Human factors and safe patient care

Exploring the impact of compassion and leadership on patient safety and quality in healthcare systems: a narrative review

BACKGROUND

Patient safety and healthcare quality are considered integral parts of the healthcare system that are driven by a dynamic combination of human and non-human factors. This review article provides an insight into the two major human factors that impact patient safety and quality including compassion and leadership. It also discusses how compassion is different from empathy and explores the impact of both compassion and leadership on patient safety and healthcare quality. In addition, this review also provides strategies for the improvement of patient safety and healthcare quality through compassion and effective leadership.

METHODS

This narrative review explores the existing literature on compassion and leadership and their combined impact on patient safety and healthcare quality. The literature for this purpose was gathered from published research articles, reports, recommendations and guidelines.

RESULTS

The findings from the literature suggest that both compassion and transformational leadership can create a positive culture where healthcare professionals (HCPs) prioritise patient safety and quality. Leaders who exhibit compassion are more likely to inspire their teams to deliver patient-centred care and focus on error prevention.

CONCLUSION

Compassion can become an antidote for the burnout of HCPs. Compassion is a behaviour that is not only inherited but can also be learnt. Both compassionate care and transformational leadership improve organisational culture, patient experience, patient engagement, outcomes and overall healthcare excellence. We propose that transformational leadership that reinforces compassion remarkably improves patient safety, patient engagement and quality.

Checklists to reduce diagnostic error: a systematic review of the literature using a human factors framework

OBJECTIVES

To apply a human factors framework to understand whether checklists reduce clinical diagnostic error have (1) gaps in composition; and (2) components that may be more likely to reduce errors.

DESIGN

Systematic review.

DATA SOURCES

PubMed, EMBASE, Scopus and Web of Science were searched through 15 February 2022.

ELIGIBILITY CRITERIA

Any article that included a clinical checklist aimed at improving the diagnostic process. Checklists were defined as any structured guide intended to elicit additional thinking regarding diagnosis.

DATA EXTRACTION AND SYNTHESIS

Two authors independently reviewed and selected articles based on eligibility criteria. Each extracted unique checklist was independently characterised according to the well-established human factors framework: Systems Engineering Initiative for Patient Safety 2.0 (SEIPS 2.0). If reported, checklist efficacy in reducing diagnostic error (eg, diagnostic accuracy, number of errors or any patient-related outcomes) was outlined. Risk of study bias was independently evaluated using standardised quality assessment tools in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

A total of 30 articles containing 25 unique checklists were included. Checklists were characterised within the SEIPS 2.0 framework as follows: Work Systems subcomponents of Tasks (n=13), Persons (n=2) and Internal Environment (n=3); Processes subcomponents of Cognitive (n=20) and Social and Behavioural (n=2); and Outcomes subcomponents of Professional (n=2). Other subcomponents, such as External Environment or Patient outcomes, were not addressed. Fourteen checklists examined effect on diagnostic outcomes: seven demonstrated improvement, six were without improvement and one demonstrated mixed results. Importantly, Tasks-oriented studies more often demonstrated error reduction (n=5/7) than those addressing the Cognitive process (n=4/10).

CONCLUSIONS

Most diagnostic checklists incorporated few human factors components. Checklists addressing the SEIPS 2.0 Tasks subcomponent were more often associated with a reduction in diagnostic errors. Studies examining less explored subcomponents and emphasis on Tasks, rather than the Cognitive subcomponents, may be warranted to prevent diagnostic errors.

Exploring the use of high-fidelity simulation training to enhance clinical skills

The use of interprofessional simulation training to enhance nursing students' performance of technical and non-technical clinical skills is becoming increasingly common. Simulation training can involve the use of role play, virtual reality or patient simulator manikins to replicate clinical scenarios and assess the nursing student's ability to, for example, undertake clinical observations or work as part of a team. Simulation training enables nursing students to practise clinical skills in a safe environment. Effective simulation training requires extensive preparation, and debriefing is necessary following a simulated training session to review any positive or negative aspects of the learning experience. This article discusses a high-fidelity simulated training session that was used to assess a group of third-year nursing students and foundation level 1 medical students. This involved the use of a patient simulator manikin in a scenario that required the collaborative management of a deteriorating patient.

