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Zaslow J, Fortier J, Garber G. The problem with 'never events'. BMJ Qual Saf 2024; 33:613-616. [PMID: 39009431 DOI: 10.1136/bmjqs-2023-016981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2024] [Indexed: 07/17/2024]
Affiliation(s)
- Joanna Zaslow
- Evidence Synthesis Unit, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | | | - Gary Garber
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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2
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Murphy L, Saab MM, Cornally N, McHugh S, Cotter P. Cardiovascular disease risk assessment in patients with rheumatoid arthritis: A scoping review. Clin Rheumatol 2024; 43:2187-2202. [PMID: 38733423 PMCID: PMC11189331 DOI: 10.1007/s10067-024-06996-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/19/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024]
Abstract
Patients with rheumatoid arthritis (RA) have an increased risk of developing cardiovascular disease (CVD). Identification of at-risk patients is paramount to initiate preventive care and tailor treatments accordingly. Despite international guidelines recommending all patients with RA undergo CVD risk assessment, rates remain suboptimal. The objectives of this review were to map the strategies used to conduct CVD risk assessments in patients with RA in routine care, determine who delivers CVD risk assessments, and identify what composite measures are used. The Joanna Briggs Institute methodological guidelines were used. A literature search was conducted in electronic and grey literature databases, trial registries, medical clearing houses, and professional rheumatology organisations. Findings were synthesised narratively. A total of 12 studies were included. Strategies reported in this review used various system-based interventions to support delivery of CVD risk assessments in patients with RA, operationalised in different ways, adopting two approaches: (a) multidisciplinary collaboration, and (b) education. Various composite measures were cited in use, with and without adjustment for RA. Results from this review demonstrate that although several strategies to support CVD risk assessments in patients with RA are cited in the literature, there is limited evidence to suggest a standardised model has been applied to routine care. Furthermore, extensive evidence to map how health care professionals conduct CVD risk assessments in practice is lacking. Research needs to be undertaken to establish the extent to which healthcare professionals are CVD risk assessing their patients with RA in routine care. Key Points • A limited number of system-based interventions are in use to support the delivery of CVD risk assessments in patients with RA. • Multidisciplinary team collaboration, and education are used to operationalise interventions to support Health Care Professionals in conducting CVD risk assessments in practice. • The extent to which Health Care Professionals are CVD risk assessing their patients with RA needs to be established.
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Affiliation(s)
- Louise Murphy
- Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland.
- Department of Rheumatology, Cork University Hospital, Wilton, Cork, Ireland.
| | - Mohamad M Saab
- Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Nicola Cornally
- Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Sheena McHugh
- School of Public Health, University College Cork, Cork, Ireland
| | - Patrick Cotter
- Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland
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3
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Tuckey N, Iasiello M, Corsini N, Koczwara B, Bareham M, Wellalagodage A, Wardill HR. 'Just Google it'-A scoping review of online mental health resources for survivors of breast cancer. Psychooncology 2024; 33:e6337. [PMID: 38570325 DOI: 10.1002/pon.6337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 01/30/2024] [Accepted: 03/17/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE As the Internet is a ubiquitous resource for information, we aimed to replicate a patient's Google search to identify and assess the quality of online mental health/wellbeing materials available to support women living with or beyond cancer. METHODS A Google search was performed using a key term search strategy including search strings 'cancer', 'wellbeing', 'distress' and 'resources' to identify online resources of diverse formats (i.e., factsheet, website, program, course, video, webinar, e-book, podcast). The quality evaluation scoring tool (QUEST) was used to analyse the quality of health information provided. RESULTS The search strategy resulted in 283 resources, 117 of which met inclusion criteria across four countries: Australia, USA, UK, and Canada. Websites and factsheets were primarily retrieved. The average QUEST score was 10.04 (highest possible score is 28), indicating low quality, with 92.31% of resources lacking references to sources of information. CONCLUSIONS Our data indicated a lack of evidence-based support resources and engaging information available online for people living with or beyond cancer. The majority of online resources were non-specific to breast cancer and lacked authorship and attribution.
