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Jacobsen HK, Ballangrud R, Birkeli GH. Learning from patient safety incidents: The Green Cross method. Nurs Crit Care 2024. [PMID: 38923706 DOI: 10.1111/nicc.13114] [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: 02/08/2023] [Revised: 05/31/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Hospitals can improve how they learn from patient safety incidents. The Green Cross method, a proactive reporting and learning method, is one strategy to meet this challenge. In it, nurses play a key role. However, describing its impact on learning from the users' perspective is important. AIM This study aimed to describe nurses' experiences of learning from patient safety incidents before and 3 months after implementing the Green Cross method in a postanaesthesia care unit. STUDY DESIGN A qualitative study with an inductive descriptive design with focus group interviews was conducted before and 3 months after implementing the Green Cross method to assess its impact. The data were analysed using qualitative content analysis. The study was conducted in a postanaesthesia care unit in a Norwegian hospital trust. RESULTS Before implementing the Green Cross method, participants indicated limited openness and learning, including the subcategories 'Lack of openness hampers learning', 'Adverse events were taken seriously' and 'Insufficient visible improvements'. After implementing the Green Cross method, participants indicated the emergence of a learning environment, including the subcategories 'Transparency increases learning', 'Increased patient safety awareness' and 'Committed to quality improvements'. CONCLUSIONS Implementing the Green Cross method in a postanaesthesia care unit positively impacted openness and nurses' patient safety awareness, which is crucial for learning and improving quality. RELEVANCE TO CLINICAL PRACTICE The Green Cross method could be useful for organizational learning and facilitating learning from patient safety incidents through transparency, discussion and involvement of nursing staff.
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Affiliation(s)
| | - Randi Ballangrud
- Department of Health Science Gjøvik, Norwegian University of Science and Technology, Gjøvik, Norway
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Birkeli GH, Ballangrud R, Jacobsen HK, Tveter Deilkas EC, Lindahl AK. Green Cross method in a postanaesthesia care unit: a qualitative study of the healthcare professionals' experiences after 3 years, including the COVID-19 pandemic period. BMJ Open Qual 2023; 12:bmjoq-2022-002247. [PMID: 37225257 DOI: 10.1136/bmjoq-2022-002247] [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: 12/30/2022] [Accepted: 05/08/2023] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVES Unsafe medical care causes morbidity and mortality among the hospital patients. In a postanaesthesia care unit (PACU), increasing patient safety is a joint effort between different professions. The Green Cross (GC) method is a user-friendly incident reporting method that incorporates daily safety briefings to support healthcare professionals in their daily patient safety work. Thus, this study aimed to describe healthcare professionals' experiences with the GC method in a PACU setting 3 years after its implementation, including the period of the coronavirus disease 2019 pandemic's three waves. DESIGN An inductive, descriptive qualitative study was conducted. The data were analysed using qualitative content analysis. SETTING The study was conducted at a PACU of a university hospital in South-Eastern Norway. PARTICIPANTS Five semistructured focus group interviews were conducted in March and April 2022. The informants (n=23) were PACU nurses (n=18) and collaborative healthcare professionals (n=5) including physicians, nurses and a pharmacist. RESULTS The theme 'still active, but in need of revitalisation' was created, describing the healthcare professionals' experiences with the GC method, 3 years post implementation. The following five categories were found: 'continuing to facilitate open communication', 'expressing a desire for more interprofessional collaboration regarding improvements', 'increasing reluctance to report', 'downscaling due to the pandemic' and 'expressing a desire to share more of what went well'. CONCLUSIONS This study offers information regarding the healthcare professionals' experiences with the GC method in a PACU setting; further, it deepens the understanding of the daily patient safety work using this incident reporting method.
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Affiliation(s)
- Gørill Helen Birkeli
- Institute of Health and Society, Department of Health Management and Health Economics, Faculty of Medicine, University of Oslo, Oslo, Norway
- Division of Surgery, Akershus University Hospital, Lorenskog, Norway
| | - Randi Ballangrud
- Department of Health Sciences, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Gjøvik, Norway
| | - Hilde Kristin Jacobsen
- Institute of Basic Medical Sciences, Department of Behavioural Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ellen Catharina Tveter Deilkas
- Health Services Research Unit, Akershus University Hospital, Lorenskog, Norway
- Department of Quality Improvement and Patient Safety, Norwegian Directorate of Health, Oslo, Norway
| | - Anne Karin Lindahl
- Institute of Health and Society, Department of Health Management and Health Economics, Faculty of Medicine, University of Oslo, Oslo, Norway
- Division of Surgery, Akershus University Hospital, Lorenskog, Norway
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Andersson J, Imberg S, Rosengren K. Documentation of pressure ulcers in medical records at an internal medicine ward in university hospital in western Sweden. Nurs Open 2022; 10:1794-1802. [PMID: 36303218 PMCID: PMC9912387 DOI: 10.1002/nop2.1439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 02/10/2022] [Accepted: 10/09/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Pressure ulcers cause suffering, prolong care periods, and increase mortality. The aim was to describe and analyze the documentation of pressure ulcers and focused on the medical records from an internal medicine ward in a university hospital in western Sweden. METHODS A quantitative, retrospective review of medical records was conducted for all care events (n = 1,458) with descriptive statistics. RESULTS Documentation of the pressure ulcers in care plans was 2.1% (n = 31) compared to 6.7 % (n = 46) within final notes written by registered nurses (RN), a lower result compared to PPM (n = 3/14, 21.4%). Risk assessments were carried out in 68 (4.7%) care events, and 31 care plans included pressure ulcers. Moreover, 198 cases of tissue damage were documented, 43 (21.7%) defined as pressure ulcers, the other 147 (74.2%) lacked definition. CONCLUSIONS Differences (2.1%-21.4%) highlight improvements; knowledge and communication of pressure ulcers ensure reliable documentation in medical records.
