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Griffeth EM, Gajic O, Schueler N, Todd A, Ramar K. Multifaceted Intervention to Improve Patient Safety Incident Reporting in Intensive Care Units. J Patient Saf 2023; 19:422-428. [PMID: 37466643 PMCID: PMC10526728 DOI: 10.1097/pts.0000000000001151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
OBJECTIVES Patient safety incident reporting in our institution's intensive care units (ICUs) had fallen 30% below national benchmarks during the COVID-19 pandemic. Underreporting diminishes awareness of risks and precludes organizational learning from near misses. We aimed to increase the ICU number of patient safety incident reports by 30% from 27 to 35 reports/1000 patient-days without negatively impacting culture of safety as measured by patient-care staff surveys. METHODS Single-institution prospective interventional study with 9 ICUs receiving a multifaceted intervention developed using quality improvement methodology during February-April 2022. Study intervention involved creation of patient safety peer-leadership role, feedback process, interactive dashboards for patient safety data, and education resources accessible via quick response codes. Primary outcome was patient safety incident reports/1000 patient-days. Intensive care unit patient-care staff culture of safety was assessed with surveys. RESULTS Intensive care unit patient safety incident reporting increased by 48% after intervention (40 versus 27 reports/1000 patient-days [ P = 0.136]). Near misses were the most common incident report. Intensive care unit patient-care staff ratings of patient safety did not change; 80% rated patient safety as good or better after intervention versus 78% at baseline ( P = 0.465). However, significant improvement was observed for subcomponents related to learning culture and support for staff involved in patient safety incidents. Most reports (>80%) were submitted by nurses. CONCLUSIONS This multifaceted quality improvement intervention increased patient safety incident reporting in the ICUs. Increases in ratings of learning culture and support for staff underline the importance of a well-functioning patient safety incident reporting system in an institutional culture of safety.
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Affiliation(s)
- Elaine M. Griffeth
- Department of Surgery; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
| | - Nicole Schueler
- Patient Safety; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
| | - Austin Todd
- Department of Quantitative Health Sciences Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
| | - Kannan Ramar
- Division of Pulmonary and Critical Care Medicine; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
- Patient Safety; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
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Zhu L, Reychav I, McHaney R, Broda A, Tal Y, Manor O. Extension to 'combined SNA and LDA methods to understand adverse medical events': Doctor and nurse perspectives. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2021; 31:221-246. [PMID: 32538872 DOI: 10.3233/jrs-190031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Physicians and nurses are responsible for reporting medical adverse events. Each views these events through a different lens subject to their role-based perceptions and barriers. Physicians typically engage with diagnosis and treatment while nurses primarily care for patients' daily lives and mental well-being. This results in reporting and describing medical adverse events differently. OBJECTIVE We aimed to compare adverse medical event reports generated by physicians and nurses to better understand the differences and similarities in perspective as well as the nature of adverse medical events using social network analysis (SNA) and latent Dirichlet allocation (LDA). METHODS The current study examined data from the Maccabi Healthcare Community. Approximately 17,868 records were collected from 2000 to 2017 regarding medical adverse events. Data analysis used SNA and LDA to perform descriptive text analytics and understand underlying phenomenon. RESULTS A significant difference in harm levels reported by physicians and nurses was discovered. Shared topic keyword lists broken down by physicians and nurses were derived. Overall, communication, lack of attention, and information transfer issues were reported in medical adverse events data. Specialized keywords, more likely to be used by a physician were determined as: repeated prescriptions, diabetes complications, and x-ray examinations. For nurses, the most common special adverse event behavior keywords were vaccine problem, certificates of fitness, death and incapacity, and abnormal dosage. CONCLUSIONS Communication and inattentiveness appeared most frequently in medical adverse events reports regardless of whether doctors or nurses did the reporting. Findings suggest feedback and information sharing processes could be implemented as a step toward alleviating many issues. Institutional management, healthcare managers and government officials should take actions to decrease medical adverse events, many of which may be preventable.
