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Mahmoud HA, Mulpuru S, Thavorn K, McIsaac D, Forster AJ. Development of a survey to support assessment of safety learning systems. BMJ Open Qual 2024; 13:e002738. [PMID: 38926135 DOI: 10.1136/bmjoq-2023-002738] [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: 12/29/2023] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Patient safety learning systems play a critical role in supporting safety culture in healthcare organisations. A lack of explicit standards leads to inconsistent implementation across organisations, causing uncertainty about their roles and impact. Organisations can address inconsistent implementation by using a self-assessment tool based on agreed-on best practices. Therefore, we aimed to create a survey instrument to assess an organisation's approach to learning from safety events. METHODS The foundation for this work was a recent systematic review that defined features associated with the performance of a safety learning system. We organised features into themes and rephrased them into questions (items). Face validity was checked, which included independent pre-testing to ensure comprehensibility and parsimony. It also included clinical sensibility testing in which a representative sample of leaders in quality at a large teaching hospital (The Ottawa Hospital) answered two questions to judge each item for clarity and necessity. If more than 20% of respondents judged a question unclear or unnecessary, we modified or removed that question accordingly. Finally, we checked the internal consistency of the questionnaire using Cronbach's alpha. RESULTS We initially developed a 47-item questionnaire based on a prior systematic review. Pre-testing resulted in the modification of 15 of the questions, 2 were removed and 2 questions were added to ensure comprehensiveness and relevance. Face validity was assessed through yes/no responses, with over 80% of respondents confirming the clarity and 85% the necessity of each question, leading to the retention of all 47 questions. Data collected from the five-point responses (strongly disagree to strongly agree) for each question were used to assess the questionnaire's internal consistency. The Cronbach's alpha was 0.94, indicating a high internal consistency. CONCLUSION This self-assessment questionnaire is evidence-based and on preliminary testing is deemed valid, comprehensible and reliable. Future work should assess the range of survey responses in a large sample of respondents from different hospitals.
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Affiliation(s)
- Hassan Assem Mahmoud
- Public Health, Canadian Red Cross, Ottawa, Ontario, Canada
- Epidemiology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sunita Mulpuru
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel McIsaac
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Anesthesia and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Alan J Forster
- Department of Medicine, McGill University, Montreal, Quebec, Canada
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Burden M, Astik G, Auerbach A, Bowling G, Kangelaris KN, Keniston A, Kochar A, Leykum LK, Linker AS, Sakumoto M, Rogers K, Schwatka N, Westergaard S. Identifying and Measuring Administrative Harms Experienced by Hospitalists and Administrative Leaders. JAMA Intern Med 2024:2820266. [PMID: 38913371 PMCID: PMC11197021 DOI: 10.1001/jamainternmed.2024.1890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/25/2024] [Indexed: 06/25/2024]
Abstract
Importance Administrative harm (AH), defined as the adverse consequences of administrative decisions within health care that impact work structure, processes, and programs, is pervasive in medicine, yet poorly understood and described. Objective To explore common AHs experienced by hospitalist clinicians and administrative leaders, understand the challenges that exist in identifying and measuring AH, and identify potential approaches to mitigate AH. Design, Setting, and Participants A qualitative study using a mixed-methods approach with a 12-question survey and semistructured virtual focus groups was held on June 13 and August 11, 2023. Rapid qualitative methods including templated summaries and matrix analysis were applied. The participants included 2 consortiums comprising hospitalist clinicians, researchers, administrative leaders, and members of a patient and family advisory council. Main Outcomes and Measures Quantitative data from the survey on specific aspects of experiences related to AH were collected. Focus groups were conducted using a semistructured focus group guide. Themes and subthemes were identified. Results Forty-one individuals from 32 different organizations participated in the focus groups, with 32 participants (78%) responding to a brief survey. Survey participants included physicians (91%), administrative professionals (6%), an advanced practice clinician (3%), and those in leadership roles (44%), with participants able to select more than one role. Only 6% of participants were familiar with the term administrative harm to a great extent, 100% felt that collaboration between administrators and clinicians is crucial for reducing AH, and 81% had personally participated in a decision that led to AH to some degree. Three main themes were identified: (1) AH is pervasive and comes from all levels of leadership, and the phenomenon was felt to be widespread and arose from multiple sources within health care systems; (2) organizations lack mechanisms for identification, measurement, and feedback, and these challenges stem from a lack of psychological safety, workplace cultures, and ambiguity in who owns a decision; and (3) organizational pressures were recognized as contributors to AHs. Many ideas were proposed as solutions. Conclusions and Relevance The findings of this study suggest that AH is widespread with wide-reaching impact, yet organizations do not have mechanisms to identify or address it.
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Affiliation(s)
- Marisha Burden
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora
| | - Gopi Astik
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew Auerbach
- Division of Hospital Medicine, University of California, San Francisco
| | - Greg Bowling
- Division of Hospital Medicine, University of Texas Health, San Antonio
| | | | - Angela Keniston
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora
| | - Aveena Kochar
- Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Luci K. Leykum
- Medicine Service, South Texas Veterans Health Care System, Department of Veterans Affairs, San Antonio
- Department of Medicine, Dell Medical School, The University of Texas at Austin
| | - Anne S. Linker
- Division of Hospital Medicine, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Matthew Sakumoto
- Division of Hospital Medicine, University of California, San Francisco
| | - Kendall Rogers
- Division of Hospital Medicine, University of New Mexico, Albuquerque
| | - Natalie Schwatka
- Center for Health, Work & Environment, Department of Environmental & Occupational Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora
| | - Sara Westergaard
- Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, Madison
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Butler JM, Taft T, Taber P, Rutter E, Fix M, Baker A, Weir C, Nevers M, Classen D, Cosby K, Jones M, Chapman A, Jones BE. Pneumonia diagnosis performance in the emergency department: a mixed-methods study about clinicians' experiences and exploration of individual differences and response to diagnostic performance feedback. J Am Med Inform Assoc 2024; 31:1503-1513. [PMID: 38796835 PMCID: PMC11187426 DOI: 10.1093/jamia/ocae112] [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: 11/14/2023] [Revised: 03/25/2024] [Accepted: 05/22/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVES We sought to (1) characterize the process of diagnosing pneumonia in an emergency department (ED) and (2) examine clinician reactions to a clinician-facing diagnostic discordance feedback tool. MATERIALS AND METHODS We designed a diagnostic feedback tool, using electronic health record data from ED clinicians' patients to establish concordance or discordance between ED diagnosis, radiology reports, and hospital discharge diagnosis for pneumonia. We conducted semistructured interviews with 11 ED clinicians about pneumonia diagnosis and reactions to the feedback tool. We administered surveys measuring individual differences in mindset beliefs, comfort with feedback, and feedback tool usability. We qualitatively analyzed interview transcripts and descriptively analyzed survey data. RESULTS Thematic results revealed: (1) the diagnostic process for pneumonia in the ED is characterized by diagnostic uncertainty and may be secondary to goals to treat and dispose the patient; (2) clinician diagnostic self-evaluation is a fragmented, inconsistent process of case review and follow-up that a feedback tool could fill; (3) the feedback tool was described favorably, with task and normative feedback harnessing clinician values of high-quality patient care and personal excellence; and (4) strong reactions to diagnostic feedback varied from implicit trust to profound skepticism about the validity of the concordance metric. Survey results suggested a relationship between clinicians' individual differences in learning and failure beliefs, feedback experience, and usability ratings. DISCUSSION AND CONCLUSION Clinicians value feedback on pneumonia diagnoses. Our results highlight the importance of feedback about diagnostic performance and suggest directions for considering individual differences in feedback tool design and implementation.
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Affiliation(s)
- Jorie M Butler
- Department of Biomedical Informatics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
- Department of Internal Medicine, Division of Geriatrics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84132, United States
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT 84148, United States
- Geriatrics Research, Education, and Clinical Center (GRECC), VA Salt Lake City Health Care System, Salt Lake City, UT 84148, United States
| | - Teresa Taft
- Department of Biomedical Informatics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - Peter Taber
- Department of Biomedical Informatics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT 84148, United States
| | - Elizabeth Rutter
- Department of Emergency Medicine, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - Megan Fix
- Department of Emergency Medicine, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - Alden Baker
- Department of Family and Preventive Medicine, Division of Physician Assistant Studies, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - Charlene Weir
- Department of Biomedical Informatics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - McKenna Nevers
- Department of Internal Medicine, Division of Epidemiology, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - David Classen
- Department of Internal Medicine, Division of Epidemiology, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - Karen Cosby
- Department of Emergency Medicine, Cook County Hospital, Rush Medical College, Chicago, IL 60612, United States
| | - Makoto Jones
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT 84148, United States
- Department of Internal Medicine, Division of Epidemiology, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - Alec Chapman
- Department of Population Health Sciences, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - Barbara E Jones
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT 84148, United States
- Department of Internal Medicine, Division of Pulmonology, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
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Lin M, Chen B, Xiao L, Zhang L. Publication Trends of Research on Adverse Event and Patient Safety in Nursing Research: A 8-Year Bibliometric Analysis. J Patient Saf 2024; 20:288-298. [PMID: 38314796 DOI: 10.1097/pts.0000000000001207] [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: 02/07/2024]
Abstract
BACKGROUND Adverse events (AEs), which are associated with medical system instability, poor clinical outcomes, and increasing socioeconomic burden, represent a negative outcome of the healthcare system and profoundly influence patient safety. However, research into AEs remains at a developmental stage according to the existing literature, and no previous studies have systematically reviewed the current state of research in the field of AEs. Therefore, the aims of this study were to interpret the results of published research in the field of AEs through bibliometric analysis and to analyze the trends and patterns in the data, which will be important for subsequent innovations in the field. METHODS A statistical and retrospective visualization bibliometric analysis was performed on July 28, 2022. The research data were extracted from the Web of Science Core Collection, and bibliometric citation analysis was performed using Microsoft Excel, VOSviewer 1.6.18, CiteSpace 6.1.R2, and the Online Analysis Platform of Literature Metrology ( http://bibliometric.com/ ). RESULTS A total of 1035 publications on AEs were included in the analysis. The number of articles increased annually from 2014 to 2022. Among them, the United States (n = 318) made the largest contribution, and Chung-Ang University (n = 20) was the affiliation with the greatest influence in this field. Despite notable international cooperation, a regional concentration of research literature production was observed in economically more developed countries. In terms of authors, Stone ND (n = 9) was the most productive author in the research of AEs. Most of the publications concerning AEs were cited from internationally influential nursing journals, and the Journal of Nursing Management (n = 62) was the most highly published journal. Regarding referencing, the article titled "Medical error-the third leading cause of death in the US" received the greatest attention on this topic (51 citations). CONCLUSIONS After systematically reviewed the current state of research in the field of AEs through bibliometric analysis, and AEs highlighted medication errors, patient safety, according reporting, and quality improvement as essential developments and research hotspots in this field. Furthermore, thematic analysis identified 2 new directions in research, concerned with psychological safety, nurse burnout, and with important research value and broad application prospects in the future.
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Affiliation(s)
| | - Bei Chen
- From the Department of Orthopaedic Surgery, The Affiliated Hospital of Zunyi Medical University
| | - Leyao Xiao
- School of Nursing, ZunyiMedical University
| | - Li Zhang
- The Affiliated Hospital of Zunyi Medical University, Zunyi
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Isaac D, Li Y, Wang Y, Jiang D, Liu C, Fan C, Boah M, Xie Y, Ma M, Shan L, Gao L, Jiao M. Healthcare workers perceptions of patient safety culture in selected Ghanaian regional hospitals: a qualitative study. BMC Psychol 2024; 12:272. [PMID: 38750584 PMCID: PMC11094925 DOI: 10.1186/s40359-024-01628-6] [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: 10/09/2023] [Accepted: 02/27/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Patient safety culture is an integral part of healthcare delivery both in Ghana and globally. Therefore, understanding how frontline health workers perceive patient safety culture and the factors that influence it is very important. This qualitative study examined the health workers' perceptions of patient safety culture in selected regional hospitals in Ghana. OBJECTIVE This study aimed to provide a voice concerning how frontline health workers perceive patient safety culture and explain the major barriers in ensuring it. METHOD In-depth semi-structured interviews were conducted with 42 health professionals in two regional government hospitals in Ghana from March to June 2022. Participants were purposively selected and included medical doctors, nurses, pharmacists, administrators, and clinical service staff members. The inclusion criteria were one or more years of clinical experience. Interviews were recorded and transcribed. Thematic analysis was used to identify themes. RESULT The health professionals interviewed were 38% male and 62% female, of whom 54% were nurses, 4% were midwives, 28% were medical doctors; lab technicians, pharmacists, and human resources workers represented 2% each; and 4% were critical health nurses. Among them, 64% held a diploma and 36% held a degree or above. This study identified four main areas: general knowledge of patient safety culture, guidelines and procedures, attitudes of frontline health workers, and upgrading patient safety culture. CONCLUSIONS This qualitative study presents a few areas for improvement in patient safety culture. Despite their positive attitudes and knowledge of patient safety, healthcare workers expressed concerns about the implementation of patient safety policies outlined by hospitals. Healthcare professionals perceived that curriculum training on patient safety during school education and the availability of dedicated officers for patient safety at their facilities may help improve patient safety.
