When Safety Event Reporting Is Seen as Punitive: "I've Been PSN-ed!"

Analysis of Intervention Employability in Pharmacy-Related Medication Safety Reports at a Tertiary Medical Center

Background: The Institute for Safe Medication Practice (ISMP) suggests that patient safety reports be addressed with systematic, fail-safe, actions to prevent error recurrence. ISMP's hierarchy of effectiveness of risk reduction strategies places education-related interventions as the least effective and fail-safes at the top. UNM Hospitals creates a positive environment for safety reporting, but often we are limited to education interventions due to resource and technology constraints. This study analyzes the intervention potential and quality of pharmacy-related medication safety reports. Methods: One thousand medication-related safety reports from selected time points between 2012 and 2022 were selected. Safety reports were included in our study if they were actionable by the pharmacy department. Each safety report was categorized by type of safety event and given an intervention potential score of 1 to 10 (1 indicating education-only, 10 being forcing function) by 2 student pharmacists and 1 pharmacy director based on their potential place on ISMP's hierarchy. Safety report quality was graded based on professionalism, organization, clarity, and completeness. A standardized evaluation form was used for evaluation for all elements. Results: Six-hundred-sixty-five safety reports were pharmacy-related and evaluated by all 3 study team members for analysis. The 3 most common pharmacy-related safety reports were medication delivery, inappropriate order verification, and transcribing errors which accounted for over half of the reports (59.5%) and on average the intervention potential score of these types of safety reports was education only. Overall, safety reports were limited to a maximum actionability of education-only 75.4% of the time. Safety reports were found to be professionally written and well organized. Conclusion: The actionability of most pharmacy-related medication safety reports was limited to low leverage interventions likely because high leverage solutions were addressed with systematic change and did not recur. Errors limited to education interventions repeated and this increased relative counts of low leverage actionability of safety reports. The ISMP hierarchy of effectiveness of risk-reduction strategies is an important guide to intervening in medication-related safety events, but pharmacy staff should not be discouraged if most of the safety reports cannot be addressed through high-leverage interventions.

Gamification in Critical Care Education and Practice

OBJECTIVES

To explore gamification as an alternative approach to healthcare education and its potential applications to critical care.

DATA SOURCES

English language manuscripts addressing: 1) gamification theory and application in healthcare and critical care and 2) implementation science focused on the knowledge-to-practice gap were identified in Medline and PubMed databases (inception to 2023).

STUDY SELECTION

Studies delineating gamification underpinnings, application in education or procedural mentoring, utilization for healthcare or critical care education and practice, and analyses of benefits or pitfalls in comparison to other educational or behavioral modification approaches.

DATA EXTRACTION

Data indicated the key gamification tenets and the venues within which they were used to enhance knowledge, support continuing medical education, teach procedural skills, enhance decision-making, or modify behavior.

DATA SYNTHESIS

Gamification engages learners in a visual and cognitive fashion using competitive approaches to enhance acquiring new knowledge or skills. While gamification may be used in a variety of settings, specific design elements may relate to the learning environment or learner styles. Additionally, solo and group gamification approaches demonstrate success and leverage adult learning theory elements in a low-stress and low-risk setting. The potential for gamification-driven behavioral modification to close the knowledge-to-practice gap and enable guideline and protocol compliance remains underutilized.

CONCLUSIONS

Gamification offers the potential to substantially enhance how critical care professionals acquire and then implement new knowledge in a fashion that is more engaging and rewarding than traditional approaches. Accordingly, educational undertakings from courses to offerings at medical professional meetings may benefit from being gamified.

Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis

BACKGROUND

Never events (NEs) are patient safety incidents that are preventable and so serious they should never happen. To reduce NEs, several frameworks have been introduced over the past two decades; however, NEs and their harms continue to occur. These frameworks have varying events, terminology and preventability, which hinders collaboration. This systematic review aims to identify the most serious and preventable events for targeted improvement efforts by answering the following questions: Which patient safety events are most frequently classified as never events? Which ones are most commonly described as entirely preventable?

METHODS

For this narrative synthesis systematic review we searched Medline, Embase, PsycINFO, Cochrane Central and CINAHL for articles published from 1 January 2001 to 27 October 2021. We included papers of any study design or article type (excluding press releases/announcements) that listed NEs or an existing NE framework.

RESULTS

Our analyses included 367 reports identifying 125 unique NEs. Those most frequently reported were surgery on the wrong body part, wrong surgical procedure, unintentionally retained foreign objects and surgery on the wrong patient. Researchers classified 19.4% of NEs as 'wholly preventable'. Those most included in this category were surgery on the wrong body part or patient, wrong surgical procedure, improper administration of a potassium-containing solution and wrong-route administration of medication (excluding chemotherapy).

