Improving healthcare systems' disclosures of large-scale adverse events: a Department of Veterans Affairs leadership, policymaker, research and stakeholder partnership

The Experience of Patient Safety Error for Nursing Students in COVID-19: Focusing on King's Conceptual System Theory

Some nursing students experience errors related to patient safety, such as falls, medication administration errors, and patient identification errors during clinical practice. However, only a few nursing students report errors during clinical practice. Accordingly, the present study aimed to investigate patient safety errors that nursing students experience during clinical practice in the context of the COVID-19 pandemic. This study conducted in-depth interviews with 14 candidates for graduation from the Department of Nursing at a university in South Korea. In addition, after transcribing the collected data, a directed content analysis for the data based on King's interacting system theory was performed. As a result, four core categories were identified: (i) nursing students' perception of patient safety error occurrence, (ii) interaction between nursing students and others, (iii) interaction between nursing students and organizations, and (iv) nursing students' training needs related to patient safety errors. Consequently, this study identified the patient safety error-related experiences of nursing students during clinical practice during the COVID-19 pandemic. The results suggest that in the future, nursing education institutions must establish a system for nursing students to report patient safety errors during clinical practice for patient safety education and develop practical and targeted education strategies in cooperation with practice training hospitals.

Involving Stakeholders as Communication Partners in Research Dissemination Efforts

Moving evidence into practice requires the support of stakeholders, who are critical actors in the research process. Yet, research teams need strategies for determining who these stakeholders are, what their roles should be, and how to involve them in research and dissemination activities. In this Perspective, we discuss steps for identifying, categorizing, and including stakeholders in the research process, as a precursor to involving them as communication partners in research dissemination efforts. Effectively communicating the results of research is critical for increasing stakeholders' buy-in for the adoption and sustainment of this evidence. However, this communication is best if it comes from the end-users themselves, the stakeholders, who have a specified involvement in the research process. Combining elements from dissemination, implementation, and management science literature, we identify specific tools and strategies for researchers to (1) understand the roles of various stakeholders potentially impacted by their work, and (2) recognize the specific communication activities these stakeholders could be engaged in, to support the dissemination of research findings. We present a 3-Step Plan for identifying, categorizing, and involving stakeholders in the research process in a way that will lead to their role as communication partners when results are ready to be disseminated widely.

Patients at the centre after a health care incident: A scoping review of hospital strategies targeting communication and nonmaterial restoration

OBJECTIVE

This study aimed to provide an overview of the strategies adopted by hospitals that target effective communication and nonmaterial restoration (i.e., without a financial or material focus) after health care incidents, and to formulate elements in hospital strategies that patients consider essential by analysing how patients have evaluated these strategies.

BACKGROUND

In the aftermath of a health care incident, hospitals are tasked with responding to the patients' material and nonmaterial needs, mainly restoration and communication. Currently, an overview of these strategies is lacking. In particular, a gap exists concerning how patients evaluate these strategies.

SEARCH STRATEGY AND INCLUSION CRITERIA

To identify studies in this scoping review, and following the methodological framework set out by Arksey and O'Malley, seven subject-relevant electronic databases were used (PubMed, Medline, Embase, CINAHL, PsycARTICLES, PsycINFO and Psychology & Behavioral Sciences Collection). Reference lists of included studies were also checked for relevant studies. Studies were included if published in English, after 2000 and as peer-reviewed articles.

MAIN RESULTS AND SYNTHESIS

The search yielded 13,989 hits. The review has a final inclusion of 16 studies. The inclusion led to an analysis of five different hospital strategies: open disclosure processes, communication-and-resolution programmes, complaints procedures, patients-as-partners in learning from health care incidents and subsequent disclosure, and mediation. The analysis showed three main domains that patients considered essential: interpersonal communication, organisation around disclosure and support and desired outcomes.

PATIENT CONTRIBUTION

This scoping review specifically takes the patient perspective in its methodological design and analysis. Studies were included if they contained an evaluation by patients, and the included studies were analysed on the essential elements for patients.