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Affiliation(s)
| | - Yuanheng Li
- Harbin Medical University, Harbin, Heilongjiang, China
| | - Yushu Wang
- Northeastern University, Shenyang, Liaoning, China
| | - Deyou Jiang
- Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang, China
| | - Chenggang Liu
- Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang, China
| | - Chao Fan
- Third Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Michael Boah
- School of Public health University for Development studies, Tamale, Ghana
| | - Yuzhuo Xie
- Harbin Medical University, Harbin, Heilongjiang, China
| | - Mingxue Ma
- Harbin Medical University, Harbin, Heilongjiang, China
| | - Linghan Shan
- Harbin Medical University, Harbin, Heilongjiang, China.
| | - Lei Gao
- Harbin Medical University, Harbin, Heilongjiang, China.
| | - Mingli Jiao
- Harbin Medical University, Harbin, Heilongjiang, China.
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Shimizu I, Watari T, Watanuki S, Hata T. Morbidity and Mortality Conferences in Internal Medicine Specialty Training in Japan: A Nationwide Cross-sectional Study. Intern Med 2024; 63:1361-1366. [PMID: 37813614 PMCID: PMC11157326 DOI: 10.2169/internalmedicine.2418-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/20/2023] [Indexed: 10/11/2023] Open
Abstract
Objective This study evaluated the implementation status of morbidity and mortality conferences in internal medicine specialty training programs in Japan. Methods This cross-sectional study surveyed hospitals in Japan with certified internal medicine specialty training programs. Program directors or equivalently responsible physicians managing certified internal medicine training programs were invited to participate in this study (n=619). Materials Data were collected using an online questionnaire that included questions about the number of morbidity and mortality conferences, types of cases covered, collaboration of the patient safety section and other health professions, and whether or not the conferences were conducted by a subspecialty department-led or program-based. Results Responses were received from 123 hospitals (19.8% response rate), of which 59 (48%) had some form of internal medicine morbidity and mortality conference in place. The average number per year was 9.63 (standard deviation: 18.12). Hospitals with morbidity and mortality conferences in subspecialty departments held significantly more conferences. Furthermore, the involvement of the patient safety department tended to be associated with holding more conferences. Autopsy rates were significantly higher in hospitals with program-based internal medicine morbidity and mortality conferences than subspecialty-led. Conclusion Internal medicine specialty training hospitals had more morbidity and mortality conferences than previously reported. Program-based morbidity and mortality conferences in internal medicine are associated with higher autopsy rates and may lead to an organizational reporting culture and lifelong learning attitudes that support patient safety. Collaboration with organizational management sections, such as patient safety, would be effective in implementing these conferences in internal medicine training programs.
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Affiliation(s)
- Ikuo Shimizu
- Department of Medical Education, Chiba University Graduate School of Medicine, Japan
- Department of Patient Safety, Chiba University Hospital, Japan
| | - Takashi Watari
- VA Hospital, Division of Hospital Medicine, University of Michigan, the United States
- General Medicine Center, Shimane University Hospital, Japan
| | - Satoshi Watanuki
- Emergency and General Medicine, Tokyo Metropolitan Tama Medical Center, Japan
- Patient Safety Office, Tokyo Metropolitan Tama Medical Center, Japan
| | - Takuma Hata
- Department of General Medicine, Mito Kyodo General Hospital, Japan
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Coleman BC, Rubinstein SM, Salsbury SA, Swain M, Brown R, Pohlman KA. The World Federation of Chiropractic Global Patient Safety Task Force: a call to action. Chiropr Man Therap 2024; 32:15. [PMID: 38741191 DOI: 10.1186/s12998-024-00536-1] [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: 01/17/2024] [Accepted: 03/26/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND The Global Patient Safety Action Plan, an initiative of the World Health Organization (WHO), draws attention to patient safety as being an issue of utmost importance in healthcare. In response, the World Federation of Chiropractic (WFC) has established a Global Patient Safety Task Force to advance a patient safety culture across all facets of the chiropractic profession. This commentary aims to introduce principles and call upon the chiropractic profession to actively engage with the Global Patient Safety Action Plan beginning immediately and over the coming decade. MAIN TEXT This commentary addresses why the chiropractic profession should pay attention to the WHO Global Patient Safety Action Plan, and what actions the chiropractic profession should take to advance these objectives. Each strategic objective identified by WHO serves as a focal point for reflection and action. Objective 1 emphasizes the need to view each clinical interaction as a chance to improve patient safety through learning. Objective 2 urges the implementation of frameworks that dismantle systemic obstacles, minimizing human errors and strengthening patient safety procedures. Objective 3 supports the optimization of clinical process safety. Objective 4 recognizes the need for patient and family engagement. Objective 5 describes the need for integrated patient safety competencies in training programs. Objective 6 explains the need for foundational data infrastructure, ecosystem, and culture. Objective 7 emphasizes that patient safety is optimized when healthcare professionals cultivate synergy and partnerships. CONCLUSIONS The WFC Global Patient Safety Task Force provides a structured framework for aligning essential considerations for patient safety in chiropractic care with WHO strategic objectives. Embracing the prescribed action steps offers a roadmap for the chiropractic profession to nurture an inclusive and dedicated culture, placing patient safety at its core. This commentary advocates for a concerted effort within the chiropractic community to commit to and implement these principles for the collective advancement of patient safety.
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Affiliation(s)
- Brian C Coleman
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Biostatistics (Health Informatics), Yale School of Public Health, New Haven, CT, USA
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Sidney M Rubinstein
- Department of Health Sciences, Faculty of Science, Amsterdam Movement Sciences Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Stacie A Salsbury
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA, USA
| | - Michael Swain
- Department of Chiropractic, Macquarie University, Sydney, Australia
| | | | - Katherine A Pohlman
- Research Center, Parker University, 2540 Walnut Hill Lane, 75229, Dallas, TX, USA.
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Mertes PM, Morgand C, Barach P, Jurkolow G, Assmann KE, Dufetelle E, Susplugas V, Alauddin B, Yavordios PG, Tourres J, Dumeix JM, Capdevila X. Validation of a natural language processing algorithm using national reporting data to improve identification of anesthesia-related ADVerse evENTs: The "ADVENTURE" study. Anaesth Crit Care Pain Med 2024; 43:101390. [PMID: 38718923 DOI: 10.1016/j.accpm.2024.101390] [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: 11/12/2023] [Revised: 04/02/2024] [Accepted: 04/22/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Reporting and analysis of adverse events (AE) is associated with improved health system learning, quality outcomes, and patient safety. Manual text analysis is time-consuming, costly, and prone to human errors. We aimed to demonstrate the feasibility of novel machine learning and natural language processing (NLP) approaches for early predictions of adverse events and provide input to direct quality improvement and patient safety initiatives. METHODS We used machine learning to analyze 9559 continuously reported AE by clinicians and healthcare systems to the French National Health accreditor (HAS) between January 1, 2009, and December 31, 2020 . We validated the labeling of 135,000 unique de-identified AE reports and determined the associations between different system's root causes and patient consequences. The model was validated by independent expert anesthesiologists. RESULTS The machine learning (ML) and Artificial Intelligence (AI) model trained on 9559 AE datasets accurately categorized 8800 (88%) of reported AE. The three most frequent AE types were "difficult orotracheal intubation" (16.9% of AE reports), "medication error" (10.5%), and "post-induction hypotension" (6.9%). The accuracy of the AI model reached 70.9% sensitivity, 96.6% specificity for "difficult intubation", 43.2% sensitivity, and 98.9% specificity for "medication error." CONCLUSIONS This unsupervised ML method provides an accurate, automated, AI-supported search algorithm that ranks and helps to understand complex risk patterns and has greater speed, precision, and clarity when compared to manual human data extraction. Machine learning and Natural language processing (NLP) models can effectively be used to process natural language AE reports and augment expert clinician input. This model can support clinical applications and methodological standards and used to better inform and enhance decision-making for improved risk management and patient safety. TRIAL REGISTRATION The study was approved by the ethics committee of the French Society of Anesthesiology (IRB 00010254-2020-20) and the CNIL (CNIL: 118 58 95) and the study was registered with ClinicalTrials.gov (NCT: NCT05185479).
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Affiliation(s)
- Paul M Mertes
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, EA 3072, FMTS de Strasbourg, Strasbourg, France; CFAR - Collège Français des Anesthésistes-Réanimateurs, 75016 Paris, France
| | - Claire Morgand
- Evaluation Department and Tools for Quality and Safety of Care, French national authority for health (Haute Autorité de Santé - EvOQSS), Saint Denis, France
| | - Paul Barach
- Thomas Jefferson School of Medicine, Philadelphia, USA; Sigmund Freud University, Vienna, Austria
| | - Geoffrey Jurkolow
- CFAR - Collège Français des Anesthésistes-Réanimateurs, 75016 Paris, France.
| | - Karen E Assmann
- Evaluation Department and Tools for Quality and Safety of Care, French national authority for health (Haute Autorité de Santé - EvOQSS), Saint Denis, France
| | | | | | - Bilal Alauddin
- Collective Thinking, 23 rue Yves Toudic, 75010 Paris, France
| | | | - Jean Tourres
- CFAR - Collège Français des Anesthésistes-Réanimateurs, 75016 Paris, France
| | - Jean-Marc Dumeix
- CFAR - Collège Français des Anesthésistes-Réanimateurs, 75016 Paris, France
| | - Xavier Capdevila
- Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France; Inserm Unit 1298 Montpellier NeuroSciences Institute, Montpellier University, 34295 Montpellier Cedex 5, France
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Sehgal A. What is the effectiveness of reporting systems in promoting learning in healthcare? Br J Hosp Med (Lond) 2024; 85:1-9. [PMID: 38708976 DOI: 10.12968/hmed.2023.0444] [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] [Indexed: 05/07/2024]
Abstract
Patient safety in healthcare remains a top priority. Learning from safety events is vital to move towards safer systems. As a result, reporting systems are recognised as the cornerstone of safety, especially in high-risk industries. However, in healthcare, the benefits of reporting systems in promoting learning remain contentious. Though the strengths of these systems, such as promoting a safety culture and providing information from near misses are noted, there are problems that mean learning is missed. Understanding the factors that both enable and act as barriers to learning from reporting is also important to consider. This review, considers the effectiveness of reporting systems in contributing to learning in healthcare.
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Affiliation(s)
- Apurv Sehgal
- Department of Anaesthesia and Critical Care Medicine, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Uematsu H, Uemura M, Kurihara M, Yamamoto H, Umemura T, Kitano F, Hiramatsu M, Nagao Y. Development of a scoring system to quantify errors from semantic characteristics in incident reports. BMJ Health Care Inform 2024; 31:e100935. [PMID: 38642920 PMCID: PMC11033660 DOI: 10.1136/bmjhci-2023-100935] [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: 10/11/2023] [Accepted: 04/02/2024] [Indexed: 04/22/2024] Open
Abstract
OBJECTIVES Incident reporting systems are widely used to identify risks and enable organisational learning. Free-text descriptions contain important information about factors associated with incidents. This study aimed to develop error scores by extracting information about the presence of error factors in incidents using an original decision-making model that partly relies on natural language processing techniques. METHODS We retrospectively analysed free-text data from reports of incidents between January 2012 and December 2022 from Nagoya University Hospital, Japan. The sample data were randomly allocated to equal-sized training and validation datasets. We conducted morphological analysis on free text to segment terms from sentences in the training dataset. We calculated error scores for terms, individual reports and reports from staff groups according to report volume size and compared these with conventional classifications by patient safety experts. We also calculated accuracy, recall, precision and F-score values from the proposed 'report error score'. RESULTS Overall, 114 013 reports were included. We calculated 36 131 'term error scores' from the 57 006 reports in the training dataset. There was a significant difference in error scores between reports of incidents categorised by experts as arising from errors (p<0.001, d=0.73 (large)) and other incidents. The accuracy, recall, precision and F-score values were 0.8, 0.82, 0.85 and 0.84, respectively. Group error scores were positively associated with expert ratings (correlation coefficient, 0.66; 95% CI 0.54 to 0.75, p<0.001) for all departments. CONCLUSION Our error scoring system could provide insights to improve patient safety using aggregated incident report data.
