Safety climate reduces medication and dislodgement errors in routine intensive care practice

Patient safety culture and medication safety in European intensive care units: a focus group study

BACKGROUND

Patients in intensive care units (ICUs) are susceptible to medication errors (MEs) for many reasons, including the complexity and intensity of care. Little is known about patient safety culture, its relationship to medication safety, and ME prevention strategies used in ICUs. This study explored the attitudes of healthcare professionals (HCPs) working in ICUs or within medication safety towards patient safety culture, medication safety, and factors influencing implementation of ME prevention strategies in ICUs across Europe.

METHODS

This qualitative study employed focus group discussions; ethical approval was obtained. Invitations to participate were distributed to HCPs working in ICUs or as medication safety officers across Europe. In May 2022, online focus group discussions were conducted. Discussions were transcribed verbatim and analysed. The framework analysis employed was inductive, systematic and transparent, and completed through a collaborative and iterative process.

RESULTS

Three nurses and 11 pharmacists, from seven different countries, participated in three focus group discussions. There was a sense of improvement in blame culture leading to more open culture, although it was not the case for all participants. Blame culture, when present, was thought to be prevalent among more senior ICU staff and hospital managers. Facilitators for improving medication safety included communicating with HCPs and providing feedback on MEs and ME prevention strategies, interprofessional working without hierarchies, and having a 'good' culture and environment. Barriers included lack of engagement of HCPs and their attitudes towards medication safety, and an existing blame culture. Participants reported 25 different ME prevention strategies in use including: assessing knowledge; teaching and training; auditing practice; incident reporting; and involvement of pharmacists.

CONCLUSIONS

This study examined the attitudes of HCPs on patient safety culture and medication safety in the ICU setting in Europe and gained their insight into facilitators and barriers to the implementation of ME prevention strategies to improve medication safety.

Epidemiology of adverse events in Intensive Medicine units

The severity of the critically ill patient, the practice of diagnostic procedures and invasive treatments, the high number of drugs administered, a high volume of data generated during the care of the critically ill patient along with a technical work environment, the stress and workload of work of professionals, are circumstances that favor the appearance of errors, turning Intensive Medicine Services into risk areas for adverse events to occur. Knowing their epidemiology is the first step to improve the safety of the care we provide to our patients, because it allows us to identify risk areas, analyze them and develop strategies to prevent the adverse events, or if this is not possible, be able to manage them. This article analyzes the main studies published to date on incidents related to safety in the field of critically ill patients.

The association between patient safety culture and adverse events - a scoping review

BACKGROUND

Adverse events (AEs) affect 10% of in-hospital patients, causing increased costs, injuries, disability and mortality. Patient safety culture (PSC) is an indicator of quality in healthcare services and is thus perceived as a proxy for the quality of care. Previous studies show variation in the association between PSC scores and AE rates. The main objective of this scoping review is to summarise the evidence on the association between PSC scores and AE rates in healthcare services. In addition, map the characteristics and the applied research methodology in the included studies, and study the strengths and limitations of the evidence.

METHODS

We applied a scoping review methodology to answer the broad research questions of this study, following the PRISMA-ScR checklist. A systematic search in seven databases was conducted in January 2022. The records were screened independently against eligibility criteria using Rayyan software, and the extracted data were collated in a charting form. Descriptive representations and tables display the systematic mapping of the literature.

RESULTS

We included 34 out of 1,743 screened articles. The mapping demonstrated a statistical association in 76% of the studies, where increased PSC scores were associated with reduced AE rates. Most of the studies had a multicentre design and were conducted in-hospital in high-income countries. The methodological approaches to measuring the association varied, including missing reports on the tools` validation and participants, different medical specialties, and work unit level of measurements. In addition, the review identified a lack of eligible studies for meta-analysis and synthesis and demonstrated a need for an in-depth understanding of the association, including context complexity.

CONCLUSIONS

We found that the vast majority of studies report reduced AE rates when PSC scores increase. This review demonstrates a lack of studies from primary care and low- and- middle-income countries. There is a discrepancy in utilised concepts and methodology, hence there is a need for a broader understanding of the concepts and the contextual factors, and more uniform methodology. Longitudinal prospective studies with higher quality can enhance efforts to improve patient safety.

Assessing Patient Safety Culture in United States Hospitals

A positive patient safety culture plays a major role in reducing medical errors and increasing productivity among healthcare staff. Furthermore, understanding staff perceptions of patient safety culture and effective patient safety factors is a first step toward enhancing quality of care and patient safety. The objectives of this study were to assess patient safety culture in hospitals in the United States and to investigate the effects of hospital and respondent characteristics on perceived patient safety culture. An analysis of 67,010 respondents in the 2018 Agency for Healthcare Research and Quality (AHRQ) comparative database was conducted with partial least squares structural equation modeling (PLS-SEM). The results revealed that perceptions of patient safety culture had a positive influence on the overall perceptions of patient safety and frequency of event reporting. Moreover, staff position, teaching status, and geographic region were found to have varying influence on the patient safety culture, overall perceptions of patient safety, and frequency of event reporting.

