Learning from high risk industries may not be straightforward: a qualitative study of the hierarchy of risk controls approach in healthcare

Identifying resilience: a system safety review of trauma and orthopaedic theatres

A prospective, qualitative study, of trauma and orthopaedic theatres was undertaken using the CARe QI handbook and the SEIPS framework, with the aim of preventing future Never Events. The study demonstrated a new approach, focussed on understanding 'work as done' to identify opportunities to improve system resilience, tested, using the Model for Improvement. Undertaken during the Covid-19 pandemic, it demonstrates that such conditions should not be a deterrent to observational studies, but requiring greater time and resource than a standard investigation, the approach may not align with current organisational or regulatory expectations. At the conclusion of this study, the mean time between Never Events in theatres had increased from 46 to 224 days, an achievement that had not previously been possible using the regulatory required, safety I, investigatory approach. These findings should be used to inform future PSIRF and Never Event Frameworks, to ensure effective systems-based analysis and improvement.

Prevalence of musculoskeletal pain and dysfunction in electrical utility workers: Practical considerations for prevention and rehabilitation in the workplace

INTRODUCTION

This study assessed the prevalence and associations of musculoskeletal pain and dysfunction in electrical utility workers, with the aim of applying the findings to better prevent and rehabilitate workplace musculoskeletal disorders.

METHODS

Employees completed an online survey recording their musculoskeletal symptoms across nine anatomical locations for the preceding 12 months. A total of 565 employees, working across eight different electrical utility organisational work units, completed the survey.

CONSUMER AND COMMUNITY INVOLVEMENT

The study was collaborative and conducted in Australia's largest, wholly government owned electricity company. The study originated from the participating organisation wanting to better understand their musculoskeletal disorder (MSD) risks.

RESULTS

Employees who experienced high job stress were 4.06 times (95% confidence interval [CI] = 1.78-9.29) more likely to report musculoskeletal symptoms in the shoulder compared with employees with lower reported job stress. Employees that perceived their work to have high physical demands report lower back musculoskeletal symptoms at 2.64 times the rate of those perceiving their job to be of low physical demand (95% CI = 1.44-4.84). There were significant differences in the lower back musculoskeletal symptoms according to work unit membership.

CONCLUSIONS

Understanding the prevalence of MSDs is critical to implementing practical prevention and rehabilitation strategies in the workplace. This anonymous survey highlighted that a large proportion of electrical utility workers reported that musculoskeletal symptoms had impacted their ability to perform their job, housework and/or hobbies in the preceding 12 months. Early access to rehabilitation services is essential. However, many workers report barriers to disclosing MSDs; therefore, workplace rehabilitation services may need to be broadened to account for these barriers.

The lingering safety menace: A 10-year review of enteral misconnection adverse events and narrative review

In 2011, "Tubing Misconnections: Normalization of Deviance" reported >100 cases of enteral tubing misconnections leading to patient harm. Despite development of safer enteral device connectors, 96 new cases of enteral misconnections have been published since 2011. Publication and safety databases were searched for reports from 2011 to 2023. Reported misconnections lead to death in 4% of the cases and survival with harm were reported in 69% of cases. Reported misconnections occurred more often in infants and children than in adults. This article outlines why these misconnections happen, the history of the issue and development of safer connector standards, the safety threats and recommendations associated with the new cases, current conversion rates, and process steps, education, and resources for the conversion to safer connectors for enteral nutrition devices.

Risk Controls Identified in Action Plans Following Serious Incident Investigations in Secondary Care: A Qualitative Study

OBJECTIVES

The impact of incident investigations in improving patient safety may be linked to the quality of risk controls recommended in investigation reports. We aimed to identify the range and apparent strength of risk controls generated from investigations into serious incidents, map them against contributory factors identified in investigation reports, and characterize the nature of the risk controls proposed.

METHODS

We undertook a content analysis of 126 action plans of serious incident investigation reports from a multisite and multispeciality UK hospital over a 3-year period to identify the risk controls proposed. We coded each risk control against the contributory factor it aimed to address. Using a hierarchy of risk controls model, we assessed the strength of proposed risk controls. We used thematic analysis to characterize the nature of proposed risk controls.