CONCLUSIONS

To improve collaboration and facilitate learning from errors, we need a single list that focuses on the most preventable and serious NEs. Our review shows that surgery on the wrong body part or patient, or the wrong surgical procedure best meet these criteria.

Speaking up as an extension of socio-cultural dynamics in hospital settings: a study of staff experiences of speaking up across seven hospitals

PURPOSE

The study aimed to understand the significance of how employee personhood and the act of speaking up is shaped by factors such as employees' professional status, length of employment within their hospital sites, age, gender and their ongoing exposure to unprofessional behaviours.

DESIGN/METHODOLOGY/APPROACH

Responses to a survey by 4,851 staff across seven sites within a hospital network in Australia were analysed to interrogate whether speaking up by hospital employees is influenced by employees' symbolic capital and situated subjecthood (SS). The authors utilised a Bourdieusian lens to interrogate the relationship between the symbolic capital afforded to employees as a function of their professional, personal and psycho-social resources and their self-reported capacity to speak up.

FINDINGS

The findings indicate that employee speaking up behaviours appear to be influenced profoundly by whether they feel empowered or disempowered by ongoing and pre-existing personal and interpersonal factors such as their functional roles, work-based peer and supervisory support and ongoing exposure to discriminatory behaviours.

ORIGINALITY/VALUE

The findings from this interdisciplinary study provide empirical insights around why culture change interventions within healthcare organisations may be successful in certain contexts for certain staff groups and fail within others.

Patient Safety Culture in Latin American Hospitals: A Systematic Review with Meta-Analysis

INTRODUCTION

Adverse events in hospitals are prevented through risk reduction and reliable processes. Highly reliable hospitals are grounded by a robust patient safety culture with effective communication, leadership, teamwork, error reporting, continuous improvement, and organizational learning. Although hospitals regularly measure their patient safety culture for strengths and weaknesses, there have been no systematic reviews with meta-analyses reported from Latin America.

PURPOSE

Our systematic review aims to produce evidence about the status of patient safety culture in Latin American hospitals from studies using the Hospital Survey on Patient Safety Culture (HSOPSC).

METHODS

This systematic review was guided by the JBI guidelines for evidence synthesis. Four databases were systematically searched for studies from 2011 to 2021 originating in Latin America. Studies identified for inclusion were assessed for methodological quality and risk of bias. Descriptive and inferential statistics, including meta-analysis for professional subgroups and meta-regression for subgroup effect, were calculated.

RESULTS

In total, 30 studies from five countries-Argentina (1), Brazil (22), Colombia (3), Mexico (3), and Peru (1)-were included in the review, with 10,915 participants, consisting primarily of nursing staff (93%). The HSOPSC dimensions most positive for patient safety culture were "organizational learning: continuous improvement" and "teamwork within units", while the least positive were "nonpunitive response to error" and "staffing". Overall, there was a low positive perception (48%) of patient safety culture as a global measure (95% CI, 44.53-51.60), and a significant difference was observed for physicians who had a higher positive perception than nurses (59.84; 95% CI, 56.02-63.66).

CONCLUSIONS

Patient safety culture is a relatively unknown or unmeasured concept in most Latin American countries. Health professional programs need to build patient safety content into curriculums with an emphasis on developing skills in communication, leadership, and teamwork. Despite international accreditation penetration in the region, there were surprisingly few studies from countries with accredited hospitals. Patient safety culture needs to be a priority for hospitals in Latin America through health policies requiring annual assessments to identify weaknesses for quality improvement initiatives.

Creating a Learning Health System for Improving Diagnostic Safety: Pragmatic Insights from US Health Care Organizations

OBJECTIVE

To identify challenges and pragmatic strategies for improving diagnostic safety at an organizational level using concepts from learning health systems METHODS: We interviewed 32 safety leaders across the USA on how their organizations approach diagnostic safety. Participants were recruited through email and represented geographically diverse academic and non-academic settings. The interview included questions on culture of reporting and learning from diagnostic errors; data gathering and analysis activities; diagnostic training and educational activities; and engagement of clinical leadership, staff, patients, and families in diagnostic safety activities. We conducted an inductive content analysis of interview transcripts and two reviewers coded all data.