Linking nurse practice environment, safety climate and job dimensions to missed nursing care

AIM

This study examined the aspects of the nurse practice environment and patient safety climate and the various job dimensions that contribute to the occurrence of missed nursing care.

BACKGROUND

Missed nursing care is a crucial healthcare concern that poses significant threats to patient safety. The available literature on missed nursing care is confined to high-resource nations, where hospital policies, mechanisms and processes to support professional nursing practice are well established.

METHODS

This is a multi-centre, cross-sectional study, using self-report scales, which involves 624 clinical nurses in selected hospitals in the Philippines.

RESULTS

Patient safety climate (β = -0.148, p = 0.001), decision authority (β = -0.101, p = 0.018) and staffing/resource adequacy (β = -0.086, p = 0.014) significantly predicted missed nursing care. Nurse, unit and hospital variables were not related with missed nursing care.

DISCUSSION

Nurses who perceived greater decision authority, positive safety climate and adequate staffing/resources were less likely to miss or omit patient care activities.

CONCLUSION AND IMPLICATIONS FOR NURSING AND HEALTH POLICY

Institutional measures to foster decision authority in nurses, improve safety climate and address staffing/resource issues can be a viable solution to reduce the occurrence of missed nursing care.

THE OUTCOME OF NURSING ERROR AS ATTRACTIVE TO THE MEDIA

ABSTRACT Objective: to interpret, from the perspective of the Theory of Communicative Action, how the outcome of nursing errors can become attractive to the media, highlighting the main implications for the image of the profession and the imaginary of society. Method: qualitative research, carried out in documentary sources using news published in the major newspapers available online in two countries, Brazil and Portugal, from 2012 to 2016. The analysis of the findings was carried out following the steps of hermeneutics, based on the Theory of Communicative Action. The data were organized and coded in the ATLAS.ti software. Results: the research included 112 published news. Four categories emerged from the analysis: The highlights in the headlines - The beginning of persuasion; Combining image and initial text - An explosive mix; The error that is not an error - The error that is a crime; and Applying the validity claims in the discourses. Conclusion: the media are continuous producers of ideologies and, therefore, possess social responsibility by inducing misinterpretations that can negatively interfere in the nurse-patient interaction. Giving greater emphasis to the outcome of the error, the media influences negatively the people perception of nursing labour which has a unique social importance.

The Relationship between Patient Safety Climate and Medical Error Reporting Rate among Iranian Hospitals Using a Structural Equation Modeling

Background

Improving patient safety is a global health imperative, and patient safety climate is one of the components one that plays an important role in promoting patient safety. Medical error reporting is a way through which it can be evaluated and prevented in the future. The aim of this study was to assess the relationship between patient safety climate and medical error reporting in military and civilian hospitals.

Methods

This research was conducted by using structural equation modeling in the selected hospitals of Iran in 2018. The study community consisted of 200 nurses in the military and 400 nurses in the civilian hospitals. By using Structural Equation Modeling, the relationship between patient safety climate and the rate of medical error reporting in the hospitals was measured by a questionnaire. Data was analyzed using SPSS 17 and LISREL 8.8 software.

Results

The mean score of patient safety climate was moderate in the hospitals. There was no significant relationship between the rate of medical error reporting and patient safety climate, while a significant difference was found between patient safety climate score and age, sex, job category, and type of hospital (P < 0.05).

Conclusion

The results suggested that patient safety climate and the rate of reporting errors were not favorable in the studied hospitals, while there was a difference between safety climate dimensions.

Nursing workload in burn intensive care unit

ABSTRACT Objectives: To measure the nursing workload in the Burn Intensive Care Units and evaluate its association with clinical variables, length of stay, and outcome of hospitalization. Methods: Cross-sectional study carried out in a Brazilian public large hospital. The study included 33 patients. The nursing workload was assessed using the Nursing Activities Score (NAS) every 24 hours. We performed 447 Nursing Activities Score assessments. For the statistical analysis, Student’s t-test, ANOVA, and Spearman’s correlation test were used. The considered significant difference was 5% (p ≤ 0.05). Results: The Nursing Activities Score mean was 84% (± 4.4), which corresponded to 20.2 hours. There was an association between the nursing workload and the patient’s severity (p <0.010), burned body surface (p = 0.010), and hospitalization outcome (p = 0.020). Conclusion: Burn victims, assisted in the ICU, demanded a high nursing workload, which was influenced by clinical aspects and the hospitalization outcome. These findings point to the need to reconsider the nurse staffing related to this care profile.

Work process: a basis for understanding nursing errors

OBJECTIVE

To identify work process-related causes associated with nursing errors reported in newspapers.