Perspectives of Oncology Unit Nurse Managers on Missed Nursing Care: A Qualitative Study

Objective:

The main objective of this study was to explore factors affecting missed nursing care in oncology units from the perspective of nurse managers.

Methods:

Twenty nurse managers working at oncology units of referral teaching hospitals in Iran participated in this study. Data were collected through individual face-to-face and telephonic interviews using an interview guide. Focus groups were also conducted. Data were analyzed using conventional content analysis.

Results:

System structure, underlying factors, and barriers to missed-care reports were identified as factors that affect missed nursing care.

Conclusions:

Nurse managers should reduce the effects of nursing staff shortages and increased workloads in addition to providing materials and equipment. They need to distribute experienced staff according to the type of ward or patients' needs. Nurse managers should create a favorable environment for reporting missed nursing care by having an open relationship with nurses by teaching and emphasizing nursing practice. Moreover, using a nonpunitive managerial approach and minimizing the use of an apathetic management style can be helpful.

Collaborating with nurse leaders to develop patient safety practices

Purpose

The organisational level and leadership development are crucial elements in advancing patient safety, because patient safety weaknesses are often caused by system failures. However, little is known about how frontline leader and director teams can be supported to develop patient safety practices. The purpose of this study is to describe the patient safety development process carried out by nursing leaders and directors. The research questions were: how the chosen development areas progressed in six months’ time and how nursing leaders view the participatory development process.

Design/methodology/approach

Participatory action research was used to engage frontline nursing leaders and directors into developing patient safety practices. Semi-structured group interviews (N = 10) were used in data collection at the end of a six-month action cycle, and data were analysed using content analysis.

Findings

The participatory development process enhanced collaboration and gave leaders insights into patient safety as a part of the hospital system and their role in advancing it. The chosen development areas advanced to different extents, with the greatest improvements in those areas with simple guidelines to follow and in which the leaders were most participative. The features of high-reliability organisation were moderately identified in the nursing leaders’ actions and views. For example, acting as a change agent to implement patient safety practices was challenging. Participatory methods can be used to support leaders into advancing patient safety. However, it is important that the participants are familiar with the method, and there are enough facilitators to steer development processes.

Originality/value

Research brings more knowledge of how leaders can increase their effectiveness in advancing patient safety and promoting high-reliability organisation features in the healthcare organisation.

Patient safety attitudes of pharmacy students in an Ethiopian university: a cross-sectional study

INTRODUCTION

Patient safety is a major health care concern and is being included in an undergraduate curriculum as it plays a major role in lessening harm. Therefore, we aim to assess the attitude of pharmacy students toward patient safety.

METHODS

A cross-sectional study using a self-administered questionnaire containing 21 items was conducted at the University of Gondar among fourth and fifth year students. Data analysis was performed to calculate mean, standard deviation, percentages, and logistic regressions using SPSS software version 22 (IBM Corporation, Armonk, NY, USA). Statistical significance was set at P<0.05.

RESULTS

A total of 83 pharmacy students (fourth year groups=50, fifth year groups=33) participated in the study with response rate of 92%. Majority of the students 70/83 (84.33%) had the overall positive attitude of patient safety. Most of the respondents (80.7%) agree or strongly agree that after an error occurs, an effective strategy is to work hard to be more careful. Most of them (79.6%) believe that pharmacists should routinely spend part of their professional time working to improve patient care. About half (48.2%) of pharmacy students disagree or strongly disagree that pharmacists should discuss and report errors to an affected patient and their family even if the patient is not harmed. No significant association between the attitude of pharmacy students toward patient safety and their age, sex and year of study was found.

