Errors and the Burden of Errors: Attitudes, Perceptions, and the Culture of Safety in Pediatric Cardiac Surgical Teams

Cardiac resternotomy after cardiac surgery in kids: CRACK the chest

OBJECTIVE

Emergent resuscitation of postoperative paediatric cardiac surgical patients requires specialised skills and multidisciplinary teamwork. Bedside resternotomy is a rare but life-saving procedure and few studies focus on ways to prepare providers and improve performance. We created a multidisciplinary educational intervention that addressed teamwork and technical skills. We aimed to evaluate the efficiency of the intervention to decrease time to perform critical tasks and improve caregiver comfort.

METHODS

A simulation-based, in situ resternotomy educational intervention was implemented. Pre-intervention data were collected. Educational aids were used weekly during day and night nursing huddles over a three-month period. All ICU charge nurses had separate educational sessions with study personnel and were required to demonstrate competency in all the critical tasks. Post-intervention simulations were performed after intervention and at 6 months and post-intervention surveys were performed.

RESULTS

A total of 186 providers participated in the intervention. There was a decrease in time to obtain defibrillator, setup resternotomy equipment and internal defibrillator paddles and deliver sedation and fluid (all p < 0.05). Time to escort family from the room and obtain blood was significantly decreased after intervention (p < 0.05). There was no difference in time to first dose of epinephrine, defibrillator pads on the patient, or time to call the cardiovascular surgeon or blood bank. Providers reported increased comfort in identifying equipment needed for resternotomy (p < 0.01) and setting up the internal defibrillator paddles (p < 0.01).

CONCLUSIONS

Implementation of a novel educational intervention increased provider comfort and decreased time to perform critical tasks in an emergent resternotomy scenario.

A systematic review critically appraising quantitative survey measures assessing power dynamics among multidisciplinary teams in acute care settings

By valuing the knowledge of each discipline holistic patient-centered care can be achieved as decisions arise from expertise rather than established hierarchies. While healthcare has historically operated as a hierarchical power structure (i.e., some voices have more influence), these dynamics are rarely discussed. This review addresses this issue by appraising extant quantitative measures that assess multidisciplinary team (MDT) power dynamics. By identifying psychometrically sound measures, change agents can uncover the collective thought processes informing power structures in practice and develop strategies to mitigate power disparities. Several databases were searched. English language articles were included if they reported on quantitative measures assessing power dynamics among MDTs in acute/hospital settings. Results were synthesized using a narrative approach. In total, 6,202 search records were obtained of which 62 met the eligibility criteria. The review reveals some promising measures to assess power dynamics (e.g., Interprofessional Collaboration Scale). However, the findings also confirm several gaps in the current evidence base: 1) need for further psychometric and pragmatic testing of measures; 2) inclusion of more representative MDT samples; 3) further evaluation of unmatured power dimensions. Addressing these gaps will support the development of future interventions aimed at mitigating power imbalances and ultimately improve collaborative working within MDTs.

Beyond the self: a novel framework to enhance non-technical team skills for anesthesiologists

Human factors and non-technical skills (NTS) have been identified as essential contributors to both the propagation and prevention of medical errors in the operating room. Despite extensive study and interventions to nurture and enhance NTS in anesthesiologists, gaps to effective team practice and patient safety remain. Furthermore, the link between added NTS training and clinically significant improved outcomes has not yet been demonstrated. We performed a narrative review to summarize the literature on existing systems and initiatives used to measure and nurture NTS in the clinical operating room setting. Controlled interventions performed to nurture NTS (N.=13) were identified and compared. We comment on the body of current evidence and highlight the achievements and limitations of interventions published thus far. We then propose a novel education and training framework to further develop and enhance non-technical skills in both individual anesthesiologists and operating room teams. We use the cardiac anesthesiology environment as a starting point to illustrate its use, with clinical examples. NTS is a key component of enhancing patient safety. Effective framing of its concepts is central to apply individual characteristics and skills in team environments in the OR and achieve tangible, beneficial patient outcomes.

Patient Safety Culture: Effects on Errors, Incident Reporting, and Patient Safety Grade

OBJECTIVES

This study mainly examines the effects of patient safety culture dimensions on 4 outcomes (self-reported errors, witnessing errors, incident reporting, and patient safety grade).

METHODS

The data were collected using the Turkish version of the Safety Attitudes Questionnaire, which consists of 6 dimensions (teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management, and working conditions). Of 1679 personnel working in 6 hospitals in Ankara, 860 were randomly selected. The data were analyzed using descriptive statistics, the Spearman correlation coefficient, and binary logistic regression analyses.

RESULTS

The response rate was 62.7%. When the overall patient safety culture score increased by 1 point; the probability of witnessing an error was 2 times lower (P < 0.001), the probability of incident reporting was 4.22 times higher (P < 0.001), and the probability of assessing the patient safety grade as excellent was 29.86 times higher (P < 0.001). The teamwork climate was negatively related to making errors and witnessing errors (P < 0.001). The safety climate and working conditions were positively related to incident reporting and patient safety grade (P < 0.001). Job satisfaction was negatively related to incident reporting (P < 0.001). Perceptions of management were positively related to making errors and patient safety grade (P < 0.001).

CONCLUSIONS

The patient safety culture scores were positively correlated with incident reporting and patient safety grade but negatively correlated with the occurrence of errors. Each dimension of the patient safety culture, except stress recognition, affected different outcomes. Therefore, managers should focus on different dimensions of patient safety culture to improve different outcomes.