METHOD

This was a documentary and qualitative study based on the work process theory and hermeneutic analysis that examined 112 news articles published between 2012 and 2016 in 21 high-circulation Brazilian newspapers, organized and codified using Atlas.ti software.

RESULTS

The causes associated with the reported errors were associated with workforce (lack of professionals and training, turnover, work overload, lack of information, recklessness, negligence, and distraction); work instruments (similar labels or packages, storage, lack of product identification and information, and medical prescriptions); and the object of nursing work (overcrowding and specific characteristics of patient).

CONCLUSION

Analysis of the possible causes of reported errors identified the negative outcomes of nursing work, while also identifying elements of the work process that influenced these results. The findings emphasize the importance of understanding these errors so they can be avoided and of reviewing nursing work conditions to guarantee quality and safety of care.

Unplanned Removal of Medical Devices in Critical Care Units in North West England Between 2011 and 2016

BACKGROUND

The unplanned removal of medical devices poses a risk of harm to critically ill patients.

OBJECTIVE

To determine rates, causes, and consequences of unplanned medical device removal, as well as factors mitigating harm to patients, in critical care units in the United Kingdom by reviewing patient safety incident reports.

METHODS

Incidents of unplanned medical device removal in critical care units in North West England between 2011 and 2016 were retrospectively reviewed and classified. The incidents were classified by type of device displaced, staff and patient factors, causes and consequences of removal, and staff actions following removal. Displacement rates were calculated per 1000 patient days per unit.

RESULTS

A total of 34 705 incident reports were reviewed, of which 1090 described unplanned device removal. The median rate of device removal was 0.7 (interquartile range, 0.4-2.2) per 1000 patient days per unit. Devices displaced most commonly included nasogastric tubes (317), central catheters (245), tracheostomy tubes (174), and endotracheal tubes (140). A total of 11 cardiac arrests were reported (8 associated with airway devices and 3 with central catheters). Factors contributing to displacement included initial placement (188), patient factors (563), and manual handling (238). Manual handling was cited in 49% of central catheter incidents and only 9% of nasogastric tube incidents. Patients' organic confusion was a factor in 16% of endotracheal tube and 80% of nasogastric tube removals.

CONCLUSIONS

Unplanned device removal may cause patient harm and is often preventable. The causes and consequences depend on the type of device removed.

Nursing errors in the media: patient safety in the window

OBJECTIVE

To analyze the nursing errors reported by the journalistic media and interpret the main implications of this communication for the visibility of this problem.

METHOD

Documental research, qualitative, descriptive and exploratory, with data collected in news reports from Brazil and Portugal, analyzed through hermeneutics with resources of Atlas Software.

RESULTS

We analyzed 112 news items published between 2012 and 2016 that resulted in six categories: Year - highest occurrence in 2012; Age group of the patient - children; Professional category - nurses; Type of error - medication; Outcome - death; Possible attributed cause - occupational conditions.

FINAL CONSIDERATIONS

Nursing mistakes are a challenge for the profession, and the way they are communicated by the media is not very explanatory, contributing to a negative visibility of the profession, and to making society insecure. Improving the way they are served in the media contributes to the visibility of the problem without affecting the professional image.

Strategies to minimize medication errors in emergency units: an integrative review

ABSTRACT Objective: To assess the strategies used by the Nursing team to minimize medication errors in emergency units. Method: Integrative literature review in the PubMed, BDenf, Cochrane and LILACS databases. Timeless research, without language limitation, performed by peers. Articles published in full that answered the guiding question were included in research. Results: Educational strategies (conducting campaigns, elaborating explanatory manuals, creating a multidisciplinary committee involved in the prevention and reduction of adverse drug events); organizational (meetings, Deviance positive, creation of protocols and changes in the work process) and new technologies (implementation of prescription by computerized system, introduction of the unit doses and of the bar code in the administration of medicines) were evidenced in the studies with the purpose of minimizing medication errors in an emergency unit. Conclusion: The strategies identified were effective in minimizing medication errors in emergency units.

Crew Resource Management in the trauma room: a prospective 3-year cohort study

OBJECTIVE

Human factors account for the majority of adverse events. Human factors awareness training entitled Crew Resource Management (CRM) is associated with improved safety and reduced complications and mortality in critically ill patients. We determined the effects of CRM implementation in the trauma room of an Emergency Department (ED).

PATIENTS AND METHODS

A prospective 3-year cohort study was carried out in a level 1 ED, admitting more than 12 000 patients annually (>1500 trauma related). At the end of the baseline year, CRM training was performed, followed by an implementation year. The third year was defined as the clinical effect year. The primary outcomes were safety climate, measured using the Safety Attitudes Questionnaire, and ED length of stay. The secondary outcome measures were hospital length of stay and 48-h crude mortality of trauma patients.

