Good Catch Campaign: Improving the Perioperative Culture of Safety

What is known about near miss events in the operating room? A systematic review of studies of mixed methods design

BACKGROUND

A near miss event (NME) in healthcare is an event that did not happen but would have caused serious harm if it did. The operating room (OR) is prone to risk and incidents, with estimates that 50% of all hospital adverse events occur in the OR, yet reporting of NME is uncommon in the OR.

OBJECTIVE

To carry out a systematic review of studies with mixed methods to establish what is known about NME reporting in the OR.

METHOD

Inclusion criteria will be those studies of mixed methods design, which have been conducted in the OR, with teams of surgeons, anaesthetists or nurses alone or in any combination. Using a publication timeframe of 2001-2023, the following databases were searched: Medline (OVID), CINAHL, Pubmed and Google Scholar. Selected papers for the review were assessed using the Quality Assessment Tool for Studies of Diverse Designs.

RESULTS

Fourteen papers were included in the review. NMEs are common occurrences that are underreported in the OR. When NMEs occur in multiples for the same patient, the risk of serious harm increases. Feedback and education about NME helps to improve reporting; ORs with high rates of NME reporting have less serious patient harm events.

DISCUSSION

The implications of the findings for improving healthcare safety are discussed and in particular the adoption of the science of Human Factors Ergonomics into healthcare.

A Study on Internet News for Patient Safety Campaigns: Focusing on Text Network Analysis and Topic Modeling

Background/Objectives: This study aimed to identify the main issues related to public patient safety campaigns reflected in Korean online news. This study utilized a text-mining method to identify keywords and topics related to patient safety campaigns. Methods: The data collection period was from 1 January 2022 to 31 December 2023, and 4110 news articles were extracted. Through data preprocessing, 2661 duplicated news and 1213 unrelated news were removed, and 236 news were selected. Using the NetMiner program, keyword co-occurrence frequency calculation, keyword centrality analysis, and topic modeling analysis were performed. Results: The results showed that the most frequently mentioned keywords with high degree centrality, betweenness centrality, and closeness centrality in online news were "hospital", "medical", "medicine", "project", and "treatment". The topics of online news related to the patient safety campaign were "patient-centered care for medical safety", "health promotion projects at a regional institution", "hand hygiene education to prevent infection", "healthcare quality improvement through the Mint Festival", and "safe use of medicines". Conclusions: This study analyzed patient safety campaign news topics using text network analysis and topic modeling. It was confirmed that patient safety campaigns are essential for fostering a patient safety culture, improving medical quality, and encouraging patient participation in hospitals. Therefore, to build a safe medical environment, it is necessary to establish an effective patient safety campaign for not only medical staff providing medical care, but also patients and their caregivers, and for this, cooperation and participation from various professional occupations are necessary.

Effect of interventions to improve safety culture on healthcare workers in hospital settings: a systematic review of the international literature

BACKGROUND

In an era of safety systems, hospital interventions to build a culture of safety deliver organisational learning methodologies for staff. Their benefits to hospital staff are unknown. We examined the literature for evidence of staff outcomes. Research questions were: (1) how is safety culture defined in studies with interventions that aim to enhance it?; (2) what effects do interventions to improve safety culture have on hospital staff?; (3) what intervention features explain these effects? and (4) what staff outcomes and experiences are identified?

METHODS AND ANALYSIS

We conducted a mixed-methods systematic review of published literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was conducted in MEDLINE, EMBASE, CINAHL, Health Business Elite and Scopus. We adopted a convergent approach to synthesis and integration. Identified intervention and staff outcomes were categorised thematically and combined with available data on measures and effects.

RESULTS

We identified 42 articles for inclusion. Safety culture outcomes were most prominent under the themes of leadership and teamwork. Specific benefits for staff included increased stress recognition and job satisfaction, reduced emotional exhaustion, burnout and turnover, and improvements to working conditions. Effects were documented for interventions with longer time scales, strong institutional support and comprehensive theory-informed designs situated within specific units.

DISCUSSION

This review contributes to international evidence on how interventions to improve safety culture may benefit hospital staff and how they can be designed and implemented. A focus on staff outcomes includes staff perceptions and behaviours as part of a safety culture and staff experiences resulting from a safety culture. The results generated by a small number of articles varied in quality and effect, and the review focused only on hospital staff. There is merit in using the concept of safety culture as a lens to understand staff experience in a complex healthcare system.