RESULTS

A substantial proportion (15%) of factors identified in investigation reports as contributing to serious incidents were not addressed by identifiable risk controls. Of the 822 proposed risk controls in action plans, most (74%) were assessed as weak, typically focusing on individualized interventions-even when the problems were organizational or systemic in character. The following 6 broad approaches to risk controls could be identified: improving individual or team performance; defining, standardizing, or reinforcing expected practice; improving the working environment; improving communication; process improvements; and disciplinary actions.

CONCLUSIONS

The identified shortfalls in the quality of risk controls following serious incident investigations-including a 15% mismatch between contributory factors and aligned risk controls and 74% of proposed risk controls centering on weaker interventions-represent significant gaps in translating incident investigations into meaningful systemic improvements. Advancing the quality of risk controls after serious incident investigations will require involvement of human factors specialists in their design, a theory-of-change approach, evaluation, and curation and sharing of learning, all supported by a common framework.

What can Safety Cases offer for patient safety? A multisite case study

BACKGROUND

The Safety Case is a regulatory technique that requires organisations to demonstrate to regulators that they have systematically identified hazards in their systems and reduced risks to being as low as reasonably practicable. It is used in several high-risk sectors, but only in a very limited way in healthcare. We examined the first documented attempt to apply the Safety Case methodology to clinical pathways.

METHODS

Data are drawn from a mixed-methods evaluation of the Safer Clinical Systems programme. The development of a Safety Case for a defined clinical pathway was a centrepiece of the programme. We base our analysis on 143 interviews covering all aspects of the programme and on analysis of 13 Safety Cases produced by clinical teams.

RESULTS

The principles behind a proactive, systematic approach to identifying and controlling risk that could be curated in a single document were broadly welcomed by participants, but was not straightforward to deliver. Compiling Safety Cases helped teams to identify safety hazards in clinical pathways, some of which had been previously occluded. However, the work of compiling Safety Cases was demanding of scarce skill and resource. Not all problems identified through proactive methods were tractable to the efforts of front-line staff. Some persistent hazards, originating from institutional and organisational vulnerabilities, appeared also to be out of the scope of control of even the board level of organisations. A particular dilemma for organisational senior leadership was whether to prioritise fixing the risks proactively identified in Safety Cases over other pressing issues, including those that had already resulted in harm.

CONCLUSIONS

The Safety Case approach was recognised by those involved in the Safer Clinical Systems programme as having potential value. However, it is also fraught with challenge, highlighting the limitations of efforts to transfer safety management practices to healthcare from other sectors.

Exploring the "Black Box" of Recommendation Generation in Local Health Care Incident Investigations: A Scoping Review

BACKGROUND

Incident investigation remains a cornerstone of patient safety management and improvement, with recommendations meant to drive action and improvement. There is little empirical evidence about how-in real-world hospital settings-recommendations are generated or judged for effectiveness.

OBJECTIVES

Our research questions, concerning internal hospital investigations, were as follows: (1) What approaches to incident investigation are used before the generation of recommendations? (2) What are the processes for generating recommendations after a patient safety incident investigation? (3) What are the number and types of recommendations proposed? (4) What criteria are used, by hospitals or study authors, to assess the quality or strength of recommendations made?

METHODS

Following PRISMA-ScR guidelines, we conducted a scoping review. Studies were included if they reported data from investigations undertaken and recommendations generated within hospitals. Review questions were answered with content analysis, and extracted recommendations were categorized and counted.

RESULTS

Eleven studies met the inclusion criteria. Root cause analysis was the dominant investigation approach, but methods for recommendation generation were unclear. A total of 4579 recommendations were extracted, largely focusing on individuals' behavior rather than addressing deficiencies in systems (<7% classified as strong). Included studies reported recommendation effectiveness as judged against predefined "action" hierarchies or by incident recurrence, which was not comprehensively reported.

CONCLUSIONS

Despite the ubiquity of incident investigation, there is a surprising lack of evidence concerning how recommendation generation is or should be undertaken. Little evidence is presented to show that investigations or recommendations result in improved care quality or safety. We contend that, although incident investigations remain foundational to patient safety, more enquiry is needed about how this important work is actually achieved and whether it can contribute to improving quality of care.