RESULTS

Of 32 participants, 12 reported having a specific program to address diagnostic errors. Multiple barriers to implement diagnostic safety activities emerged: serious concerns about psychological safety associated with diagnostic error; lack of infrastructure for measurement, monitoring, and improvement activities related to diagnosis; lack of leadership investment, which was often diverted to competing priorities related to publicly reported measures or other incentives; and lack of dedicated teams to work on diagnostic safety. Participants provided several strategies to overcome barriers including adapting trigger tools to identify safety events, engaging patients in diagnostic safety, and appointing dedicated diagnostic safety champions.

CONCLUSIONS

Several foundational building blocks related to learning health systems could inform organizational efforts to reduce diagnostic error. Promoting an organizational culture specific to diagnostic safety, using science and informatics to improve measurement and analysis, leadership incentives to build institutional capacity to address diagnostic errors, and patient engagement in diagnostic safety activities can enable progress.

Strategies and interventions for improving safety culture in Australian Emergency Departments: A modified Delphi study

BACKGROUND

Patient safety and safety culture are critical for quality healthcare delivery in general and in Emergency Departments (EDs) in particular. The aim of this study is to identify strategies that may contribute to the improvement and maintenance of patient safety culture and which are considered most feasible in the ED environment.

METHODS

A two-step modified Delphi method with 11 experts' panel was performed to establish consensus. A list of potential expert participants with a background in patient safety culture in EDs was compiled through the professional networks of the supervisory team. Snowball sampling was used to identify additional possible participants. The expert panel included key leaders in the emergency medicine community in Queensland, Australia: patient safety experts and researchers, patient safety directors, and healthcare providers in an Australian ED The study ran from September 2018 to December 2018. The tool used in Round 1 in this study was developed through triangulating the outcomes of a review of literature, results from a survey of ED staff and findings from semi-structured interviews with key stakeholders in ED. The results from Round 1 informed the development of the Round 2 tool. The responses from the Delphi Round 1 tool were analysed as both qualitative data and quantitative data. The responses from the Delphi Round 2 tool were treated as quantitative data and analysed with the SPSS software. Consensus was calculated based on more than 80% agreement in collapsed categories 1 and 2 (or 4 and 5) of the five-point Likert scale.

RESULTS

Only six strategies out of 17 (35%) achieved consensus for both importance and feasibility. These strategies may therefore be considered the most important and feasible key strategies for improving safety culture in EDs. Seven strategies (41.1%) achieved consensus for importance, but not for feasibility and four strategies (23.55%) did not achieve consensus for either importance or feasibility.

CONCLUSIONS

This study offers practical solutions for safety culture improvement in the ED context. Six key strategies were seen as both important and feasible and these grouped into three main themes; leadership through agenda setting, operational management approaches to reinforce the agenda and commitment, and systems and structures to reinforce the agenda and monitor progress.

Safety Culture: Identifying a Healthcare Organization’s Approach to Safety Event Review and Response Through the Analysis of Event Recommendations

A nonpunitive approach to safety event reporting and analysis is an important dimension of healthcare organization safety culture. A system-based safety event review process, one focused on understanding and improving the conditions in which individuals do their work, generally leads to more effective and sustainable safety solutions. On the contrary, the more typical person-based approach, that blames individuals for errors, often results in unsustainable and ineffective safety solutions, but these solutions can be faster and less resource intensive to implement. We sought to determine the frequency of system-based and person-based approaches to adverse event reviews through analysis of the recommendation text provided by a healthcare organization in response to an event report. Human factors and clinical safety science experts developed a taxonomy to describe the content of the recommendation text, reviewed 8,546 event report recommendations, and assigned one or more taxonomy category labels to each recommendation. The taxonomy categories aligned with a system-based approach, aligned with a person-based approach, did not provide an indicator of the approach, or indicated the review/analysis was pending. A total of 9,848 category labels were assigned to the 8,546 event report recommendations. The most frequently used category labels did not provide an indicator of the approach to event review (4,145 of 9,848 category labels, 42.1%), followed by a person-based approach (2,327, 23.6%), review/analysis pending (1,862 ,18.9%), and a system-based approach (1,514, 15.4%). Analyzing the data at the level of each recommendation, 23.2% (1,979 of 8,546) had at least one person-based and no system-based category, 13.3% (1,133) had at least one system-based and no person-based category, and 3% (254) had at least one person-based and one system-based category. There was variability in the event review approach based on the general event type assigned to the safety event (e.g., medication, transfusion, etc.) as well as harm severity. Results suggest improvements in applying system-based approaches are needed, especially for certain general event type categories. Recommendations for improving safety event reviews are provided.