Perioperative Environment Safety Culture: A Scoping Review Addressing Safety Culture, Climate, Enacting Behaviors, and Enabling Factors

While there is an increasing interest in patient safety and in transforming safety culture in the perioperative environment, it is not clear what methods are being used to understand, assess, and influence safety culture and climate. This article seeks to uncover what instruments and measures are used to assess safety culture and investigates how these measures are applied in baseline assessments and interventions in the perioperative environment to enhance/support safety culture. Study investigators are encouraged to collect and analyze data about engaging in behaviors that prevent, respond to, or resolve safety issues, and related factors that support understanding their effects.

Implementing patient safety and quality improvement in dermatology. Part 1: Patient safety science

Patient safety (PS) and quality improvement (QI) have gained momentum over the last decade and are becoming more integrated into medical training, physician reimbursement, maintenance of certification, and practice improvement initiatives. While PS and QI are often lumped together, they differ in that PS is focused on preventing adverse events while QI is focused on continuous improvements to improve outcomes. The pillars of health care as defined by the 1999 Institute of Medicine report "To Err is Human: Building a Safer Health System" are safety, timeliness, effectiveness, efficiency, equity, and patient-centered care. Implementing a safety culture is dependent on all levels of the health care system. Part 1 of this CME will provide dermatologists with an overview of how PS fits into our current health care system and will include a focus on basic QI/PS terminology, principles, and processes. This article also outlines systems for the reporting of medical errors and sentinel events and the steps involved in a root cause analysis.

The Value of Learning From Near Misses to Improve Patient Safety: A Scoping Review

OBJECTIVES

For years, health care has recognized that learning from near misses offers potential opportunities to reduce unintended harm to patients. However, these benefits have yet to be realized. It is assumed that effective actions are being implemented as a result of learning from healthcare near misses, leading to improvements in patient safety. A scoping review of the healthcare literature was undertaken to explore the value of learning from near misses in the improvement of patient safety.

METHODS

The scoping review was conducted on Ovid MEDLINE, Embase, and CINAHL. Eligible articles published since 2000 were included.

RESULTS

A total of 4745 articles were identified through the searches, with 19 included in the final review. The articles included one randomized control trial. All the included articles had evidence of action after reporting or investigation of near misses, with the majority showing evaluation of impact. Actions were human, administrative, and engineering focused. Impact evaluation focused on the reduction of near misses, but without consideration of patient safety outcome measures, such as harm. The review also noted limited availability of experimental research and variability in near-miss definitions and that actions are not just the result of near misses.

CONCLUSIONS

Currently, health care assumes that reporting and learning from near misses improves patient safety. The literature provides limited evidence supporting these assumptions and shows that actions as a result of near misses are commonly aimed at the human. There is a need to prove the benefits of focusing on near misses in health care and for more system-level actions.

Evaluation of Medication Incidents in a Long-term Care Facility Using Electronic Medication Administration Records and Barcode Technology

Objective To describe the frequency, type, and severity of reported medication incidents that occurred at a long-term care facility (LTCF) despite electronic medication administration record and barcode-assisted medication administration (eMAR-BCMA) use. The study also contains analysis for the contribution of staff workarounds to reported medication administration errors (MAEs) using an established typology for BCMA workarounds, characterize if the eMAR-BCMA technology contributed to MAEs, and explore characteristics influencing incident severity. Design Retrospective incident report review. Setting A 239-bed LTCF in Alberta, Canada, that implemented eMAR-BCMA in 2013. Participants 270 paper-based, medication incident reports submitted voluntarily between June 2015 and October 2017. Interventions None. Results Most of the 264 resident-specific medication incidents occurred during the administration (71.9%, 190/264) or dispensing (28.4%, 75/264) phases, and 2.3% (6/264) resulted in temporary harm. Medication omission (43.7%, 83/190) and incorrect time (22.6%, 43/190) were the most common type of MAE. Workarounds occurred in 41.1% (78/190) of MAEs, most commonly documenting administration before the medication was administered (44.9%, 35/78). Of the non-workaround MAEs, 52.7% (59/112) were notassociated with the eMAR-BCMA technology, while 26.8% (30/112) involved system design shortcomings, most notably lack of a requirement to scan each medication pouch during administration. MAEs involving workarounds were less likely to reach the resident (74.4 vs 88.8%; relative risk = 0.84, 95% CI 0.72-0.97). Conclusion Administration and dispensing errors were the most reported medication incidents. eMAR-BCMA workarounds, and design shortcomings were involved in a large proportion of reported MAEs. Attention to optimal eMAR-BCMA use and design are required to facilitate medication safety in LTCFs.