Reviewing High Reliability Team (HRT) Scholarship: A 21st Century Approach to Safety

High reliability team (HRT) theorizing emerged from high reliability organization (HRO) theory and now represents a distinct subset of HRO literature. Seeking to capture the development and range of HRT research, a comprehensive literature review was conducted. This systematic review of HRT scholarship, the first of its kind, provides a foundation from which small group and team scholars across disciplines may reflect on key lessons and chart future research. This review includes 71 articles across 21 disciplines and incorporates historical reflection on HRT theory foundations, existing empirical support, critiques and rivals, theory extensions, and ideas for future scholarship efforts.

Resilience and Protection of Health Care and Research Laboratory Workers During the SARS-CoV-2 Pandemic: Analysis and Case Study From an Austrian High Security Laboratory

The SARS-CoV-2 pandemic has highlighted the interdependency of healthcare systems and research organizations on manufacturers and suppliers of personnel protective equipment (PPE) and the need for well-trained personnel who can react quickly to changing working conditions. Reports on challenges faced by research laboratory workers (RLWs) are rare in contrast to the lived experience of hospital health care workers. We report on experiences gained by RLWs (e.g., molecular scientists, pathologists, autopsy assistants) who significantly contributed to combating the pandemic under particularly challenging conditions due to increased workload, sickness and interrupted PPE supply chains. RLWs perform a broad spectrum of work with SARS-CoV-2 such as autopsies, establishment of virus cultures and infection models, development and verification of diagnostics, performance of virus inactivation assays to investigate various antiviral agents including vaccines and evaluation of decontamination technologies in high containment biological laboratories (HCBL). Performance of autopsies and laboratory work increased substantially during the pandemic and thus led to highly demanding working conditions with working shifts of more than eight hours working in PPE that stressed individual limits and also the ergonomic and safety limits of PPE. We provide detailed insights into the challenges of the stressful daily laboratory routine since the pandemic began, lessons learned, and suggest solutions for better safety based on a case study of a newly established HCBL (i.e., BSL-3 laboratory) designed for autopsies and research laboratory work. Reduced personal risk, increased resilience, and stress resistance can be achieved by improved PPE components, better training, redundant safety measures, inculcating a culture of safety, and excellent teamwork.

Medical errors, medical negligence and defensive medicine: A narrative review

Error in medicine and medical liability has a long history dating back to Antiquity. During the 19th Century, most lawsuits related to errors in treating surgical problems were settled. However, in the first half of the 20th Century, lawsuits claimed that mistakes were related to the doctor's action: the doctor made something wrong (errors of commission). In Brazil, medical error is defined as inappropriate conduct, including negligence and recklessness, that causes harm to the patient. The physician's fear of being suited is the reason for some practice named defensive Medicine (D.M.), defined as ordering unnecessary tests and procedures or avoiding treatments for patients considered at high-risk. Thus, this narrative review aims to analyze and describe the relationship between medical errors, medical negligence, and the practice of D.M. So, the authors propose procedures and attitudes to avoid medical errors and the approach of D.M.: a national focus to create leadership and research tools to enhance the knowledge base about patient safety; a reporting system that would help to identify and learn from errors; the use of a computer-based protocol reminder; some technological devices to help the medical practice (electronic prescribing and information technology systems); creating risk management programs in hospitals. Therefore, the authors conclude that the most critical attitude to avoid medical liability is a good and ethical medical practice with the proper use of technology, based on knowledge of scientific evidence and ethical principles of medicine - for the benefit of patients.

Relationship Between Work Experience and Safety Climate in Veterans Affairs Nursing Homes Nationwide

OBJECTIVES

Staff values and beliefs about resident safety (safety climate) represent one potential driver of nursing home safety. Staff with more work experience (length of service) may possess richer knowledge of resident safety for strengthening safety climate. We investigated the association of length of service with safety climate in the U.S. Department of Veterans Affairs nursing homes or Community Living Centers (CLCs).

METHODS

Fifty-six of 134 CLCs participated in 2017 and then 2018 in the previously validated CLC Employee Survey of Attitudes about Resident Safety, which comprised 7 safety climate domains and employee characteristics. We conducted 2 cross-sectional analyses of length of service on each safety climate domain, controlling for occupation, shift, work hours, and clustering by VA hospital, service network, and geographic region, in mixed random-effect regression models.

RESULTS

A total of 1397 and 1645 staff participated in the survey (26% and 28% response rates) at round 1 and 2, respectively. At each round participants working greater than 6 months were less positive than those working less than 6 months about supervisor commitment to safety, coworker interactions around safety, and CLC global ratings.

CONCLUSIONS

Differences in work experience contributed to incongruence in perceptions about supervisors, coworkers, and the facility. Workers with more experience may have higher perceived job aptitude and thus higher expectations of supervisory recognition and more criticisms of coworkers. Pairing experienced workers with newer ones may narrow the knowledge gap and increase collaboration. Huddles, team meetings, and organizational initiatives represent opportunities to recognize and leverage experienced workers' accumulated safety knowledge.

The High Stakes of Outsourcing in Health Care

Outsourcing in health care has become increasingly common as health system administrators seek to enhance profitability and efficiency while maintaining clinical excellence. When clinical services are outsourced, however, the outsourcing organization relinquishes control over its most important service value: high-quality patient care. Farming out work to an external service provider can have many unintended results, including inconsistencies in standards of care; harmful medical errors; declines in patient and employee satisfaction; and damage to clinicians' morale and income, and to the health organization's culture, reputation, and long-term financial performance. Research on outsourcing in the areas of emergency medicine, radiology, laboratory services, and environmental services provides concerning evidence of potentially large downsides when outsourcing is driven by short-term cost concerns or is planned without diligently considering all of the ramifications of not keeping key clinical and nonclinical services in-house. To better equip health system leaders for decision-making about outsourcing, we examine this body of literature, identify common pitfalls of outsourcing in specific clinical and nonclinical health services and scenarios, explore alternatives to outsourcing, and consider how outsourcing (when necessary) can be done in a strategic manner that does not compromise the values of the organization and its commitment to patients.

