Toward the modelling of safety violations in healthcare systems

Preventing healthcare-associated infections by decontaminating the clinical environment

Healthcare-associated infections (HAIs) continue to cause patient harm and at increasing rates. Factors contributing to this increase include suboptimal hand hygiene, antimicrobial resistance, and inadequate decontamination of the patient environment and shared patient equipment. To reduce the risk of HAIs and enhance patient safety, it is important that nurses and other healthcare professionals adhere to infection prevention and control guidance, including decontamination procedures. It is also important to identify and address the barriers that can affect adherence to this guidance. This article discusses effective decontamination of the patient environment and non-critical shared patient equipment, the barriers to adhering to guidance and strategies for improving decontamination procedures.

Mind the gap: Examining work-as-imagined and work-as-done when dispensing medication in the community pharmacy setting

Reducing errors within a healthcare setting remains high on the patient safety research agenda. More consistent performance has been sought by increased development of standardised operating procedures, but they are not always adhered to in practice. Previous studies have identified that a difference exists between the way a task is imagined to be completed, based on standardised protocols and procedures, and how the task is actually completed in reality. This study explores one area of healthcare, community pharmacy, and more specifically the task of dispensing medicines from prescriptions, to identify the gap between how dispensing is imagined to be completed through standardised operating procedures, and how it is actually completed in practice, by using Hierarchical Task Analysis as a framework. Document analysis of standardised operating procedures in 3 community pharmacies was used to produce 3 task analyses, which were compared with 3 task analyses produced from data collected through non-participant observations of the same 3 community pharmacies. Deviations between the two forms of task analyses were presented to community pharmacists in focus group discussions and it was found staff may deviate from standardised protocols because of various reasons, including: efficiency; availability of resources; thoroughness; and delegating safeguards. Potential implications for the work system include the benefit of greater collaboration between procedure writers and frontline workers, and the introduction of more flexible procedures, that allow the risks of any adaptions to be clearly realised. Further work must establish whether pharmacists recognise the safety implications of these gaps between work as imagined, and work as done, and initiatives should be established to ensure patient safety is not compromised due to these differences.

Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread of COVID-19 in nursing facilities for the elderly

Background

To analyse a medical accident, much time and experience are needed. However, people without experience in analysis have difficulty understanding its conditions and methods, and as a result it takes longer to establish countermeasures. It must be noted that understanding conditions by simply aligning occurrences in the accident in a chronological order is difficult.

Purpose

A workflow chart that considers time was proposed so that individuals without adequate experience in analysis could easily carry out root cause analysis.

Methods

In the ‘workflow chart (WFC)’, the time sequence was described horizontally. On the vertical axis, the business manual, the occurrence of the accident, and the time of the occurrence are displayed. In the bottom column of patient event, information regarding damage to patients was written in accordance with time axis. Regarding the degree of damage, the time of error until the accident was identified was connected using a straight line (when the patient was not affected, a dotted line was used) in order to show the overall picture of the accident.

Results

According to the time flow chart, hints to identify potential risks were proposed. Focus was placed not only on the error event, but also on keywords such as manual inadequacy, time gap, degree of error and so on to easily lead to the question ‘why?’ To visualise this, I proposed an operation flow chart. By using time-WFC, even beginners can easily develop accident countermeasure strategies.

Conclusion

Using a WFC that considers time, time of error and the occurrence of accident could be visualised. As a result, even individuals without experience in analysis could easily perform an analysis.

Speaking up about hand hygiene failures: A vignette survey study among healthcare professionals

BACKGROUND

Speaking up by healthcare professionals (HCPs) is an important resource to reduce risks to patient safety. Due to complex tradeoffs, HCPs are often reluctant to voice their concerns. A survey investigated HCPs' likelihood to speak up.

METHODS

A cross-sectional survey study among HCPs in 5 Swiss hospitals addressed speaking-up behaviors, safety climate, and likelihood to speak up about poor hand hygiene practice described in a vignette. Likelihood to speak up was analyzed using a multilevel regression model.