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Affiliation(s)
- Natalie Tuckey
- Mental Health and Wellbeing Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Psychology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Matthew Iasiello
- Mental Health and Wellbeing Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- College of Education, Psychology and Social Work, Flinders University, Adelaide, South Australia, Australia
| | - Nadia Corsini
- Rosemary Bryant AO Research Centre, Clinical & Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Bogda Koczwara
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Monique Bareham
- Patient Advocate and Cancer Survivor - SA 2022 Local Hero, Adelaide, South Australia, Australia
| | - Amy Wellalagodage
- Supportive Oncology Research Group, Precision Medicine Theme (Cancer Program), The South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Hannah R Wardill
- Supportive Oncology Research Group, Precision Medicine Theme (Cancer Program), The South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
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4
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Murphy KD, O' Mahony C, McCarthy M, Saab MM, Barbosa TM, Fleming A, Cotter P, Noonan B, Breen E, Carroll G, De Frein A, Heckmann P, Triggs M, Sahm L. Quality assurance standards and their use in the preparation of parenteral systemic anticancer therapy products in healthcare establishments: a scoping review. Eur J Hosp Pharm 2024; 31:88-93. [PMID: 37879730 PMCID: PMC10895183 DOI: 10.1136/ejhpharm-2023-003922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/03/2023] [Indexed: 10/27/2023] Open
Abstract
OBJECTIVES The use of parenteral systemic anticancer therapy (SACT) has led to improved cancer survival. A quality assurance (QA) system of the aseptic compounding process is necessary to ensure safe and consistent production of parenteral SACT. This scoping review identifies international evidence and practice relating to QA standards in the preparation of parenteral SACT in healthcare establishments. METHODS Standards relating to aseptic compounding in hospital pharmacies and literature exploring the aseptic compounding of parenteral SACT were included. Literature relating to the non-aseptic compounding of medicines and records specific to sterile manufacturing in industrial settings were excluded. A search of several electronic databases, trial registries, the grey literature and websites of key European hospital pharmacy groups and accreditation bodies was conducted on 16 March 2022. A narrative discussion was performed by country, and content analysis of articles was conducted. RESULTS Thirty-seven records were included. Standards reviewed covered the work environment, the preparation process and the safety of the workers who are potentially exposed to hazardous chemicals. It was a common practice to include frequent audits to ensure adherence to standards. Some standards also recommended external inspections to allow for further learnings. Periodic reviews are encouraged to ensure standards maintain relevance. National standards of the countries reviewed were based on international standards, with minor adaptations for local conditions. CONCLUSIONS The main limitation of this review is that it is limited to countries with a high human development index. The review shows that the use of an internationally recognised standard as a basis for national standards is best practice, and will allow for relevance into the future.
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Affiliation(s)
- Kevin D Murphy
- School of Pharmacy, University College Cork, Cork, Ireland
| | - Cian O' Mahony
- School of Pharmacy, University College Cork, Cork, Ireland
| | - Megan McCarthy
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Mohamad M Saab
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | | | - Aoife Fleming
- School of Pharmacy, University College Cork, Cork, Ireland
- Department of Pharmacy, Mercy University Hospital, Cork, Ireland
| | - Patrick Cotter
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Brendan Noonan
- School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Elizabeth Breen
- National Cancer Control Programme, Health Service Executive, Dublin, Ireland
| | - Grant Carroll
- National Cancer Control Programme, Health Service Executive, Dublin, Ireland
| | - AnneMarie De Frein
- National Cancer Control Programme, Health Service Executive, Dublin, Ireland
| | - Patricia Heckmann
- National Cancer Control Programme, Health Service Executive, Dublin, Ireland
| | - Margaret Triggs
- National Cancer Control Programme, Health Service Executive, Dublin, Ireland
| | - Laura Sahm
- School of Pharmacy, University College Cork, Cork, Ireland
- Department of Pharmacy, Mercy University Hospital, Cork, Ireland