Effect of Patient Safety Training Program of Nurses in Operating Room

PURPOSE

This study developed an in-service training program for patient safety and aimed to evaluate the impact of the program on nurses in the operating room (OR).

METHODS

A pretest-posttest self-controlled survey was conducted on OR nurses from May 6 to June 14, 2020. An in-service training program for patient safety was developed on the basis of the knowledge-attitude-practice (KAP) theory through various teaching methods. The levels of safety attitude, cognition, and attitudes toward the adverse event reporting of nurses were compared to evaluate the effect of the program. Nurses who attended the training were surveyed one week before the training (pretest) and two weeks after the training (posttest).

RESULTS

A total of 84 nurses participated in the study. After the training, the scores of safety attitude, cognition, and attitudes toward adverse event reporting of nurses showed a significant increase relative to the scores before the training (p < .001). The effects of safety training on the total score and the dimensions of safety attitude, cognition, and attitudes toward nurses' adverse event reporting were above the moderate level.

CONCLUSION

The proposed patient safety training program based on KAP theory improves the safety attitude of OR nurses. Further studies are required to develop an interprofessional patient safety training program. In addition to strength training, hospital managers need to focus on the aspects of workflow, management system, department culture, and other means to promote safety culture.

Near Miss Research in the Healthcare System: A Scoping Review

OBJECTIVES

The aim of this study was to depict a comprehensive description of near miss research and clarify research gaps.

BACKGROUND

Learning from near miss can provide early warnings and is critical for proactive and prospective risk management. Because of the lack of structured reviews, there is little knowledge about how near miss management has been managed in the past.

METHODS

This review was conducted following the Arksey and O'Malley's methodology and reported by the PRISMA Extension for Scoping Reviews.

RESULTS

Sixty-seven research articles were included. The results revealed that the most investigated fields include near miss reporting, near miss characteristics, and good catch project. Poor theoretical investigation, underreporting, and inconsistent outcome indicators are major problems.

CONCLUSIONS

Solely understanding causes of near misses cannot guarantee effective learning; we also need to apply appropriate learning theories. Advanced technologies should be applied to solve long-standing underreporting issues. Accurate and consistent indicators should be applied in near miss research and management.

The expansion of National Healthcare Safety Network enrollment and reporting in nursing homes: Lessons learned from a national qualitative study

BACKGROUND

This study explored nursing home (NH) personnel perceptions of the National Healthcare Safety Network (NHSN).

METHODS

NHs were purposively sampled based on NHSN enrollment and reporting status, and other facility characteristics. We recruited NH personnel knowledgeable about the facility's decision-making processes and infection prevention program. Interviews were conducted over-the-phone and audio-recorded; transcripts were analyzed using conventional content analysis.

RESULTS

We enrolled 14 NHs across the United States and interviewed 42 personnel. Six themes emerged: Benefits of NHSN, External Support and Motivation, Need for a Champion, Barriers, Risk Adjustment, and Data Integrity. We did not find substantive differences in perceptions of NHSN value related to participants' professional roles or enrollment category. Some participants from newly enrolled NHs felt well supported through the NHSN enrollment process, while participants from earlier enrolled NHs perceived the process to be burdensome. Among participants from non-enrolled NHs, as well as some from enrolled NHs, there was a lack of knowledge of NHSN.

CONCLUSIONS

This qualitative study helps fill a gap in our understanding of barriers and facilitators to NHSN enrollment and reporting in NHs. Improved understanding of factors influencing decision-making processes to enroll in and maintain reporting to NHSN is an important first step towards strengthening infection surveillance in NHs.