Human factors in anaesthesia: a narrative review

Healthcare relies on high levels of human performance, as described by the 'human as the hero' concept. However, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. Human factors is a broad-based scientific discipline which aims to make it as easy as possible for workers to do things correctly. The human factors strategies most likely to be effective are those which 'design out' the chance of an error or adverse event occurring. When errors or adverse events do happen, barriers are in place to trap them and reduce the risk of progression to patient and/or worker harm. If errors or adverse events are not trapped by these barriers, mitigations are in place to minimise the consequences. Non-technical skills form an important part of human factors barriers and mitigation strategies and include: situation awareness; decision-making; task management; and team working. Human factors principles are not a substitute for proper investment and appropriate staffing levels. Although applying human factors science has the potential to save money in the long term, its proper implementation may require investment before reward can be reaped. This narrative review describes what is known about human factors in anaesthesia to date.

Risk control drives risk assessment and risk review: A cause and effect model of pharmaceutical drug recall on patient safety

Background

Pharmaceutical drug recall is a relentless issue that is composed of multidimensional criteria. The distinct criteria that contributed to drug recalls have been identified in previous literature; however, there is limited information regarding the causal relationships between each criterion. Highlighting key influential aspects and criteria of pharmaceutical drug recall is critical in addressing this ongoing issue and promoting patient safety.

Objective

The objective of this study is as follows: (1) identify critical criteria of pharmaceutical drug recalls for improvements, (2) determine the interrelationships among the criteria, and (3) define the causal relationships of pharmaceutical drug recall and provide theoretical insights and practice recommendations to minimize risks associated with pharmaceutical recalls and maximize patient safety.

Design

This study proposes five aspects and 42 criteria to identify the impact of pharmaceutical drug recalls on patient safety by evaluating the interrelationships between the criteria by employing the fuzzy decision-making trial and evaluation laboratory method.

Methods

A group of 11 professionals across the pharmaceutical industry, hospitals, ambulatory care, regulatory authority, and community care settings were selected for interviews.

Results

Risk control is the influencing aspect of pharmaceutical drug recalls that has the most substantial impact on risk assessment and risk review; it generates medium effects on risk communication and technology. Risk assessment, risk communication, and risk review demonstrated comparative weak interrelationships, while risk communication exhibits a weak unidirectional effect on risk review. Finally, risk assessment exerts a weak influence on technology application and development. Product contamination, product subpotent or superpotent, injury to patients, product not sterile or impure, and system detectability of hazards have the strongest influence in the causal group of pharmaceutical drug recalls.

Conclusion

The study shows that risk control drives risk assessment and risk review in the pharmaceutical industry manufacturing process. To achieve patient safety, this study suggests focusing on risk control strategies, as this aspect displays the most substantial effect on influencing other critical risk management aspects such as risk assessment and risk review.

Blockchain for Patient Safety: Use Cases, Opportunities and Open Challenges

Medical errors are recognized as major threats to patient safety worldwide. Lack of streamlined communication and an inability to share and exchange data are among the contributory factors affecting patient safety. To address these challenges, blockchain can be utilized to ensure a secure, transparent and decentralized data exchange among stakeholders. In this study, we discuss six use cases that can benefit from blockchain to gain operational effectiveness and efficiency in the patient safety context. The role of stakeholders, system requirements, opportunities and challenges are discussed in each use case in detail. Connecting stakeholders and data in complex healthcare systems, blockchain has the potential to provide an accountable and collaborative milieu for the delivery of safe care. By reviewing the potential of blockchain in six use cases, we suggest that blockchain provides several benefits, such as an immutable and transparent structure and decentralized architecture, which may help transform health care and enhance patient safety. While blockchain offers remarkable opportunities, it also presents open challenges in the form of trust, privacy, scalability and governance. Future research may benefit from including additional use cases and developing smart contracts to present a more comprehensive view on potential contributions and challenges to explore the feasibility of blockchain-based solutions in the patient safety context.

'Like building a plane and flying it all in one go': an interview study of infection prevention and control in Australian general practice during the first 2 years of the SARS-CoV-2 pandemic

OBJECTIVES

General practitioners (GPs) and their staff have been at the frontline of the SARS-CoV-2 pandemic in Australia. However, their experiences of responding to and managing the risks of viral transmission within their facilities are poorly described. The aim of this study was to describe the experiences, and infection prevention and control (IPC) strategies adopted by general practices, including enablers of and challenges to implementation, to contribute to our understanding of the pandemic response in this critical sector.

