemic periods.

RESULTS

36,494 incidents were reported. Comparing both periods, an overall decrease in pandemic notifications of 60.7% was observed, being higher in primary care, falling to 33% of previous levels. The reduction in notifications was similar in the peaks and valleys of the waves. The three most frequent SIs in both periods and care settings were: diagnostic tests, medical devices/equipment/clinical furniture and organisational management/citations. In ME, dose failure and inappropriate selection were the most frequent in both settings and periods. There were no relevant differences in patient consequences in both periods.

CONCLUSIONS

During the pandemic, patient safety notifications decreased although the most frequent types remained the same, as did their impact on the patient, both in hospitals and in primary care. The safety culture of organisations is a critical aspect for the maintenance of reporting systems.

Use of systematic evidence maps within the US environmental protection agency (EPA) integrated risk information system (IRIS) program: Advancements to date and looking ahead

Systematic evidence maps (SEMs) are increasingly used to inform decision-making and risk management priority-setting and to serve as problem formulation tools to refine the focus of questions that get addressed in full systematic reviews. Within the U.S. Environmental Protection Agency (EPA) Office of Research and Development (ORD) Integrated Risk Information System (IRIS), SEMs have been used to inform data gaps, determine the need for updated assessments, inform assessment priorities, and inform development of study evaluation considerations, among other uses. Increased utilization of SEMs across the environmental health field has the potential to increase transparency and efficiency for data gathering, problem formulation, read-across, and evidence surveillance. Use of the SEM templates published in the companion text (Thayer et al.) can promote harmonization in the environmental health community and create more opportunities for sharing extracted content.

How Informed Is Your Informed Consent: Evaluating Differences Between Resident and Attending Obtained Consents for Cholecystectomy

OBJECTIVE

There is considerable variability in surgeons' approach to write and obtain informed consent for surgery, particularly among resident trainees. We analyzed differences in procedures and complications described in documented surgical consents for cholecystectomy between residents and attendings. We hypothesized that attending consents would describe more comprehensive procedures and complications than those done by residents.

DESIGN

This is a retrospective analysis of 334 patients who underwent cholecystectomy. Charts were queried for demographics, surgical approach, whether the consent was completed electronically, and which provider completed the consent. Specifically, consents were evaluated for inclusion of possible conversion to open procedure, intraoperative cholangiogram, bile duct injury, injury to nearby structures, reoperation, bile leak, as well as if the consent matched the actual procedure performed.

SETTING

This study was conducted at an accredited general surgery training program at an academic tertiary care center in the Midwest.

PARTICIPANTS

This was a review of 334 patients who underwent cholecystectomy over a 1 year period.

RESULTS

Of all documented consents analyzed, 153 (47%) specifically included possible intraoperative cholangiogram, 156 (47%) included bile duct injury, 76 (23%) included injury to nearby structures, 22 (7%) included reoperation, and 62 (19%) included bile leak. In comparing residents and attendings, residents were more likely to consent for bile duct injury (p = 0.002), possible intraoperative cholangiogram (p = 0.0007), injury to nearby structures (p < 0.0001), reoperation (p < 0.0001), and bile leak (p < 0.0001).

CONCLUSIONS

Significant variation exists between documentation between resident and attending cholecystectomy consents, with residents including more complications than attendings on their consent forms. These data suggest that experience alone does not predict content of written consents, particularly for common ambulatory procedures. Education regarding the purpose of informed consent and what should be included in one may lead to a reduction in variability between providers.