Hospital work environments affect the patient safety climate: A longitudinal follow-up using a logistic regression analysis model

Background

Occupational worker wellness and safety climate are key determinants of healthcare organizations’ ability to reduce medical harm to patients while supporting their employees. We designed a longitudinal study to evaluate the association between work environment characteristics and the patient safety climate in hospital units.

Methods

Primary data were collected from Norwegian hospital staff from 970 clinical units in all 21 hospitals of the South-Eastern Norway Health Region using the validated Norwegian Work Environment Survey and the Norwegian version of the Safety Attitudes Questionnaire. Responses from 91,225 surveys were collected over a three year period. We calculated the factor mean score and a binary outcome to measure study outcomes. The relationship between the hospital unit characteristics and the observed changes in the safety climate was analyzed by linear and logistic regression models.

Results

A work environment conducive to safe incident reporting, innovation, and teamwork was found to be significant for positive changes in the safety climate. In addition, a work environment supportive of patient needs and staff commitment to their workplace was significant for maintaining a mature safety climate over time.

Conclusions

A supportive work environment is essential for patient safety. The characteristics of the hospital units were significantly associated with the unit’s safety climate scores, hence improvements in working conditions are needed for enhancing patient safety.

Dimensions of safety culture: a systematic review of quantitative, qualitative and mixed methods for assessing safety culture in hospitals

BACKGROUND

The study of safety culture and its relationship to patient care have been challenged by variation in definition, dimensionality and methods of assessment. This systematic review aimed to map methods to assess safety culture in hospitals, analyse the prevalence of these methods in the published research literature and examine the dimensions of safety culture captured through these processes.

METHODS

We included studies reporting on quantitative, qualitative and mixed methods to assess safety culture in hospitals. The review was conducted using four academic databases (PubMed, CINAHL, Scopus and Web of Science) with studies from January 2008 to May 2020. A formal quality appraisal was not conducted. Study purpose, type of method and safety culture dimensions were extracted from all studies, coded thematically, and summarised narratively and using descriptive statistics where appropriate.

RESULTS

A total of 694 studies were included. A third (n=244, 35.2%) had a descriptive or exploratory purpose, 225 (32.4%) tested relationships among variables, 129 (18.6%) evaluated an intervention, while 13.8% (n=96) had a methodological focus. Most studies exclusively used surveys (n=663; 95.5%), with 88 different surveys identified. Only 31 studies (4.5%) used qualitative or mixed methods. Thematic analysis identified 11 themes related to safety culture dimensions across the methods, with 'Leadership' being the most common. Qualitative and mixed methods approaches were more likely to identify additional dimensions of safety culture not covered by the 11 themes, including improvisation and contextual pressures.

DISCUSSION

We assessed the extent to which safety culture dimensions mapped to specific quantitative and qualitative tools and methods of assessing safety culture. No single method or tool appeared to measure all 11 themes of safety culture. Risk of publication bias was high in this review. Future attempts to assess safety culture in hospitals should consider incorporating qualitative methods into survey studies to evaluate this multi-faceted construct.

Simulation as an Educational Tool in the Pediatric Cardiac Intensive Care Unit

Purpose of Review

This review highlights the use of simulation as an educational tool in the highly specialized pediatric cardiac intensive care unit (PCICU).

Recent Findings

Healthcare simulation is used in high acuity medical environments to test healthcare systems. Healthcare simulation can improve team training, patient safety, and improve medical decision-making. Complex physiologies in the PCICU demand effective teamwork to consistently deliver high-quality patient care. Simulation-based PCICU learning objectives depend on a structured cognitive load framework to account for individual learner abilities, team constructs, and healthcare resources.

Summary

PCICU simulation programs are strengthened by utilizing traditional education theory, with careful consideration of complex physiologies, interprofessional personnel, and center-specific resources. Virtual platforms should continue to evolve to provide additional, more convenient venues for individual learners and teams. Healthcare systems should frequently intersect with simulation educators to create relevant learning objectives that will contribute to patient safety, improve team performance, and patient outcomes.

Associations between work satisfaction, engagement and 7-day patient mortality: a cross-sectional survey

OBJECTIVE

This study examines the association between profession-specific work environments and the 7-day mortality of patients admitted to these units with acute myocardial infarction (AMI), stroke and hip fracture.

DESIGN

A cross-sectional study combining patient mortality data extracted from the South-Eastern Norway Health Region, and the work environment scores at the hospital ward levels. A case-mix adjustment model was developed for the comparison between hospital wards.

SETTING

Fifty-six patient wards in 20 hospitals administered by the South-Eastern Norway Regional Health Authority.

PARTICIPANTS

In total, 46 026 patients admitted to hospitals with AMI, stroke and hip fracture, and supported by 8800 survey responses from physicians, nurses and managers over a 3-year period (2010-2012).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measures were the associations between the relative mortality rate for patients admitted with AMI, stroke and hip fractures and the profession-specific (ie, nurses, physicians, middle managers) mean scores on the 19 organisational factors in a validated cross sectional, staff survey conducted annually in Norway. The secondary outcome measures were the mean scores with SD on the organisational factors in the staff survey reported by each profession.