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Affiliation(s)
- Haruhiro Uematsu
- Department of Quality and Patient Safety, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masakazu Uemura
- Department of Patient Safety, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Masaru Kurihara
- Department of Patient Safety, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Hiroo Yamamoto
- Department of Patient Safety, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Tomomi Umemura
- Department of Patient Safety, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Fumimasa Kitano
- Department of Patient Safety, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Mariko Hiramatsu
- Department of Patient Safety, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Yoshimasa Nagao
- Department of Quality and Patient Safety, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
- Department of Patient Safety, Nagoya University Hospital, Nagoya, Aichi, Japan
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11
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Boyer L, Fond G, Auquier P, Khouani J, Boussat B, Wu AW. Enhancing healthcare worker resilience and health in underserved communities and rural areas: Lessons and strategies for global health. JOURNAL OF EPIDEMIOLOGY AND POPULATION HEALTH 2024; 72:202529. [PMID: 38632932 DOI: 10.1016/j.jeph.2024.202529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Affiliation(s)
- Laurent Boyer
- CEReSS - Health Service Research and Quality of Life Center, UR3279, Aix-Marseille University, Marseille, France.
| | - Guillaume Fond
- CEReSS - Health Service Research and Quality of Life Center, UR3279, Aix-Marseille University, Marseille, France
| | - Pascal Auquier
- CEReSS - Health Service Research and Quality of Life Center, UR3279, Aix-Marseille University, Marseille, France
| | - Jeremy Khouani
- CEReSS - Health Service Research and Quality of Life Center, UR3279, Aix-Marseille University, Marseille, France; Department of General Practice, Aix-Marseille University, Marseille, France
| | - Bastien Boussat
- Department of Clinical Epidemiology, Grenoble University Hospital, Grenoble Alps University, Grenoble, France; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Albert W Wu
- Johns Hopkins University School of Medicine, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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12
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Ralston K, Smith SE, Kerins J, Clark-Stewart S, Tallentire V. Safety on the ground: using critical incident technique to explore the factors influencing medical registrars' provision of safe care. BMJ Open Qual 2024; 13:e002641. [PMID: 38413094 PMCID: PMC10900368 DOI: 10.1136/bmjoq-2023-002641] [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: 10/09/2023] [Accepted: 02/12/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Avoidable patient harm in hospitals is common, and doctors in training can provide underused but crucial insights into the influencers of patient safety as those working 'on the ground' within the system. This study aimed to explore the factors that influence safe care from the perspective of medical registrars, to identify targets for safety-related improvements. METHODS This study used enhanced critical incident technique (CIT), a qualitative methodology that results in a focused understanding of significant factors influencing an activity, to identify practical solutions. We interviewed 12 out of 17 consenting medical registrars in Scotland, asking them to recount their observations during clinical experiences where something happened that positively or negatively impacted on patient safety. Data were analysed manually using a modified content analysis with credibility checks as per enhanced CIT, with data exhaustiveness reached after six registrars. RESULTS A total of 221 critical incidents impacting patient safety were identified. These were inductively placed into 24 categories within 4 overarching categories: Individual skills, encompassing individual behavioural and technical skills; Collaboration, regarding how communication, trust, support and flexibility shape interprofessional collaboration; Organisation, concerning organisational systems and staffing and Training environment, relating to culture, civility, having a voice and learning at work. Practical targets for safety-related interventions were identified, such as clear policies for patient care ownership or educational interventions to foster civility. CONCLUSIONS This study provides a rigorous and focused understanding of the factors influencing patient safety in hospitals, using the 'insider' perspective of the medical registrar. Safety goes beyond the individual and is reliant on safe system design, interprofessional collaboration and a culture of support, learning and respect. Organisations should also promote flexibility within clinical practice when patient needs do not conform to standardised care pathways. We suggest targeted interventions within educational and organisational priorities to improve safety in hospitals.
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Affiliation(s)
- Katherine Ralston
- NHS Lothian Medical Education Directorate, Edinburgh, UK
- Medicine of the Elderly and General Medicine, NHS Lothian, Edinburgh, UK
| | | | - Joanne Kerins
- Scottish Centre for Simulation and Clinical Human Factors, Larbert, UK
- Acute Medicine, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Saskia Clark-Stewart
- NHS Lothian Medical Education Directorate, Edinburgh, UK
- General Surgery, NHS Tayside, Dundee, UK
| | - Victoria Tallentire
- NHS Lothian Medical Education Directorate, Edinburgh, UK
- Scottish Centre for Simulation and Clinical Human Factors, Larbert, UK
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13
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Recsky C, Rush KL, MacPhee M, Stowe M, Blackburn L, Muniak A, Currie LM. Clinical Informatics Team Members' Perspectives on Health Information Technology Safety After Experiential Learning and Safety Process Development: Qualitative Descriptive Study. JMIR Form Res 2024; 8:e53302. [PMID: 38315544 PMCID: PMC10877498 DOI: 10.2196/53302] [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: 10/02/2023] [Revised: 01/11/2024] [Accepted: 01/11/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Although intended to support improvement, the rapid adoption and evolution of technologies in health care can also bring about unintended consequences related to safety. In this project, an embedded researcher with expertise in patient safety and clinical education worked with a clinical informatics team to examine safety and harm related to health information technologies (HITs) in primary and community care settings. The clinical informatics team participated in learning activities around relevant topics (eg, human factors, high reliability organizations, and sociotechnical systems) and cocreated a process to address safety events related to technology (ie, safety huddles and sociotechnical analysis of safety events). OBJECTIVE This study aimed to explore clinical informaticians' experiences of incorporating safety practices into their work. METHODS We used a qualitative descriptive design and conducted web-based focus groups with clinical informaticians. Thematic analysis was used to analyze the data. RESULTS A total of 10 informants participated. Barriers to addressing safety and harm in their context included limited prior knowledge of HIT safety, previous assumptions and perspectives, competing priorities and organizational barriers, difficulty with the reporting system and processes, and a limited number of reports for learning. Enablers to promoting safety and mitigating harm included participating in learning sessions, gaining experience analyzing reported events, participating in safety huddles, and role modeling and leadership from the embedded researcher. Individual outcomes included increased ownership and interest in HIT safety, the development of a sociotechnical systems perspective, thinking differently about safety, and increased consideration for user perspectives. Team outcomes included enhanced communication within the team, using safety events to inform future work and strategic planning, and an overall promotion of a culture of safety. CONCLUSIONS As HITs are integrated into care delivery, it is important for clinical informaticians to recognize the risks related to safety. Experiential learning activities, including reviewing safety event reports and participating in safety huddles, were identified as particularly impactful. An HIT safety learning initiative is a feasible approach for clinical informaticians to become more knowledgeable and engaged in HIT safety issues in their work.
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Affiliation(s)
- Chantelle Recsky
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
| | - Kathy L Rush
- School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Maura MacPhee
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
| | - Megan Stowe
- Digital Health, Provincial Health Services Authority, Vancouver, BC, Canada
| | | | | | - Leanne M Currie
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
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Moldovan F, Moldovan L. Assessment of Patient Matters in Healthcare Facilities. Healthcare (Basel) 2024; 12:325. [PMID: 38338210 PMCID: PMC10855928 DOI: 10.3390/healthcare12030325] [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: 01/05/2024] [Revised: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Ensuring the sustainability of healthcare facilities requires the evaluation of patient matters with appropriate methods and tools. The objective of this research is to develop a new tool for assessing patient matters as a component of social responsibility requirements that contribute to the sustainability of healthcare facilities. MATERIALS AND METHODS We carried out an analytical observational study in which, starting from the domains of the reference framework for the sustainability of health facilities (economic, environmental, social, provision of sustainable medical care services and management processes), we designed indicators that describe patient matters. To achieve this, we extracted from the scientific literature the most recent data and aspects related to patient matters that have been reported by representative hospitals from all over the world. These were organized into the four sequences of the quality cycle. We designed the method of evaluating the indicators based on the information couple achievement degree-importance of the indicator. In the experimental part of the study, we validated the indicators for the evaluation of patient matters and the evaluation method at an emergency hospital with an orthopedic profile. RESULTS We developed the patient matters indicator matrix, the content of the 8 indicators that make it up, questions for the evaluation of the indicators, and the evaluation grids of the indicators. They describe five levels for each variable of the achievement degree-importance couple. The practical testing of the indicators at the emergency hospital allowed the calculation of sustainability indicators and the development of a prioritization matrix for improvement measures. CONCLUSIONS Indicators designed in this research cover social responsibility requirements that describe patient matters. They are compatible and can be used by health facilities along with other implemented national and international requirements. Their added value consists in promoting social responsibility and sustainable development of healthcare facilities.
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Affiliation(s)
- Flaviu Moldovan
- Orthopedics—Traumatology Department, Faculty of Medicine, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Targu Mures, Romania
| | - Liviu Moldovan
- Faculty of Engineering and Information Technology, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Targu Mures, Romania;
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15
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Fröding E, Vincent C, Andersson-Gäre B, Westrin Å, Ros A. Six Major Steps to Make Investigations of Suicide Valuable for Learning and Prevention. Arch Suicide Res 2024; 28:1-19. [PMID: 36259504 DOI: 10.1080/13811118.2022.2133652] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE The decline in suicide rates has leveled off in many countries during the last decade, suggesting that new interventions are needed in the work with suicide prevention. Learnings from investigations of suicide should contribute to the development of these new interventions. However, reviews of investigations have indicated that few new lessons have been learned. To be an effective tool, revisions of the current investigation methods are required. This review aimed to describe the problems with the current approaches to investigations of suicide as patient harm and to propose ways to move forward. METHODS Narrative literature review. RESULTS Several weaknesses in the current approaches to investigations were identified. These include failures in embracing patient and system perspectives, not addressing relevant factors, and insufficient competence of the investigation teams. Investigation methods need to encompass the progress of knowledge about suicidal behavior, suicide prevention, and patient safety. CONCLUSIONS There is a need for a paradigm shift in the approaches to investigations of suicide as potential patient harm to enable learning and insights valuable for healthcare improvement. Actions to support this paradigm shift include involvement of patients and families, education for investigators, multidisciplinary analysis teams with competence in and access to relevant parts across organizations, and triage of cases for extensive analyses. A new model for the investigation of suicide that support these actions should facilitate this paradigm shift.HIGHLIGHTSThere are weaknesses in the current approaches to investigations of suicide.A paradigm shift in investigations is needed to contribute to a better understanding of suicide.New knowledge of suicidal behavior, prevention, and patient safety must be applied.
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16
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Li H, Guo Z, Yang W, He Y, Chen Y, Zhu J. Perceptions of medical error among general practitioners in rural China: a qualitative interview study. BMJ Open Qual 2023; 12:e002528. [PMID: 38160021 PMCID: PMC10759142 DOI: 10.1136/bmjoq-2023-002528] [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: 07/31/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Medical error (ME) is a serious public health problem and a leading cause of death. The reported adverse incidents in China were much less than western countries, and the research on patient safety in rural China's primary care institutions was scarce. This study aims to identify the factors contributing to the under-reporting of ME among general practitioners in township health centres (THCs). METHODS A qualitative semi-structured interview study was conducted with 31 general practitioners working in 30 THCs across 6 provinces. Thematic analysis was conducted using a grounded theory approach. RESULTS The understanding of ME was not unified, from only mild consequence to only almost equivalent to medical malpractice. Common coping strategies for THCs after ME occurs included concealing and punishment. None of the participants reported adverse events through the National Clinical Improvement System website since they worked in THCs. Discussions about ME always focused on physicians rather than the system. CONCLUSIONS The low reported incidence of ME could be explained by unclear concept, unawareness and blame culture. It is imperative to provide supportive environment, patient safety training and good examples of error-based improvements to rural primary care institutions so that ME could be fully discussed, and systemic factors of ME could be recognised and improved there in the future.