Information needs, approaches, and case studies in human health risk communication

This article uses ten case studies to illustrate the information needs, various communication approaches, and the communicator's role in explaining environmental health risks from a variety of hazards, to a variety of audiences, over time frames from days to years, using in person consultation, lectures, zooms, and email formats. Events often had a long history before the communication began and may have had a long tail afterward. Audiences may be public officials, companies, workers, communities, or individuals. Each individual may have their own understanding or mental model regarding the hazard, exposure, and risk. The communicator's role or intention may be to reassure an audience that has unrealistic exaggerated concerns or fears or to protect a client if the fears are realistic. Or it may be altruistic to inform a complacent audience to take the risks it faces more seriously. Although risk assessment research has advanced the techniques for communicating abstruse probabilities to audiences with low numeracy, in my experience, audiences are unimpressed by precise-sounding probability numbers, and are more interested in whether exposure is occurring or may occur and how to stop it. Often audiences have reason to be outraged and may be more concerned about punishing wrong doers than about the hazard itself, particularly when the exposure is past and cannot be undone. Thus, there is a difference between discussing the riskiness of a situation (risk communication) and what you are going to do about the situation (risk management). Risk communication is successful when the audience responds as intended, calming down or taking action. These case studies are drawn from a large number of risk communication experiences that I and my Rutgers colleagues have engaged in over the past four decades. Through the 20th century, New Jersey was the most densely industrialized State in United States. New Jersey experienced growth of the chemical and petrochemical industries and the unfortunately profligate disposal of toxic wastes. Having the most Superfund sites of any state is a dubious distinction, but New Jersey also has the most experience in evaluating and responding to these hazards.

Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation, and risk management

Suicide prevention in psychiatric practice has been dominated by efforts to predict risk of suicide in individual patients. However, traditional risk prediction measures have been shown repeatedly in studies from high income countries to be ineffective. Several factors might contribute to clinicians' preoccupation with risk prediction, which can have negative effects on patient care and also on clinicians where prediction is seen as failing. The model of therapeutic risk assessment, formulation, and management we outline in this article regards all patients with mental health problems as potentially at increased risk of suicide. It is aimed at reducing risk through use of a person-centred approach. We describe how a move towards therapeutic risk assessment, formulation, and risk management, including collaborative safety planning, could help clinicians develop a more tailored approach to managing risk for all patients, incorporating potentially therapeutic effects as well as helping to identify other risk reduction interventions. Such an approach could lead to enhanced patient safety and quality of care, which is more acceptable to patients.

Empowering Indigenous natural hazards management in northern Australia

Northern Australia is prone to recurring severe natural hazards, especially frequent cyclones, flooding, and extensive wildfires. The region is sparsely populated (≪ 0.5 persons km^-2), with Indigenous (Aboriginal) residents comprising 14% of the population, and typically the majority in remote regions. Despite national policy committed to addressing emergency management (EM) in vulnerable Indigenous communities, implementation remains unfunded. We synthesise participatory intercultural research conducted over seven years exploring core challenges, opportunities and potential solutions towards developing effective EM partnerships. Similar EM engagement and empowerment issues face First Nations and local communities in many international settings. In search of solutions, we explore developing effective partnership arrangements between EM agencies and culturally diverse Indigenous communities. Observing that government already provides substantial investment in cultural and natural resource management programmes conducted by over 150 Indigenous Ranger Groups (IRGs) nationally, we demonstrate that expansion of IRG roles to incorporate EM community engagement and service delivery can provide multiple cost-effective community and business development benefits for many remote communities.

Consent and the requirement for accessible information

Richard Griffith, Senior Lecturer in Health Law at Swansea University, considers the importance of accessible information when obtaining consent from patients.

Original Research: How Will the TNFD Impact the Health Sector's Nature-Risks Management?

