Strengthening the Medical Error "Meme Pool"

Development and applications of the Anaesthetists' Non-Technical Skills behavioural marker system: a systematic review

OBJECTIVES

To comprehensively synthesise evidence regarding the validity and reliability of the Anaesthetists' Non-Technical Skills (ANTS) behavioural marker system and its application as a tool for the training and assessment of non-technical skills to improve patient safety.

DESIGN

Systematic review.

DATA SOURCES

We employed a citation search strategy. The Scopus and Web of Science databases were searched for articles published from 2002 to May 2022.

ELIGIBILITY CRITERIA

English-language publications that applied the ANTS system in a meaningful way, including its use to guide data collection, analysis and reporting.

DATA EXTRACTION AND SYNTHESIS

Study screening, data extraction and quality assessment were performed by two independent reviewers. We appraised the quality of included studies using the Joanna Briggs Institute Critical Appraisal Checklists. A framework analysis approach was used to summarise and synthesise the included articles.

RESULTS

54 studies were identified. The ANTS system was applied across a wide variety of study objectives, settings and units of analysis. The methods used in these studies varied and included quantitative (n=42), mixed (n=8) and qualitative (n=4) approaches. Most studies (n=47) used the ANTS system to guide data collection. The most commonly reported reliability statistic was inter-rater reliability (n=35). Validity evidence was reported in 51 (94%) studies. The qualitative application outcomes of the ANTS system provided a reference for the analysis and generation of new theories across disciplines.

CONCLUSION

Our results suggest that the ANTS system has been used in a wide range of studies. It is an effective tool for assessing non-technical skills. Investigating the methods by which the ANTS system can be evaluated and implemented for training within clinical environments is anticipated to significantly enhance ongoing enhancements in staff performance and patient safety.

PROSPERO REGISTRATION NUMBER

CRD42022297773.

Evaluation of a Standard Handover Tool at a Pediatric Tertiary Care Unit in Oman

Background The handover system is a great communication tool physicians use to transfer and receive patients' care-related information. The introduction of structured handover tools has resulted in a dramatic reduction in hospital-acquired injuries. We hypothesize that the I-PASS handover tool will improve both written and verbal communication without compromising the handover duration. The current study aims to improve the quality of care and patient safety by evaluating the applicability of I-PASS handover in the Child Health Department at Sultan Qaboos University Hospital, Oman.  Results A total of 20 trainees were enrolled in this study. After the implementation of I-PASS, 70% (14/20) of the respondents thought that the handover was well-structured, compared to 30% (6/20) prior to the implementation of I-PASS (P = .003). Due to I-PASS, about 80% of the participants could identify deteriorating patients and around 60% were confident in addressing emergencies. The I-PASS handover technique has raised participants' satisfaction from 80% to 95%. Before I-PASS, the mean adherence rate across all 10 variables was 28.7/50 (57.4%), compared to the post-I-PASS rate of 47/50 (94%). Conclusion The I-PASS system is a feasible and flexible clinical handover tool. This study showed that I-PASS has improved on-call handovers and patient safety.

Development and applications of the anaesthetists' non-technical skills behavioural marker system: protocol for a systematic review

INTRODUCTION

The high incidence of unsafe anaesthetic care leads to adverse events and increases the burden on patient safety. An important reason for unsafe anaesthesia care is the lack of non-technical skills (NTS), which are defined as personal cognitive, social or interpersonal skills, among anaesthetists. The anaesthetists' NTS (ANTS) behavioural marker system has been widely used to evaluate and improve anaesthetists' behavioural performance to ensure patient safety. This protocol describes a planned systematic review aiming to determine the validity and reliability of the ANTS behavioural marker system and its application as a tool for the training and assessment of ANTS and for improving patient safety.

METHODS AND ANALYSIS

This systematic review follows the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol. Studies that applied the ANTS behavioural marker system in a meaningful way, including using the ANTS behavioural marker system to guide data collection, analysis, coding, measurement, and/or reporting, which have been published in peer-reviewed journals, will be eligible. A citation search strategy will be employed. We will search Scopus and Web of Science for publications from 2002 to May 2022, which cite the three original ANTS behavioural marker system publications by Fletcher et al. We will also search the references of the relevant reviews for additional eligible studies. For each study, two authors will independently screen papers to determine eligibility and will extract the data. The quality of the included studies will be assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklists. A framework analysis approach that consists of five steps-familiarisation, identifying a thematic data extraction framework, indexing, charting, mapping and interpretation-will be used to synthesise and report the data.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study. The findings will be disseminated primarily through peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42022297773.