Risk Communication After Health Care Exposures: An Experimental Vignette Survey With Patients

Purpose. We investigated how health care systems should communicate with patients about possible exposures to blood-borne pathogens that may have occurred during their care. Our goal was to determine how best to communicate uncertain risk information in a way that would minimize harm to patients, maintain their trust, and encourage patients to seek follow-up treatment. Methods. Participants (N = 1103) were randomized to receive one of six vignette surveys; 997 (98.4%) responded. All vignettes described the same event, but differed by risk level and recommendations (lower risk v. higher risk) and by communication mode (telephone, letter, social media). We measured participants’ perceived risk of blood-borne infection, trust in the health care system, and shared decision making about next clinical steps. Open-ended questions were analyzed using grounded thematic analysis. Results. When the vignette requested patients to undergo testing and practice certain health behaviors (higher risk), participants’ likelihood of seeking follow-up testing for blood-borne pathogens and their understanding of health issues increased. Perceived trust was unaffected by risk level or communication processes. Qualitative data indicated a desire for telephone communication from providers known to the patient. Limitations. It is not clear whether higher risk language or objective risk levels in vignettes motivated patients’ behavioral intentions. Conclusion. Using higher risk language when disclosing large-scale adverse events increased participants’ willingness to seek follow-up care. Implications. Health care organizations’ disclosures should focus on the next steps to take after health care exposures. This communication should involve helping patients to understand their personal health issues better, make them feel that they know which steps to take following the receipt of this information, and encouraging them to seek follow-up infectious disease testing in order to better take care of themselves.

From implementation to sustainment: A large-scale adverse event disclosure support program generated through embedded research in the Veterans Health Administration

In 2008, the Veterans Health Administration published a groundbreaking policy on disclosing large-scale adverse events to patients in order to promote transparent communication in cases where harm may not be obvious or even certain. Without embedded research, the evidence on whether or not implementation of this policy was generating more harm than good among Veteran patients was unknown. Through an embedded research-operations partnership, we conducted four research projects that led to the development of an evidence-based large-scale disclosure toolkit and disclosure support program, and its implementation across VA healthcare. Guided by the Consolidated Framework for Implementation Research, we identified specific activities corresponding to planning, engaging, executing, reflecting and evaluating phases in the process of implementation. These activities included planning with operational leaders to establish a shared research agenda; engaging with stakeholders to discuss early results, establishing buy-in of our efforts and receiving feedback; joining existing operational teams to execute the toolkit implementation; partnering with clinical operations to evaluate the toolkit during real-time disclosures; and redesigning the toolkit to meet stakeholders' needs. Critical lessons learned for implementation success included a need for stakeholder collaboration and engagement, an organizational culture involving a strong belief in evidence, a willingness to embed researchers in clinical operation activities, allowing for testing and evaluation of innovative practices, and researchers open to constructive feedback. At the conclusion of the research, VA operations worked with the researchers to continue to support efforts to spread, scale-up and sustain toolkit use across the VA healthcare system, with the final goal to establish long-term sustainability.

Models of Arthritis Care: A Systems-level Evaluation of Acceptability as a Dimension of Quality of Care

OBJECTIVE

To describe a systems-level baseline evaluation of central intake (CI) and triage systems in arthritis care within Alberta, Canada. The specific objectives were to (1) describe a process for systems evaluation for the provision of arthritis care; (2) report the findings of the evaluation for different clinical sites that provide arthritis care; and (3) identify opportunities for improving appropriate and timely access based on the findings of the evaluation.

METHODS

The study used a convergent mixed methods design. Surveys and semistructured interviews were the main data collection methods. Participants were recruited through 2 rheumatology clinics and 1 hip and knee clinic providing CI and triage, and included patients, referring physicians, specialists, and clinic staff who experienced CI processes.

RESULTS

A total of 237 surveys were completed by patients (n = 169), referring physicians (n = 50), and specialists (n = 18). Interviews (n = 25) with care providers and patients provided insights to the survey data. Over 95% of referring physicians agreed that the current process of CI was satisfactory. Referring physicians and specialists reported issues with the referral process and perceived support in care for wait-listed patients. Patients reported positive experiences with access and navigation of arthritis care services but expressed concerns around communication and receiving minimal support for self-management of their arthritis before and after receiving specialist care.