CONCLUSION

Pharmacy students have the overall good attitude to patient safety. However, they claimed the culture and attitude within the pharmacy workplace lacked for patient safety. Moreover, standardized patient safety course should be considered in the curriculum for junior pharmacy students to improve their attitude toward patient safety.

Medication errors in chemotherapy preparation and administration: a survey conducted among oncology nurses in Turkey

BACKGROUND

Medication errors in oncology may cause severe clinical problems due to low therapeutic indices and high toxicity of chemotherapeutic agents. We aimed to investigate unintentional medication errors and underlying factors during chemotherapy preparation and administration based on a systematic survey conducted to reflect oncology nurses experience.

MATERIALS AND METHODS

This study was conducted in 18 adult chemotherapy units with volunteer participation of 206 nurses. A survey developed by primary investigators and medication errors (MAEs) defined preventable errors during prescription of medication, ordering, preparation or administration. The survey consisted of 4 parts: demographic features of nurses; workload of chemotherapy units; errors and their estimated monthly number during chemotherapy preparation and administration; and evaluation of the possible factors responsible from ME. The survey was conducted by face to face interview and data analyses were performed with descriptive statistics. Chi-square or Fisher exact tests were used for a comparative analysis of categorical data.

RESULTS

Some 83.4% of the 210 nurses reported one or more than one error during chemotherapy preparation and administration. Prescribing or ordering wrong doses by physicians (65.7%) and noncompliance with administration sequences during chemotherapy administration (50.5%) were the most common errors. The most common estimated average monthly error was not following the administration sequence of the chemotherapeutic agents (4.1 times/month, range 1-20). The most important underlying reasons for medication errors were heavy workload (49.7%) and insufficient number of staff (36.5%).

CONCLUSIONS

Our findings suggest that the probability of medication error is very high during chemotherapy preparation and administration, the most common involving prescribing and ordering errors. Further studies must address the strategies to minimize medication error in chemotherapy receiving patients, determine sufficient protective measures and establishing multistep control mechanisms.

Re-finding the 'human side' of human factors in nursing: helping student nurses to combine person-centred care with the rigours of patient safety

In this paper the authors explore the centrality of both patient safety and person-centred care when preparing student nurses for their role. By examining these two goals against the understanding of human factors, the concept of risk and the interpersonal elements of patient centred, compassionate care, the authors identify the challenges that nurse educators must recognise in preparing the nurses of the future who must achieve both. The authors introduce the notion of human factors and their role in promoting safe environments. Thereafter the authors explore the development of the student nurse in coming to understand that optimal patient care must primarily be safe but must also have the wishes of individual patients at its core. Finally the authors raise the challenge for nurse educators of supporting students' growing understanding of safety, risk and how these must be balanced with individual needs and wishes.

Human factors and health information technology: current challenges and future directions

OBJECTIVES

Recent federal mandates and incentives have spurred the rapid growth, development and adoption of health information technology (HIT). While providing significant benefits for better data integration, organization, and availability, recent reports have raised questions regarding their potential to cause medication errors, decreased clinician performance, and lowered efficiency. The goal of this survey article is to (a) examine the theoretical and foundational models of human factors and ergonomics (HFE) that are being advocated for achieving patient safety and quality, and their use in the evaluation of healthcare systems; (b) and the potential for macroergonomic HFE approaches within the context of current research in biomedical informatics.

METHODS

We reviewed literature (2007-2013) on the use of HFE approaches in healthcare settings, from databases such as Pubmed, CINAHL, and Cochran.

RESULTS

Based on the review, we discuss the systems-oriented models, their use in the evaluation of HIT, and examples of their use in the evaluation of EHR systems, clinical workflow processes, and medication errors. We also discuss the opportunities for better integrating HFE methods within biomedical informatics research and its potential advantages.

CONCLUSIONS

The use of HFE methods is still in its infancy - better integration of HFE within the design lifecycle, and quality improvement efforts can further the ability of informatics researchers to address the key concerns regarding the complexity in clinical settings and develop HIT solutions that are designed within the social fabric of the considered setting.