The G20-led TNFD taskforce or TNFD is under development and should be ready in September 2023. With one year to go before its official release, the study of the beta versions of the 0.2 framework is crucial to know the strategy of the taskforce regarding metrics and sectors with high natural risks. Its big sister, the Taskforce on Climate-related Financial Disclosure or TCFD, had defined the health sector as a non-key in terms of climate change and carbon risks, but the TNFD decided that it was a priority in terms of nature-related risks and co-dependencies. This research therefore focuses on the innovations of the TNFD and its impact on future disclosures in the sector. The goal being to predict if the TNFD will lead to more disclosures and therefore better risk management from the health firms. To complete this research, the analysis of the sector's risks and dependencies on nature-related issues and biodiversity loss was essential. To do so, a policy analysis on the framework of the TNFD was conducted, as well as a literature review on nature related risks and opportunities for the health sector. The Health Sector-Wide Approach (SWAp) was analysed to highlight the Task Force's focus on the health sector. Finally, a due diligence of the TNFD's stakeholders and partners was carried out to ascertain the interest and participation of health sector actors in the TNFD. Results have shown that Nature risks were important for the sector and that the TNFD was giving more importance to the sector in terms of priority. On the contrary, the health sector does not show an improved interest in this new taskforce. There is a need for more research in the implementation of Nature-financial metrics for disclosures.

The Barriers and Enhancers to Trust in a Just Culture in Hospital Settings: A Systematic Review

OBJECTIVES

Healthcare workers wanting to report errors often encounter a culture of fear or blame. A just culture can improve patient safety by promoting safe and open communication, trust is hereby essential. We defined trust in a just culture when healthcare professionals believe that error communication is honest, safe, and reliable. In this study, we investigated barriers and enhancers to trust in error reporting in a just culture.

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PubMed, Embase, Emcare, and Web of Science database were searched on June 21, 2021.

RESULTS

Several factors were found to influence trust in error reporting in a just culture, namely, organizational factors, team factors, and experience. Trust depends on the management style, open information about error handling, a focus on patient safety instead of blaming an individual, a well-executed walk-round, a code of professionalism, and a departmental incident reporting system (organizational factors). A close relationship between employee and primary supervisor, with discussion of the nature of an error and ascribing clear roles to physicians in care teams, can be enhancers of trust in error reporting. Moreover, creating a mutual understanding of the challenges faced by professionals can enhance trust (team factors). Trust in error reporting is also influenced by a health professional's experience and training in patient safety. Factors such as a lack of confidence in clinical skills, more fear of shame/blame by less experienced workers, and knowledge of the existing error reporting system will influence a person's trust in error reporting (experience).

CONCLUSIONS

This systematic review identified barriers and enhancers to trust in error reporting in a just culture. The barriers and enhancers can be divided into 3 main themes: organizational factors, team factors, and experience. Findings show that trust can be learned and created based on practical principles.

Toward Zero Harm: Mackenzie Health's Journey Toward Becoming a High Reliability Organization and Eliminating Avoidable Harm

OBJECTIVES

In response to an organizational survey revealing low safety culture scores, we implemented a "zero harm" approach to eliminate preventable harm across a wide variety of clinical areas. We aimed to achieve this objective within 3 years.

METHODS

We developed a 5-part strategy for cultural and process redesign that included (1) engaging leadership; (2) developing an organization-specific patient safety framework; (3) monitoring specific quality aims based on high-risk, high-volume, high-cost, and problem-prone areas; (4) standardizing a 3-part review process that includes a root cause analysis for moderate and critical patient safety incidents; and (5) communicating progress to staff in real time via unit-specific electronic dashboards.

RESULTS

In less than 1 year, we increased patient safety incident reporting by 37% while simultaneously decreasing falls with injury by 39%, pressure injury rates by 37%, and central line-associated blood stream infections by 34%. We also improved medication reconciliation rate by 3.3% and decreased our irretrievable specimen rate to 0. Finally, we noted increased awareness around patient safety within clinical teams, with open discussions about patient safety becoming a routine part of patient care.

CONCLUSIONS

This study describes an initiative that sought to introduce system-wide changes to practice and patient safety culture in a rapid time frame. Results suggest that our 5-step approach to transformation may confer substantial gains in patient safety for peer institutions. Next steps include continuing to expand and monitor quality aims as we progress through our journey to eliminating preventable patient harm in our healthcare system.