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Affiliation(s)
- Hange Li
- Vanke School of Public Health, Tsinghua University, Beijing, China
- Institute for Healthy China, Tsinghua University, Beijing, China
| | - Ziting Guo
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Wenbin Yang
- Department of Oral and Maxillofacial Surgery, Department of Medical Affairs, Sichuan University West China Hospital of Stomatology, Chengdu, Sichuan, China
- Sichuan University State Key Laboratory of Oral Diseases, Chengdu, Sichuan, China
| | - Yanrong He
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Yanhua Chen
- Vanke School of Public Health, Tsinghua University, Beijing, China
- School of Medicine, Tsinghua University, Beijing, China
| | - Jiming Zhu
- Vanke School of Public Health, Tsinghua University, Beijing, China
- Institute for Healthy China, Tsinghua University, Beijing, China
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Rotteau L, Othman D, Dunbar-Yaffe R, Fortin C, Go K, Mayo A, Pelc J, Wolfstadt J, Guo M, Soong C. Physician engagement in organisational patient safety through the implementation of a Medical Safety Huddle initiative: a qualitative study. BMJ Qual Saf 2023; 33:33-42. [PMID: 37468150 DOI: 10.1136/bmjqs-2022-015725] [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: 11/03/2022] [Accepted: 06/28/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Efforts to increase physician engagement in quality and safety are most often approached from an organisational or administrative perspective. Given hospital-based physicians' strong professional identification, physician-led strategies may offer a novel strategic approach to enhancing physician engagement. It remains unclear what role medical leadership can play in leading programmes to enhance physician engagement. In this study, we explore physicians' experience of participating in a Medical Safety Huddle initiative and how participation influences engagement with organisational quality and safety efforts. METHODS We conducted a qualitative study of the Medical Safety Huddle initiative implemented across six sites. The initiative consisted of short, physician focused and led, weekly meetings aimed at reviewing, anticipating and addressing patient safety issues. We conducted 29 semistructured interviews with leaders and participants. We applied an interpretive thematic analysis to the data using self-determination theory as an analytic lens. RESULTS The results of the thematic analysis are organised in two themes, (1) relatedness and meaningfulness, and (2) progress and autonomy, representing two forms of intrinsic motivation for engagement that we found were leveraged through participation in the initiative. First, participation enabled a sense of community and a 'safe space' in which professionally relevant safety issues are discussed. Second, participation in the initiative created a growing sense of ability to have input in one's work environment. However, limited collaboration with other professional groups around patient safety and the ability to consistently address reported concerns highlights the need for leadership and organisational support for physician engagement. CONCLUSION The Medical Safety Huddle initiative supports physician engagement in quality and safety through intrinsic motivation. However, the huddles' implementation must align with the organisation's multipronged patient safety agenda to support multidisciplinary collaborative quality and safety efforts and leaders must ensure mechanisms to consistently address reported safety concerns for sustained physician engagement.
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Affiliation(s)
- Leahora Rotteau
- Centre for Quality Improvment and Patient Safety, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Dalia Othman
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Richard Dunbar-Yaffe
- Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada
| | - Chris Fortin
- Division of Physical Medicine and Rehabilitation, Sinai Health System, Toronto, Ontario, Canada
| | - Katharyn Go
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Amanda Mayo
- Centre for Quality Improvment and Patient Safety, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jordan Pelc
- Division of Hospital Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Jesse Wolfstadt
- Granovsky Gluskin Division of Orthopaedics, Sinai Health System, Toronto, Ontario, Canada
| | - Meiqi Guo
- Division of Physical Medicine and Rehabilitation, University Health Network, Toronto, Ontario, Canada
| | - Christine Soong
- Centre for Quality Improvment and Patient Safety, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
- Division of General Internal Medicine, Sinai Health System, Toronto, Ontario, Canada
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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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Recsky C, Stowe M, Rush KL, MacPhee M, Blackburn L, Muniak A, Currie LM. Characterization of Safety Events Involving Technology in Primary and Community Care. Appl Clin Inform 2023; 14:1008-1017. [PMID: 38151041 PMCID: PMC10752655 DOI: 10.1055/s-0043-1777454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 10/10/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND The adoption of technology in health care settings is often touted as an opportunity to improve patient safety. While some adverse events can be reduced by health information technologies, technology has also been implicated in or attributed to safety events. To date, most studies on this topic have focused on acute care settings. OBJECTIVES To describe voluntarily reported safety events that involved health information technology in community and primary care settings in a large Canadian health care organization. METHODS Two years of safety events involving health information technology (2016-2018) were extracted from an online voluntary safety event reporting system. Events from primary and community care settings were categorized according to clinical setting, type of event, and level of harm. The Sittig and Singh sociotechnical system model was then used to identify the most prominent sociotechnical dimensions of each event. RESULTS Of 104 reported events, most (n = 85, 82%) indicated the event resulted in no harm. Public health had the highest number of reports (n = 45, 43%), whereas home health had the fewest (n = 7, 7%). Of the 182 sociotechnical concepts identified, many events (n = 61, 59%) mapped to more than one dimension. Personnel (n = 48, 46%), Workflow and Communication (n = 37, 36%), and Content (n = 30, 29%) were the most common. Personnel and Content together was the most common combination of dimensions. CONCLUSION Most reported events featured both technical and social dimensions, suggesting that the nature of these events is multifaceted. Leveraging existing safety event reporting systems to screen for safety events involving health information technology, and applying a sociotechnical analytic framework can aid health organizations in identifying, responding to, and learning from reported events.
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Affiliation(s)
- Chantelle Recsky
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Megan Stowe
- Regional Digital Solutions, Digital Health, Provincial Health Services Authority, Vancouver, Canada
| | - Kathy L. Rush
- School of Nursing, University of British Columbia Okanagan, Kelowna, Canada
| | - Maura MacPhee
- School of Nursing, University of British Columbia, Vancouver, Canada
| | | | - Allison Muniak
- Human Factors and Administrative Burdens, Health Quality BC, Vancouver, Canada
| | - Leanne M. Currie
- School of Nursing, University of British Columbia, Vancouver, Canada
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Mrayyan MT, Al-Atiyyat N, Al-Rawashdeh S, Algunmeeyn A, Abunab HY, Othman WW, Sayaheen MN. How does authentic leadership influence the safety climate in nursing? BMJ LEADER 2023; 7:189-195. [PMID: 37192096 DOI: 10.1136/leader-2022-000677] [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: 08/28/2022] [Accepted: 12/26/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Authentic leadership controls quality care and the safety of patients and healthcare professionals, especially nurses. AIM This study examined the influence of nurses' authentic leadership on the safety climate. METHODS In this predictive research, 314 Jordanian nurses from various hospitals were convenience sampled for cross-sectional and correlational design. This research included all hospital nurses with 1 year of experience, at least at the present hospital. SPSS (V.25) conducted descriptive statistics and multivariate analyses. As needed, sample variables' means, SD and frequencies were supplied. RESULTS The mean scores on the entire Authentic Leadership Questionnaire and its subscales were moderate. The mean score of the SCS was below 4 (out of 5), indicating negative safety climate perceptions. A significant positive moderate association was found between nurses' authentic leadership and safety climate. Nurses' authentic leadership predicted a safe climate. Internalised moral and balanced processing subscales were significant predictors of safety climate. Being woman and having a diploma inversely predicted the nurses' authentic leadership; however, the model was insignificant. CONCLUSION Interventions are needed to enhance the perception of the safety climate in hospitals. Nurses' authentic leadership increases their perceptions of a positive safety climate, and thus different strategies to build on nurses' authentic leadership characteristics are warranted. IMPLICATIONS FOR NURSING MANAGEMENT The negative perceptions of the safety climate mandate that organisations create strategies to increase nurses' awareness about the safety climate. Shared leadership, learning environments and information sharing would improve nurses' perceptions of the safety climate. Future studies should examine other variables influencing safety climate with a more extensive and randomised sample. Safety climate and authentic leadership should be integrated into the nursing curricula and continuing education courses.
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Affiliation(s)
- Majd T Mrayyan
- Department of Community and Mental Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa, Jordan
| | - Nijmeh Al-Atiyyat
- Department of Adult Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa, Jordan
| | - Sami Al-Rawashdeh
- Department of Community and Mental Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa, Jordan
| | - Abdullah Algunmeeyn
- Advanced Nursing Department, Faculty of Nursing, Isra University, Amman, Jordan
| | - Hamzeh Y Abunab
- Basic Nursing Department, Faculty of Nursing, Isra University, Amman, Jordan
| | - Wafa'a W Othman
- Department of Adult Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa, Jordan
| | - Mohammad N Sayaheen
- Department of Adult Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa, Jordan
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Seys D, Panella M, Russotto S, Strametz R, Joaquín Mira J, Van Wilder A, Godderis L, Vanhaecht K. In search of an international multidimensional action plan for second victim support: a narrative review. BMC Health Serv Res 2023; 23:816. [PMID: 37525127 PMCID: PMC10391912 DOI: 10.1186/s12913-023-09637-8] [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: 03/29/2023] [Accepted: 06/03/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Insights around second victims (SV) and patient safety has been growing over time. An overview of the available evidence is lacking. This review aims to describe (i) the impact a patient safety incident can have and (ii) how healthcare professionals can be supported in the aftermath of a patient safety incident. METHODS A literature search in Medline, EMBASE and CINAHL was performed between 1 and 2010 and 26 November 2020 with studies on SV as inclusion criteria. To be included in this review the studies must include healthcare professionals involved in the aftermath of a patient safety incident. RESULTS In total 104 studies were included. SVs can suffer from both psychosocial (negative and positive), professional and physical reactions. Support can be provided at five levels. The first level is prevention (on individual and organizational level) referring to measures taken before a patient safety incident happens. The other four levels focus on providing support in the aftermath of a patient safety incident, such as self-care of individuals and/or team, support by peers and triage, structured support by an expert in the field (professional support) and structured clinical support. CONCLUSION The impact of a patient safety incident on healthcare professionals is broad and diverse. Support programs should be organized at five levels, starting with preventive actions followed by self-care, support by peers, structured professional support and clinical support. This multilevel approach can now be translated in different countries, networks and organizations based on their own culture, support history, structure and legal context. Next to this, they should also include the stage of recovery in which the healthcare professional is located in.
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Affiliation(s)
- Deborah Seys
- Department Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35, Leuven, Belgium.
- Department Public Health and Primary Care, KU Leuven, Leuven, Belgium.
| | - Massimiliano Panella
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Sophia Russotto
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | | | - José Joaquín Mira
- The Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Alicante, Spain
- Health Psychology Department, Miguel Hernandez University, Elche, Spain
| | - Astrid Van Wilder
- Department Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Lode Godderis
- Department Public Health and Primary Care, KU Leuven, Leuven, Belgium
- External Service for Prevention and Protection at Work, IDEWE, Heverlee, Belgium
| | - Kris Vanhaecht
- Department Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Department of Quality, University Hospitals Leuven, 3000, Leuven, Belgium
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22
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Hibbert PD, Molloy CJ, Schultz TJ, Carson-Stevens A, Braithwaite J. Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic review. Int J Qual Health Care 2023; 35:mzad056. [PMID: 37440353 PMCID: PMC10367579 DOI: 10.1093/intqhc/mzad056] [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: 01/02/2023] [Revised: 06/21/2023] [Accepted: 07/11/2023] [Indexed: 07/15/2023] Open
Abstract
Many hospitals continue to use incident reporting systems (IRSs) as their primary patient safety data source. The information IRSs collect on the frequency of harm to patients [adverse events (AEs)] is generally of poor quality, and some incident types (e.g. diagnostic errors) are under-reported. Other methods of collecting patient safety information using medical record review, such as the Global Trigger Tool (GTT), have been developed. The aim of this study was to undertake a systematic review to empirically quantify the gap between the percentage of AEs detected using the GTT to those that are also detected via IRSs. The review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies published in English, which collected AE data using the GTT and IRSs, were included. In total, 14 studies met the inclusion criteria. All studies were undertaken in hospitals and were published between 2006 and 2022. The studies were conducted in six countries, mainly in the USA (nine studies). Studies reviewed 22 589 medical records using the GTT across 107 institutions finding 7166 AEs. The percentage of AEs detected using the GTT that were also detected in corresponding IRSs ranged from 0% to 37.4% with an average of 7.0% (SD 9.1; median 3.9 and IQR 5.2). Twelve of the fourteen studies found <10% of the AEs detected using the GTT were also found in corresponding IRSs. The >10-fold gap between the detection rates of the GTT and IRSs is strong evidence that the rate of AEs collected in IRSs in hospitals should not be used to measure or as a proxy for the level of safety of a hospital. IRSs should be recognized for their strengths which are to detect rare, serious, and new incident types and to enable analysis of contributing and contextual factors to develop preventive and corrective strategies. Health systems should use multiple patient safety data sources to prioritize interventions and promote a cycle of action and improvement based on data rather than merely just collecting and analysing information.