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Kang J, Kwon SS, Lee Y. Clinical nurses' work-life balance prediction due to patient safety incidents using classification and regression tree analysis: a secondary data analysis. BMC Nurs 2024; 23:70. [PMID: 38267902 PMCID: PMC10809596 DOI: 10.1186/s12912-024-01719-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 01/07/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Patient safety incidents lead to performance difficulties for nurses when providing nursing practice. This affects work-life balance and causes second and third-victimization. This study predicts factors affecting clinical nurses' work-life balance due to patient safety incidents using classification and regression tree analysis techniques. METHODS This study was a secondary analysis of data from a cohort research project, which used a descriptive survey for data collection. Participants comprised 372 nurses. Data were collected using SurveyMonkey, a mobile-based survey software solution, from January to September 2021. Data included the general characteristics of clinical nurses, second damage, second damage support, third damage, and work-life balance. The specific variables included in the analysis chosen through rigorous Lasso analysis form the foundation for predicting work-life balance. Variables with low explanatory power were excluded, thereafter, the variables selected by Lasso were analyzed with a classification and regression tree model to predict work-life balance. RESULTS A regression tree was applied to predict work-life balance using seven variables-education level, marital status, position, physical distress, second-victim support, turnover intentions, and absenteeism (selected through Lasso analysis). After pruning, at tree size four, when turnover intentions were < 4.250, physical distress < 2.875, and second-victim support < 2.345, the predicted work-life balance was 3.972. However, when turnover intentions were < 4.250, physical distress < 2.875, and second-victim support ≥ 2.345, then the predicted work-life balance was 2.760. CONCLUSIONS This study's insights offer crucial groundwork for crafting targeted workforce risk management strategies and fostering a conducive organizational culture to mitigate nursing occupational stress, potentially curbing the recurrence of patient safety incidents and improving nursing practice while enhancing patient outcomes. Future research should explore second and third victim experiences across various healthcare settings globally to understand their impact on WLB and patient safety outcomes.
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Affiliation(s)
- Jiwon Kang
- Department of Family, Health and Wellbeing, University of Minnesota Extension, 1420 Eckles Ave, St Paul, MN, 55108, US
- College of Nursing, Ajou University, 164 World Cup-Ro, Yeongtong-Gu, Suwon, 16499, South Korea
| | - Soon-Sun Kwon
- Departments of Mathematics and Department of Artificial Intelligence, College of Natural Sciences, Ajou University, 164 World Cup-Ro, Yeongtong-Gu, Suwon, 16499, South Korea
| | - Youngjin Lee
- College of Nursing, Ajou University, 164 World Cup-Ro, Yeongtong-Gu, Suwon, 16499, South Korea.
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Abreu T, Freysteinson WM, Clutter P, Aulbach R. Demystifying the experience of participating in a root cause analysis: A hermeneutic phenomenological study. Appl Nurs Res 2023; 74:151746. [PMID: 38007246 DOI: 10.1016/j.apnr.2023.151746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 08/04/2023] [Accepted: 10/24/2023] [Indexed: 11/27/2023]
Abstract
AIM This study aimed to explore registered nurses' experience participating in a root cause analysis (RCA) meeting because of their involvement in an adverse event. BACKGROUND An RCA is the most common strategy used by organizations for adverse event investigations. Nursing healthcare professionals directly involved in an adverse event may be asked to participate in the RCA. However, no studies were found in the literature on their experience. METHODS Semi-structured audio-taped interviews were held with 13 registered nurses who participated in an RCA. Ricoeur's hermeneutic phenomenology guided data analysis. RESULTS Two structural elements represented the world of the nurses: 1) Learning about an RCA, and 2) being on the other side of the RCA table. Three phenomenological themes emerged: 1) anticipatory and embodied fear, 2) to speak or not to speak, 3) the aftermath. CONCLUSION Nurses desire RCA education to assist in understanding and support from nurse leaders throughout the process. Healthcare organizations must create a safe and collaborative environment to empower nurses to speak up and have their voices heard during the RCA process. IMPLICATIONS FOR NURSING LEADERS Nurses want to participate in RCA meetings. However, leaders must demystify the RCA process for nurses through education and training.
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Affiliation(s)
- Tamu Abreu
- Nelda C. Stark College of Nursing, Texas Woman's University, USA.
