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O'Malley T, Capone J, Perla B, Vasbinder S. Let's Talk Safety - Data from the Neonatal Intensive Care Unit Safety and Bed Capacity Huddles. Adv Neonatal Care 2024; 24:393-399. [PMID: 38907696 DOI: 10.1097/anc.0000000000001180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2024]
Abstract
BACKGROUND Huddles are brief team meetings designed to communicate essential information. Safety huddles provide a forum to identify and review patient safety events. In a just culture, everyone is accountable for patient safety. PURPOSE The purpose of this project is to discuss safety issues/events at the twice daily bed capacity huddles in a Level IV Neonatal Intensive Care Unit (NICU) utilizing a just culture model. Having daily discussions of patient safety and the escalation process for follow-up promotes a just culture. The aims are to improve the unit's culture of safety and learn from patient safety issues. METHODS A just culture model was adopted to promote discussion of safety events during the huddles. A structured checklist of safety events was utilized along with a script of ground rules. Twice a day, a multidisciplinary group gathers to huddle. Nurse leaders facilitate the discussion, track the results, and provide follow-up. RESULTS The structured safety huddle began in May of 2020 and continues twice daily. All required staff attend. The escalation process is defined and has prevented recurrence of some safety issues. The NICU experienced a 14% increase in favorable results on the Agency for Healthcare Research and Quality (AHRQ) culture of safety survey since the inception of the structured safety huddles. IMPLICATIONS FOR PRACTICE AND RESEARCH Safety huddle discussions have impacted the culture of safety on this unit. Tracking of discussions can help to identify trends, improve processes, and impact patient safety.
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Affiliation(s)
- Teresa O'Malley
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh , Pittsburgh, Pennsylvania
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2
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Jacobson JO, Brooks GA. Unspoken Risks of Cancer Care. JCO Oncol Pract 2024; 20:617-620. [PMID: 38382006 DOI: 10.1200/op.23.00795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/03/2024] [Accepted: 01/22/2024] [Indexed: 02/23/2024] Open
Affiliation(s)
- Joseph O Jacobson
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Gabriel A Brooks
- Dartmouth Cancer Center/Dartmouth Hitchcock Medical Center, Lebanon, NH
- Dartmouth Geisel School of Medicine, Hanover, NH
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Call RC, Espiritu SG, Barrows DA. "Plans are worthless, but planning is everything": advancing patient safety by better managing the paradox of planning versus adaptation. Int Anesthesiol Clin 2024; 62:9-15. [PMID: 38268421 DOI: 10.1097/aia.0000000000000433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Affiliation(s)
- R Christopher Call
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Samuel G Espiritu
- Department of Anesthesia & Critical Care, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - David A Barrows
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Hibbert PD, Stewart S, Wiles LK, Braithwaite J, Runciman WB, Thomas MJW. Improving patient safety governance and systems through learning from successes and failures: qualitative surveys and interviews with international experts. Int J Qual Health Care 2023; 35:0. [PMID: 37978851 PMCID: PMC10656601 DOI: 10.1093/intqhc/mzad088] [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: 04/12/2023] [Revised: 10/04/2023] [Accepted: 10/15/2023] [Indexed: 11/19/2023] Open
Abstract
Patient harm is a leading cause of global disease burden with considerable morbidity, mortality, and economic impacts for individuals, families, and wider society. Large bodies of evidence exist for strategies to improve safety and reduce harm. However, it is not clear which patient safety issues are being addressed globally, and which factors are the most (or least) important contributors to patient safety improvements. We aimed to explore the perspectives of international patient safety experts to identify: (1) the nature and range of patient safety issues being addressed, and (2) aspects of patient safety governance and systems that are perceived to provide value (or not) in improving patient outcomes. English-speaking Fellows and Experts of the International Society for Quality in Healthcare participated in a web-based survey and in-depth semistructured interview, discussing their experience in implementing interventions to improve patient safety. Data collection focused on understanding the elements of patient safety governance that influence outcomes. Demographic survey data were analysed descriptively. Qualitative data were coded, analysed thematically (inductive approach), and mapped deductively to the System-Theoretic Accident Model and Processes framework. Findings are presented as themes and a patient safety governance model. The study was approved by the University of South Australia Human Research Ethics Committee. Twenty-seven experts (59% female) participated. Most hailed from Africa (n = 6, 22%), Australasia, and the Middle East (n = 5, 19% each). The majority were employed in hospital settings (n = 23, 85%), and reported blended experience across healthcare improvement (89%), accreditation (76%), organizational operations (64%), and policy (60%). The number and range of patient safety issues within our sample varied widely with 14 topics being addressed. Thematically, 532 textual segments were grouped into 90 codes (n = 44 barriers, n = 46 facilitators) and used to identify and arrange key patient safety governance actors and factors as a 'system' within the System-Theoretic Accident Model and Processes framework. Four themes for improved patient safety governance were identified: (1) 'safety culture' in healthcare organizations, (2) 'policies and procedures' to investigate, implement, and demonstrate impact from patient safety initiatives, (3) 'supporting staff' to upskill and share learnings, and (4) 'patient engagement, experiences, and expectations'. For sustainable patient safety governance, experts highlighted the importance of safety culture in healthcare organizations, national patient safety policies and regulatory standards, continuing education for staff, and meaningful patient engagement approaches. Our proposed 'patient safety governance model' provides policymakers and researchers with a framework to develop data-driven patient safety policy.