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Affiliation(s)
- Peter D Hibbert
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, Macquarie Park, New South Wales 2109, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001, Australia
- South Australian Health and Medical Research Institute, North Terrace, Adelaide, South Australia 5000, Australia
| | - Charlotte J Molloy
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, Macquarie Park, New South Wales 2109, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001, Australia
- South Australian Health and Medical Research Institute, North Terrace, Adelaide, South Australia 5000, Australia
| | - Timothy J Schultz
- Flinders Health and Medical Research Institute, Flinders University, Sturt Rd, Bedford Park 5042, South Australia, Australia
| | - Andrew Carson-Stevens
- PRIME Centre Wales & Division of Population Medicine, Cardiff University, Heath Park, Cardiff, Wales CF14 4XN, United Kingdom
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, Macquarie Park, New South Wales 2109, Australia
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23
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Idilbi N, Dokhi M, Malka-Zeevi H, Rashkovits S. The Relationship Between Patient Safety Culture and the Intentions of the Nursing Staff to Report a Near-Miss Event During the COVID-19 Crisis. J Nurs Care Qual 2023; 38:264-271. [PMID: 36947813 DOI: 10.1097/ncq.0000000000000695] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
BACKGROUND Reporting a near-miss event has been associated with better patient safety culture. PURPOSE To examine the relationship between patient safety culture and nurses' intention to report a near-miss event during COVID-19, and factors predicting that intention. METHODS This mixed-methods study was conducted in a tertiary medical center during the fourth COVID-19 waves in 2020-2021 among 199 nurses working in COVID-19-dedicated departments. RESULTS Mean perception of patient safety culture was low overall. Although 77.4% of nurses intended to report a near-miss event, only 20.1% actually did. Five factors predicted nurses' intention to report a near-miss event; the model explains 20% of the variance. Poor departmental organization can adversely affect the intention to report a near-miss event. CONCLUSIONS Organizational learning, teamwork between hospital departments, transfers between departments, and departmental disorganization can affect intention to report a near-miss event and adversely affect patient safety culture during a health crisis.
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Affiliation(s)
- Nasra Idilbi
- Departments of Nursing (Dr Idilbi) and Health Systems Management (Dr Rashkovits), Max Stern Yezreel Valley Academic College, Emek Yezreel, Israel; Galilee Medical Center, Nahariya, Israel (Dr Idilbi and Mss Dokhi and Malka-Zeevi); and University of Haifa, Haifa, Israel (Ms Dokhi)
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24
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Abstract
PURPOSE OF REVIEW Learning from errors has been the main objective of patient safety initiatives for the last decades. The different tools have played a role in the evolution of the safety culture to a nonpunitive system-centered one. The model has shown its limits, and resilience and learning from success have been advocated as the key strategies to deal with healthcare complexity. We intend to review the recent experiences in applying these to learn about patient safety. RECENT FINDINGS Since the publication of the theoretical basis for resilient healthcare and Safety-II, there is a growing experience applying these concepts into reporting systems, safety huddles, and simulation training, as well as applying tools to detect discrepancies between the intended work as imagined when designing the procedures and the work as done when front-line healthcare providers face the real-life conditions. SUMMARY As part of the evolution in patient safety science, learning from errors has its function to open the mindset for the next step: implementing learning strategies beyond the error. The tools for it are ready to be adopted.
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Affiliation(s)
- Daniel Arnal-Velasco
- Unit of Anesthesiology and Reanimation, Hospital Universitario Fundacion Alcorcon, Alcorcon, Spain
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25
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Øyri SF, Søreide K, Søreide E, Tjomsland O. Learning from experience: a qualitative study of surgeons' perspectives on reporting and dealing with serious adverse events. BMJ Open Qual 2023; 12:bmjoq-2023-002368. [PMID: 37286299 DOI: 10.1136/bmjoq-2023-002368] [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: 04/04/2023] [Accepted: 05/27/2023] [Indexed: 06/09/2023] Open
Abstract
INTRODUCTION In surgery, serious adverse events have effects on the patient journey, the patient outcome and may constitute a burden to the surgeon involved. This study aims to investigate facilitators and barriers to transparency around, reporting of and learning from serious adverse events among surgeons. METHODS Based on a qualitative study design, we recruited 15 surgeons (4 females and 11 males) with 4 different surgical subspecialties from four Norwegian university hospitals. The participants underwent individual semistructured interviews and data were analysed according to principles of inductive qualitative content analysis. RESULTS AND DISCUSSION We identified four overarching themes. All surgeons reported having experienced serious adverse events, describing these as part of 'the nature of surgery'. Most surgeons reported that established strategies failed to combine facilitation of learning with taking care of the involved surgeons. Transparency about serious adverse events was by some felt as an extra burden, fearing that openness on technical-related errors could affect their future career negatively. Positive implications of transparency were linked with factors such as minimising the surgeon's feeling of personal burden with positive impact on individual and collective learning. A lack of facilitation of individual and structural transparency factors could entail 'collateral damage'. Our participants suggested that both the younger generation of surgeons in general, and the increasing number of women in surgical professions, might contribute to 'maturing' the culture of transparency. CONCLUSION AND IMPLICATIONS This study suggests that transparency associated with serious adverse events is hampered by concerns at both personal and professional levels among surgeons. These results emphasise the importance of improved systemic learning and the need for structural changes; it is crucial to increase the focus on education and training curriculums and offer advice on coping strategies and establish arenas for safe discussions after serious adverse events.
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Affiliation(s)
- Sina Furnes Øyri
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Stavanger University Hospital, Stavanger, Norway
- SHARE Centre for Resilience in Healthcare, University of Stavanger, Stavanger, Norway
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- SAFER Surgery, Surgical Research Group, Stavanger University Hospital, Stavanger, Norway
| | - Eldar Søreide
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Stavanger University Hospital, Stavanger, Norway
| | - Ole Tjomsland
- South-Eastern Norway Regional Health Authority, Oslo, Norway
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26
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Li P, Wang C, Zhou R, Tan L, Deng X, Zhu T, Chen G, Li W, Hao X. Development and evaluation of a data-driven integrated management app for perioperative adverse events: protocol for a mixed-design study. BMJ Open 2023; 13:e069754. [PMID: 37192808 DOI: 10.1136/bmjopen-2022-069754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
INTRODUCTION A patient record review study conducted in 2006 in a random sample of 21 Dutch hospitals found that 51%-77% of adverse events are related to perioperative care, while Centers for Disease Control and Prevention data in USA in 2013 estimated that the medical error is the third-leading cause of mortality. To capitalise on the potential of apps to enhance perioperative medical quality, there is a need for interventions developed in consultation with real-world users designed to support integrated management for perioperative adverse events (PAEs). This study aims: (1) to access the knowledge, attitude and practices for PAEs among physicians, nurses and administrators, and to identify the needs of healthcare providers for a mobile-based PAEs tool; (2) to develop a data-driven app for integrated PAE management that meets those needs and (3) to test the usability, clinical efficacy and cost-effectiveness of the developed app. METHODS AND ANALYSIS We will adopt an embedded mixed-methods research technique; qualitative data will be used to assess user needs and app adoption, while quantitative data will provide crucial insights to establish the demand for the app, and measure the app effects. Phase 1 will enrol surgery-related healthcare providers from the West China Hospital and identify their latent demand for mobile-based PAEs management using a self-designed questionnaire underpinned by the knowledge, attitude and practice model, as well as expert interviews. In phase 2, we will develop the app for integrated PAE management and test its effectiveness and sustainability. In phase 3, the effects on the total number and severity of reported PAEs will be evaluated using Poisson regression with interrupted time-series analysis over a 2-year period, while users' engagement, adherence, process evaluation and cost-effectiveness will be evaluated using quarterly surveys and interviews. ETHICS AND DISSEMINATION The West China Hospital of Sichuan University's Institutional Review Board authorised this study after approving the study protocol, permission forms and questionnaires (number: 2022-1364). Participants will be provided with study information, and informed written consent will be obtained. Study findings will be disseminated through peer-reviewed publications and conference presentations.
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Affiliation(s)
- Peiyi Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Research Unit for Perioperative Stress Assessment and Clinical Decision, Chinese Academy of Medical Sciences (2018RU012), West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ce Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Research Unit for Perioperative Stress Assessment and Clinical Decision, Chinese Academy of Medical Sciences (2018RU012), West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ruihao Zhou
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Research Unit for Perioperative Stress Assessment and Clinical Decision, Chinese Academy of Medical Sciences (2018RU012), West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lingcan Tan
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaoqian Deng
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Research Unit for Perioperative Stress Assessment and Clinical Decision, Chinese Academy of Medical Sciences (2018RU012), West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Guo Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Research Unit for Perioperative Stress Assessment and Clinical Decision, Chinese Academy of Medical Sciences (2018RU012), West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Weimin Li
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Frontiers Science Center for Disease-Related Molecular Network, Institute of Respiratory Health, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- President's Office, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xuechao Hao
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Research Unit for Perioperative Stress Assessment and Clinical Decision, Chinese Academy of Medical Sciences (2018RU012), West China Hospital, Sichuan University, Chengdu, Sichuan, China
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27
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Maeda Y, Kawahira H, Asada Y, Yamamoto S, Shimpo M. The effect of refresher training on fact description in medical incident report writing in the Japanese language. APPLIED ERGONOMICS 2023; 109:103987. [PMID: 36716527 DOI: 10.1016/j.apergo.2023.103987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/12/2022] [Accepted: 01/25/2023] [Indexed: 06/18/2023]
Abstract
To maintain the effectiveness of the training (1st-Training Session: 1st-TS) to accurate describe facts in the medical incident reports (IRs) in Japanese, a refresher TS was designed and its effectiveness was examined. First, textual analysis showed that IRs' accuracy significantly decreased six months after the 1st-TS. Based on this result, the refresher TS was designed and conducted with 64 residents. To verify the refresher TS' effectiveness, IRs after the 1st-TS, six months later, and after the refresher TS were compared via text analysis. The results showed that the refresher TS restored the description rate of patient's background, safety check procedures, original work procedures, information on equipment used, reporter's actions, and post-incident response. The questionnaire was also administered and showed that the refresher TS contributed to residents' motivation to learn about IRs. In conclusion, the refresher TS contributed to sustaining the effect of the 1st-TS on accurately describing IRs.
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Affiliation(s)
- Yoshitaka Maeda
- Medical Simulation Centre, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Hiroshi Kawahira
- Medical Simulation Centre, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Yoshikazu Asada
- Medical Education Centre, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Shinichi Yamamoto
- Centre for Graduate Medical Education, Jichi Medical University Hospital, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Masahisa Shimpo
- Centre for Quality Improvement and Patient Safety, Jichi Medical University Hospital, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
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28
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Uibu E, Põlluste K, Lember M, Toompere K, Kangasniemi M. Planned improvement actions based on patient safety incident reports in Estonian hospitals: a document analysis. BMJ Open Qual 2023; 12:bmjoq-2022-002058. [PMID: 37188481 DOI: 10.1136/bmjoq-2022-002058] [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: 07/18/2022] [Accepted: 05/05/2023] [Indexed: 05/17/2023] Open
Abstract
AIM Aim of this study was to describe and analyse associations of incidents and their improvement actions in hospital setting. METHODS It was a retrospective document analysis of incident reporting systems' reports registered during 2018-2019 in two Estonian regional hospitals. Data were extracted, organised, quantified and analysed by statistical methods. RESULTS In total, 1973 incident reports were analysed. The most commonly reported incidents were related to patient violent or self-harming behaviour (n=587), followed by patient accidents (n=379), and 40% of all incidents were non-harm incidents (n=782). Improvement actions were documented in 83% (n=1643) of all the reports and they were focused on (1) direct patient care, (2) staff-related actions; (3) equipment and general protocols and (4) environment and organisational issues. Improvement actions were mostly associated with medication and transfusion treatment and targeted to staff. The second often associated improvement actions were related to patient accidents and were mostly focused on that particular patient's further care. Improvement actions were mostly planned for incidents with moderate and mild harm, and for incidents involving children and adolescents. CONCLUSION Patient safety incidents-related improvement actions need to be considered as a strategy for long-term development in patient safety in organisations. It is vital for patient safety that the planned changes related to the reporting will be documented and implemented more visibly. As a result, it will boost the confidence in managers' work and strengthens all staff's commitment to patient safety initiatives in an organisation.