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Affiliation(s)
- Lin Zhu
- Industrial Engineering & Management Department, Ariel University, Ariel, Israel
| | - Iris Reychav
- Industrial Engineering & Management Department, Ariel University, Ariel, Israel
| | - Roger McHaney
- Daniel D. Burke Chair for Exceptional Faculty, Management Information Systems, Kansas State University, Manhattan, KS, USA
| | - Arik Broda
- Risk Management Department, Maccabi Healthcare Services, Israel
| | - Yossi Tal
- Risk Management Department, Maccabi Healthcare Services, Israel
| | - Orly Manor
- Risk Management Department, Maccabi Healthcare Services, Israel
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A Multilevel Analysis of U.S. Hospital Patient Safety Culture Relationships With Perceptions of Voluntary Event Reporting. J Patient Saf 2021; 16:187-193. [PMID: 27820722 DOI: 10.1097/pts.0000000000000336] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Patient safety events offer opportunities to improve patient care, but, unfortunately, events often go unreported. Although some barriers to event reporting can be reduced with electronic reporting systems, insight on organizational and cultural factors that influence reporting frequency may help hospitals increase reporting rates and improve patient safety. The purpose of this study was to evaluate the associations between dimensions of patient safety culture and perceived reporting practices of safety events of varying severity. METHODS We conducted a cross-sectional survey study using previously collected data from The Agency for Healthcare Research and Quality Hospital Survey of Patient Safety Culture as predictors and outcome variables. The dataset included health-care professionals in U.S. hospitals, and data were analyzed using multilevel modeling techniques. RESULTS Data from 223,412 individuals, 7816 work areas/units, and 967 hospitals were analyzed. Whether examining near miss, no harm, or potential for harm safety events, the dimension feedback about error accounted for the most unique predictive variance in the outcome frequency of events reported. Other significantly associated variables included organizational learning, nonpunitive response to error, and teamwork within units (all P < 0.001). As the perceived severity of the safety event increased, more culture dimensions became significantly associated with voluntary reporting. CONCLUSIONS To increase the likelihood that a patient safety event will be voluntarily reported, our study suggests placing priority on improving event feedback mechanisms and communication of event-related improvements. Focusing efforts on these aspects may be more efficient than other forms of culture change.
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Cottell M, Wätterbjörk I, Hälleberg Nyman M. Medication-related incidents at 19 hospitals: A retrospective register study using incident reports. Nurs Open 2020; 7:1526-1535. [PMID: 32802373 PMCID: PMC7424444 DOI: 10.1002/nop2.534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/18/2020] [Accepted: 05/05/2020] [Indexed: 12/15/2022] Open
Abstract
Aim To examine (a) when medication incidents occur and which type is most frequent; (b) consequences for patients; (c) incident reporters' perceptions of causes; and (d) professional categories reporting the incidents. Design A descriptive multicentre register study. Methods This study included 775 medication incident reports from 19 Swedish hospitals during 2016-2017. From the 775 reports, 128 were chosen to establish the third aim. Incidents were classified and analysed statistically. Perceived causes of incidents were analysed using content analysis. Results Incidents occurred as often in prescribing as in administering. Wrong dose was the most common error, followed by missed dose and lack of prescription. Most incidents did not harm the patients. Errors in administering reached the patients more often than errors in prescribing. The most frequently perceived causes were shortcomings in knowledge, skills and abilities, followed by workload. Most medication incidents were reported by nurses.
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Affiliation(s)
- Maria Cottell
- Department of Patient SafetyÖrebro University HospitalÖrebroSweden
| | - Inger Wätterbjörk
- School of Health SciencesFaculty of Medicine and HealthÖrebro UniversityÖrebroSweden
| | - Maria Hälleberg Nyman
- School of Health SciencesFaculty of Medicine and HealthÖrebro UniversityÖrebroSweden
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Hayashi R, Fujita S, Iida S, Nagai Y, Shimamori Y, Hasegawa T. Relationship of patient safety culture with factors influencing working environment such as working hours, the number of night shifts, and the number of days off among healthcare workers in Japan: a cross-sectional study. BMC Health Serv Res 2020; 20:310. [PMID: 32293448 PMCID: PMC7158118 DOI: 10.1186/s12913-020-05114-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/17/2020] [Indexed: 11/23/2022] Open
Abstract
Background Patient safety culture is defined as a product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management. Factors influencing healthcare workers’ working environment such as working hours, the number of night shifts, and the number of days off may be associated with patient safety culture, and the association pattern may differ by profession. This study aimed to examine the relationship between patient safety culture and working environment. Methods Questionnaire surveys were conducted in 2015 and 2016. The first survey was conducted in hospitals in Japan to investigate their patient safety management system and activities and intention to participate in the second survey. The second survey was conducted in 40 hospitals; 100 healthcare workers from each hospital answered a questionnaire that was the Japanese version of the Hospital Survey on Patient Safety Culture for measuring patient safety culture. The relationship of patient safety culture with working hours in a week, the number of night shifts in a month, and the number of days off in a month was analyzed. Results Response rates for the first and second surveys were 22.4% (731/3270) and 94.2% (3768/4000), respectively. Long working hours, numerous night shifts, and few days off were associated with low patient safety culture. Despite adjusting the working hours, the number of event reports increased with an increase in the number of night shifts. Physicians worked longer and had fewer days off than nurses. However, physicians had fewer composites of patient safety culture score related to working hours, the number of night shifts, and the number of days off than nurses. Conclusions This study suggested a possibility of improving the patient safety culture by managing the working environment of healthcare workers. High number of night shifts may lead to high number of event reports. Working hours, the number of night shifts, and the number of days off may differently influence patient safety culture in physicians and nurses.