RESULTS

The Nurse workload (beta 0.019 (95% CI0.009-0.028)) and middle manager engagement (beta 0.024 (95% CI0.010-0.037)) levels were associated with a case-mix adjusted 7-day patient mortality rates. There was no significant association between physician work environment scores and patient mortality rates.

CONCLUSION

7-day mortality rates in hospital wards were negatively correlated with the nurse workload and manager engagement levels. A deeper understanding of the relationships between patient outcomes, organisational structure and their underlying cultural barriers is needed because they may provide a better understanding of the harm and death risks for patients due to organisational characteristics.

Patient safety culture in university hospital's emergency departments: A case study

BACKGROUND

Improving patient safety culture in healthcare organization is the first step in reducing medical errors and improving patient safety. The aim of the study was to determine and to compare patient safety culture dimensions in emergency departments of selected educational hospitals of Kerman University of Medical Sciences.

METHODS

This descriptive-analytical study was conducted in 2018 in the emergency departments Shahid Bahonar, Afzalipour, Shahid Beheshti, and Shafa hospitals. Data collection was carried using the Hospital Survey of Patient Safety Culture questionnaire which includes 42 questions and 12 dimensions. Data were analyzed using descriptive and analytical statistics.

RESULTS

The highest and lowest mean related to the organizational learning (3.96 ± 0.34) and handoffs and transitions (2.27 ± 0.55). According to independent t test, there was a significant relationship between nurse's gender and patient safety culture. Also, according to analysis of variance test, there was a significant relationship between work experience and patient safety culture.

CONCLUSIONS

The situation of patient safety culture was average at a moderate level. Development of reporting system and encouraging staff to report errors and adjusting nursing number and workload is suggested.

Evaluating the implementation and effectiveness of a multi-component intervention to reduce post-surgical opioid prescribing: study protocol of a mixed-methods design

INTRODUCTION

Opioids prescribed after surgery accounted for 5% of the 191 million opioid prescriptions filled in 2017. Approximately 80% of the opioid pills prescribed by surgical care providers remain unused, leaving a substantial number of opioids available for non-medical use. We developed a multi-component intervention to address surgical providers' role in the overprescribing of opioids. Our study will determine effective strategies for reducing post-surgical prescribing while ensuring adequate post-surgery patient-reported pain-related outcomes, and will assess implementation of the strategies.

METHODS AND ANALYSIS

The Minimising Opioid Prescribing in Surgery study will implement a multi-component intervention, in an Illinois network of six hospitals (one academical, two large community and three small community hospitals), to decrease opioid analgesics prescribed after surgery. The multi-component intervention involves four domains: (1) patient expectation setting, (2) baseline assessment of opioid use, (3) perioperative pain control optimisation and (4) post-surgical opioid minimisation. Four surgical specialities (general, orthopaedics, urology and gynaecology) at the six hospitals will implement the intervention. A mixed-methods approach will be used to assess the implementation and effectiveness of the intervention. Data from the network's enterprise data warehouse will be used to evaluate the intervention's effect on post-surgical prescriptions and a survey will collect pain-related patient-reported outcomes. Intervention effectiveness will be determined using a triangulation design, mixed-methods approach with staggered speciality-specific implementation for contemporaneous control of opioid prescribing changes over time. The Consolidated Framework for Implementation Research will be used to evaluate the site-specific contextual factors and adaptations to achieve implementation at each site.

ETHICS AND DISSEMINATION

The study aims to identify the most effective hospital-type and speciality-specific intervention bundles for rapid dissemination into our 56-hospital learning collaborative and in hospitals throughout the USA. All study activities have been approved by the Northwestern University Institutional Review Board (ID STU00205053).

Association Between Hospital Safety Culture and Surgical Outcomes in a Statewide Surgical Quality Improvement Collaborative

BACKGROUND

The "safety culture" within hospital systems is increasingly recognized as important to delivery of high-quality care. We examine the safety culture in a statewide hospital quality improvement collaborative and its associations with surgical outcomes.

STUDY DESIGN

A modified Safety Attitudes Questionnaire was sent to administrators, quality improvement teams, nurses, anesthesiologists, and surgeons in 49 hospitals participating in the Illinois Surgical Quality Improvement Collaborative in 2015. Associations between positive safety culture, as measured by percentage of positive responses on the Safety Attitudes Questionnaire, and the following NSQIP 30-day adverse outcomes: hospital-level risk-adjusted morbidity, mortality, death, or serious morbidity and readmission rates. Linear regression models with hospitals clustered by system were used to assess the relationship between safety culture and patient outcomes.

RESULTS

Operating room safety culture scores were highest (97.7% positive) compared with the other domains, and ratings of hospital management were lowest (75.9% positive). Hospital administrators consistently had the most positive perception of the safety culture (90.5% positive) and front-line providers were less positive: physicians (85.3%), advanced practice providers (88.1%), and nurses (80%). Teamwork was rated as a strength by patient care providers (physicians 88.3%, advanced practice providers 90.2%, and nurses 82.2%), but was perceived as weakest by administrators. Higher percentage of positive Safety Attitudes Questionnaire responses was significantly associated with lower risk of postoperative morbidity (p = 0.007) and death or serious morbidity (p = 0.04). No significant association between safety culture and the risk of mortality (p = 0.23) or readmissions (p = 0.52) was observed.

CONCLUSIONS

Hospital safety culture can influence certain surgical patient outcomes. Improving the safety culture within a hospital can represent a previously unrecognized approach that can be leveraged to strengthen surgical quality improvement efforts at the hospital level.