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Affiliation(s)
- Ere Uibu
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Kaja Põlluste
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Margus Lember
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Karolin Toompere
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Mari Kangasniemi
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
- Department of Nursing Science, University of Turku, Turku, Finland
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29
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Harris CK, Chen Y, Alston EL, Brown A, Chabot-Richards D, Dintzis SM, Graber ML, Jackups Jr. R, Lomo LC, Laudadio J, Markwood PS, Nielson KJ, Samedi V, Sampson B, Haspel RL, Zafar N, Montone KT, Childs J, White KL, Heher YK. The next phase in patient safety education: Towards a standardized, tools-based pathology patient safety curriculum: A call to action from the Association of Pathology Chairs' Residency Program Directors Section Training Residents in Patient Safety Workgroup. Acad Pathol 2023; 10:100081. [PMID: 37313035 PMCID: PMC10258240 DOI: 10.1016/j.acpath.2023.100081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/26/2023] [Accepted: 01/29/2023] [Indexed: 06/15/2023] Open
Abstract
Patient safety education is a mandated Common Program Requirement of the Accreditation Council for Graduate Medical Education and for the Royal College of Physicians and Surgeons of Canada in all medical residency and fellowship programs. Although many hospitals and healthcare environments have general patient safety education tools for trainees, few to none focus on the unique training milieu of pathologists, including a mix of highly automated and manual error-prone processes, frequent multiplicity of events, and lack of direct patient relationships for error disclosure. We established a national Association of Pathology Chairs-Program Directors Section Workgroup focused on patient safety education for pathology trainees entitled Training Residents in Patient Safety (TRIPS). TRIPS included diverse representatives from across the United States, as well as representatives from pathology organizations including the American Board of Pathology, the American Society for Clinical Pathology, the United States and Canadian Academy of Pathology, the College of American Pathologists, and the Society to Improve Diagnosis in Medicine. Objectives of the workgroup included developing a standardized patient safety curriculum, designing teaching and assessment tools, and refining them with pilot sites. Here we report the establishment of TRIPS as well as data from national needs assessment of Program Directors across the country, who confirmed the need for a standardized patient safety curriculum.
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Affiliation(s)
- Cynthia K. Harris
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- The New York City Office of Chief Medical Examiner, New York, NY, USA
| | - Yigu Chen
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Erin L. Alston
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Ali Brown
- American Society for Clinical Pathology, Chicago, IL, USA
| | | | - Suzanne M. Dintzis
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Mark L. Graber
- Society to Improve Diagnosis in Medicine, Evanston, IL, USA
| | - Ronald Jackups Jr.
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Lesley C. Lomo
- Department of Pathology, University of Utah Health, Salt Lake City, UT, USA
| | - Jennifer Laudadio
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | - Von Samedi
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Barbara Sampson
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Richard L. Haspel
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Nadeem Zafar
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Kathleen T. Montone
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John Childs
- Department of Pathology, Geisinger Medical Center, Danville, PA, USA
| | - Kristie L. White
- Departments of Pathology and Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Yael K. Heher
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
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30
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Hyvämäki P, Sneck S, Meriläinen M, Pikkarainen M, Kääriäinen M, Jansson M. Interorganizational health information exchange-related patient safety incidents: A descriptive register-based qualitative study. Int J Med Inform 2023; 174:105045. [PMID: 36958225 DOI: 10.1016/j.ijmedinf.2023.105045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 01/13/2023] [Accepted: 03/12/2023] [Indexed: 03/19/2023]
Abstract
PURPOSE The current literature related to patient safety of interorganizational health information is fragmented. This study aims to identify interorganizational health information exchange-related patient safety incidents occurring in the emergency department, emergency medical services, and home care. The research also aimed to describe the causes and consequences of these incidents. METHODS A total of sixty (n = 60) interorganizational health information exchange-related patient safety incident free text reports were analyzed. The reports were reported in the emergency department, emergency medical services, or home care between January 2016 and December 2019 in one hospital district in Finland. RESULTS The identified interorganizational health information exchange-related incidents were grouped under two main categories: "Inadequate documentation"; and "Inadequate use of information". The causes of these incidents were grouped under the two main categories "Factors related to the healthcare professional " and "Organizational factors", while the consequences of these incidents fell under the two main categories "Adverse events" and "Additional actions to prevent, avoid, and correct adverse events". CONCLUSION This study shows that the inadequate documentation and use of information is mainly caused by factors related to the healthcare professional and organization, including technical problems. These incidents cause adverse events and additional actions to prevent, avoid, and correct the events. The sociotechnical perspective, including factors related to health care professionals, organization, and technology, should be emphasized in patient safety development of inter-organizational health information exchange and it will be the focus of our future research. Continuous research and development work is needed because the processes and information systems used in health care are constantly evolving.
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Affiliation(s)
- Piia Hyvämäki
- Research Unit of Health Sciences and Technology, University of Oulu, Finland; Oulu University of Applied Sciences, Oulu, Finland.
| | - Sami Sneck
- Oulu University Hospital, Nursing Administration, Oulu, Finland.
| | - Merja Meriläinen
- Oulu University Hospital, Nursing Administration, Oulu, Finland; Medical Research Center Oulu, MRC.
| | - Minna Pikkarainen
- Department for Rehabilitation Science and Health Technology & Department of Product Design Oslomet, Oslo Metropolitan University, Finland.
| | - Maria Kääriäinen
- Research Unit of Health Sciences and Technology, University of Oulu, Finland; The Finnish Centre for Evidence-Based Health Care: A Joanna Briggs Institute Excellence Group, Helsinki, Finland.
| | - Miia Jansson
- Research Unit of Health Sciences and Technology, University of Oulu, Oulu, Finland; RMIT University, Australia.
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31
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Blankenship JC, Doll JA, Latif F, Truesdell AG, Young MN, Ibebuogu UN, Vallabhajosyula S, Kadavath SM, Maestas CM, Vetrovec G, Welt F. Best Practices for Cardiac Catheterization Laboratory Morbidity and Mortality Conferences. JACC Cardiovasc Interv 2023; 16:503-514. [PMID: 36922035 DOI: 10.1016/j.jcin.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/19/2022] [Accepted: 10/04/2022] [Indexed: 03/18/2023]
Abstract
Cardiac catheterization laboratory (CCL) morbidity and mortality conferences (MMCs) are a critical component of CCL quality improvement programs and are important for the education of cardiology trainees and the lifelong learning of CCL physicians and team members. Despite their fundamental role in the functioning of the CCL, no consensus exists on how CCL MMCs should identify and select cases for review, how they should be conducted, and how results should be used to improve CCL quality. In addition, medicolegal ramifications of CCL MMCs are not well understood. This document from the American College of Cardiology's Interventional Section attempts to clarify current issues and options in the conduct of CCL MMCs and to recommend best practices for their conduct.
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Affiliation(s)
- James C Blankenship
- Division of Cardiology, University of New Mexico, Albuquerque, New Mexico, USA.
| | - Jacob A Doll
- University of Washington, Seattle, Washington, USA
| | - Faisal Latif
- SSM Health St. Anthony Hospital, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | | | - Michael N Young
- Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Uzoma N Ibebuogu
- University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Camila M Maestas
- Virginia Commonwealth University Pauley Heart Center, Richmond, Virginia, USA
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Duffy CC, Bass GA, Yura C, Dymek M, Lorenzi C, Kaplan LJ, Clapp JT, Atkins JH. Thematic mapping of perioperative incident reporting data to relational coordination domains. J Interprof Care 2023; 37:245-253. [PMID: 36739556 DOI: 10.1080/13561820.2022.2057454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Communication failure is a common root cause of adverse clinical events. Problematic communication domains are difficult to decipher, and communication improvement strategies are scarce. This study compared perioperative incident reports (IR) identifying potential communication failures with the results of a contemporaneous peri-operative Relational Coordination (RC) survey. We hypothesised that IR-prevalent themes would map to areas-of-weakness identified in the RC survey. Perioperative IRs filed between 2018 and 2020 (n = 6,236) were manually reviewed to identify communication failures (n = 1049). The IRs were disaggregated into seven RC theory domains and compared with the RC survey. Report disaggregation ratings demonstrated a three-way inter-rater agreement of 91.2%. Of the 1,049 communication failure-related IRs, shared knowledge deficits (n = 479, 46%) or accurate communication (n = 465, 44%) were most frequently identified. Communication frequency failures (n = 3, 0.3%) were rarely coded. Comparatively, shared knowledge was the weakest domain in the RC survey, while communication frequency was the strongest, correlating well with our IR data. Linking IR with RC domains offers a novel approach to assessing the specific elements of communication failures with an acute care facility. This approach provides a deployable mechanism to trend intra- and inter-domain progress in communication success, and develop targeted interventions to mitigate against communication failure-related adverse events.
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Affiliation(s)
- Caoimhe C Duffy
- Department of Anesthesiology & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Perioperative & Procedural Services, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gary A Bass
- Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Chris Yura
- Division of Perioperative & Procedural Services, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Malwina Dymek
- Department of Anesthesiology & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Cara Lorenzi
- Division of Perioperative & Procedural Services, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Section of Surgical Critical Care, Corporal Michael Crescencz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Justin T Clapp
- Department of Anesthesiology & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua H Atkins
- Department of Anesthesiology & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Identifying Safety Practices Perceived as Low Value: An Exploratory Survey of Healthcare Staff in the United Kingdom and Australia. J Patient Saf 2023; 19:143-150. [PMID: 36729436 PMCID: PMC9940841 DOI: 10.1097/pts.0000000000001091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Up to 30% of healthcare spending is considered unnecessary and represents systematic waste. While much attention has been given to low-value clinical tests and treatments, much less has focused on identifying low-value safety practices in healthcare settings. With increasing recognition of the problem of "safety clutter" in organizations, it is important to consider deimplementing safety practices that do not benefit patients, to create the time needed to deliver effective, person-centered, and safe care. This study surveyed healthcare staff to identify safety practices perceived to be of low value. METHODS Purposive and snowball sampling was used. Data collection was conducted from April 2018 to November 2019 (United Kingdom) and May 2020 to November 2020 (Australia). Participants completed the survey online or in hard copy to identify practices they perceived to not contribute to safe care. Responses were analyzed using content and thematic analysis. RESULTS A total of 1394 responses from 1041 participants were analyzed. Six hundred sixty-three responses were collected from 526 UK participants and 515 Australian participants contributed 731 responses. Frequently identified categories of practices identified included "paperwork," "duplication," and "intentional rounding." Five cross-cutting themes (e.g., covering ourselves) offered an underpinning rationale for why staff perceived the practices to be of low value. CONCLUSIONS Staff identified safety practices that they perceived to be low value. In healthcare systems under strain, removing existing low-value practices should be a priority. Careful evaluation of these identified safety practices is required to determine whether they are appropriate for deimplementation and, if not, to explore how to better support healthcare workers to perform them.
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Automated Capture of Intraoperative Adverse Events Using Artificial Intelligence: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12041687. [PMID: 36836223 PMCID: PMC9963108 DOI: 10.3390/jcm12041687] [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] [Received: 01/13/2023] [Revised: 02/08/2023] [Accepted: 02/14/2023] [Indexed: 02/22/2023] Open
Abstract
Intraoperative adverse events (iAEs) impact the outcomes of surgery, and yet are not routinely collected, graded, and reported. Advancements in artificial intelligence (AI) have the potential to power real-time, automatic detection of these events and disrupt the landscape of surgical safety through the prediction and mitigation of iAEs. We sought to understand the current implementation of AI in this space. A literature review was performed to PRISMA-DTA standards. Included articles were from all surgical specialties and reported the automatic identification of iAEs in real-time. Details on surgical specialty, adverse events, technology used for detecting iAEs, AI algorithm/validation, and reference standards/conventional parameters were extracted. A meta-analysis of algorithms with available data was conducted using a hierarchical summary receiver operating characteristic curve (ROC). The QUADAS-2 tool was used to assess the article risk of bias and clinical applicability. A total of 2982 studies were identified by searching PubMed, Scopus, Web of Science, and IEEE Xplore, with 13 articles included for data extraction. The AI algorithms detected bleeding (n = 7), vessel injury (n = 1), perfusion deficiencies (n = 1), thermal damage (n = 1), and EMG abnormalities (n = 1), among other iAEs. Nine of the thirteen articles described at least one validation method for the detection system; five explained using cross-validation and seven divided the dataset into training and validation cohorts. Meta-analysis showed the algorithms were both sensitive and specific across included iAEs (detection OR 14.74, CI 4.7-46.2). There was heterogeneity in reported outcome statistics and article bias risk. There is a need for standardization of iAE definitions, detection, and reporting to enhance surgical care for all patients. The heterogeneous applications of AI in the literature highlights the pluripotent nature of this technology. Applications of these algorithms across a breadth of urologic procedures should be investigated to assess the generalizability of these data.