| | | | - Paula Clutter
- Nelda C. Stark College of Nursing, Texas Woman's University, USA
| | - Rebecca Aulbach
- Nelda C. Stark College of Nursing, Texas Woman's University, USA
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Hameed S, Humayun A, Yaqoob M, Rehm MH. Patient Safety Culture: A Healthcare Provider's Prospect. Cureus 2023; 15:e49989. [PMID: 38179365 PMCID: PMC10766388 DOI: 10.7759/cureus.49989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/06/2024] Open
Abstract
INTRODUCTION AND OBJECTIVE Safe care is a challenge around the globe, especially in developing countries. In resource-limited settings achieving patient safety is an additional complexity. Patient safety is now considered a significant public health concern worldwide. Despite a vital role in delivering quality care, little attention has been given to describe healthcare professionals' perceptions of the patient safety culture in Pakistan. This study aimed to assess the patient safety culture at a tertiary care public hospital in Lahore from the perspectives of doctors and nurses. METHODS During this cross-sectional study, data were collected from 290 nurses and doctors using a validated safety assessment survey tool of the Hospital Survey of Patient Safety Culture (HSOPSC). The respondent's demographic characteristics and study variables influencing patient safety culture were presented, and a chi-square test was applied to identify the variables influencing patient safety. RESULTS A total of 114 medical doctors (39.3%) and 176 registered nurses (60.7%) participated in assessing patient safety culture (PSC) across tertiary care public healthcare centers in Lahore. The dimensions of organizational learning and continuous improvement (90.6%) and teamwork within units (86.6%) were the highest. Other dimensions include feedback and communication about the error (71.8%), teamwork across units (74.9%), management support for patient safety (67.3%), supervisor/manager expectations, and actions promoting patient safety (64.6%), communication openness (64.5%), overall perceptions of patient safety (65.3%), frequency of events reported (58.7%), and handoffs and transitions (60.9%) showed moderate status. The dimensions of staffing (35.8%) and non-punitive response to errors (39.1%) had the lowest score. CONCLUSIONS The present public hospital survey results revealed that medical staff working in a healthcare setting have a less positive perception of patient safety culture.
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Affiliation(s)
- Sajid Hameed
- Public Health, University Institute of Public Health, Faculty of Allied Health Sciences, The University of Lahore, Lahore, PAK
| | - Ayesha Humayun
- Public Health and Community Medicine, Shaikh Zayed Postgraduate Medical Institute, Lahore, PAK
| | - Muhammad Yaqoob
- Public Health, University Institute of Public Health, Faculty of Allied Health Sciences, The University of Lahore, Lahore, PAK
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Bodek A, Pommée M, Berger A, Giraki M, Müller BS, Schütze D. Blackbox error management: how do practices deal with critical incidents in everyday practice? A qualitative interview study. BMC PRIMARY CARE 2023; 24:251. [PMID: 38030963 PMCID: PMC10685626 DOI: 10.1186/s12875-023-02206-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 11/14/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Error management plays a key role in patient safety. It is a systematic approach aimed at identifying and learning from critical incidents by reporting, documenting and analyzing them. Almost nothing is known about the incidents physicians in outpatient care consider to be critical and how they deal with them. We carried out an interview study to explore outpatient physicians' views on error management, discover what they regard as critical incidents, and find out how error management is put into practice in ambulatory care. METHODS We conducted 72 semi-structured interviews with physicians from ambulatory practices. We asked participants what they considered to be a critical incident, how they reacted following an incident, how they discussed incidents with their coworkers, and whether they used critical incident reporting systems. The interviews were transcribed verbatim and analyzed using qualitative content analysis. RESULTS Interviewed physicians defined the term "critical incident" differently. Most participants reported that they recorded information on incidents and discussed them in their teams. Several physicians reported taking a 'pay better attention next time-approach' to the analysis of incidents. Systematic error management involving incident documentation, analysis, preventive measure development, and follow-up, was the exception. CONCLUSIONS To promote error management, medical training should include teaching on the topic, so that medical professionals can learn about critical incidents and how to deal with them in an open and structured manner. This would help establish the culture of safety that has long been called for internationally.
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Affiliation(s)
- Aljoscha Bodek
- Institute of General Practice, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
| | - Marina Pommée
- Institute of General Practice, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
- Association of Statutory Health Insurance Physicians Westphalia-Lippe, Robert-Schimrigk-Str. 4-6, 44141, Dortmund, Germany
| | - Alexandra Berger
- Institute of General Practice, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
- Frankfurt Reference Centre for Rare Diseases, University Hospital of the Goethe University Frankfurt, Theodor Stern-Kai 7, 60590, Frankfurt, Germany
| | - Maria Giraki
- Department of Operative Dentistry, Center for Dentistry and Oral Medicine (Carolinum), Goethe University Frankfurt, Theodor-Stern-Kai 7, 60596, Frankfurt Am Main, Germany
| | - Beate Sigrid Müller
- Institute of General Practice, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
- Faculty of Medicine and University Hospital Cologne, Institute of General Practice, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Dania Schütze
- Institute of General Practice, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany.