RESULTS

All 5070 trauma patients admitted to the ED during the study period were included. Following CRM implementation, safety climate improved significantly in three out of six Safety Attitudes Questionnaire domains, both at the end of the implementation and clinical effect years: teamwork climate, safety climate, and stress recognition. ED length of stay of these patients increased from 141 (102-192) in the baseline year to 161 (116-211) and 170 (128-223) min in the implementation and clinical effect years, respectively (P<0.05 vs. baseline). Hospital length of stay was prolonged by 1 day in the implementation and clinical effect years (P<0.05 vs. baseline), whereas mortality was unaltered.

CONCLUSION

Although CRM implementation in the ED was associated with an improved safety climate, the time spent by trauma patients in the ED increased.

Safety Culture, Patient Safety, and Quality of Care Outcomes: A Literature Review

This integrative literature review was conducted to examine the relationships between safety culture and patient safety and quality of care outcomes in hospital settings and to identify directions for future research. Using a search of six electronic databases, 17 studies that met the study criteria were selected for review. This review revealed semantic inconsistencies, infrequent use of a theory or theoretical framework, limited discussions of validity of instruments used, and significant methodological variations. Most notably, this review identified a large array of nonsignificant and inconsistent relationships between safety culture and patient safety and quality of care outcomes. To improve understanding of the relationships, investigators should consider using a theoretical framework and valid measures of the key concepts. Researchers should also give more attention to selecting appropriate sampling and data collection methods, units of analysis, levels of data measurement and aggregation, and statistical analyses.

Challenges and factors likely to promote coping as anticipated by nurses preparing for a merger of intensive and intermediate care units

OBJECTIVE

To describe challenges and factors that support coping as anticipated by nursing staff preparing for a merger of intensive and intermediate care units.

RESEARCH METHODOLOGY

The method of empathy-based stories was employed to collect data from staff. The stories (n=20) were analysed using inductive content analysis.

SETTING

Nursing staff from the cardiac observation and evaluation, intensive care and surgical observation units in a central hospital in Finland.

FINDINGS

Participants anticipated challenges related to personal factors that affect coping at work, challenges in co-operation among nursing staff and problems associated with the new work context. Participants expected to need informational, concrete and social support from colleagues in future clinical nursing situations.

CONCLUSION

Fostering peer support and team spirit is important to ensure staff co-operation and smooth care processes following restructuring.

The patient safety climate in healthcare organizations (PSCHO) survey: Short-form development

RATIONALE, AIMS, AND OBJECTIVES

Measures of safety climate are increasingly used to guide safety improvement initiatives. However, cost and respondent burden may limit the use of safety climate surveys. The purpose of this study was to develop a 15- to 20-item safety climate survey based on the Patient Safety Climate in Healthcare Organizations survey, a well-validated 38-item measure of safety climate.

METHODS

The Patient Safety Climate in Healthcare Organizations was administered to all senior managers, all physicians, and a 10% random sample of all other hospital personnel in 69 private sector hospitals and 30 Veterans Health Administration hospitals. Both samples were randomly divided into a derivation sample to identify a short-form subset and a confirmation sample to assess the psychometric properties of the proposed short form.

RESULTS

The short form consists of 15 items represented 3 overarching domains in the long-form scale-organization, work unit, and interpersonal.

CONCLUSION

The proposed short form efficiently captures 3 important sources of variance in safety climate: organizational, work-unit, and interpersonal. The short-form development process was a practical method that can be applied to other safety climate surveys. This safety climate short form may increase response rates in studies that involve busy clinicians or repeated measures.

Medication Errors in Injured Patients

Trauma patients are vulnerable to medication error given multiple handoffs throughout the hospital. The purpose of this study was to assess trends in medication errors in trauma patients and the role these errors play in patient outcomes. Injured adults admitted from 2009 to 2015 to a Level I trauma center were included. Medication errors were determined based on a nurse-driven, validated, and prospectively maintained database. Multivariable logistic regression modeling was used to control for differences between groups. Among 15,635 injured adults admitted during the study period, 132 patients experienced 243 errors. Patients who experienced errors had significantly worse injury severity, lower Glasgow Coma Scale scores and higher rates of hypotension on admission, and longer lengths of stay. Before adjustment, mortality was similar between groups but morbidity was higher in the medication error group. After risk adjustment, there were no significant differences in morbidity or mortality between the groups. Medication errors in trauma patients tend to occur in significantly injured patients with long hospital stays. Appropriate adjustment when studying the impact of medical errors on patient outcomes is important.

Sizing of nursing staff associated with self-care promotion in a pediatric semi-intensive care unit

OBJECTIVES

To calculate and compare the nursing staff size associated with self-care promotion at a pediatric semi-intensive care unit.

METHODS

This was a prospective study in which 31 children and their caregivers participated. The nursing workload associated with each participant was evaluated at two different times (first and second hospital stays) using the Nursing Activities Score instrument. The first hospital stay corresponded to self-care promotion. Staff size was calculated according to the nursing hours recommended by the Nursing Activities Score instrument and by Conselho Federal de Enfermagem (COFEN) resolution no. 527/16, in the two hospital stays, and the results were compared.