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Affiliation(s)
- Peter D Hibbert
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, 75 Talavera Rd, Macquarie Park, NSW 2109, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, GPO Box 2471, Adelaide SA 5001, Australia
| | - Sasha Stewart
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, 75 Talavera Rd, Macquarie Park, NSW 2109, Australia
| | - Louise K Wiles
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, 75 Talavera Rd, Macquarie Park, NSW 2109, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, GPO Box 2471, Adelaide SA 5001, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, 75 Talavera Rd, Macquarie Park, NSW 2109, Australia
| | - William B Runciman
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, GPO Box 2471, Adelaide SA 5001, Australia
| | - Matthew J W Thomas
- Appleton Institute, School of Health, Medical and Applied Sciences, Central Queensland University, 114-190 Canning Street, Rockhampton, Queensland 4700, Australia
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Murray JS, Lee J, Larson S, Range A, Scott D, Clifford J. Requirements for implementing a 'just culture' within healthcare organisations: an integrative review. BMJ Open Qual 2023; 12:bmjoq-2022-002237. [PMID: 37173096 DOI: 10.1136/bmjoq-2022-002237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
PURPOSE To identify requirements for implementing a 'just culture' within healthcare organisations. METHODS Using Whittemore and Knafl's methodology for integrative reviews, we searched PubMed, PsychInfo, Cumulative Index of Nursing and Allied Health Literature, ScienceDirect, Cochrane Library and ProQuest Dissertations and Theses. Publications were considered eligible when reporting requirements for implementing a 'just culture' within healthcare organisations. RESULTS After screening for inclusion and exclusion criteria, 16 publications were included in the final review. Four main themes were identified: leadership commitment, education and training, accountability and open communication. CONCLUSION The themes identified in this integrative review provide some insight into the requirements for implementing a 'just culture' within healthcare organisations. To date, most of the published literature on 'just culture' is theoretical in nature. Additional efforts are needed to conduct research to explore further what requirements must be addressed in order to successfully implement a 'just culture' which is needed to promote and sustain a culture of safety.
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Affiliation(s)
- John S Murray
- HRO Support, Cognosante LLC, Falls Church, Virginia, USA
| | - Jonathan Lee
- Veterans Health Administration, Bedford, Massachusetts, USA
| | - Stacey Larson
- Veterans Health Administration, Bedford, Massachusetts, USA
| | - Amy Range
- Veterans Health Administration, Bedford, Massachusetts, USA
| | - Donald Scott
- Veterans Health Administration, Bedford, Massachusetts, USA
| | - Joan Clifford
- Veterans Health Administration, Bedford, Massachusetts, USA
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Schimmels J, Groh C, Neft M, Wocial L, Young C, Davidson JE. American Academy of Nursing Expert Panel Consensus Statement on leveraging equity in policy to improve recognition and treatment of mental health, substance use disorders, and nurse suicide. Nurs Outlook 2023; 71:101970. [PMID: 37104889 PMCID: PMC10129051 DOI: 10.1016/j.outlook.2023.101970] [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: 08/17/2022] [Revised: 03/02/2023] [Accepted: 03/09/2023] [Indexed: 04/29/2023]
Abstract
Rates of nurse mental health and substance use disorders are high. Heightened by the COVID-19 pandemic, nurses are challenged to care for patients in ways that often jeopardize their own health and increase risks for their families. These trends exacerbate the epidemic of suicide in nursing underscored by several professional organization clarion calls to nurses' risk. Principles of health equity and trauma-informed care dictate urgent action. The purpose of this paper is to establish consensus among clinical and policy leaders from Expert Panels of the American Academy of Nursing about actions to address risks to mental health and factors contributing to nurse suicide. Recommendations for mitigating barriers drew from the CDC's 2022 Suicide Prevention Resource for Action strategies to guide the nursing community to inform policy, education, research, and clinical practice with the goals of greater health promotion, risk reduction, and sustainment of nurses' health and well-being are provided.