DESIGN

Semistructured interviews were conducted in person, by telephone or online video conferencing software, between November 2020 and August 2021.

PARTICIPANTS

Twenty general practice personnel working in New South Wales, Australia, including nine GPs, one general practice registrar, four registered nurses, one nurse practitioner, two practice managers and two receptionists.

RESULTS

Participants described implementing wide-ranging repertoires of IPC strategies-including telehealth, screening of patients and staff, altered clinic layouts and portable outdoor shelters, in addition to appropriate use of personal protective equipment (PPE)-to manage the demands of the SARS-CoV-2 pandemic. Strategies were proactive, influenced by the varied contexts of different practices and the needs and preferences of individual GPs as well as responsive to local, state and national requirements, which changed frequently as the pandemic evolved.

CONCLUSIONS

Using the 'hierarchy of controls' as a framework for analysis, we found that the different strategies adopted in general practice often functioned in concert with one another. Most strategies, particularly administrative and PPE controls, were subjected to human variability and so were less reliable from a human factors perspective. However, our findings highlight the creativity, resilience and resourcefulness of general practice staff in developing, implementing and adapting their IPC strategies amidst constantly changing pandemic conditions.

Managing ongoing swallow safety through information-sharing: An ethnography of speech and language therapists and nurses at work on stroke units

BACKGROUND

Speech and language therapists and nurses need to work together to keep patients with swallowing difficulties safe throughout their acute stroke admission. Speech and language therapists make recommendations for safe swallowing following assessment and nurses put recommendations into practice and monitor how patients cope. There has been little research into the everyday realities of ongoing swallow safety management by these two disciplines. Patient safety research in other fields of healthcare indicates that safety can be enhanced through understanding the cultural context in which risk decisions are made.

AIMS

To generate new understanding for how speech and language therapists (SLTs) and nurses share information for ongoing management of swallows safety on stroke units.

METHODS & PROCEDURES

An ethnographic methodology involving 40 weeks of fieldwork on three stroke wards in England between 2015 and 2017. Fieldwork observation (357 h) and interviews with 43 members of SLT and nursing staff. Observational and interview data were analysed iteratively using techniques from the constant comparative method to create a thematically organized explanation.

OUTCOMES & RESULTS

An explanation for how disciplinary differences in time and space influenced how SLT and nursing staff shared information for ongoing management of swallow safety, based around three themes: (1) SLTs and nurses were aligned in concern for swallow safety across all information-sharing routes; however, (2) ambiguity was introduced by the need for the information contained in swallowing recommendations to travel across time, creating dilemmas for nurses. Patients could improve or deteriorate after recommendations were made and nurses had competing demands on their time. Ambiguity had consequences for (3) critical incident reporting and relationships. SLTs experienced dilemmas over how to act when recommendations were not followed.

CONCLUSIONS & IMPLICATIONS

This study provides new understanding for patient safety dilemmas associated with the enactment and oversight of swallowing recommendations in context, on stroke wards. Findings can support SLTs and nurses to explore together how information for ongoing dysphagia management can be safely implemented within ward realities and kept up to date. This could include considering nursing capacity to act when SLTs are not there, mealtime staffing and SLT 7-day working. Together they can review their understanding of risk and preferred local and formal routes for learning from it.

WHAT THIS PAPER ADDS

What is already known on the subject It is known that information to keep swallowing safe is shared through swallowing recommendations, which are understood to involve a balance of risks between optimizing the safety of the swallow mechanism and maintaining physiological and emotional health. There is increasing appreciation from patient safety research, of the importance of understanding the context in which hospital staff make decisions about risk and patient safety. What this paper adds to existing knowledge The paper provides new empirical understanding for the complexities of risk management associated with SLT and nursing interactions and roles with respect to ongoing swallow safety. What are the potential or actual clinical implications of this work? Findings can underpin SLT and nurse discussion about how swallow safety could be improved in their own settings.