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Morrissey D, O'Donnell EA, Behan L, McMahon M, Keyes LM. Definitions of serious injury in long-term residential care: a systematic review protocol. HRB Open Res 2023; 6:66. [PMID: 38384972 PMCID: PMC10879755 DOI: 10.12688/hrbopenres.13705.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 02/23/2024] Open
Abstract
Background: Evidence indicates that the reporting of serious injury in long-term residential care has increased substantially over the past decade. However, what constitutes a serious injury in residential care is poorly and inconsistently defined. This may result in incidences being unnecessarily reported as a serious injury. It is therefore, crucial to develop a consistent definition of serious injury to reduce reporting burden and to facilitate comparison between different residential care settings and across jurisdictions. This protocol describes the methods for a systematic review of existing definitions from the literature to inform the development of a consistent definition of serious injury in long-term residential care. Methods: A wide range of published peer-reviewed and grey literature will be sought for this review, including guidance and policy documents. Searches will be conducted of databases including MEDLINE, CINAHL, SocINDEX, Academic Search Ultimate, and Westlaw International. Grey literature database searches will include Trip and Social Care Online. Country specific searches of government and health and social care websites will be conducted. Quality appraisal will be facilitated using the Quality Assessment for Diverse Studies (QuADS) tool and Tyndall's checklist. The level of confidence in the findings will be assessed using the GRADE CERQual approach. A customised data extraction form will be used to extract data to reduce the risk of bias. Conceptual content analysis of data will facilitate identification of definitions of serious injury and their frequency within texts. Conclusions: The findings will inform the development of a consistent definition of serious injury in long-term residential care that will reduce reporting burden, facilitate the accuracy of data collected and allow for comparison across jurisdictions. A more universal and consistent definition will enable regulators, policy makers, service providers and researchers to develop policy and practical interventions to prevent the occurrence of serious injury in long-term residential care.
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Affiliation(s)
- David Morrissey
- Health Information and Quality Authority (HIQA), Cork, T12 Y2XT, Ireland
| | | | - Laura Behan
- Health Information and Quality Authority (HIQA), Cork, T12 Y2XT, Ireland
| | - Martin McMahon
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, D02 PN40, Ireland
| | - Laura M. Keyes
- Health Information and Quality Authority (HIQA), Cork, T12 Y2XT, Ireland
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Karjalainen M, Taittonen L, Huhtala H, Palmu S, Tammela O. Systematic analysis of adverse incident reports revealed the need for improvements in the neonatal unit. Acta Paediatr 2023; 112:2322-2328. [PMID: 37485868 DOI: 10.1111/apa.16918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/11/2023] [Accepted: 07/20/2023] [Indexed: 07/25/2023]
Abstract
AIM The aims were to characterise adverse incident reports and recommendations to avoid the reoccurrence of adverse incidents and detect a possible increase in incidents outside of office hours and on vacation season. METHODS Analysis of adverse incidents reported at the neonatal intensive care unit of Tampere University Hospital in Finland between 2013 and 2020. RESULTS Analysis of 925 fully processed adverse incident reports revealed that 36.3% of the reports were related to medication, fluid management and blood products, and 34.8% of these were administering errors. Nurses reported 828 (89.5%) adverse incidents and physicians reported 37 (4.0%). Near misses constituted 35.3% of nurses' and 21.6% of physicians' reports. There were significantly more adverse incident reports on day shifts, on Thursdays and, Saturdays and in June, November and December than at other times. The interventions recommended were to inform the staff or other parties after 673 (72.7%) reports and to recommend improvements after 56 (6.0%) reports. CONCLUSION Analysis of adverse incident reports can reveal the need for improvements in existing protocols in the neonatal intensive care unit.