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Nilsson L, Lindblad M, Johansson N, Säfström L, Schildmeijer K, Ekstedt M, Unbeck M. Exploring nursing-sensitive events in home healthcare: A national multicenter cohort study using a trigger tool. Int J Nurs Stud 2023; 138:104434. [PMID: 36630873 DOI: 10.1016/j.ijnurstu.2022.104434] [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: 10/07/2022] [Revised: 12/10/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND The provision of home healthcare is increasing in response to the growing aging population with the need for chronic disease management in their homes. Safety work differs from hospital care. The incidence of adverse events in home healthcare is sparsely studied but is estimated to occur in-one third of patients, and most are deemed preventable. Although nursing care is crucial for risk assessment and preventive work in the home environment, the role of registered nurses in the prevention of no-harm incidents and adverse events has not received sufficient scientific attention. OBJECTIVES To explore nursing-sensitive events in patients receiving home healthcare. DESIGN, SETTING AND PARTICIPANTS A Swedish national multicenter study based on a structured record review of 600 randomly chosen healthcare records from 10 organizations in different regions of the country. METHODS Ten trained teams, each including physician(s) and registered nurses, undertook a review based on the Global Trigger Tool method. The review covered a maximum of 90 days from admission to home healthcare. First, each record was screened for the presence of 38 predefined triggers. In the second step, every potential event was assessed according to preventability, types of events, severity, time of occurrence, consequences of the event, and potential contributing causes. RESULTS In total, 699 events were identified in the study. Of these, 495 (74.0%) were classified as nursing-sensitive (227 no-harm incidents and 268 adverse events) and affected 267 (44.5%) patients, with a mean of 1.9 events per patient. The majority (n = 367, 73.1%) were considered preventable. The most prominent types of nursing-sensitive event were falls (n = 138, 27.9%), pressure ulcers (n = 62, 12.5%), healthcare-associated infections (n = 58, 11.7%) and medication management (n = 50, 10.1%). Concerning severity, 45.9% were classified as no-harm incidents and another 36.6% resulted in temporary harm that required extra healthcare resources: 226 hospital days, 66 physician visits in outpatient care, and 99 in home healthcare. All severity types occurred from day 1, except death, which included only one patient. The most frequent contributing factors were deficiencies in nursing care, treatment & diagnosis, with the subgroups nursing care, observation, treatment & follow-up, followed by deficiencies in the organization. CONCLUSIONS Nursing-sensitive events in home healthcare are common, often preventable, and occur from the start of the care period. This study contributes to increased knowledge of patient safety shortcomings and points to the important role that registered nurses play in patient safety work.
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Affiliation(s)
- Lena Nilsson
- Department of Anaesthesiology and Intensive Care, Department of Medical and Health Sciences, Faculty of Medicine and Health Science, Linköping University, Linköping, Sweden.
| | - Marléne Lindblad
- Department of Health Sciences, Swedish Red Cross University, Stockholm, Sweden
| | - Nathalie Johansson
- School of Health and Welfare, Dalarna University, Falun, Sweden; Örsundsbro Health Center, Region Uppsala, Sweden
| | - Lisa Säfström
- School of Health and Welfare, Dalarna University, Falun, Sweden; Heby Home Health Care, Heby, Sweden
| | | | - Mirjam Ekstedt
- Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden; Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Maria Unbeck
- School of Health and Welfare, Dalarna University, Falun, Sweden; Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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Strengths and weaknesses of the incident reporting system: An Italian experience. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2023. [DOI: 10.1177/25160435221150568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
One of the cornerstones for enhancing the patient safety culture is the incident reporting system (IRS). It is a process for detecting, reporting, collecting, and summarizing adverse events (AEs) and near-misses in healthcare, and so it represents a vital tool for clinical risk management. We analyzed the 5-year experience of a third-level hospital's IRSs, showing its trends and highlighting its main strengths and weaknesses. Patients’ falls and physical or verbal aggression toward the providers or between patients are the most reported events. Underreporting is the main limitation of the system, especially among nurses. Visible actions, forceful analysis of the reports, operators’ education, no-blame culture promotion, and organizational adjustments may improve operators’ adherence to IRS. Providers do not willingly inform patients’ relatives about fatal incidents. Despite that, the IRS is far from its potential, and the number of data collected has increased.
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Ruano-Ferrer F, Gutiérrez- Giner MI. Safety perception in the operating environment: The nurses' perspective versus that of the surgeons. Heliyon 2023; 9:e12676. [PMID: 36685413 PMCID: PMC9849966 DOI: 10.1016/j.heliyon.2022.e12676] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 01/06/2023] Open
Abstract
Background Adverse effects due to surgery occur in 25% of patients, and the patient safety perception seems to differ between nurses and surgeons in the operating room (OR). This difference can be attributed to lack of communication. However, our hospital has not conducted any studies on patient safety climate (PSC) in the OR. Aims To determine if the perception of PSC of nurses and surgeons in the OR diverges and understand whether these differences could be explained by communication gap. Methods A total of 42 perioperative nurses and 44 surgeons in the OR of a tertiary hospital answered the Spanish version of the US Hospital Survey on PSC. This was an observational, cross-sectional study with descriptive statistics and a non-parametric test. Results Nurses had a worse perception of the dimensions of overall safety, leader expectations, teamwork within units, feedback, staffing, and hospital management (p < .05). Although no differences were found concerning organizational learning/continuous improvement, communication openness, nonpunitive responses, and teamwork across hospital unit dimensions, the findings suggest that the nurses' perception was worse than that of the surgeons. Conclusions In general, OR nurses have worse PSC than surgeons, mainly in the areas where communication it's important. Our study has provided the data that will enable the hospital management team to make decisions to improve the PSC in the operating room area. We recommend a more active presence of nurses in directive teams.
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Affiliation(s)
- Fátima Ruano-Ferrer
- Hospital Universitario Materno-Infantil (HUMIC). Universidad de Las Palmas de Gran Canaria, Avenida Marítima del Sur, S/n, 35016, Las Palmas de Gran Canaria, Las Palmas, Spain,Corresponding author.
| | - María Isabel Gutiérrez- Giner
- Complejo Hospitalario Universitario Insular-Materno Infantil, Universidad de Las Palmas de Gran Canaria, Avenida Marítima del Sur, S/n, 35016, Las Palmas de Gran Canaria, Las Palmas, Spain
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Elsayed MM, Makram AM, Alresheedi AA, Makram OM. Electronic Occurrence Variance Reporting System: A Reliable Multi-Platform System for the Low-income Settings. HEALTH POLICY AND TECHNOLOGY 2023. [DOI: 10.1016/j.hlpt.2022.100720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Uematsu H, Uemura M, Kurihara M, Umemura T, Hiramatsu M, Kitano F, Fukami T, Nagao Y. Development of a Novel Scoring System to Quantify the Severity of Incident Reports: An Exploratory Research Study. J Med Syst 2022; 46:106. [PMID: 36503962 DOI: 10.1007/s10916-022-01893-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 11/18/2022] [Indexed: 12/14/2022]
Abstract
Incident reporting systems have been widely adopted to collect information about patient safety incidents. Much of the value of incident reports lies in the free-text section. Computer processing of semantic information may be helpful to analyze this. We developed a novel scoring system for decision making to assess the severity of incidents using the semantic characteristics of the text in incident reports, and compared its results with experts' opinions. We retrospectively analyzed free-text data from incident reports from January 2012 to September 2021 at Nagoya University Hospital, Aichi, Japan. The sample was allocated to training and validation datasets using the hold-out method. Morphological analysis was used to segment terms in the training dataset. We calculated a severity term score, a severity report score and severity group score, by report volume size, and compared these with conventional severity classifications by patient safety experts and reporters. We allocated 96,082 incident reports into two groups. We calculated 1,802 severity term scores from the 48,041 reports in the training dataset. There was a significant difference in severity report score between reports categorized as severe and not severe by experts (95% confidence interval [CI] -0.83 to -0.80, p < 0.001, d = 0.81). Severity group scores were positively associated with severity ratings from experts and reporters (correlation coefficients 0.73 [95% CI 0.63-0.80, p < 0.001] and 0.79 [95% CI 0.71-0.85, p < 0.001]) for all departments. Our severity scoring system could therefore contribute to better organizational patient safety.
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Affiliation(s)
- Haruhiro Uematsu
- Department of Patient Safety, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, 466-8560, Nagoya, Japan.
| | - Masakazu Uemura
- Department of Patient Safety, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, 466-8560, Nagoya, Japan
| | - Masaru Kurihara
- Department of Patient Safety, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, 466-8560, Nagoya, Japan
| | - Tomomi Umemura
- Department of Patient Safety, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, 466-8560, Nagoya, Japan
| | - Mariko Hiramatsu
- Department of Patient Safety, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, 466-8560, Nagoya, Japan
| | - Fumimasa Kitano
- Department of Patient Safety, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, 466-8560, Nagoya, Japan
| | - Tatsuya Fukami
- Department of Patient Safety, Shimane University Hospital, Izumo, Japan
| | - Yoshimasa Nagao
- Department of Patient Safety, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, 466-8560, Nagoya, Japan
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Harb NH, Said PA, Gusta SL, Wesson AM, Brautigam JD, Lemke JH, DeLessio ST, Cropper DP, Shammas NW. A Regional Health System Journey from Volume to Value: Roadmap to the Recognition as a 15 Top Health System in the USA for Quality Excellence. J Healthc Leadersh 2022; 14:203-213. [PMID: 36506852 PMCID: PMC9733692 DOI: 10.2147/jhl.s378664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
The 15 Top Health System program, an IBM Watson study, objectively measures health systems' performance overall on an annual basis using publicly reported data available from the Center for Medicare and Medicaid Services (CMS) and state data banks. Genesis Health System was recognized as an IBM Watson Health 15 Top Health System for two consecutive years in 2020 and 2021. A system-based approach with a "physician-lead, professionally-managed" framework, led to accomplishing the 15 Top Health System. The steps needed included adoption of the IBM Watson database to determine current status of certain key performance indicators, establishing a clinical effectiveness program and governance structure, and adopting Lean methodologies to analyze and determine appropriate interventions with long-term solution. The desire and willingness to accomplish this ambitious goal start with adoption by the Board and the administration of the health system while supplying appropriate financial and human resources that are dedicated to the success of the journey. In this manuscript, we describe the journey and steps implemented to accomplish the outcomes that led to the recognition as a 15 Top Health System for quality excellence.