3D Virtual Reality Smartphone Training for Chemotherapy Drug Administration by Non-oncology Nurses: A Randomized Controlled Trial

Chemotherapy agents are cytotoxic materials. Thus, there is a need for the operators to be familiar with the knowledge and procedures before operation. We conducted a randomized controlled trial investigating the effectiveness of an immersive 3D VR teaching of chemotherapy administration operated in a smartphone coupled with a visual and audio device. We adopted a two-arm single-blind design and recruited 83 nurses, and they were randomized using a cluster approach. The VR group learned chemotherapy administration through VR, while the controlled group learned through document reading. The Knowledge and Attitude of Chemotherapy Administration (KACA) was administrated before the intervention, while the Objective Structured Clinical Examination (OSCE) and the Checklist of Action Accomplishment (CAA) were administrated one month after the intervention. The VR group scored higher than the controlled group in the CAA (95.69 ± 5.37 vs. 91.98 ± 9.31, p = 0.02) and the OSCE (73.07 ± 10.99 vs. 67.44 ±10.65, p = 0.02). Stepwise regression demonstrated that service years, an education level of undergraduate or above, and VR exposure contributed positively to the OSCE score (adjusted R² = 0.194, p = 0.028). The use of VR improves the learning efficacy of chemotherapy administration in non-oncology nurses. We recommend using VR as a teaching tool for chemotherapy administration and other chemotherapy-related skills in a VR learning group with senior nurses with higher education levels as advisors. The study provides an approach to online training, especially during the COVID-19 pandemic. (CONSORT 2010 guidelines, registry number: NCT 04840732).

Systems-based investigation of patient safety incidents

Patient safety events are common in healthcare. We can learn from other safety-critical industries that further incidents are most likely to be prevented where lessons are learned at the system level rather than looking to attribute blame for errors to individuals. Progress has been made over the last 20 years and relies on a positive safety culture (or just culture) where staff trust organisations to investigate safety events for learning rather than blame. Systems-based investigation models, such as the Systems Engineering Initiative for Patient Safety (SEIPS), help investigators to consider the full range of contributory factors across a system and to identify important findings. Considering the hierarchy of controls, recommendations should be targeted at system changes which are more likely to produce sustained safety improvements, rather than at individual behaviours or training, which are less likely to influence future safety. Systems-based safety investigations can positively influence safety culture in organisations.

Safety Checklists for Emergency Response Driving and Patient Transport: Experiences from Emergency Medical Services

BACKGROUND

Emergency response driving (ERD) is considered one of the most significant occupational risk factors affecting both patient and traffic safety in emergency medical services (EMS). The majority of the risk factors in ERD are crew related and could be affected positively with crew resource management (CRM). The aim of this study was to examine how the safety checklists developed for ERD and patient transport are experienced in practical work in EMS by paramedics.

METHODS

Safety checklists for ERD and patient transport were developed and then piloted in practical work among 30 paramedics in five different EMS areas around Finland for a two-month period in fall 2019. Afterward, semistructured thematic interviews were performed with the pilot participants, and the material was analyzed using inductive content analysis.

RESULTS

Paramedics experienced that use of ERD and patient transport safety checklists improved safety, and deployment of the checklists required systematic planning. Use of the safety checklists was seen as changing the mindset of the ERD drivers to a more safety critical stance and increasing a systematic approach to ERD. Paramedics also stated that when deploying the checklists in EMS, their use should be standardized as a nationwide operating model and that service-dependent fine-tuning is required.

CONCLUSION

This study's findings support the use of ERD and patient transport safety checklists in practical work in EMS for promoting safety. In addition to safety checklists, other sections of CRM and its applications to EMS should also be studied.

Interventions to Reduce Pediatric Prescribing Errors in Professional Healthcare Settings: A Systematic Review of the Last Decade

INTRODUCTION

Pediatric medication therapy is prone to errors due to the need for pharmacokinetic and pharmacodynamic individualization and the diverse settings in which pediatric patients are treated. Prescribing errors have been reported as the most common medication error.

OBJECTIVES

The aim of this review was to systematically identify interventions to reduce prescribing errors and corresponding patient harm in pediatric healthcare settings and to evaluate their impact.

METHODS

Four databases were systematically screened (time range November 2011 to December 2019), and experimental studies were included. Interventions to reduce prescribing errors were extracted and classified according to a 'hierarchy of controls' model.