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Affiliation(s)
- Maria Karjalainen
- Department of Paediatrics, Wellbeing Services County of Pirkanmaa, Tampere, Finland
- Tampere Center for Child, Adolescent, and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Leena Taittonen
- Department of Paediatrics, Wellbeing Services County of Pirkanmaa, Tampere, Finland
- Tampere Center for Child, Adolescent, and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Sauli Palmu
- Department of Paediatrics, Wellbeing Services County of Pirkanmaa, Tampere, Finland
- Tampere Center for Child, Adolescent, and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Outi Tammela
- Department of Paediatrics, Wellbeing Services County of Pirkanmaa, Tampere, Finland
- Tampere Center for Child, Adolescent, and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Pavithra A, Mannion R, Li L, Westbrook J. The impact of vulnerability and exposure to pervasive interprofessional incivility among medical staff on wellbeing. Front Public Health 2023; 11:1168978. [PMID: 37521972 PMCID: PMC10375044 DOI: 10.3389/fpubh.2023.1168978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Introduction Traditional methods for modelling human interactions within organisational contexts are often hindered by the complexity inherent within these systems. Building on new approaches to information modelling in the social sciences and drawing on the work of scholars in transdisciplinary fields, we proposed that a reliable model of human interaction as well as its emergent properties can be demonstrated using theories related to emergent information. Methods We demonstrated these dynamics through a test case related to data from a prevalence survey of incivility among medical staff. For each survey respondent we defined their vulnerability profile based upon a combination of their biographical characteristics, such as age, gender, and length of employment within a hospital and the hospital type (private or public). We modelled the interactions between the composite vulnerability profile of staff against their reports of their exposure to incivility and the consequent negative impact on their wellbeing. Results We found that vulnerability profile appeared to be proportionally related to the extent to which they were exposed to rudeness in the workplace and to a negative impact on subjective wellbeing. Discussion This model can potentially be used to tailor resources to improve the wellbeing of hospital medical staff at increased risk of facing incivility, bullying and harassment at their workplaces.
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Affiliation(s)
- Antoinette Pavithra
- Faculty of Medicine, Health and Human Sciences, Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Russell Mannion
- Faculty of Medicine, Health and Human Sciences, Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
- Health Services Management Centre, School of Social Policy, College of Social Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Ling Li
- Faculty of Medicine, Health and Human Sciences, Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Johanna Westbrook
- Faculty of Medicine, Health and Human Sciences, Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
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Bowman CL, De Gorter R, Zaslow J, Fortier JH, Garber G. Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis. BMJ Open Qual 2023; 12:e002264. [PMID: 37364940 PMCID: PMC10314656 DOI: 10.1136/bmjoq-2023-002264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Never events (NEs) are patient safety incidents that are preventable and so serious they should never happen. To reduce NEs, several frameworks have been introduced over the past two decades; however, NEs and their harms continue to occur. These frameworks have varying events, terminology and preventability, which hinders collaboration. This systematic review aims to identify the most serious and preventable events for targeted improvement efforts by answering the following questions: Which patient safety events are most frequently classified as never events? Which ones are most commonly described as entirely preventable? METHODS For this narrative synthesis systematic review we searched Medline, Embase, PsycINFO, Cochrane Central and CINAHL for articles published from 1 January 2001 to 27 October 2021. We included papers of any study design or article type (excluding press releases/announcements) that listed NEs or an existing NE framework. RESULTS Our analyses included 367 reports identifying 125 unique NEs. Those most frequently reported were surgery on the wrong body part, wrong surgical procedure, unintentionally retained foreign objects and surgery on the wrong patient. Researchers classified 19.4% of NEs as 'wholly preventable'. Those most included in this category were surgery on the wrong body part or patient, wrong surgical procedure, improper administration of a potassium-containing solution and wrong-route administration of medication (excluding chemotherapy). CONCLUSIONS To improve collaboration and facilitate learning from errors, we need a single list that focuses on the most preventable and serious NEs. Our review shows that surgery on the wrong body part or patient, or the wrong surgical procedure best meet these criteria.