The attitudes of nursing students and clinical instructors towards reporting irregular incidents in the medical clinic

Despite efforts to increase patient safety, medical incidents and near misses occur daily. Much is still unknown about this phenomenon, especially due to underreporting. This study examined why nursing students and clinical instructors underreport medical events, and whether they believe that changes within their institutions could increase reporting. 103 third- and fourth-year nursing students and 55 clinical instructors completed a validated questionnaire. The results showed that about one-third of the instructors and one-half of the nursing students believed that circumstances and lack of awareness, and fear of consequences, lead to underreporting. Both nursing students and clinical instructors ranked "fear of consequences" as the main reason for not reporting, yet students ranked this higher than their instructors. Moreover, both groups believed that incident reporting could be increased following changes in the clinical field, mainly by increasing awareness and knowledge. A large percentage of participants also wrote that they do not report errors that are the result of circumstances and lack of awareness, mainly fear of consequences. Therefore, hospitals and academic institutions may need to create a more accepting organizational climate. Moreover, institutions that allow incident reports to be submitted anonymously and that take educational (not disciplinary) action, may increase incident reporting.

How Does Patient Safety Culture in the Surgical Departments Compare to the Rest of the County Hospitals in Xiaogan City of China?

Objectives: Patient safety culture affects patient safety and the performance of hospitals. The Hospital Survey on Patient Safety Culture (HSOPSC) is generally used to assess the safety culture in hospitals and unit levels. However, only a few studies in China have measured surgical settings compared with other units in county hospitals using the HSOPSC. This study aims to assess the strengths and weaknesses of surgical departments compared with all other departments in county hospitals in China with HSOPSC. Design: This research is a cross-sectional study. Methods: In 2015, a Chinese translation of HSOPSC was administered to 1379 staff from sampled departments from 19 county hospitals in Xiaogan City (Hubei Province, China) using a simple random and cluster sampling method. Outcome Measures: The HSOPSC was completed by 1379 participants. The percent positive ratings (PPRs) of 12 dimensions (i.e., teamwork within units, organizational learning and continuous improvement, staffing, non-punitive response to errors, supervisor/ manager expectations and actions promoting patient safety, feedback and communication about errors, communication openness, hospital handoffs and transitions, teamwork across hospital units, hospital management support for patient safety, overall perception of safety, as well as frequency of events reported) and the positive proportion of outcome variables (patient safety grade and number of events reported) between surgical departments and other departments were compared with t-tests and X² tests, respectively. A multiple regression analysis was conducted, with the outcome dimensions serving as dependent variables and basic characteristics and other dimensions serving as independent variables. Similarly, ordinal logistic regression was used to explore the influencing factors of two categorical outcomes. Results: A total of 56.49% of respondents were from surgical departments. The PPRs for “teamwork within units” and “organizational learning and continuous improvement” were ≥75%, which denoted strengths, and the PPRs for “staffing” and “non-punitive response to errors” were ≤50%, which denoted weaknesses in surgical units and other units. Three dimensions for surgical departments were weaker than those for other departments (p < 0.05). The staff from surgical units reported more events compared with the other units, but only a few respondents in surgical settings evaluated patient safety grade as good/excellent. Four dimensions influenced patient safety grade, and three dimensions influenced event reporting in surgical units. Conclusions: Strategies including recruiting workers, using the reporting system, and building a non-punitive culture should be adopted in the surgical units of county hospitals in China to improve safety culture. Supervisors should also prioritise patient safety.

Systematic review of psychological, emotional and behavioural impacts of surgical incidents on operating theatre staff

BACKGROUND

Adverse surgical incidents affect both patients and health professionals. This study sought to explore the effect of surgical incidents on operating theatre staff and their subsequent behaviours.

METHODS

Eligible studies were primary research or reviews that focused on the effect of incidents on operating theatre staff in primary, secondary or tertiary care settings. MEDLINE, Embase, CINALH and PsycINFO were searched. A data extraction form was used to capture pertinent information from included studies and the Critical Appraisal Skills Programme (CASP) tool to appraise their quality. PRISMA-P reporting guidelines were followed and the review is registered with PROSPERO.

RESULTS

A total of 3918 articles were identified, with 667 duplicates removed and 3230 excluded at the title, abstract and full-text stages. Of 21 included articles, eight focused on the impact of surgical incidents on surgeons and anaesthetists. Only two involved theatre nurses and theatre technicians. Five key themes emerged: the emotional impact on health professionals, organization culture and support, individual coping strategies, learning from surgical complications and recommended changes to practice.

CONCLUSION

Health professionals suffered emotional distress and often changed their behaviour following a surgical incident. Both organizations and individual clinicians can do a great deal to support staff in the aftermath of serious incidents.

Learning from error: leading a culture of safety

A recent shift towards more collective leadership in the NHS can help to achieve a culture of safety, particularly through encouraging frontline staff to participate and take responsibility for improving safety through learning from error and near misses. Leaders must ensure that they provide psychological safety, organizational fairness and learning systems for staff to feel confident in raising concerns, that they have the autonomy and skills to lead continual improvement, and that they have responsibility for spreading this learning within and across organizations.

Assessing the culture of safety in cardiovascular perfusion: attitudes and perceptions

Introduction:

The Hospital Survey on Patient Safety Culture was developed by the Agency for Healthcare Research and Quality (AHRQ) to assess the culture of safety in hospitals. The purpose of this study was to identify specific domains of perfusion that are indicators of a high quality culture of safety.

Methods:

Perfusionists were recruited to participate in the survey through email invitation through Perflist, Perfmail and LinkedIn. The survey consisted of 37 questions across six safety domains. Questions were developed using the AHRQ Hospital Survey on Patient Safety Culture. ‘Positive scores’ were defined as a response that either agreed or strongly agreed with a safety standard. Survey responses that resulted in a 75 percent or higher positive response rate were identified as vital components of a high culture of safety. Logistic regression analysis was used to determine importance components of perceived safety.