The Impact of Market Orientation on Patient Safety Climate Among Hospital Nurses

Improving market orientation and patient safety have become the key concerns of nursing management. For nurses, establishing a patient safety climate is the key to enhancing nursing quality. This study explores how market orientation affects the climate of patient safety among hospital nurses. We proposed adopting a cross-sectional research design and using questionnaires to collect responses from nurses working in two Taiwanese hospitals. Three-hundred and forty-three valid samples were obtained. Multiple regression and path analyses were conducted to test the study. Market orientation was defined as the combination of customer orientation, competitor orientation, and interfunctional coordination. Customer orientation directly affects the climate of patient safety. Although the findings only supported Hypothesis 1, competitor orientation and interfunctional coordination positively affected the patient safety climate through the mediating effects of hospital support for staff. Health care managers could encourage nurses to adopt customer-oriented perspectives to enhance their nursing care. In addition, to enhance competitor orientation, interfunctional coordination, and the patient safety climate, hospital managers could strengthen their support for staff members.

Human factors in critical care: towards standardized integrated human-centred systems of work

PURPOSE OF REVIEW

Improvements in safety and quality benefit from a systems approach. Human factors is the study and practice of the relationship between humans and systems. This review examines recent advances in human factors in healthcare.

RECENT FINDINGS

Early studies focused on understanding incidents, and on the translation of principles from aviation to healthcare, which demonstrated a useful but limited application of the human factors approach. More recent studies have begun to address the complexity of the relationship between human behaviour and technology, tasks, environment and organization. Human factors frameworks have been usefully applied that aid in these complex considerations, providing a better understanding of the healthcare system, and a much broader range of solutions to problems than checklists, protocols or training. In particular, in improving equipment design and procurement; improving job design by understanding the demands and tasks of individual healthcare practitioners; in improving what and when training is delivered; and the integration of these complex system components into a coherent whole.

SUMMARY

The human factors approach is not yet mature in healthcare, but the importance is being increasingly recognized, and the breadth of application continually expanded.

Quality improvement initiative to reduce serious safety events and improve patient safety culture

BACKGROUND AND OBJECTIVE

Many thousands of patients die every year in the United States as a result of serious and largely preventable safety events or medical errors. Safety events are common in hospitalized children. We conducted a quality improvement initiative to implement cultural and system changes with the goal of reducing serious safety events (SSEs) by 80% within 4 years at our large, urban pediatric hospital.

METHODS

A multidisciplinary SSE reduction team reviewed the safety literature, examined recent SSEs, interviewed internal leaders, and visited other leading organizations. Senior hospital leaders provided oversight, monitored progress, and helped to overcome barriers. Interventions focused on: (1) error prevention; (2) restructuring patient safety governance; (3) a new root cause analysis process and a common cause database; (4) a highly visible lessons learned program; and (5) specific tactical interventions for high-risk areas. Our outcome measures were the rate of SSEs and the change in patient safety culture.

RESULTS

SSEs per 10000 adjusted patient-days decreased from a mean of 0.9 at baseline to 0.3 (P < .0001). The days between SSEs increased from a mean of 19.4 at baseline to 55.2 (P < .0001). After a worsening of patient safety culture outcomes in the first year of intervention, significant improvements were observed between 2007 and 2009.

CONCLUSIONS

Our multifaceted approach was associated with a significant and sustained reduction of SSEs and improvements in patient safety culture. Multisite studies are needed to better understand contextual factors and the significance of specific interventions.