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Affiliation(s)
- Cara L Bowman
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Ria De Gorter
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Joanna Zaslow
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Jacqueline H Fortier
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Gary Garber
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
- Department of Medicine, and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Zaslow J, Fortier J, Bowman C, de Gorter R, Tsai E, Desai D, O’Neill P, Mimeault R, Garber G. Defining healthcare never events to effect system change: A protocol for systematic review. PLoS One 2022; 17:e0279113. [PMID: 36520805 PMCID: PMC9754204 DOI: 10.1371/journal.pone.0279113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION A never event is the most egregious of patient safety incidents. It refers to events that should theoretically never happen, such amputating the wrong limb. The term "never event" is used around the world by a variety of medical and patient safety organizations and is synonymous with sentinel events and serious reportable events. Unfortunately, there is little consensus about which events, in particular, are never events. These differing lists hinder potential collaboration or large-scale analyses. A recent systematic review by Hegarty et al. (2020) identified the need for a standardized definition for serious reportable events. The objective of our systematic review is to build on this by identifying which events are consistently or frequently identified as never events in order to isolate those which are core never events. MATERIALS AND METHODS A systematic review will be conducted using Medline, Medline in Process, Scopus, PsychINFO, Embase via OVID, and CINAHL via EBSCO databases, as well as grey literature. We will include articles of any study design that discuss never events or one of its synonymous terms in the context of medical care. Four independent reviewers will conduct the title and abstract as well as the full-text screening, and 2 reviewers will abstract data. Data will be analyzed using narrative synthesis. Results will be categorized by year and geographic location, and by other factors determined during full-text screening. DISCUSSION AND CONCLUSION The lack of consensus regarding never events hinders progress in reducing their occurrence. Differing data sources makes comparison challenging, and limits the ability for patient safety groups to work collaboratively and share learnings with others. Identifying a core set of never events will serve as a first step to focus our efforts to reduce these harmful incidents.
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Affiliation(s)
- Joanna Zaslow
- The Canadian Medical Protective Association, Ottawa, ON, Canada
- * E-mail:
| | | | - Cara Bowman
- The Canadian Medical Protective Association, Ottawa, ON, Canada
| | - Ria de Gorter
- The Canadian Medical Protective Association, Ottawa, ON, Canada
| | - Ellen Tsai
- The Canadian Medical Protective Association, Ottawa, ON, Canada
| | - Dennis Desai
- The Canadian Medical Protective Association, Ottawa, ON, Canada
| | - Peter O’Neill
- The Canadian Medical Protective Association, Ottawa, ON, Canada
| | | | - Gary Garber
- The Canadian Medical Protective Association, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON Canada
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Saab MM, Murphy M, Meehan E, Dillon CB, O'Connell S, Hegarty J, Heffernan S, Greaney S, Kilty C, Goodwin J, Hartigan I, O'Brien M, Chambers D, Twomey U, O'Donovan A. Suicide and Self-Harm Risk Assessment: A Systematic Review of Prospective Research. Arch Suicide Res 2022; 26:1645-1665. [PMID: 34193026 DOI: 10.1080/13811118.2021.1938321] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Suicide and self-harm are widespread yet underreported. Risk assessment is key to effective self-harm and suicide prevention and management. There is contradicting evidence regarding the effectiveness of risk assessment tools in predicting self-harm and suicide risk. This systematic review examines the effect of risk assessment strategies on predicting suicide and self-harm outcomes among adult healthcare service users. METHOD Electronic and gray literature databases were searched for prospective research. Studies were screened and selected by independent reviewers. Quality and level of evidence assessments were conducted. Due to study heterogeneity, we present a narrative synthesis under three categories: (1) suicide- and self-harm-related outcomes; (2) clinician assessment of suicide and self-harm risk; and (3) healthcare utilization due to self-harm or suicide. RESULTS Twenty-one studies were included in this review. The SAD PERSONS Scale was the most used tool. It outperformed the Beck Scale for Suicide Ideation in predicting hospital admissions and stay following suicide and self-harm, yet it failed to predict repeat suicide and self-harm and was not recommended for routine use. There were mixed findings relating to clinician risk assessment, with some studies recommending clinician assessment over structured tools, whilst others found that clinician assessment failed to predict future attempts and deaths. CONCLUSIONS There is insufficient evidence to support the use of any one tool, inclusive of clinician assessment of risk, for self-harm and suicidality. The discourse around risk assessment needs to move toward a broader discussion on the safety of patients who are at risk for self-harm and/or suicide.HIGHLIGHTSThere is insufficient evidence to support using standalone risk assessment tools.There are mixed findings relating to clinician assessment of risk.Structured professional judgment is widely accepted for risk assessment.