Development of a Quality Improvement Dental Chart Review Training Program

INTRODUCTION

Chart review is central to understanding adverse events (AEs) in medicine. In this article, we describe the process and results of educating chart reviewers assigned to evaluate dental AEs.

METHODS

We developed a Web-based training program, "Dental Patient Safety Training," which uses both independent and consensus-based curricula, for identifying AEs recorded in electronic health records in the dental setting. Training included (1) didactic education, (2) skills training using videos and guided walkthroughs, (3) quizzes with feedback, and (4) hands-on learning exercises. In addition, novice reviewers were coached weekly during consensus review discussions. TeamExpert was composed of 2 experienced reviewers, and TeamNovice included 2 chart reviewers in training. McNemar test, interrater reliability, sensitivity, specificity, positive predictive value, and negative predictive value were calculated to compare accuracy rates on the identification of charts containing AEs at the start of training and 7 months after consensus building discussions between the 2 teams.

RESULTS

TeamNovice completed independent and consensus development training. Initial chart reviews were conducted on a shared set of charts (n = 51) followed by additional training including consensus building discussions. There was a marked improvement in overall percent agreement, prevalence and bias-adjusted κ correlation, and diagnostic measures (sensitivity, specificity, positive predictive value, and negative predictive value) of reviewed charts between both teams from the phase I training program to phase II consensus building.

CONCLUSIONS

This study detailed the process of training new chart reviewers and evaluating their performance. Our results suggest that standardized training and continuous coaching improves calibration between experts and trained chart reviewers.

Implementing Just Culture to Improve Patient Safety

INTRODUCTION

The number of deaths in the United States related to medical errors remains unacceptably high. Further complicating this situation is the problem of underreporting due to the fear of the consequences. In fact, the most commonly reported cause of underreporting worldwide is the fear of the negative consequences associated with reporting. As health care organizations along the journey to high-reliability strive to improve patient safety, a concerted effort needs to be focused on changing how medical errors are addressed. A paradigm shift is needed from immediately assigning blame and punishing individuals to one that is trusting and just. Staff must trust that when errors occur, organizations will respond in a manner that is fair and appropriate.

MATERIALS AND METHODS

An extensive review of the literature from 2017 until January 2022 was conducted for the most current evidence describing the principles and practices of "just culture" in health care organizations. Additionally, recommendations were sought on how health care organizations can go about implementing "just culture" principles.

RESULTS

Twenty sources of evidence on "just culture' were retrieved and reviewed. The evidence was used to describe the concept and principles of "just culture" in health care organizations. Furthermore, five strategies for implementing "just culture" principles were identified.

CONCLUSIONS

Improving patient safety requires that high-reliability organizations strive to ensure that the culture of the organization is trusting and just. In a trusting and just culture, adverse events are recognized as valuable opportunities to understand contributing factors and learn rather than immediately assign blame. Moving away from a blame culture is a paradigm shift for many health care organizations yet critically important for improving patient safety.

Improving Patient Handoffs and Transitions through Adaptation and Implementation of I-PASS Across Multiple Handoff Settings

INTRODUCTION

Communication failures are common root causes of serious medical errors. Standardized, structured handoffs improve communication and patient safety. I-PASS is a handoff program that decreases medical errors and preventable patient harm. The I-PASS mnemonic is defined as illness severity, patient information, action list, situational awareness and contingency plans, and synthesis by receiver. I-PASS was validated for physician handoffs, yet has the potential for broader application. The objectives of this quality improvement initiative were to adapt and implement I-PASS to handoff contexts throughout a pediatric hospital, including those with little or no known evidence of using I-PASS.

METHODS

We adapted and implemented I-PASS for inpatient nursing bedside report, physician handoff, and imaging/procedures handoff. Throughout the initiative, end-user stakeholders participated as team members and informed the adaptation of the I-PASS mnemonic, handoff processes, written handoff documents, and performance evaluation methods. Peers observed handoffs, scored performance, and provided formative feedback. Adherence to I-PASS was the primary outcome. We also evaluated changes in handoff-related error frequency and clinician attitudes about the effects of I-PASS on personal and overall handoff performance.

RESULTS

All 5 elements of the I-PASS mnemonic were used in 87% of inpatient nursing, 76% of physician, and 89% of imaging/procedures handoffs. Inpatient nurses reported reductions in handoff-related errors following I-PASS implementation. Clinicians across most handoff settings reported that using I-PASS improved both general and personal handoff performance.

CONCLUSIONS

I-PASS is adaptable to many handoff settings, which expands its potential to improve patient safety. Clinicians reported reductions in errors and improvements in handoff performance. We identified broad institutional support, customized written handoff documents, and peer observations with feedback as crucial factors in sustaining I-PASS usage.