CONCLUSION

This baseline evaluation of CI and triage for arthritis care indicates satisfaction with the service, but areas that require further consideration are referral completion, timely waiting lists, and further supporting patients to self-manage their arthritis.

Nurses' Experiences with Disclosure of Patient Safety Incidents: A Qualitative Study

Background

Patient safety incidents trigger conflict between healthcare providers and patients. Patients and families want to hear detailed explanations and apologies from medical staff, but nurses may face difficulties with disclosure of patient safety incidents.

Purpose

To identify nurses’ experiences with disclosure of patient safety incidents.

Methods

Data were collected through in-depth interviews with nine clinical and five head nurses and were analyzed using Colaizzi’s phenomenological method.

Findings

After formulating 18 themes representing nurses’ experiences with disclosure of patient safety incidents, we clustered them into four theme clusters: “mixed responses from patients and families,” “caught in a swirl of negative emotions,” “facing the reality that hinders disclosure,” and “waiting for a breakthrough that would enable disclosure”.

Conclusion

Policies, systems, and culture that help both patients and healthcare professionals should be developed.

Exploring the Association Between Organizational Culture and Large-Scale Adverse Events: Evidence from the Veterans Health Administration

BACKGROUND

Large-scale adverse events (LSAEs) involve unsafe clinical practices stemming from system issues that may affect multiple patients. Although literature suggests a supportive organizational culture may protect against system-related adverse events, no study has explored such a relationship within the context of LSAEs. This study aimed to identify whether staff perceptions of organizational culture were associated with LSAE incidence.

METHODS

The team conducted an exploratory analysis using the 2008-2010 data from the US Department of Veterans Affairs (VA) All Employee Survey (AES). LSAE incidence was the outcome variable in two facilities where similar infection control practice issues occurred, leading to LSAEs. For comparison, four facilities where LSAEs had not occurred were selected, matched on VA-assigned facility complexity and geography. The AES explanatory factors included workgroup-level (civility, employee engagement, leadership, psychological safety, resources, rewards) and hospital-level Likert-type scales for four cultural factors (group, rational, entrepreneurial, bureaucratic). Bivariate analyses and logistic regressions were performed, with individual staff as the unit of analysis from the anonymous AES data.

RESULTS

Responses from 209 AES participants across the six facilities in the sample indicated that the four comparison facilities had significantly higher mean scores compared to the two LSAE facilities for 9 of 10 explanatory factors. The adjusted analyses identified that employee engagement significantly predicted LSAE incidence (odds ratio = 0.58, 95% confidence interval = 0.37-0.90).

CONCLUSION

Staff at the two exposure facilities in this study described their organizational culture to be less supportive. Lower scores in employee engagement may be a contributing factor for LSAEs.

Frequency, Expected Effects, Obstacles, and Facilitators of Disclosure of Patient Safety Incidents: A Systematic Review

Objectives

We performed a systematic review to assess and aggregate the available evidence on the frequency, expected effects, obstacles, and facilitators of disclosure of patient safety incidents (DPSI).

Methods

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for this systematic review and searched PubMed, Scopus, and the Cochrane Library for English articles published between 1990 and 2014. Two authors independently conducted the title screening and abstract review. Ninety-nine articles were selected for full-text reviews. One author extracted the data and another verified them.

Results

There was considerable variation in the reported frequency of DPSI among medical professionals. The main expected effects of DPSI were decreased intention of the general public to file medical lawsuits and punish medical professionals, increased credibility of medical professionals, increased intention of patients to revisit and recommend physicians or hospitals, higher ratings of quality of care, and alleviation of feelings of guilt among medical professionals. The obstacles to DPSI were fear of medical lawsuits and punishment, fear of a damaged professional reputation among colleagues and patients, diminished patient trust, the complexity of the situation, and the absence of a patient safety culture. However, the factors facilitating DPSI included the creation of a safe environment for reporting patient safety incidents, as well as guidelines and education for DPSI.