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Affiliation(s)
- Julia Andersson
- Institute of Health and Care Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Sara Imberg
- Institute of Health and Care Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Kristina Rosengren
- Institute of Health and Care Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden,Centre for Person‐centred Care (GPCC), Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden,Department of Internal MedicineSahlgrenska University HospitalMölndalSweden
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van Marum S, Verhoeven D, de Rooy D. The Barriers and Enhancers to Trust in a Just Culture in Hospital Settings: A Systematic Review. J Patient Saf 2022; 18:e1067-e1075. [PMID: 35588066 DOI: 10.1097/pts.0000000000001012] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Healthcare workers wanting to report errors often encounter a culture of fear or blame. A just culture can improve patient safety by promoting safe and open communication, trust is hereby essential. We defined trust in a just culture when healthcare professionals believe that error communication is honest, safe, and reliable. In this study, we investigated barriers and enhancers to trust in error reporting in a just culture. METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PubMed, Embase, Emcare, and Web of Science database were searched on June 21, 2021. RESULTS Several factors were found to influence trust in error reporting in a just culture, namely, organizational factors, team factors, and experience. Trust depends on the management style, open information about error handling, a focus on patient safety instead of blaming an individual, a well-executed walk-round, a code of professionalism, and a departmental incident reporting system (organizational factors). A close relationship between employee and primary supervisor, with discussion of the nature of an error and ascribing clear roles to physicians in care teams, can be enhancers of trust in error reporting. Moreover, creating a mutual understanding of the challenges faced by professionals can enhance trust (team factors). Trust in error reporting is also influenced by a health professional's experience and training in patient safety. Factors such as a lack of confidence in clinical skills, more fear of shame/blame by less experienced workers, and knowledge of the existing error reporting system will influence a person's trust in error reporting (experience). CONCLUSIONS This systematic review identified barriers and enhancers to trust in error reporting in a just culture. The barriers and enhancers can be divided into 3 main themes: organizational factors, team factors, and experience. Findings show that trust can be learned and created based on practical principles.
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Affiliation(s)
- Sjoerd van Marum
- From the Transparant Center for Mental Healthcare, Leiden, The Netherlands
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Wahl K, Stenmarker M, Ros A. Experience of learning from everyday work in daily safety huddles-a multi-method study. BMC Health Serv Res 2022; 22:1101. [PMID: 36042516 PMCID: PMC9424837 DOI: 10.1186/s12913-022-08462-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To reduce patient harm, healthcare has focused on improvement based on learning from errors and adverse events (Safety-I). Daily huddles with staff are used to support incident reporting and learning in healthcare. It is proposed that learning for improvement should also be based on situations where work goes well (Safety-II); daily safety huddles should also reflect this approach. A Safety-II-inspired model for safety huddles was developed and implemented at the Neonatal Care Unit at a regional hospital in Sweden. This study followed the implementation with the research questions: Do patient safety huddles with a focus on Safety-II affect the results of measurements of the patient safety culture? What are the experiences of these huddles amongst staff? What experiences of everyday work arise in the patient safety huddles? METHODS A multi-method approach was used. The quantitative part consisted of a questionnaire (151 items), submitted on four different occasions, and analysed using Mann Whitney U-test and Kruskal Wallis ANOVA-test. The qualitative data were analysed using thematic content analyses of interviews with staff (n = 14), as well as answers to open questions in the questionnaires. RESULTS There were 151 individual responses to the questionnaires. The response rates were 44% to 59%. For most comparisons, there were no differences. There were minor changes in patient safety culture measurements. A lower rating was found in December 2020, compared to October 2019 (p < 0.05), regarding whether the employees pointed out when something was about to go wrong. The interviews revealed that, even though most respondents were generally positive towards the huddles (supporting factors), there were problems (hindering factors) in introducing Safety-II concepts in daily safety huddles. There was a challenge to understanding and describing things that go well. CONCLUSIONS For patient safety huddles aimed at exploring everyday work to be experienced as a base for learning, including both negative and positive events (Safety-II); there is a need for an open and permissive climate, that all professions participate and stable conditions in management. Support from managers and knowledge of the underpinning Safety-II theories of those who lead the huddles, may also be of importance.