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Implementing a New Electronic Health Record System in a University Hospital: The Effect on Reported Medication Errors. Healthcare (Basel) 2022; 10:healthcare10061020. [PMID: 35742071 PMCID: PMC9222436 DOI: 10.3390/healthcare10061020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/24/2022] [Accepted: 05/29/2022] [Indexed: 11/16/2022] Open
Abstract
Closed-loop electronic medication management systems (EMMS) have been seen as a potential technology to prevent medication errors (MEs), although the research on them is still limited. The aim of this paper was to describe the changes in reported MEs in Helsinki University Hospital (HUS) during and after implementing an EPIC-based electronic health record system (APOTTI), with the first features of a closed-loop EMMS. MEs reported from January 2018 to May 2021 were analysed to identify changes in ME trends with quantitative analysis. Severe MEs were also analysed via qualitative content analysis. A total of 30% (n = 23,492/79,272) of all reported patient safety incidents were MEs. Implementation phases momentarily increased the ME reporting, which soon decreased back to the earlier level. Administration and dispensing errors decreased, but medication reconciliation, ordering, and prescribing errors increased. The ranking of the TOP 10 medications related to MEs remained relatively stable. There were 92 severe MEs related to APOTTI (43% of all severe MEs). The majority of these (55%, n = 53) were related to use and user skills, 24% (n = 23) were technical failures and flaws, and 21% (n = 21) were related to both. Using EMMS required major changes in the medication process and new technical systems and technology. Our medication-use process is approaching a closed-loop system, which seems to provide safer dispensing and administration of medications. However, medication reconciliation, ordering, and prescribing still need to be improved.
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Dillon CB, Saab MM, Meehan E, Goodwin MJ, Murphy M, Heffernan MS, Greaney MS, Kilty C, Hartigan I, Chambers D, Twomey U, Horgan A. Staff awareness of suicide and self-harm risk in healthcare settings: A mixed-methods systematic review. J Affect Disord 2020; 276:898-906. [PMID: 32739708 DOI: 10.1016/j.jad.2020.07.113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Suicide risk screening in healthcare settings plays a significant role in suicide prevention. Healthcare staff who are poorly informed about self-harm and suicide risk are less likely to identify and subsequently screen at-risk individuals. This mixed-method systematic review aimed to appraise and synthesise evidence from studies that explored and promoted healthcare staff's knowledge and awareness of suicide and self-harm risk in healthcare settings. METHODS Electronic databases (CINAHL, MEDLINE, APA PsycInfo, APA PsycARTICLES, Psychology and behavioural Science Collection, ERIC, and SocINDEX), the Cochrane Library, and various grey literature databases were searched for relevant studies. The level of evidence and methodological quality of the included studies were assessed. RESULTS Eighteen empirical studies were included. Levels of knowledge about suicide and self-harm risk varied significantly across the reviewed studies. Face-to-face group training and educational programmes, digital or online educational programmes, and an educational poster campaign were amongst the strategies used to promote awareness of suicide and self-harm risk, with the majority marginally succeeding in doing so. LIMITATIONS The reviewed studies were heterogeneous in terms of design, interventions, and outcome measures which made it difficult to make comparisons. The overall level of scientific evidence was classified as being relatively low. The lack of blinding and lack of a control group were amongst the limitations for experimental studies. CONCLUSIONS Long-term, routine face-to-face group training programmes should be established to educate healthcare staff about suicide risk across all professions and in specific patient groups.
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Affiliation(s)
- Christina B Dillon
- Environmental Research Institute/School of Public Health, University College Cork, Ireland.
| | - Mohamad M Saab
- School of Nursing and Midwifery, University College Cork, Ireland
| | - Elaine Meehan
- School of Nursing and Midwifery, University College Cork, Ireland
| | - Mr John Goodwin
- School of Nursing and Midwifery, University College Cork, Ireland
| | - Margaret Murphy
- School of Nursing and Midwifery, University College Cork, Ireland
| | | | | | - Caroline Kilty
- School of Nursing and Midwifery, University College Cork, Ireland
| | - Irene Hartigan
- School of Nursing and Midwifery, University College Cork, Ireland
| | | | - Una Twomey
- Health Service Executive Southern Area, Ireland
| | - Aine Horgan
- School of Nursing and Midwifery, University College Cork, Ireland.
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