RESULTS

Forty-five studies were included, and 70 individual interventions were identified. A bundle of interventions was more likely to reduce prescribing errors than a single intervention. Interventions classified as 'substitution or engineering controls' were more likely to reduce errors in comparison with 'administrative controls', as is expected from the hierarchy of controls model. Fourteen interventions were classified as substitution or engineering controls, including computerized physician order entry (CPOE) and clinical decision support (CDS) systems. Administrative controls, including education, expert consultations, and guidelines, were more commonly identified than higher level controls, although they may be less likely to reduce errors. Of the administrative controls, expert consultations were most likely to reduce errors.

CONCLUSIONS

Interventions to reduce pediatric prescribing errors are more likely to be successful when implemented as part of a bundle of interventions. Interventions including CPOE and CDS that substitute risks or provide engineering controls should be prioritized and implemented with appropriate administrative controls including expert consultation.

The Quality Measures Domain in Nursing Home Compare: Is High Performance Meaningful or Misleading?

BACKGROUND AND OBJECTIVES

The reported percent of nursing home residents suffering adverse outcomes decreased dramatically since Nursing Home Compare began reporting them, but the validity of scores is questionable for nursing homes that score well on measures using facility-reported data but poorly on inspections. Our objective is to assess whether nursing homes with these "discordant" scores are meaningfully better than nursing homes that score poorly across domains.

RESEARCH DESIGN AND METHODS

We used a convergent mixed-methods design, starting with quantitative analyses of 2012-2016 national data. We conducted in-depth interviews and observations in 12 nursing homes in 2017-2018, focusing on how facilities achieved their Nursing Home Compare ratings. Additional quantitative analyses were conducted in parallel to study performance trajectories over time. Quantitative and qualitative results were interpreted together.

RESULTS

Discordant facilities engage in more quality improvement strategies than poor performers, but do not seem to invest in quality improvement in resource-intensive, broad-based ways that would spill over into other domains of quality and change their trajectory of improvement. Instead, they focus on lower-resource improvements related to data quality, staff training, leadership, and communication. In contrast, poor-performing facilities seemed to lack the leadership and continuity of staff required for even these low-resource interventions.

DISCUSSION AND IMPLICATIONS

High performance on the quality measures using facility-reported data is mostly meaningful rather than misleading to consumers who care about those outcomes, although discordant facilities still have quality deficits. The quality measures domain should continue to have a role in Nursing Home Compare.

Interventions to Reduce Medication Dispensing, Administration, and Monitoring Errors in Pediatric Professional Healthcare Settings: A Systematic Review

Introduction: Pediatric patients cared for in professional healthcare settings are at high risk of medication errors. Interventions to improve patient safety often focus on prescribing; however, the subsequent stages in the medication use process (dispensing, drug administration, and monitoring) are also error-prone. This systematic review aims to identify and analyze interventions to reduce dispensing, drug administration, and monitoring errors in professional pediatric healthcare settings. Methods: Four databases were searched for experimental studies with separate control and intervention groups, published in English between 2011 and 2019. Interventions were classified for the first time in pediatric medication safety according to the "hierarchy of controls" model, which predicts that interventions at higher levels are more likely to bring about change. Higher-level interventions aim to reduce risks through elimination, substitution, or engineering controls. Examples of these include the introduction of smart pumps instead of standard pumps (a substitution control) and the introduction of mandatory barcode scanning for drug administration (an engineering control). Administrative controls such as guidelines, warning signs, and educational approaches are lower on the hierarchy and therefore predicted by this model to be less likely to be successful. Results: Twenty studies met the inclusion criteria, including 1 study of dispensing errors, 7 studies of drug administration errors, and 12 studies targeting multiple steps of the medication use process. A total of 44 interventions were identified. Eleven of these were considered higher-level controls (four substitution and seven engineering controls). The majority of interventions (n = 33) were considered "administrative controls" indicating a potential reliance on these measures. Studies that implemented higher-level controls were observed to be more likely to reduce errors, confirming that the hierarchy of controls model may be useful in this setting. Heterogeneous study methods, definitions, and outcome measures meant that a meta-analysis was not appropriate. Conclusions: When designing interventions to reduce pediatric dispensing, drug administration, and monitoring errors, the hierarchy of controls model should be considered, with a focus placed on the introduction of higher-level controls, which may be more likely to reduce errors than the administrative controls often seen in practice. Trial Registration Prospero Identifier: CRD42016047127.