Conclusions

The reported frequency of the experience of the general public with DPSI was somewhat lower than the reported frequency of DPSI among medical professionals. Although we identified various expected effects of DPSI, more empirical evidence from real cases is required.

Evaluating the implementation of a national disclosure policy for large-scale adverse events in an integrated health care system: identification of gaps and successes

BACKGROUND

Many healthcare organizations have developed disclosure policies for large-scale adverse events, including the Veterans Health Administration (VA). This study evaluated VA's national large-scale disclosure policy and identifies gaps and successes in its implementation.

METHODS

Semi-structured qualitative interviews were conducted with leaders, hospital employees, and patients at nine sites to elicit their perceptions of recent large-scale adverse events notifications and the national disclosure policy. Data were coded using the constructs of the Consolidated Framework for Implementation Research (CFIR).

RESULTS

We conducted 97 interviews. Insights included how to handle the communication of large-scale disclosures through multiple levels of a large healthcare organization and manage ongoing communications about the event with employees. Of the 5 CFIR constructs and 26 sub-constructs assessed, seven were prominent in interviews. Leaders and employees specifically mentioned key problem areas involving 1) networks and communications during disclosure, 2) organizational culture, 3) engagement of external change agents during disclosure, and 4) a need for reflecting on and evaluating the policy implementation and disclosure itself. Patients shared 5) preferences for personal outreach by phone in place of the current use of certified letters. All interviewees discussed 6) issues with execution and 7) costs of the disclosure.

CONCLUSIONS

CFIR analysis reveals key problem areas that need to be addresses during disclosure, including: timely communication patterns throughout the organization, establishing a supportive culture prior to implementation, using patient-approved, effective communications strategies during disclosures; providing follow-up support for employees and patients, and sharing lessons learned.

Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses

OBJECTIVES

We examined print, broadcast and social media reports about health care systems' disclosures of large scale adverse events to develop future effective messaging.

STUDY DESIGN

Directed content analysis.

METHODS

We systematically searched four communication databases, YouTube and Really Simple Syndication (RSS) feeds relating to six disclosures of lapses in infection control practices in the Department of Veterans Affairs occurring between 2009 and 2012. We assessed these with a coding frame derived from effective crisis and risk communication models.

RESULTS

We identified 148 unique media reports. Some components of effective communication (discussion of cause, reassurance, self-efficacy) were more present than others (apology, lessons learned). Media about 'promoting secrecy' and 'slow response' appeared in reports when time from event discovery to patient notification was over 75 days. Elected officials' quotes (n = 115) were often negative (83%). Hospital officials' comments (n = 165) were predominantly neutral (92%), and focused on information sharing.

CONCLUSIONS

Health care systems should work to ensure that they develop clear messages focused on what is not well covered by the media, including authentic apologies, remedial actions taken, and shorten the timeframe between event identification and disclosure to patients.

Sentinel events in ophthalmology: experience from Hong Kong

Purpose. To arouse ophthalmologists' awareness in patient safety by reviewing sentinel events in Ophthalmology submitted to a web-based incident reporting system involving all public hospitals in Hong Kong. Methods. Sentinel events in Ophthalmology reported from November 2007 to October 2014 were identified and classified into different categories for further presentation and analysis. Key contributing factors attributing to the occurrence of the incidents were described. Suggestions aiming to prevent future occurrence of similar events were made. Relevant literature and case law were discussed. Results. Twelve sentinel events were included in this observational case series. They were classified into 4 main categories, namely "wrong eye" (5 cases, 41%), "wrong prescription" (3 cases, 25%), "wrong patient and surgery" (2 cases, 17%), and "retained surgical items" (2 cases, 17%). The key contributing factor leading to the occurrence of the incidents was largely human error. Increased staff awareness and proper time-out procedures were recommended to help prevent occurrence of these errors. Conclusion. Sentinel events in Ophthalmology do occur. Many of these incidents were attributed to human error. Surgeon's awareness and willingness to prevent occurrence of sentinel events are warranted.