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Affiliation(s)
| | - Shigeru Fujita
- Department of Social Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Shuhei Iida
- Nerima General Hospital, Tokyo, Japan.,Institute of Healthcare Quality Improvement, Tokyo, Japan
| | - Yoji Nagai
- Hitachinaka General Hospital, Ibaraki, Japan
| | - Yoshiko Shimamori
- Department of Common Fundamental Nursing, Iwate Medical University School of Nursing, Iwate, Japan
| | - Tomonori Hasegawa
- Department of Social Medicine, Toho University School of Medicine, Tokyo, Japan.
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Zhu L, Reychav I, McHaney R, Broda A, Tal Y, Manor O. Combined SNA and LDA methods to understand adverse medical events. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2020; 30:129-153. [PMID: 31476171 DOI: 10.3233/jrs-180052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To compare primary medical adverse event keywords from reporters (e.g. physicians and nurses) and harm level perspectives to explore the underlying behaviors of medical adverse events using social network analysis (SNA) and latent Dirichlet allocation (LDA) leading to process improvements. DESIGN Used SNA methods to explore primary keywords used to describe the medical adverse events reported by physicians and nurses. Used LDA methods to investigate topics used for various harm levels. Combined the SNA and LDA methods to discover common shared topic keywords to better understand underlying behaviors of physicians and nurses in different harm level medical adverse events. SETTING Maccabi Healthcare Community is the second largest healthcare organization in Israel. DATA 17,868 medical adverse event data records collected between 2000 and 2017. METHODS Big data analysis techniques using social network analysis (SNA) and latent Dirichlet allocation (LDA). RESULTS Shared topic keywords used by both physicians and nurses were determined. The study revealed that communication, information transfer, and inattentiveness were the most common problems reported in the medical adverse events data. CONCLUSIONS Communication and inattentiveness were the most common problems reported in medical adverse events regardless of healthcare professional reporting or harm levels. Findings suggested that an information-sharing and feedback mechanism should be implemented to eliminate preventable medical adverse events. Healthcare institutions managers and government officials should take targeted actions to decrease these preventable medical adverse events through quality improvement efforts.
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Affiliation(s)
- Lin Zhu
- Industrial Engineering & Management Department, Ariel University, Ariel, Israel
| | - Iris Reychav
- Industrial Engineering & Management Department, Ariel University, Ariel, Israel
| | - Roger McHaney
- Daniel D. Burke Chair for Exceptional Faculty, Professor and University Distinguished Teaching Scholar, Management Information Systems, Kansas State University, Manhattan, KS, USA
| | - Aric Broda
- Head of Risk Management Department, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Yossi Tal
- Risk Management and Patient Safety Advisor, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Orly Manor
- Deputy of Risk Management Department, Maccabi Healthcare Services, Tel Aviv, Israel
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Jiang F, Wilson JRF, Badhiwala JH, Santaguida C, Weber MH, Wilson JR, Fehlings MG. Quality and Safety Improvement in Spine Surgery. Global Spine J 2020; 10:17S-28S. [PMID: 31934516 PMCID: PMC6947676 DOI: 10.1177/2192568219839699] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Review article. OBJECTIVES A narrative review of the literature on the current advances and limitations in quality and safety improvement initiatives in spine surgery. METHODS A comprehensive literature search was performed using Ovid MEDLINE focusing on 3 preidentified concepts: (1) quality and safety improvement, (2) reporting of outcomes and adverse events, and (3) prediction model and practice guidelines. The search was conducted under appropriate subject headings and using relevant text words. Articles were screened, and manuscripts relevant to this discussion were included in the narrative review. RESULTS Quality and safety improvement remains a major research focus attracting investigators from the global spine community. Multiple databases and registries have been developed for the purpose of generating data and monitoring the progress of quality and safety improvement initiatives. The development of various prediction models and clinical practice guidelines has helped shape the care of spine patients in the modern era. With the reported success of exemplary programs initiated by the Northwestern and Seattle Spine Team, other quality and safety improvement initiatives are anticipated to follow. However, despite these advancements, the reporting metrics for outcomes and adverse events remain heterogeneous in the literature. CONCLUSION Constant surveillance and continuous improvement of the quality and safety of spine treatments is imperative in modern health care. Although great advancement has been made, issues with reporting outcomes and adverse events persist, and improvement in this regard is certainly needed.