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Affiliation(s)
- Karina Wahl
- Department of Paediatrics, Region Jönköping County, 55185, Jönköping, SE, Sweden. .,Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
| | - Margaretha Stenmarker
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Futurum/Department of Paediatrics, Region Jönköping County, Jönköping, Sweden.,Department of Paediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Axel Ros
- Jönköping Academy for Improvement of Health and Welfare, Jönköping University and Futurum, Jönköping Region Jönköping County, Jönköping, Sweden
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Isaksson S, Schwarz A, Rusner M, Nordström S, Källman U. Monitoring Preventable Adverse Events and Near Misses: Number and Type Identified Differ Depending on Method Used. J Patient Saf 2022; 18:325-330. [PMID: 35617591 PMCID: PMC9162067 DOI: 10.1097/pts.0000000000000921] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study aimed to investigate how many preventable adverse events (PAEs) and near misses are identified through the methods structured record review, Web-based incident reporting (IR), and daily safety briefings, and to distinguish the type of events identified by each method. METHODS One year of retrospective data from 2017 were collected from one patient cohort in a 422-bed acute care hospital. Preventable adverse events and near misses were collected from the hospital's existing resources and presented descriptively as number per 1000 patient-days. RESULTS The structured record review identified 19.9 PAEs; the IR system, 3.4 PAEs; and daily safety briefings, 5.4 PAEs per 1000 patient-days. The most common PAEs identified by the record review method were drug-related PAEs, pressure ulcers, and hospital-acquired infections. The most common PAEs identified by the IR system and daily safety briefings were fall injury and pressure ulcers, followed by skin/superficial vessel injuries for the IR system and hospital-acquired infections for the daily safety briefings. Incident reporting and daily safety briefings identified 7.8 and 31.9 near misses per 1000 patient-days, respectively. The most common near misses were related to how care is organized. CONCLUSIONS The different methods identified different amounts and types of PAEs and near misses. The study supports that health care organizations should adopt multiple methods to get a comprehensive review of the number and type of events occurring in their setting. Daily safety briefings seem to be a particularly suitable method for assessing an organization's inherent security and may foster a nonpunitive culture.
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Affiliation(s)
- Stina Isaksson
- From the Department of Research, Education and Innovation, South Älvsborg Hospital, Region Västra Götaland, Borås
| | - Anneli Schwarz
- From the Department of Research, Education and Innovation, South Älvsborg Hospital, Region Västra Götaland, Borås
| | - Marie Rusner
- From the Department of Research, Education and Innovation, South Älvsborg Hospital, Region Västra Götaland, Borås
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg
| | - Sophia Nordström
- Department of Medicine, South Älvsborg Hospital, Region Västra Götaland, Borås, Sweden
| | - Ulrika Källman
- From the Department of Research, Education and Innovation, South Älvsborg Hospital, Region Västra Götaland, Borås
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg
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Birkeli GH, Jacobsen HK, Ballangrud R. Nurses' experience of the incident reporting culture before and after implementing the Green Cross method: A quality improvement project. Intensive Crit Care Nurs 2021; 69:103166. [PMID: 34895974 DOI: 10.1016/j.iccn.2021.103166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 10/04/2021] [Accepted: 10/16/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Adverse events are a leading cause of death worldwide, although many are considered preventable. Incident reporting is a prerequisite for preventing adverse events; however, underreporting is common. The Green Cross method is an alternative incident reporting process that includes a daily team meeting to discuss incidents and work on improvements. OBJECTIVES The aim of this quality improvement project was to improve the culture of incident reporting by implementing the Green Cross method and to evaluate the improvement by describing nurses' experience with the culture of incident reporting. METHODS The project included a three-month implementation of the method in a postanesthesia care unit, which was evaluated by focus group interviews (n = 22 nurses) and analysed by qualitative content analysis. FINDINGS Four focus group interviews were conducted before implementation (n = 19 nurses) and four after implementation (n = 16 nurses). Before implementation, Theme 1, "Incident reporting with potential for improvement", was constructed, describing a culture wherein nurses expressed motivation to report incidents but barriers, such as finding the system complicated and experiencing emotional obstacles towards reporting, prevented them. After implementation, Theme 2, "Increased focus on transparency", was constructed, describing a culture wherein nurses perceived an increased rate of incident reporting but still encountered barriers, such as finding reporting uncomfortable and demanding, experiencing a threatened working environment, and still wanting visible improvement. CONCLUSION The nurses in the postanesthesia care unit experienced the Green Cross method as a useful patient safety initiative for improving the rate of incident reporting, but barriers to reporting still existed.
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Affiliation(s)
- Gørill Helen Birkeli
- Akershus University Hospital, Postanesthesia Care Unit, Sykehusveien 25, 1478 Nordbyhagen, Norway.
| | - Hilde Kristin Jacobsen
- Akershus University Hospital, Neonatal Intensive Care Unit, Sykehusveien 25, 1478 Nordbyhagen, Norway.
| | - Randi Ballangrud
- Department of Health Science Gjøvik, Faculty of Medicine and Health Sciences, Norwegian University of Sciences and Technology, Teknologivn. 22, 2815 Gjøvik, Norway.
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