Infection Control Measures, in situ Simulation, and Failure Modes and Effect Analysis to Fine-Tune Change Management during COVID-19

Coronavirus disease 2019 (COVID-19) was an impetus for a multitude of transformations – from the ever-changing clinical practice frameworks, to changes in our execution of education and research. It called for our decisiveness, innovativeness, creativity, and adaptability in many circumstances. Even as care for our patients was always top priority, we tried to integrate, where possible, educational and research activities in order to ensure these areas continue to be harnessed and developed. COVID-19 provided a platform that stretched our ingenuity in all these domains.

One of the mnemonics we use at SingHealth in responding to crisis is PACERS:

P: Preparedness (in responding to any crisis, this is critical)

A: Adaptability (needed especially with the ever-changing situation)

C: Communications (the cornerstone in handling any crisis)

E: Education (must continue, irrespective of what)

R: Research (new opportunities to share and learn)

S: Support (both physical and psychological).

This article shares our experience integrating the concept of simulation-based training, quality improvement, and failure mode analysis.

Beyond the corrective action hierarchy: A systems approach to organizational change

BACKGROUND

Many patient safety organizations recommend the use of the action hierarchy (AH) to identify strong corrective actions following an investigative analysis of patient harm events. Strong corrective actions, such as forcing functions and equipment standardization, improve patient safety by either preventing the occurrence of active failures (i.e. errors or violations) or reducing their consequences if they do occur.

PROBLEM

We propose that the emphasis on implementing strong fixes that incrementally improve safety one event at a time is necessary, yet insufficient, for improving safety. This singular focus has detracted from the pursuit of major changes that transform systems safety by targeting the latent conditions which consistently underlie active failures. To date, however, there are no standardized models or methods that enable patient safety professionals to assess, develop and implement systems changes to improve patient safety.

APPROACH

We propose a multifaceted definition of 'systems change'. Based on this definition, various types and levels of systems change are described. A rubric for determining the extent to which a specific corrective action reflects a 'systems change' is provided. This rubric incorporates four fundamental dimensions of systems change: scope, breadth, depth and degree. Scores along these dimensions can then be used to classify corrective actions within our proposed systems change hierarchy (SCH).

CONCLUSION

Additional research is needed to validate the proposed rubric and SCH. However, when used in conjunction with the AH, the SCH perspective will serve to foster a more holistic and transformative approach to patient safety.

Occupational health and safety hazards faced by healthcare professionals in Taiwan: A systematic review of risk factors and control strategies

Background

Healthcare professionals in Taiwan are exposed to a myriad of occupational health and safety hazards, including physical, biological, chemical, ergonomic, and psychosocial hazards. Healthcare professionals working in hospitals and healthcare facilities are more likely to be subjected to these hazards than their counterparts working in other areas.

Objectives

This review aims to assess current research literature regarding this situation with a view to informing policy makers and practitioners about the risks of exposure and offer evidence-based recommendations on how to eliminate or reduce such risks.

Methods

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses review strategy, we conducted a systematic review of studies related to occupational health and safety conducted between January 2000 and January 2019 using MEDLINE (Ovid), PubMed, PMC, TOXLINE, CINAHL, PLOS One, and Access Pharmacy databases.

Results

The review detected 490 studies addressing the issue of occupational health and safety hazards; of these, 30 articles were included in this systematic review. These articles reported a variety of exposures faced by healthcare professionals. This review also revealed a number of strategies that can be adopted to control, eliminate, or reduce hazards to healthcare professionals in Taiwan.

Conclusion

Hospitals and healthcare facilities have many unique occupational health and safety hazards that can potentially affect the health and performance of healthcare professionals. The impact of such hazards on healthcare professionals poses a serious public health issue in Taiwan; therefore, controlling, eliminating, or reducing exposure can contribute to a stronger healthcare workforce with great potential to improve patient care and the healthcare system in Taiwan. Eliminating or reducing hazards can best be achieved through engineering measures, administrative policy, and the use of personal protective equipment.

Implications

This review has research, policy, and practice implications and provides future students and researchers with information on systematic review methodologies based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses strategy. It also identifies occupational health and safety risks and provides insights and strategies to address them.