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Affiliation(s)
- Fan Jiang
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | - Jamie R. F. Wilson
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | - Jetan H. Badhiwala
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | | | | | - Jefferson R. Wilson
- University of Toronto, Toronto, Ontario, Canada,St Michael’s Hospital, Toronto, Ontario, Canada
| | - Michael G. Fehlings
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada,Michael G. Fehlings, Division of Neurosurgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, Ontario, M5T2S8, Canada.
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Abstract
OBJECTIVE To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill. DATA SOURCES PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015. STUDY SELECTION Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system. The committee collectively developed Population, Intervention, Comparator, Outcome questions and quality of evidence statements pertaining to medication errors and adverse drug events addressing the key components. A total of 34 Population, Intervention, Comparator, Outcome questions, five quality of evidence statements, and one commentary on disclosure was developed. DATA EXTRACTION Subcommittee members were assigned selected Population, Intervention, Comparator, Outcome questions or quality of evidence statements. Subcommittee members completed their Grading of Recommendations Assessment, Development, and Evaluation of the question with his/her quality of evidence assessment and proposed strength of recommendation, then the draft was reviewed by the relevant subcommittee. The subcommittee collectively reviewed the evidence profiles for each question they developed. After the draft was discussed and approved by the entire committee, then the document was circulated among all members for voting on the quality of evidence and strength of recommendation. DATA SYNTHESIS The committee followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation system to determine quality of evidence and strength of recommendations. CONCLUSIONS This guideline evaluates the ICU environment as a risk for medication-related events and the environmental changes that are possible to improve safe medication use. Prevention strategies for medication-related events are reviewed by medication use process node (prescribing, distribution, administration, monitoring). Detailed considerations to an active surveillance system that includes reporting, identification, and evaluation are discussed. Also, highlighted is the need for future research for safe medication practices that is specific to critically ill patients.
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9
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Error Detection and Reporting in the Intensive Care Unit: Progress, Barriers, and Future Direction. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0228-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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10
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Chen BP, Garland K, Roffey DM, Poitras S, Dervin G, Lapner P, Phan P, Wai EK, Kingwell SP, Beaulé PE. Can Surgeons Adequately Capture Adverse Events Using the Spinal Adverse Events Severity System (SAVES) and OrthoSAVES? Clin Orthop Relat Res 2017; 475:253-260. [PMID: 27511203 PMCID: PMC5174042 DOI: 10.1007/s11999-016-5021-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 08/03/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Physicians have consistently shown poor adverse-event reporting practices in the literature and yet they have the clinical acumen to properly stratify and appraise these events. The Spine Adverse Events Severity System (SAVES) and Orthopaedic Surgical Adverse Events Severity System (OrthoSAVES) are standardized assessment tools designed to record adverse events in orthopaedic patients. These tools provide a list of prespecified adverse events for users to choose from-an aid that may improve adverse-event reporting by physicians. QUESTIONS/PURPOSES The primary objective was to compare surgeons' adverse-event reporting with reporting by independent clinical reviewers using SAVES Version 2 (SAVES V2) and OrthoSAVES in elective orthopaedic procedures. METHOD This was a 10-week prospective study where SAVES V2 and OrthoSAVES were used by six orthopaedic surgeons and two independent, non-MD clinical reviewers to record adverse events after all elective procedures to the point of patient discharge. Neither surgeons nor reviewers received specific training on adverse-event reporting. Surgeons were aware of the ongoing study, and reported adverse events based on their clinical interactions with the patients. Reviewers recorded adverse events by reviewing clinical notes by surgeons and other healthcare professionals (such as nurses and physiotherapists). Adverse events were graded using the severity-grading system included in SAVES V2 and OrthoSAVES. At discharge, adverse events recorded by surgeons and reviewers were recorded in our database. RESULTS Adverse-event data for 164 patients were collected (48 patients who had spine surgery, 51 who had hip surgery, 34 who had knee surgery, and 31 who had shoulder surgery). Overall, 99 adverse events were captured by the reviewers, compared with 14 captured by the surgeons (p < 0.001). Surgeons adequately captured major adverse events, but failed to record minor events that were captured by the reviewers. A total of 93 of 99 (94%) adverse events reported by reviewers required only simple or minor treatment and had no long-term adverse effect. Three patients experienced adverse events that resulted in use of invasive or complex treatment that had a temporary adverse effect on outcome. CONCLUSION Using SAVES V2 and OrthoSAVES, independent reviewers reported more minor adverse events compared with surgeons. The value of third-party reviewers requires further investigation in a detailed cost-benefit analysis. LEVEL OF EVIDENCE Level II, therapeutic study.