RESULTS

The nursing workload in the first hospital stay (14.6 hours) was higher than the nursing workload in the second stay (9.9 hours) (p < 0.001). The Nursing Activities Score revealed that according to the nursing hours, the nursing staff size corresponded to 26 and 18 professionals in the first and second hospital stays, respectively, and to 15 professionals according to COFEN resolution no. 527/16.

CONCLUSION

The number of personnel responsible for promoting self-care in pediatric semi-intensive care units, according to the nursing hours suggested by the Nursing Activities Score, was higher than that recommended by the existing legislation. This demonstrates the necessity of reconsidering staff size for this healthcare profile.

Impact of random safety analyses on structure, process and outcome indicators: multicentre study

Background

To assess the impact of a real-time random safety tool on structure, process and outcome indicators.

Methods

Prospective study conducted over a period of 12 months in two adult patient intensive care units. Safety rounds were conducted three days a week ascertaining 37 safety measures (grouped into 10 blocks). In each round, 50% of the patients and 50% of the measures were randomized. The impact of this safety tool was analysed on indicators of structure (safety culture, healthcare protocols), process (improvement proportion related to tool application, IPR) and outcome (mortality, average stay, rate of catheter-related bacteraemias and rate of ventilator-associated pneumonia, VAP).

Results

A total of 1214 patient-days were analysed. Structure indicators: the use of the safety tool was associated with an increase in the safety climate and the creation/modification of healthcare protocols (sedation/analgesia and weaning). Process indicators: Twelve of the 37 measures had an IPR > 10%; six showed a progressive decrease in the IPR over the study period. Nursing workloads and patient severity on the day of analysis were independently associated with a higher IPR in half of the blocks of variables. Outcome indicators: A significant decrease in the rate of VAP was observed.

Conclusions

The real-time random safety tool improved the care process and adherence to clinical practice guidelines and was associated with an improvement in structure, process and outcome indicators.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-017-0245-x) contains supplementary material, which is available to authorized users.

NURSING ERRORS: A STUDY OF THE CURRENT LITERATURE

ABSTRACT Objective: to characterize what the current literature states about nursing errors, with a specific review on how these errors are communicated to society by the media. Method: a qualitative documental research, characterized as an integrative literature review, performed using four databases and guided by a formal protocol, in the period from 2011 to 2015, by two independent collaborators. The analysis of the studies occurred through the analysis of thematic content articulated with the resources of the Atlas.ti software. Results: 32 studies were analyzed and organized into two macro categories: main errors practiced by the nursing team; reported forms of prevention to avoid errors. Such categories reveal that most of the errors are made with medication, the main causes are related to work overload and management problems, and the main sources of prevention are to improve working conditions, continuing education and safety culture. Conclusion: nursing errors are determined by multiple factors and their coping requires professional and institutional measures.

Certified Registered Nurse Anesthetist Perceptions of Factors Impacting Patient Safety

Certified registered nurse anesthetists (CRNAs) provide more than 40 million anesthetics each year in the United States. This article describes a study that investigates relationships among CRNA organizational structures (CRNA practice models, work setting, workload, level of education, work experience), CRNA ratings of patient safety culture, and CRNA adverse anesthesia-related event (ARE) reporting. This is a cross-sectional survey study of 336 CRNAs randomly selected from American Association of Nurse Anesthetists database. Workload was measured using NASA Task-Load Index and the Revised Individual Workload Perception Scale. Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Overall Perceptions of Safety Scale and Hospital Survey on Patient Safety Patient Safety Grade Scale were utilized to measure safety culture. Dependent variables (ARE) included difficult intubation/extubation, inadequate ventilation/oxygenation, and pulmonary aspiration. The Revised Individual Workload Perception Scale workload was significantly associated with ARE. Years' experience and Patient Safety Grade Scale were inversely associated with ARE. Overall Perceptions of Safety Scale was significantly and inversely associated with ARE. Practice model, education, and work setting were not associated with ARE. Based on findings, CRNA workload, years' experience, and patient safety culture may be important markers for ARE. Administrative interventions designed to upgrade patient safety culture and ensure manageable CRNA workload may foster quality patient care.

Validation of the Dutch language version of the Safety Attitudes Questionnaire (SAQ-NL)

Background

As the first objective of caring for patients is to do no harm, patient safety is a priority in delivering clinical care. An essential component of safe care in a clinical department is its safety climate. Safety climate correlates with safety-specific behaviour, injury rates, and accidents. Safety climate in healthcare can be assessed by the Safety Attitudes Questionnaire (SAQ), which provides insight by scoring six dimensions: Teamwork Climate, Job Satisfaction, Safety Climate, Stress Recognition, Working Conditions and Perceptions of Management.