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Affiliation(s)
- JoEllen Schimmels
- Psychiatric Mental Health and Substance Use Expert Panel, Detroit, MI; Military and Veterans Health Expert Panel.
| | - Carla Groh
- Psychiatric Mental Health and Substance Use Expert Panel, Detroit, MI
| | - Michael Neft
- Psychiatric Mental Health and Substance Use Expert Panel, Detroit, MI
| | | | - Cara Young
- Psychiatric Mental Health and Substance Use Expert Panel, Detroit, MI
| | - Judy E Davidson
- Psychiatric Mental Health and Substance Use Expert Panel, Detroit, MI
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Pavithra A, Mannion R, Sunderland N, Westbrook J. Speaking up as an extension of socio-cultural dynamics in hospital settings: a study of staff experiences of speaking up across seven hospitals. J Health Organ Manag 2022; ahead-of-print:245-271. [PMID: 36380424 PMCID: PMC10424643 DOI: 10.1108/jhom-04-2022-0129] [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: 04/29/2022] [Revised: 09/05/2022] [Accepted: 09/26/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE The study aimed to understand the significance of how employee personhood and the act of speaking up is shaped by factors such as employees' professional status, length of employment within their hospital sites, age, gender and their ongoing exposure to unprofessional behaviours. DESIGN/METHODOLOGY/APPROACH Responses to a survey by 4,851 staff across seven sites within a hospital network in Australia were analysed to interrogate whether speaking up by hospital employees is influenced by employees' symbolic capital and situated subjecthood (SS). The authors utilised a Bourdieusian lens to interrogate the relationship between the symbolic capital afforded to employees as a function of their professional, personal and psycho-social resources and their self-reported capacity to speak up. FINDINGS The findings indicate that employee speaking up behaviours appear to be influenced profoundly by whether they feel empowered or disempowered by ongoing and pre-existing personal and interpersonal factors such as their functional roles, work-based peer and supervisory support and ongoing exposure to discriminatory behaviours. ORIGINALITY/VALUE The findings from this interdisciplinary study provide empirical insights around why culture change interventions within healthcare organisations may be successful in certain contexts for certain staff groups and fail within others.
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Affiliation(s)
- Antoinette Pavithra
- Centre for Health Systems and Safety Research
,
Australian Institute of Health Innovation
, Sydney,
Australia
| | - Russell Mannion
- Australian Institute of Health Innovation
, Sydney,
Australia
- Health Services Management Centre
,
University of Birmingham
, Birmingham,
UK
| | - Neroli Sunderland
- Centre for Health Systems and Safety Research
,
Australian Institute of Health Innovation
, Sydney,
Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research
,
Australian Institute of Health Innovation
, Sydney,
Australia
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Schwappach D, Müller H, Müller BS. Public Expectations on Regulatory Requirements for Management of Hospital "Never Events" in Germany. Int J Qual Health Care 2022; 34:6650074. [PMID: 35880745 DOI: 10.1093/intqhc/mzac064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/24/2022] [Accepted: 07/25/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- David Schwappach
- Swiss Patient Safety Foundation, Asylstrasse 77, 8032 Zurich, Switzerland.,Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Hardy Müller
- Techniker Krankenkasse, Bramfelder Str. 140, 22305 Hamburg, Germany
| | - Beate S Müller
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
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