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Affiliation(s)
- Brian P. Chen
- Faculty of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Katie Garland
- Faculty of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Darren M. Roffey
- Ottawa Combined Adult Spinal Surgery Program (OCASSP), The Ottawa Hospital, Ottawa, ON Canada ,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Stephane Poitras
- Faculty of Health Sciences, School of Rehabilitation Sciences, University of Ottawa, Ottawa, ON Canada ,Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1646, Ottawa, ON K1H 8L6 Canada
| | - Geoffrey Dervin
- Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1646, Ottawa, ON K1H 8L6 Canada
| | - Peter Lapner
- Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1646, Ottawa, ON K1H 8L6 Canada
| | - Philippe Phan
- Ottawa Combined Adult Spinal Surgery Program (OCASSP), The Ottawa Hospital, Ottawa, ON Canada ,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada ,Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1646, Ottawa, ON K1H 8L6 Canada
| | - Eugene K. Wai
- Ottawa Combined Adult Spinal Surgery Program (OCASSP), The Ottawa Hospital, Ottawa, ON Canada ,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada ,Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1646, Ottawa, ON K1H 8L6 Canada
| | - Stephen P. Kingwell
- Ottawa Combined Adult Spinal Surgery Program (OCASSP), The Ottawa Hospital, Ottawa, ON Canada ,Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1646, Ottawa, ON K1H 8L6 Canada
| | - Paul E. Beaulé
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada ,Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1646, Ottawa, ON K1H 8L6 Canada
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Wessman BT, Sona C, Schallom M. A Novel ICU Hand-Over Tool: The Glass Door of the Patient Room. J Intensive Care Med 2016; 32:514-519. [PMID: 27271750 DOI: 10.1177/0885066616653947] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Poor communication among health-care providers is cited as the most common cause of sentinel events involving patients. Patient care in the critical care setting is incredibly complex. A consistent care plan is necessary between day/night shift teams and among bedside intensive care unit (ICU) nurses, consultants, and physicians. Our goal was to create a novel, easily accessible communication device to improve ICU patient care. METHODS This communication improvement project was done at an academic tertiary surgical/trauma/mixed 36-bed ICU with an average of 214 admissions per month. We created a glass door template embossed on the glass that included 3 columns for daily goals to be written: "day team," "night team," and "surgery/consultant team." Assigned areas for tracking "lines," "antibiotics," "ventilator weaning," and "Deep vein thrombosis (DVT) screening" were included. These doors are filled out/updated throughout the day by all of the ICU providers. All services can review current plans/active issues while evaluating the patient at the bedside. Patient-identifying data are not included. We retrospectively reviewed all ICU safety reported events over a 4-year period (2 years prior/2 years after glass door implementation) for specific handover communication-related errors and compared the 2 cohorts. RESULTS Information on the glass doors is entered daily on rounds by all services. Prior to implementation, 7.96% of reported errors were related to patient handover communication errors. The post glass-door era had 4.26% of reported errors related to patient handover communication errors with a relative risk reduction of 46.5%. Due to its usefulness, this method of communication was quickly adopted by the other critical care services (cardiothoracic, medical, neurology/neurosurgery, cardiology) at our institution and is now used for over 150 ICU beds. CONCLUSIONS Our glass door patient handover tool is an easily adaptable intervention that has improved communication leading to an overall decrease in the number of handover communication errors.