Results:

Four responses were found to have a significant predictive level of a positive safety environment in the work unit: (1) in this unit, we discuss ways to prevent errors from happening again; OR=3.09, (2) in this unit, we treat others with respect; OR=1.09 (3) my supervisor/manager seriously considers staff suggestions for improving patient safety; OR=1.89 and (4) there is good cooperation among hospital units that need to work together; OR=1.77. There were two predictors of a negative work unit safety environment: (1) staff are afraid to ask questions when something does not seem right; OR=0.62 and (2) it is just by chance that more serious mistakes don’t happen around here; OR=0.55.

Conclusions:

The results from this survey indicate that effective communication secondary to both incident and near-miss reporting is associated with a higher perceived culture of safety. A positive safety environment is associated with being able to speak up regarding safety issues without fear of negative repercussions.

Assessment of the culture of safety in public hospitals in Brazil

OBJECTIVE:

to assess the culture of safety in three public hospitals.

METHOD:

transversal study undertaken in three Brazilian public hospitals, with health professionals through applying the Safety Attitudes Questionnaire (SAQ). Scores greater than or equal to 75 were considered positive.

RESULTS:

a total of 573 professionals participated in the study, including nurse technicians and auxiliary nurses 292 (51%), nurses 105 (18.3%), physicians 59 (10.3%), and other professionals 117 (20.4%). The mean of the SAQ varied between 65 and 69 in the three hospitals. Among the domains, however, 'Job satisfaction' presented a higher score, and the opposite was observed for the domain 'Perceptions of management'. The outsourced professionals presented a better perception of the culture of safety than did the statutory professionals. The professionals with higher education presented a better perception of the stressing factors than did the professionals educated to senior high school level.

CONCLUSION:

the level of the culture of safety found is below the ideal. The managerial actions are considered the main contributing factor to the culture's weakness; however, the professionals demonstrated themselves to be satisfied with the work.

OBJETIVO:

evaluar la cultura de seguridad en tres hospitales públicos.

MÉTODO:

estudio transversal realizado en tres hospitales públicos brasileños, desarrollado con profesionales de la salud aplicando el Safety Attitudes Questionnaire (SAQ). Fueron considerados positivos puntajes mayores o iguales a 75.

RESULTADOS:

participaron del estudio 573 profesionales, incluyendo técnicos y auxiliares de enfermería 292 (51%), enfermeros 105 (18,3%), médicos 59 (10,3%), y otros profesionales 117 (20,4%). El promedio del SAQ varió entre 65 a 69 en los tres hospitales. Sin embargo, en los dominios, Satisfacción en el Trabajo presentó mayor puntaje y lo opuesto fue observado en el dominio Percepción de la Administración. Los profesionales tercerizados presentaron mejor percepción de la cultura de seguridad que los profesionales estatutarios. Los profesionales de nivel superior presentaron mejor percepción de los factores estresores que los profesionales de nivel medio.

CONCLUSIÓN:

el nivel de cultura de seguridad encontrado se encuentra debajo de lo ideal. Las acciones administrativas son consideradas como el principal contribuyente para la fragilidad de la cultura, entretanto los profesionales se demostraron satisfechos con el trabajo.

OBJETIVO:

avaliar a cultura de segurança em três hospitais públicos.

MÉTODO:

estudo transversal realizado em três hospitais públicos brasileiros, desenvolvido com profissionais de saúde aplicando-se o Safety Attitudes Questionnaire (SAQ). Foram considerados positivos escores maiores ou iguais a 75.

RESULTADOS:

participaram do estudo 573 profissionais, incluindo técnicos e auxiliares de enfermagem 292 (51%), enfermeiros 105 (18,3%), médicos 59 (10,3%), e outros profissionais 117 (20,4%). A média do SAQ variou entre 65 a 69 nos três hospitais. No entanto, entre os domínios, Satisfação no trabalho apresentou maior escore e o oposto foi observado no domínio Percepção da gerência. Os profissionais terceirizados apresentaram melhor percepção da cultura de segurança do que os profissionais estatutários. Os profissionais de nível superior apresentaram melhor percepção dos fatores estressores do que os profissionais de nível médio.

CONCLUSÃO:

o nível de cultura de segurança encontrado é abaixo do ideal. As ações gerenciais são consideradas o principal contribuinte para a fragilidade da cultura, entretanto os profissionais demonstraram-se satisfeitos com o trabalho.

Huddles and Debriefings: Improving Communication on Labor and Delivery

Interprofessional teams work together on the labor and delivery unit, where clinical care is often unscheduled, rapidly evolving, and fast paced. Effective communication is key for coordinated delivery of optimal care and for fostering a culture of community and safety in the workplace. The preoperative huddle allows for information sharing, cross-checking, and preparation before the start of surgery. Postoperative debriefings allow the operative team to engage in ongoing process improvement. Debriefings after adverse events allow for shared understanding, mutual healing, and help mitigating the harm to potential "second victims."

Patient safety in organizational culture as perceived by leaderships of hospital institutions with different types of administration

OBJECTIVE

To identify the perceptions of leaderships toward patient safety culture dimensions in the routine of hospitals with different administrative profiles: government, social and private organizations, and make correlations among participating institutions regarding dimensions of patient safety culture used.

METHOD

A quantitative cross-sectional study that used the Self Assessment Questionnaire 30 translated into Portuguese. The data were processed by analysis of variance (ANOVA) in addition to descriptive statistics, with statistical significance set at p-value ≤ 0.05.