The objective of this study was to assess the psychometric properties of the Dutch language version of the SAQ in a variety of clinical departments in Dutch hospitals.

Methods

The Dutch version (SAQ-NL) of the SAQ was back translated, and analyzed for semantic characteristics and content. From October 2010 to November 2015 SAQ-NL surveys were carried out in 17 departments in two university and seven large non-university teaching hospitals in the Netherlands, prior to a Crew Resource Management human factors intervention. Statistical analyses were used to examine response patterns, mean scores, correlations, internal consistency reliability and model fit. Cronbach’s α’s and inter-item correlations were calculated to examine internal consistency reliability.

Results

One thousand three hundred fourteen completed questionnaires were returned from 2113 administered to health care workers, resulting in a response rate of 62 %. Confirmatory Factor Analysis revealed the 6-factor structure fit the data adequately. Response patterns were similar for professional positions, departments, physicians and nurses, and university and non-university teaching hospitals. The SAQ-NL showed strong internal consistency (α = .87). Exploratory analysis revealed differences in scores on the SAQ dimensions when comparing different professional positions, when comparing physicians to nurses and when comparing university to non-university hospitals.

Conclusions

The SAQ-NL demonstrated good psychometric properties and is therefore a useful instrument to measure patient safety climate in Dutch clinical work settings. As removal of one item resulted in an increased reliability of the Working Conditions dimension, revision or deletion of this item should be considered. The results from this study provide researchers and practitioners with insight into safety climate in a variety of departments and functional positions in Dutch hospitals.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1648-3) contains supplementary material, which is available to authorized users.

The interplay between teamwork, clinicians' emotional exhaustion, and clinician-rated patient safety: a longitudinal study

Background

Effectively managing patient safety and clinicians’ emotional exhaustion are important goals of healthcare organizations. Previous cross-sectional studies showed that teamwork is associated with both. However, causal relationships between all three constructs have not yet been investigated. Moreover, the role of different dimensions of teamwork in relation to emotional exhaustion and patient safety is unclear. The current study focused on the long-term development of teamwork, emotional exhaustion, and patient safety in interprofessional intensive care teams by exploring causal relationships between these constructs. A secondary objective was to disentangle the effects of interpersonal and cognitive-behavioral teamwork.

Methods

We employed a longitudinal study design. Participants were 2100 nurses and physicians working in 55 intensive care units. They answered an online questionnaire on interpersonal and cognitive-behavioral aspects of teamwork, emotional exhaustion, and patient safety at three time points with a 3-month lag. Data were analyzed with cross-lagged structural equation modeling. We controlled for professional role.

Results

Analyses showed that emotional exhaustion had a lagged effect on interpersonal teamwork. Furthermore, interpersonal and cognitive-behavioral teamwork mutually influenced each other. Finally, cognitive-behavioral teamwork predicted clinician-rated patient safety.

Conclusions

The current study shows that the interrelations between teamwork, clinician burnout, and clinician-rated patient safety unfold over time. Interpersonal and cognitive-behavioral teamwork play specific roles in a process leading from clinician emotional exhaustion to decreased clinician-rated patient safety. Emotionally exhausted clinicians are less able to engage in positive interpersonal teamwork, which might set in motion a vicious cycle: negative interpersonal team interactions negatively affect cognitive-behavioral teamwork and vice versa. Ultimately, ineffective cognitive-behavioral teamwork negatively impacts clinician-rated patient safety. Thus, reducing clinician emotional exhaustion is an important prerequisite of managing teamwork and patient safety. From a practical point of view, team-based interventions targeting patient safety are less likely to be effective when clinicians are emotionally exhausted.

Crew Resource Management in the Intensive Care Unit: a prospective 3-year cohort study

BACKGROUND

Human factors account for the majority of adverse events in both aviation and medicine. Human factors awareness training entitled "Crew Resource Management (CRM)" is associated with improved aviation safety. We determined whether implementation of CRM impacts outcome in critically ill patients.

METHODS

We performed a prospective 3-year cohort study in a 32-bed ICU, admitting 2500-3000 patients yearly. At the end of the baseline year, all personnel received CRM training, followed by 1 year of implementation. The third year was defined as the clinical effect year. All 7271 patients admitted to the ICU in the study period were included. The primary outcome measure was ICU complication rate. Secondary outcome measures were ICU and hospital length of stay, and standardized mortality ratio.

RESULTS

Occurrence of serious complications was 67.1/1000 patients and 66.4/1000 patients during the baseline and implementation year respectively, decreasing to 50.9/1000 patients in the post-implementation year (P = 0.03). Adjusted odds ratios for occurrence of complications were 0.92 (95% CI 0.71-1.19, P = 0.52) and 0.66 (95% CI 0.51-0.87, P = 0.003) in the implementation and post-implementation year. The incidence of cardiac arrests was 9.2/1000 patients and 8.3/1000 patients during the baseline and implementation year, decreasing to 3.5/1000 patients (P = 0.04) in the post-implementation year, while cardiopulmonary resuscitation success rate increased from 19% to 55% and 67% (P = 0.02). Standardized mortality ratio decreased from 0.72 (95% CI 0.63-0.81) in the baseline year to 0.60 (95% CI 0.53-0.67) in the post-implementation year (P = 0.04).