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Affiliation(s)
- Brian T Wessman
- 1 Division of Critical Care Medicine, Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.,2 Division of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Carrie Sona
- 3 Department of Nursing, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Marilyn Schallom
- 4 Department of Research for Patient Care Services, Barnes-Jewish Hospital, St. Louis, MO, USA
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Brunsveld-Reinders AH, Arbous MS, De Vos R, De Jonge E. Incident and error reporting systems in intensive care: a systematic review of the literature. Int J Qual Health Care 2015; 28:2-13. [DOI: 10.1093/intqhc/mzv100] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2015] [Indexed: 01/19/2023] Open
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13
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Pannick S, Sevdalis N, Athanasiou T. Beyond clinical engagement: a pragmatic model for quality improvement interventions, aligning clinical and managerial priorities. BMJ Qual Saf 2015; 25:716-25. [PMID: 26647411 PMCID: PMC5013121 DOI: 10.1136/bmjqs-2015-004453] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 10/13/2015] [Indexed: 12/04/2022]
Abstract
Despite taking advantage of established learning from other industries, quality improvement initiatives in healthcare may struggle to outperform secular trends. The reasons for this are rarely explored in detail, and are often attributed merely to difficulties in engaging clinicians in quality improvement work. In a narrative review of the literature, we argue that this focus on clinicians, at the relative expense of managerial staff, has proven counterproductive. Clinical engagement is not a universal challenge; moreover, there is evidence that managers—particularly middle managers—also have a role to play in quality improvement. Yet managerial participation in quality improvement interventions is often assumed, rather than proven. We identify specific factors that influence the coordination of front-line staff and managers in quality improvement, and integrate these factors into a novel model: the model of alignment. We use this model to explore the implementation of an interdisciplinary intervention in a recent trial, describing different participation incentives and barriers for different staff groups. The extent to which clinical and managerial interests align may be an important determinant of the ultimate success of quality improvement interventions.
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Affiliation(s)
- Samuel Pannick
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
| | - Nick Sevdalis
- Centre for Implementation Science, King's College London, London, UK
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14
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Heavner JJ, Siner JM. Adverse Event Reporting and Quality Improvement in the Intensive Care Unit. Clin Chest Med 2015; 36:461-7. [PMID: 26304283 DOI: 10.1016/j.ccm.2015.05.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patients in the intensive care unit are at high risk for experiencing adverse events and errors. The high-acuity health care needs of these vulnerable patients expose them to numerous medications, procedures, and health care providers. The occurrence of adverse events is associated with detriments to patient outcomes including increased mortality. Adverse event reporting is the most commonly used event-detection tool, but it should also be complimented with other tools such as trigger tools, chart review, and direct observation. Although adverse event reporting is essential for continuous improvement processes and is associated with improvements in safety culture, it remains significantly underutilized.
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Affiliation(s)
- Jason J Heavner
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
| | - Jonathan M Siner
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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Lipshutz AKM, Caldwell JE, Robinowitz DL, Gropper MA. An analysis of near misses identified by anesthesia providers in the intensive care unit. BMC Anesthesiol 2015; 15:93. [PMID: 26082147 PMCID: PMC4468961 DOI: 10.1186/s12871-015-0075-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 06/09/2015] [Indexed: 11/23/2022] Open
Abstract
Background Learning from adverse events and near misses may reduce the incidence of preventable errors. Current literature on adverse events and near misses in the ICU focuses on errors reported by nurses and intensivists. ICU near misses identified by anesthesia providers may reveal critical events, causal mechanisms and system weaknesses not identified by other providers, and may differ in character and causality from near misses in other anesthesia locations. Methods We analyzed events reported to our anesthesia near miss reporting system from 2009 to 2011. We compared causative mechanisms of ICU near misses with near misses in other anesthesia locations. Results A total of 1,811 near misses were reported, of which 22 (1.2 %) originated in the ICU. Five causal mechanisms explained over half of ICU near misses. Compared to near misses from other locations, near misses from the ICU were more likely to occur while on call (45 % vs. 19 %, p = 0.001), and were more likely to be associated with airway management (50 % vs. 12 %, p < 0.001). ICU near misses were less likely to be associated with equipment issues (23 % vs. 48 %, p = 0.02). Conclusions A limited number of causal mechanisms explained the majority of ICU near misses, providing targets for quality improvement. Errors associated with airway management in the ICU may be underappreciated. Specialist consultants can identify systems weaknesses not identified by critical care providers, and should be engaged in the ICU patient safety movement.