RESULTS

Of surveyed HCPs (n = 1217), 56% reported that they would speak up to a colleague with poor hand hygiene practice. Nurses as compared to doctors rated the situation as more realistic (5.25 vs 4.32, P < .001), felt more discomfort with speaking up (4.00 vs 3.34, P < .001), and reported a slightly lower likelihood of speaking up (4.41 vs 4.77, P < .001). Clinical function (hierarchy) was strongly associated with speaking-up behavior (P < .001). Higher risk of harm to the patient (P < .001) and higher frequencies of past speaking-up behaviors (P = .006) were positively associated with the likelihood to speak up. Higher frequencies of past withholding voice (P = .013) and higher levels of resignation (P = .008) were both associated with a lower likelihood to speak up.

CONCLUSIONS

Infection control interventions should empower HCPs to speak up about non-adherence with prevention practices by addressing authority gradients and risk perceptions and by focusing on resignation.

Understanding the human and system factors involved in medication errors

Medication errors involving patients are a serious concern in healthcare practice. Nurses, more than any other healthcare professional group, are principally involved in medicines administration. This article recognises the complexity of why medication errors occur and considers the many factors involved, including those from an individual and organisational system perspective. It adopts a solution-focused approach, based on the evidence underpinning the knowledge of medication errors.

Hand hygiene as a caring practice: a reflection on professional responsibility

Hand hygiene represents a fundamental nursing care practice and is traditionally considered the most important and effective measure in the prevention and control of healthcare-related infections. However, studies indicate that adherence to the procedure is unsatisfactory throughout the world, and show low adherence rates. In a context in which patient safety stands out as a priority, this text submits refl ections about professional responsibility when not adhering to hand hygiene practices, and ethical aspects related to this conduct.

Silence that can be dangerous: a vignette study to assess healthcare professionals' likelihood of speaking up about safety concerns

Purpose

To investigate the likelihood of speaking up about patient safety in oncology and to clarify the effect of clinical and situational context factors on the likelihood of voicing concerns.

Patients and Methods

1013 nurses and doctors in oncology rated four clinical vignettes describing coworkers’ errors and rule violations in a self-administered factorial survey (65% response rate). Multiple regression analysis was used to model the likelihood of speaking up as outcome of vignette attributes, responder’s evaluations of the situation and personal characteristics.

Results

Respondents reported a high likelihood of speaking up about patient safety but the variation between and within types of errors and rule violations was substantial. Staff without managerial function provided significantly higher levels of decision difficulty and discomfort to speak up. Based on the information presented in the vignettes, 74%−96% would speak up towards a supervisor failing to check a prescription, 45%−81% would point a coworker to a missed hand disinfection, 82%−94% would speak up towards nurses who violate a safety rule in medication preparation, and 59%−92% would question a doctor violating a safety rule in lumbar puncture. Several vignette attributes predicted the likelihood of speaking up. Perceived potential harm, anticipated discomfort, and decision difficulty were significant predictors of the likelihood of speaking up.

Conclusions

Clinicians’ willingness to speak up about patient safety is considerably affected by contextual factors. Physicians and nurses without managerial function report substantial discomfort with speaking up. Oncology departments should provide staff with clear guidance and trainings on when and how to voice safety concerns.

Using simulation to improve root cause analysis of adverse surgical outcomes

OBJECTIVE

The purpose of this study was to develop and test a simulation method of conducting investigation of the causality of adverse surgical outcomes.

DESIGN

Six hundred and thirty-one closed claims of a major medical malpractice insurance company were reviewed. Each case had undergone conventional root cause analysis (RCA). Claims were categorized by comparing the predominant underlying cause documented in the case files. Three cases were selected for simulation.

SETTING

All records (medical and legal) were analyzed. Simulation scenarios were developed by abstracting data from the records and then developing paper and electronic medical records, choosing appropriate

STUDY PARTICIPANTS

including test subjects and confederates, scripting the simulation and choosing the appropriate simulated environment.

INTERVENTION

In a simulation center, each case simulation was run 6-7 times and recorded, with participants debriefed at the conclusion.

MAIN OUTCOME MEASURES

Sources of error identified during simulation were compared with those noted in the closed claims. Test subject decision-making was assessed qualitatively.

RESULTS

Simulation of adverse outcomes (SAOs) identified more system errors and revealed the way complex decisions were made by test subjects. Compared with conventional RCA, SAO identified root causes less focused on errors by individuals and more on systems-based error.

CONCLUSIONS

The use of simulation for investigation of adverse surgical outcomes is feasible and identifies causes that may be more amenable to effective systems changes than conventional RCA. The information that SAO provides may facilitate the implementation of corrective measures, decreasing the risk of recurrence and improving patient safety.