CONCLUSION

Our data indicate an association between CRM implementation and reduction in serious complications and lower mortality in critically ill patients.

Critical care nursing organizations and activities: a fourth worldwide review

AIM

To examine the activities and concerns of critical care nurses and professional critical care nursing organizations around the world and to identify expectations held of nursing leaders and policy makers to help address their concerns.

BACKGROUND

This study is the fourth worldwide review of its type. Previous surveys were undertaken in 2001, 2005 and 2009.

METHODS

An online descriptive survey was emailed to 88 potential participants from countries with critical care nursing organizations or known critical care nursing leaders. Responses were downloaded into Survey Monkey™ (Version 22) and analysed by geographical region and income level.

RESULTS

Fifty-nine respondents from 58 countries completed the questionnaire, of whom 43 had critical care nursing organizations established in their countries and 29 were members of the World Federation of Critical Care Nurses. The services provided by the organizations to be of most value were national conferences, website, professional representation, and practice standards and guidelines. Professional policies had been developed by some organizations on workforce, education and practice, while almost half provided their members with either a newsletter or journal. Collectively, the most important issues for critical care nurses were working conditions, provision of formal practice guidelines and competencies, staffing levels and access to quality education programmes.

CONCLUSIONS

Important issues continue to challenge the specialty of critical care nursing as new developments, priorities, clinical issues and other global events and influences impact critical care nursing worldwide.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

This study will help guide nursing leaders and policy makers to address the needs of critical care nurses and their patients. Collaborative approaches between the specialty, nursing leaders and health policy advisors will assist to inform appropriate change in areas recommended for further action.

Adverse in-hospital events are associated with increased in-hospital mortality and length of stay in patients with or at risk of acute respiratory distress syndrome

OBJECTIVE

To explore the effect of various adverse hospital events on short- and long-term outcomes in a cohort of acutely ill hospitalized patients.

PATIENTS AND METHODS

In a secondary analysis of a retrospective cohort of acutely ill hospitalized patients with sepsis, shock, or pneumonia or undergoing high-risk surgery who were at risk for or had developed acute respiratory distress syndrome between 2001 and 2010, the effects of potentially preventable hospital exposures and adverse events (AEs) on in-hospital and intensive care unit (ICU) mortality, length of stay, and long-term survival were analyzed. Adverse effects chosen for inclusion were inadequate empiric antimicrobial coverage, hospital-acquired aspiration, medical or surgical misadventure, inappropriate blood product transfusion, and injurious tidal volume while on mechanical ventilation.

RESULTS

In 828 patients analyzed, the distribution of 0, 1, 2, and 3 or more cumulative AEs was 521 (63%), 126 (15%), 135 (16%), and 46 (6%) patients, respectively. The adjusted odds ratios (95% CI) for in-hospital mortality in patients who had 1, 2, and 3 or more AEs were 0.9 (0.5-1.7), 0.9 (0.5-1.6), and 1.4 (0.6-3.3), respectively. One AE increased the length of stay, difference between means (95% CI), in the hospital by 8.7 (3.8-13.7) days and in the ICU by 2.4 (0.6-4.2) days.

CONCLUSION

Potentially preventable hospital exposure to AEs is associated with prolonged ICU and hospital lengths of stay. Implementation of effective patient safety interventions is of utmost priority in acute care hospitals.

Error in intensive care: psychological repercussions and defense mechanisms among health professionals

OBJECTIVE

To identify the psychological repercussions of an error on professionals in intensive care and to understand their evolution. To identify the psychological defense mechanisms used by professionals to cope with error.

DESIGN

Qualitative study with clinical interviews. We transcribed recordings and analysed the data using an interpretative phenomenological analysis.

SETTING

Two ICUs in the teaching hospitals of Besançon and Dijon (France).

SUBJECTS

Fourteen professionals in intensive care (20 physicians and 20 nurses).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We conducted 40 individual semistructured interviews. The participants were invited to speak about the experience of error in ICU. The interviews were transcribed and analyzed thematically by three experts. In the month following the error, the professionals described feelings of guilt (53.8%) and shame (42.5%). These feelings were associated with anxiety states with rumination (37.5%) and fear for the patient (23%); a loss of confidence (32.5%); an inability to verbalize one's error (22.5%); questioning oneself at a professional level (20%); and anger toward the team (15%). In the long term, the error remains fixed in memory for many of the subjects (80%); on one hand, for 72.5%, it was associated with an increase in vigilance and verifications in their professional practice, and on the other hand, for three professionals, it was associated with a loss of confidence. Finally, three professionals felt guilt which still persisted at the time of the interview. We also observed different defense mechanisms implemented by the professional to fight against the emotional load inherent in the error: verbalization (70%), developing skills and knowledge (43%), rejecting responsibility (32.5%), and avoidance (23%). We also observed a minimization (60%) of the error during the interviews.