RESULTS

According to the participants' perceptions, the significant dimensions of patient safety culture were 'patient safety climate' and 'organizational learning', with 81% explanatory power. Mean scores showed that among private organizations, higher values were attributed to statements; however, the correlation between dimensions was stronger among government hospitals.

CONCLUSION

Different hospital organizations present distinct values for each dimension of patient safety culture and their investigation enables professionals to identify which dimensions need to be introduced or improved to increase patient safety.

OBJETIVO

Identificar percepções das lideranças sobre as dimensões da cultura de segurança do paciente no cotidiano de hospitais de diferentes perfis administrativos: públicos, organizações sociais e privados, e realizar correlação entre as instituições participantes, de acordo com as dimensões da cultura de segurança do paciente utilizadas.

MÉTODO

Estudo transversal de aspecto quantitativo obtido por meio da aplicação do instrumento Self Assessment Questionnaire 30, traduzido para a língua portuguesa. Os dados foram tratados com análise de variância (ANOVA), além das estatísticas descritivas, considerando como de significância estatística valores de p-valor ≤ 0,05.

RESULTADOS

Segundo a percepção dos participantes do estudo, as dimensões significativas para a cultura de segurança do paciente foram Ambiente de Segurança do Paciente e Aprendizado Organizacional, com poder explicativo de 81%. A média de respostas obtidas evidenciou que nas organizações privadas houve maiores valores atribuídos às questões, porém a correlação entre as dimensões foi mais forte nas organizações públicas.

CONCLUSÃO

As dimensões da cultura de segurança do paciente têm valores distintos nas diferentes organizações hospitalares e a sua investigação possibilita identificar quais necessitam ser introduzidas ou aprimoradas para maior segurança do paciente.

Factors that influence the recognition, reporting and resolution of incidents related to medical devices and other healthcare technologies: a systematic review

BACKGROUND

Medical devices have improved the treatment of many medical conditions. Despite their benefit, the use of devices can lead to unintended incidents, potentially resulting in unnecessary harm, injury or complications to the patient, a complaint, loss or damage. Devices are used in hospitals on a routine basis. Research to date, however, has been primarily limited to describing incidents rates, so the optimal design of a hospital-based surveillance system remains unclear. Our research objectives were twofold: i) to explore factors that influence device-related incident recognition, reporting and resolution and ii) to investigate interventions or strategies to improve the recognition, reporting and resolution of medical device-related incidents.

METHODS

We searched the bibliographic databases: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and PsycINFO database. Grey literature (literature that is not commercially available) was searched for studies on factors that influence incident recognition, reporting and resolution published and interventions or strategies for their improvement from 2003 to 2014. Although we focused on medical devices, other health technologies were eligible for inclusion.

RESULTS

Thirty studies were included in our systematic review, but most studies were concentrated on other health technologies. The study findings indicate that fear of punishment, uncertainty of what should be reported and how incident reports will be used and time constraints to incident reporting are common barriers to incident recognition and reporting. Relevant studies on the resolution of medical errors were not found. Strategies to improve error reporting include the use of an electronic error reporting system, increased training and feedback to frontline clinicians about the reported error.

CONCLUSIONS

The available evidence on factors influencing medical device-related incident recognition, reporting and resolution by healthcare professionals can inform data collection and analysis in future studies. Since evidence gaps on medical device-related incidents exist, telephone interviews with frontline clinicians will be conducted to solicit information about their experiences with medical devices and suggested strategies for device surveillance improvement in a hospital context. Further research also should investigate the impact of human, system, organizational and education factors on the development and implementation of local medical device surveillance systems.

Patient and procedural characteristics for successful and failed immediate tracheal extubation in the operating room following cardiac surgery in infancy

BACKGROUND

Immediate extubation in the operating room after congenital heart surgery is practiced with rising frequency at many cardiac institutions to decrease costs and complications. Infants less than one year of age are also increasingly selected for this 'fast track'. However, factors for patient selection, success, or failure of this practice have not been well defined in this population, yet are critical for patient safety.

OBJECTIVE

To identify selection criteria, patient and procedural characteristics for successful or failed very early endotracheal extubation in the operating room immediately following infant heart surgery.

METHODS

A retrospective analysis was performed for 326 consecutive patients undergoing neonatal and infant heart surgery from 2009 to 2012. Extubation and reintubation data were taken from the institutional Society of Thoracic Surgeons database and patients' charts. Patient characteristics were derived using multivariable logistic regression models.

RESULTS

Very early extubation in the operating room was performed for 130 of 326 neonates and infants (40%). Weight >4 kg, lesser procedural complexity, and absence of trisomy 21 were identified as significant predictors for attempted very early extubation. Of these patients, 12% required reintubation within 48 h following surgery, predominantly due to respiratory failure or for mediastinal re-exploration. Greater procedural complexity was associated with failed extubations. Reintubation was associated with prolonged hospitalization.

CONCLUSIONS

Extubation immediately after infant heart surgery in the operating room can be safely achieved. However, our data suggest that patients undergoing more complex procedures should be selected more conservatively for immediate early extubation.

Setting culture apart: distinguishing culture from behavior and social structure in safety and injury research

The concept of culture is now widely used by those who conduct research on safety and work-related injury outcomes. We argue that as the term has been applied by an increasingly diverse set of disciplines, its scope has broadened beyond how it was defined and intended for use by sociologists and anthropologists. As a result, this more inclusive concept has lost some of its precision and analytic power. We suggest that the utility of this "new" understanding of culture could be improved if researchers more clearly delineated the ideological - the socially constructed abstract systems of meaning, norms, beliefs and values (which we refer to as culture) - from concrete behaviors, social relations and other properties of workplaces (e.g., organizational structures) and of society itself. This may help researchers investigate how culture and social structures can affect safety and injury outcomes with increased analytic rigor. In addition, maintaining an analytical distinction between culture and other social factors can help intervention efforts better understand the target of the intervention and therefore may improve chances of both scientific and instrumental success.