Facilitating safe care: a qualitative study of Iranian nurse leaders

Aim  The purpose of this study was to explore and describe how nurse leaders facilitate safe care from the perspectives of both nurses and nurse leaders. Background  The health-care system's success in improving patient safety pivots on nursing leadership. However, there is a lack of knowledge in the international literature about how nurse leaders facilitate provision of safe care and reaching the goal of a safe health-care system. Method  A qualitative design using a content analysis approach was applied for data gathering and analysis. In this study, 20 nurses (16 nurses and four head nurses) working in a referral teaching hospital in Tehran, Iran, were recruited through purposive sampling. Semi-structured interviews and 10 hours of structured observations were conducted to collect data. Results  The data analysis resulted in three main themes: 'providing environmental prerequisites for safe nursing practice', 'uniting and integrating health-care providers', and 'creating an atmosphere of safe care'. Conclusion  The results indicate that to facilitate providing safe care, nurse leaders should improve nurses' working conditions, develop the nurses' practical competencies, assign duties to nurses according to their skills and capabilities, administer appropriate supervision, improve health-care providers' professional relationships and encourage their collaboration, empower nurses and reward their safe practice. Implications for nursing management  Approaching the challenge of patient safety requires the health-care system to combine its efforts and strategies with nursing leadership in its vital role of facilitating safe care and improving patient safety.

Influence of organizational culture on quality healthcare delivery

PURPOSE

The purpose of this paper is to identify if aspects of organizational culture may indicate a new terrain in the cultural influences-quality healthcare relationship. This research stems from the author's belief that viewing the role of head of department or directorate as pivotal to health care management is critical to health care planning and quality healthcare delivery.

DESIGN/METHODOLOGY/APPROACH

Interviews were undertaken among 50 professional clinician and non-clinician managers working in the role of head of department, in acute care hospitals in Ireland. The sample was drawn from the total population of 850 managers, utilized in a previous survey study.

FINDINGS

Organizational culture is more complex than was previously thought. Several cultural influences such as excellence in care delivery, ethical values, involvement, professionalism, value-for-money, cost of care, commitment to quality and strategic thinking were found to be key cultural determinants in quality care delivery.

RESEARCH LIMITATIONS/IMPLICATIONS

Health care managers perceive that in order to deliver quality focused care they need to act in a professional, committed manner and to place excellence at the forefront of care delivery, whilst at the same time being capable of managing the tensions that exist between cost effectiveness and quality of care. These tensions require further research in order to determine if quality of care is affected in a negative manner by those tensions.

ORIGINALITY/VALUE

Originality relates to the new cultural terrain presented in this paper that recognizes the potential of health service managers to influence the organizations' culture and through this influence to take a greater part in ensuring that quality health care is delivered to their patients. It also seems to be important that value-for-money is viewed as an ethical means of delivering healthcare, and not as a conflict between quality and cost.

The nature and causes of unintended events reported at ten emergency departments

Background

Several studies on patient safety have shown that a substantial number of patients suffer from unintended harm caused by healthcare management in hospitals. Emergency departments (EDs) are challenging hospital settings with regard to patient safety. There is an increased sense of urgency to take effective countermeasures in order to improve patient safety. This can only be achieved if interventions tackle the dominant underlying causes. The objectives of our study are to examine the nature and causes of unintended events in EDs and the relationship between type of event and causal factor structure.

Methods

Study at EDs of 10 hospitals in the Netherlands. The study period per ED was 8 to 14 weeks, in which staff were asked to report unintended events. Unintended events were broadly defined as all events, no matter how seemingly trivial or commonplace, that were unintended and could have harmed or did harm a patient. Reports were analysed with a Root Cause Analysis tool (PRISMA) by an experienced researcher.

Results

522 unintended events were reported. Of the events 25% was related to cooperation with other departments and 20% to problems with materials/equipment. More than half of the events had consequences for the patient, most often resulting in inconvenience or suboptimal care. Most root causes were human (60%), followed by organisational (25%) and technical causes (11%). Nearly half of the root causes was external, i.e. attributable to other departments in or outside the hospital.

Conclusion

Event reporting gives insight into diverse unintended events. The information on unintended events may help target research and interventions to increase patient safety. It seems worthwhile to direct interventions on the collaboration between the ED and other hospital departments.