CONCLUSIONS

It is important to take into account the psychological experience of error and the defense mechanisms developed following an error because they appear to determine the professional's capacity to acknowledge and disclose his/her error and to learn from it.

Approaches to decreasing medication and other care errors in the ICU

PURPOSE OF REVIEW

The very complex process of intensive care is accompanied by a not unexpected accumulation of risk for error and adverse events. The present review addresses strategies to decrease care errors in several domains of daily intensive care practice.

RECENT FINDINGS

Strategies to decrease care errors now focus on a systematic approach by identifying latent system failures and change the design of the care process in such a way that inevitable human errors are prevented or their consequences are mitigated. Recent examples refer to the standardization of processes, adaptation to cognitive limitations of human beings, optimization of working conditions, and the increasing use of supporting information technologies. The development of a safety climate constitutes a key element and apparently contributes to reduction of medical errors in ICUs.

SUMMARY

The present review discusses recent approaches aimed to decrease care errors in ICUs. A growing body of evidence demonstrates that a system based approach with the change of process characteristics and the development of a safety climate is most essential in the effort to increase patient safety.

Intensive care nurses' perceptions of simulation-based team training for building patient safety in intensive care: a descriptive qualitative study

OBJECTIVES

To describe intensive care nurses' perceptions of simulation-based team training for building patient safety in intensive care.

BACKGROUND

Failures in team processes are found to be contributory factors to incidents in an intensive care environment. Simulation-based training is recommended as a method to make health-care personnel aware of the importance of team working and to improve their competencies.

DESIGN

The study uses a qualitative descriptive design.

METHODS

Individual qualitative interviews were conducted with 18 intensive care nurses from May to December 2009, all of which had attended a simulation-based team training programme. The interviews were analysed by qualitative content analysis.

RESULTS

One main category emerged to illuminate the intensive care nurse perception: "training increases awareness of clinical practice and acknowledges the importance of structured work in teams". Three generic categories were found: "realistic training contributes to safe care", "reflection and openness motivates learning" and "finding a common understanding of team performance".

CONCLUSIONS

Simulation-based team training makes intensive care nurses more prepared to care for severely ill patients. Team training creates a common understanding of how to work in teams with regard to patient safety.

Medication errors in the intensive care unit: literature review using the SEIPS model

Medication errors in intensive care units put patients at risk for injury or death every day. Safety requires an organized and systematic approach to improving the tasks, technology, environment, and organizational culture associated with medication systems. The Systems Engineering Initiative for Patient Safety model can help leaders and health care providers understand the complicated and high-risk work associated with critical care. Using this model, the author combines a human factors approach with the well-known structure-process-outcome model of quality improvement to examine research literature. The literature review reveals that human factors, including stress, high workloads, knowledge deficits, and performance deficits, are associated with medication errors. Factors contributing to medication errors are frequent interruptions, communication problems, and poor fit of health information technology to the workflow of providers. Multifaceted medication safety interventions are needed so that human factors and system problems can be addressed simultaneously.

Insights and advances in multidisciplinary critical care: a review of recent research

The intensive care unit is a work environment where superior dedication is pivotal to optimize patients' outcomes. As this demanding commitment is multidisciplinary in nature, it requires special qualities of health care workers and organizations. Thus research in the field covers a broad spectrum of activities necessary to deliver cutting-edge care. However, given the abundance of research articles and education activities available, it is difficult for modern critical care clinicians to keep up with the latest progress and innovations in the field. This article broadly summarizes new developments in multidisciplinary intensive care, providing elementary information about advanced insights in the field by briefly describing selected articles bundled in specific topics. Issues considered include cardiovascular care, monitoring, mechanical ventilation, infection and sepsis, nutrition, education, patient safety, pain assessment and control, delirium, mental health, ethics, and outcomes research.

Medication Errors in the Intensive Care Unit

Medication errors in intensive care units put patients at risk for injury or death every day. Safety requires an organized and systematic approach to improving the tasks, technology, environment, and organizational culture associated with medication systems. The Systems Engineering Initiative for Patient Safety model can help leaders and health care providers understand the complicated and high-risk work associated with critical care. Using this model, the author combines a human factors approach with the well-known structure-process-outcome model of quality improvement to examine research literature. The literature review reveals that human factors, including stress, high workloads, knowledge deficits, and performance deficits, are associated with medication errors. Factors contributing to medication errors are frequent interruptions, communication problems, and poor fit of health information technology to the workflow of providers. Multifaceted medication safety interventions are needed so that human factors and system problems can be addressed simultaneously.