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Affiliation(s)
- Angela K M Lipshutz
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - James E Caldwell
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - David L Robinowitz
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - Michael A Gropper
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA.
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Critical incident monitoring in paediatric and adult critical care: from reporting to improved patient outcomes? Curr Opin Crit Care 2013; 16:649-53. [PMID: 20930624 DOI: 10.1097/mcc.0b013e32834044d8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Critical incident reporting alone does not necessarily improve patient safety or even patient outcomes. Substantial improvement has been made by focusing on the further two steps of critical incident monitoring, that is, the analysis of critical incidents and implementation of system changes. The system approach to patient safety had an impact on the view about the patient's role in safety. This review aims to analyse recent advances in the technique of reporting, the analysis of reported incidents, and the implementation of actual system improvements. It also explores how families should be approached about safety issues. RECENT FINDINGS It is essential to make as many critical incidents as possible known to the intensive care team. Several factors have been shown to increase the reporting rate: anonymity, regular feedback about the errors reported, and the existence of a safety climate. Risk scoring of critical incident reports and root cause analysis may help in the analysis of incidents. Research suggests that patients can be successfully involved in safety. SUMMARY A persisting high number of reported incidents is anticipated and regarded as continuing good safety culture. However, only the implementation of system changes, based on incident reports, and also involving the expertise of patients and their families, has the potential to improve patient outcome. Hard outcome criteria, such as standardized mortality ratio, have not yet been shown to improve as a result of critical incident monitoring.
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Wang SC, Li YC, Huang HC. The effect of a workflow-based response system on hospital-wide voluntary incident reporting rates. Int J Qual Health Care 2012; 25:35-42. [DOI: 10.1093/intqhc/mzs078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Martowirono K, Jansma JD, van Luijk SJ, Wagner C, Bijnen AB. Possible solutions for barriers in incident reporting by residents. J Eval Clin Pract 2012; 18:76-81. [PMID: 20973871 DOI: 10.1111/j.1365-2753.2010.01544.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Incident reporting can contribute to safer health care. Since the rate of reporting by residents is low, it is useful to investigate which barriers exist and how these can be solved. METHODS Data were collected in a large teaching hospital in the Netherlands. The hospital uses a confidential, voluntary and web-based incident reporting system. Residents working in the hospital participated in focus group discussions to explore barriers and possible solutions. A grounded theory approach was used to analyse the transcribed discussions. RESULTS In each focus group six to eight residents participated, resulting in a total number of 22 participants. After three focus group discussions, information saturation had been reached. Residents do not report all incidents because of a negative attitude towards incident reporting, because they experience a non-stimulating culture and because of a lack of perceived ability to report. Residents suggest several solutions to solve the barriers: providing the possibility to report anonymously, providing feedback, creating an incident reporting culture, simplifying the procedure, clarifying what and how to report, and exciting residents to report. CONCLUSIONS Residents have useful suggestions to resolve the barriers that prevent them from reporting incidents. They include solutions that influence attitude, culture and perceived ability. These suggestions should be considered when making an effort to improve incident reporting by residents.
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Rowin EJ, Lucier D, Pauker SG, Kumar S, Chen J, Salem DN. Does Error and Adverse Event Reporting by Physicians and Nurses Differ? Jt Comm J Qual Patient Saf 2008; 34:537-45. [DOI: 10.1016/s1553-7250(08)34068-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Patient safety is a critical component of the U.S. healthcare system: thousands of people, including children, die or are injured yearly as a result of medical error. We designed and implemented a novel error-reporting tool for the pediatric intensive care unit. More errors were reported with the use of this paper-based tool than with the existing computerized error-reporting system. We also developed a scoring system to assess potential harm to the patient. The tool provided information about frequent and high-risk errors that guided successful improvements in patient care and safety and the achievement of measurable success.
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Affiliation(s)
- Nikoleta S Kolovos
- Division of Critical Care Medicine, St. Louis Children's Hospital, St. Louis, MO, USA.
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How safe is my intensive care unit? An overview of error causation and prevention. Curr Opin Crit Care 2007; 13:697-702. [DOI: 10.1097/mcc.0b013e3282f12cc8] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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