Teamwork assessment in internal medicine: a systematic review of validity evidence and outcomes

OBJECTIVE

Valid teamwork assessment is imperative to determine physician competency and optimize patient outcomes. We systematically reviewed published instruments assessing teamwork in undergraduate, graduate, and continuing medical education in general internal medicine and all medical subspecialties.

DATA SOURCES

We searched MEDLINE, MEDLINE In-process, CINAHL and PsycINFO from January 1979 through October 2012, references of included articles, and abstracts from four professional meetings. Two content experts were queried for additional studies.

STUDY ELIGIBILITY

Included studies described quantitative tools measuring teamwork among medical students, residents, fellows, and practicing physicians on single or multi-professional (interprofessional) teams.

STUDY APPRAISAL AND SYNTHESIS METHODS

Instrument validity and study quality were extracted using established frameworks with existing validity evidence. Two authors independently abstracted 30 % of articles and agreement was calculated.

RESULTS

Of 12,922 citations, 178 articles describing 73 unique teamwork assessment tools met inclusion criteria. Interrater agreement was intraclass correlation coefficient 0.73 (95 % CI 0.63-0.81). Studies involved practicing physicians (142, 80 %), residents/fellows (70, 39 %), and medical students (11, 6 %). The majority (152, 85 %) assessed interprofessional teams. Studies were conducted in inpatient (77, 43 %), outpatient (42, 24 %), simulation (37, 21 %), and classroom (13, 7 %) settings. Validity evidence for the 73 tools included content (54, 74 %), internal structure (51, 70 %), relationships to other variables (25, 34 %), and response process (12, 16 %). Attitudes and opinions were the most frequently assessed outcomes. Relationships between teamwork scores and patient outcomes were directly examined for 13 (18 %) of tools. Scores from the Safety Attitudes Questionnaire and Team Climate Inventory have substantial validity evidence and have been associated with improved patient outcomes.

LIMITATIONS

Review is limited to quantitative assessments of teamwork in internal medicine.

CONCLUSIONS

There is strong validity evidence for several published tools assessing teamwork in internal medicine. However, few teamwork assessments have been directly linked to patient outcomes.

Evaluation of patient safety culture: a survey of clinicians in a cardiovascular operating room

OBJECTIVE

The aim of this study was to understand the perceived safety culture and attitudes of caregivers in a large cardiovascular operating room (CVOR) in a mid-Atlantic state where more than 1500 procedures are performed annually to include ventricular assist device placement and heart and lung transplantations.

METHODS

We analyzed deidentified data obtained from a safety survey completed anonymously by frontline caregivers in the CVOR via the Safety Attitudes Questionnaire developed by Pasquel Metrics.

RESULTS

The responses from the CVOR clinicians were overall positive for their perceptions of the CVOR safety climate, with the majority saying they would feel safe being treated as a patient, liked their job, and were aware of the proper channels regarding patient safety. However, many made claims of experiencing fatigue and stress due to an excessive workload and participation in emergency situations. Furthermore, the support/clinical perfusion teams were found to have experienced the greatest amount of stress and discomfort, whereas it seems the surgeons were impacted the least.

CONCLUSIONS

This study suggests that reactions to different situations in the operating room are dependent on the role of the caregiver. Therefore, interventions to improve communication among the caregivers must be geared on an individual group basis.

Organizational safety culture and medical error reporting by Israeli nurses

PURPOSE

To investigate the association between patient safety culture (PSC) and the incidence and reporting rate of medical errors by Israeli nurses.

DESIGN

Self-administered structured questionnaires were distributed to a convenience sample of 247 registered nurses enrolled in training programs at Tel Aviv University (response rate = 91%).

METHODS

The questionnaire's three sections examined the incidence of medication mistakes in clinical practice, the reporting rate for these errors, and the participants' views and perceptions of the safety culture in their workplace at three levels (organizational, departmental, and individual performance). Pearson correlation coefficients, t tests, and multiple regression analysis were used to analyze the data.

FINDINGS

Most nurses encountered medical errors from a daily to a weekly basis. Six percent of the sample never reported their own errors, while half reported their own errors "rarely or sometimes." The level of PSC was positively and significantly correlated with the error reporting rate. PSC, place of birth, error incidence, and not having an academic nursing degree were significant predictors of error reporting, together explaining 28% of variance.

CONCLUSIONS

This study confirms the influence of an organizational safety climate on readiness to report errors. Senior healthcare executives and managers can make a major impact on safety culture development by creating and promoting a vision and strategy for quality and safety and fostering their employees' motivation to implement improvement programs at the departmental and individual level.

CLINICAL RELEVANCE

A positive, carefully designed organizational safety culture can encourage error reporting by staff and so improve patient safety.

Depicting adverse events in cardiac theatre: the preliminary conception of the RECORD model

Human error is a byproduct of the human activity and may results in random unintended events; they may have major consequences when it comes to delivery of medicine. Furthermore the causes of error in surgical practice are multifaceted and complex. This article aims to raise awareness for safety measures in the cardiac surgical room and briefly "touch upon" the human factors that could lead to adverse outcomes. Finally, we describe a model that would enable us to depict and study adverse events in the operating theatre.