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Affiliation(s)
- Nidal H Harb
- Quality and Safety Department, Genesis Health System, Davenport, IA, USA,Cardiovascular Division, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Patricia A Said
- Quality and Safety Department, Genesis Health System, Davenport, IA, USA
| | - Shirley L Gusta
- Quality and Safety Department, Genesis Health System, Davenport, IA, USA
| | - Amanda M Wesson
- Quality and Safety Department, Genesis Health System, Davenport, IA, USA
| | - Jordan D Brautigam
- Quality and Safety Department, Genesis Health System, Davenport, IA, USA
| | - Jon H Lemke
- Quality and Safety Department, Genesis Health System, Davenport, IA, USA
| | - Stephen T DeLessio
- Quality and Safety Department, Genesis Health System, Davenport, IA, USA
| | - Douglas P Cropper
- Quality and Safety Department, Genesis Health System, Davenport, IA, USA
| | - Nicolas W Shammas
- Quality and Safety Department, Genesis Health System, Davenport, IA, USA,Cardiology Research Unit, Midwest Cardiovascular Research Foundation, Davenport, IA, USA,Correspondence: Nicolas W Shammas, Midwest Cardiovascular Research Foundation, 630 E 4th Street, Davenport, IA, 52801, USA, Tel +1 563-320-0263, Email
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Vetrugno G, Foti F, Grassi VM, De-Giorgio F, Cambieri A, Ghisellini R, Clemente F, Marchese L, Sabatelli G, Delogu G, Frati P, Fineschi V. Malpractice Claims and Incident Reporting: Two Faces of the Same Coin? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192316253. [PMID: 36498327 PMCID: PMC9739332 DOI: 10.3390/ijerph192316253] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/25/2022] [Accepted: 12/01/2022] [Indexed: 05/27/2023]
Abstract
Incident reporting is an important method to identify risks because learning from the reports is crucial in developing and implementing effective improvements. A medical malpractice claims analysis is an important tool in any case. Both incident reports and claims show cases of damage caused to patients, despite incident reporting comprising near misses, cases where no event occurred and no-harm events. We therefore compare the two worlds to assess whether they are similar or definitively different. From 1 January 2014 to 31 December 2021, the claims database of Policlinico Universitario A. Gemelli IRCCS collected 843 claims. From 1 January 2020 to 31 December 2021, the incident-reporting database collected 1919 events. In order to compare the two, we used IBNR calculation, usually adopted by the insurance industry to determine loss to a company and to evaluate the real number of adverse events that occurred. Indeed, the number of reported adverse events almost overlapped with the total number of events, which is indicative that incurred-but-not-reported events are practically irrelevant. The distribution of damage events reported as claims in the period from 1 January 2020 to 31 December 2021 and related to incidents that occurred in the months of the same period, grouped by quarter, was then compared with the distribution of damage events reported as adverse events and sentinel events in the same period, grouped by quarter. The analysis of the claims database showed that the claims trend is slightly decreasing. However, the analysis of the reports database showed that, in the period 2020-2021, the reports trend was increasing. In our study, the comparison of the two, malpractice claims and incident reporting, documented many differences and weak areas of overlap. Nevertheless, this contribution represents the first attempt to compare the two and new studies focusing on single types of adverse events are, therefore, desirable.
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Affiliation(s)
- Giuseppe Vetrugno
- UOS Risk Management Fondazione Policlinico A. Gemelli IRCCS, Department of Health Surveillance and Bioethics, Section of Legal Medicine, School of Medicine, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy
| | - Federica Foti
- UOS Risk Management Fondazione Policlinico A. Gemelli IRCCS, Department of Health Surveillance and Bioethics, Section of Legal Medicine, School of Medicine, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy
| | - Vincenzo M. Grassi
- UOS Risk Management Fondazione Policlinico A. Gemelli IRCCS, Department of Health Surveillance and Bioethics, Section of Legal Medicine, School of Medicine, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy
| | - Fabio De-Giorgio
- UOS Risk Management Fondazione Policlinico A. Gemelli IRCCS, Department of Health Surveillance and Bioethics, Section of Legal Medicine, School of Medicine, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy
| | - Andrea Cambieri
- UOS Risk Management Fondazione Policlinico A. Gemelli IRCCS, Department of Health Surveillance and Bioethics, Section of Legal Medicine, School of Medicine, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy
- Fondazione Policlinico A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
| | | | - Francesco Clemente
- UOS Risk Management Fondazione Policlinico A. Gemelli IRCCS, Department of Health Surveillance and Bioethics, Section of Legal Medicine, School of Medicine, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy
| | - Luca Marchese
- UOS Risk Management Fondazione Policlinico A. Gemelli IRCCS, Department of Health Surveillance and Bioethics, Section of Legal Medicine, School of Medicine, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy
| | - Giuseppe Sabatelli
- Responsabile Centro Regionale Rischio Clinico Regione Lazio, 00145 Rome, Italy
| | - Giuseppe Delogu
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00128 Rome, Italy
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00128 Rome, Italy
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00128 Rome, Italy
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Ramsey L, McHugh S, Simms-Ellis R, Perfetto K, O’Hara JK. Patient and Family Involvement in Serious Incident Investigations From the Perspectives of Key Stakeholders: A Review of the Qualitative Evidence. J Patient Saf 2022; 18:e1203-e1210. [PMID: 35921645 PMCID: PMC9698195 DOI: 10.1097/pts.0000000000001054] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Investigations of healthcare harm often overlook the valuable insights of patients and families. Our review aimed to explore the perspectives of key stakeholders when patients and families were involved in serious incident investigations. METHODS The authors searched three databases (Medline, PsycInfo, and CINAHL) and Connected Papers software for qualitative studies in which patients and families were involved in serious incident investigations until no new articles were found. RESULTS Twenty-seven papers were eligible. The perspectives of patients and families, healthcare professionals, nonclinical staff, and legal staff were sought across acute, mental health and maternity settings. Most patients and families valued being involved; however, it was important that investigations were flexible and sensitive to both clinical and emotional aspects of care to avoid compounding harm. This included the following: early active listening with empathy for trauma, sincere and timely apology, fostering trust and transparency, making realistic timelines clear, and establishing effective nonadversarial communication. Most staff perceived that patient and family involvement could improve investigation quality, promote an open culture, and help ensure future safety. However, it was made difficult when multidisciplinary input was absent, workload and staff turnover were high, training and support needs were unmet, and fears surrounded litigation. Potential solutions included enhancing the clarity of roles and responsibilities, adequately training staff, and providing long and short-term support to stakeholders. CONCLUSIONS Our review provides insights to ensure patient and family involvement in serious incident investigations considers both clinical and emotional aspects of care, is meaningful for all key stakeholders, and avoids compounding harm. However, significant gaps in the literature remain.
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Affiliation(s)
- Lauren Ramsey
- From the Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary Duckworth Lane, Bradford, United Kingdom
| | - Siobhan McHugh
- From the Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary Duckworth Lane, Bradford, United Kingdom
| | - Ruth Simms-Ellis
- From the Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary Duckworth Lane, Bradford, United Kingdom
| | | | - Jane K. O’Hara
- From the Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary Duckworth Lane, Bradford, United Kingdom
- University of Leeds School of Healthcare, 3 Beech Grove Terrace, Woodhouse, Leeds, United Kingdom
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Feng T, Zhang X, Tan L, Su Y, Liu H. Near-miss organizational learning in nursing within a tertiary hospital: a mixed methods study. BMC Nurs 2022; 21:315. [PMID: 36380309 PMCID: PMC9667619 DOI: 10.1186/s12912-022-01071-1] [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: 01/06/2022] [Revised: 10/05/2022] [Accepted: 10/10/2022] [Indexed: 11/17/2022] Open
Abstract
Background Near-miss organizational learning is important for perspective and proactive risk management. Although nursing organizations are the largest component of the healthcare system and act as the final safety barrier, there is little research about the current status of near-miss organizational learning. Thus, we conducted this study to explore near-miss organizational learning in a Chinese nursing organization and offer suggestions for future improvement. Methods This was a mixed methods study with an explanatory sequence. It was conducted in a Chinese nursing organization of a tertiary hospital under the guidance of the 4I Framework of Organizational Learning. The quantitative study surveyed 600 nurses by simple random sampling. Then, we applied purposive sampling to recruit 16 nurses across managerial levels from low-, middle- and high-scored nursing units and conducted semi-structured interviews. Descriptive statistics, structured equation modelling and content analysis were applied in the data analysis. The Good Reporting of A Mixed Methods Study (GRAMMS) checklist was used to report this study. Results Only 33% of participants correctly recognized near-misses, and 4% of participants always reported near-misses. The 4I Framework of Organizational Learning was verified in the surveyed nursing organization (χ2 = 0.775, p = 0.379, RMSEA < 0.01). The current organizational learning behaviour was not conducive to near-miss organizational learning due to poor group-level learning (βGG = 0.284) and poor learning absorption (βMisalignment= -0.339). In addition, the researchers developed 13 codes, 9 categories and 5 themes to depict near-miss organizational learning, which were characterized by nurses’ unfamiliarity with near-misses, preferences and the dominance of first-order problem-solving behaviour, the suspension of near-miss learning at the group level and poor learning absorption. Conclusion The performance of near-miss organizational learning is unsatisfactory across all levels in surveyed nursing organization, especially with regard to group-level learning and poor learning absorption. Our research findings offer a scientific and comprehensive description of near-miss organizational learning and shed light on how to measure and improve near-miss organizational learning in the future. Supplementary information The online version contains supplementary material available at 10.1186/s12912-022-01071-1.
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Abuosi AA, Poku CA, Attafuah PYA, Anaba EA, Abor PA, Setordji A, Nketiah-Amponsah E. Safety culture and adverse event reporting in Ghanaian healthcare facilities: Implications for patient safety. PLoS One 2022; 17:e0275606. [PMID: 36260634 PMCID: PMC9581362 DOI: 10.1371/journal.pone.0275606] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 09/20/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Recognizing the values and norms significant to healthcare organizations (Safety Culture) are the prerequisites for safety and quality care. Understanding the safety culture is essential for improving undesirable workforce attitudes and behaviours such as lack of adverse event reporting. The study assessed the frequency of adverse event reporting, the patient safety culture determinants of the adverse event reporting, and the implications for Ghanaian healthcare facilities. METHODS The study employed a multi-centre cross-sectional survey on 1651 health professionals in 13 healthcare facilities in Ghana using the Survey on Patient Safety (SOPS) Culture, Hospital Survey questionnaire. Analyses included descriptive, Spearman Rho correlation, one-way ANOVA, and a Binary logistic regression model. RESULTS The majority of health professionals had at least reported adverse events in the past 12 months across all 13 healthcare facilities. Teamwork (Mean: 4.18, SD: 0.566) and response to errors (Mean: 3.40, SD: 0.742) were the satisfactory patient safety culture. The patient safety culture dimensions were statistically significant (χ2 (9, N = 1642) = 69.28, p < .001) in distinguishing between participants who frequently reported adverse events and otherwise. CONCLUSION Promoting an effective patient safety culture is the ultimate way to overcome the challenges of adverse event reporting, and this can effectively be dealt with by developing policies to regulate the incidence and reporting of adverse events. The quality of healthcare and patient safety can also be enhanced when healthcare managers dedicate adequate support and resources to ensure teamwork, effective communication, and blame-free culture.
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Affiliation(s)
- Aaron Asibi Abuosi
- Department of Public Administration and Health Services Management, University of Ghana Business School, Legon, Ghana
| | - Collins Atta Poku
- Department of Nursing, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Department of Research, Education, and Administration, School of Nursing and Midwifery, University of Ghana, Legon, Ghana
| | - Priscilla Y. A. Attafuah
- Department of Community Health Nursing, School of Nursing and Midwifery, University of Ghana, Legon, Ghana
| | - Emmanuel Anongeba Anaba
- Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Legon, Ghana
| | - Patience Aseweh Abor
- Department of Public Administration and Health Services Management, University of Ghana Business School, Legon, Ghana
| | - Adelaide Setordji
- Department of Public Administration and Health Services Management, University of Ghana Business School, Legon, Ghana
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Ozonoff A, Milliren CE, Fournier K, Welcher J, Landschaft A, Samnaliev M, Saluvan M, Waltzman M, Kimia AA. Electronic surveillance of patient safety events using natural language processing. Health Informatics J 2022; 28:14604582221132429. [PMID: 36330784 DOI: 10.1177/14604582221132429] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Objective We describe our approach to surveillance of reportable safety events captured in hospital data including free-text clinical notes. We hypothesize that a) some patient safety events are documented only in the clinical notes and not in any other accessible source; and b) large-scale abstraction of event data from clinical notes is feasible. Materials and Methods We use regular expressions to generate a training data set for a machine learning model and apply this model to the full set of clinical notes and conduct further review to identify safety events of interest. We demonstrate this approach on peripheral intravenous (PIV) infiltrations and extravasations (PIVIEs). Results During Phase 1, we collected 21,362 clinical notes, of which 2342 were reviewed. We identified 125 PIV events, of which 44 cases (35%) were not captured by other patient safety systems. During Phase 2, we collected 60,735 clinical notes and identified 440 infiltrate events. Our classifier demonstrated accuracy above 90%. Conclusion Our method to identify safety events from the free text of clinical documentation offers a feasible and scalable approach to enhance existing patient safety systems. Expert reviewers, using a machine learning model, can conduct routine surveillance of patient safety events.
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Affiliation(s)
- Al Ozonoff
- Boston Children’s Hospital, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | | | | | | | - Mihail Samnaliev
- Boston Children’s Hospital, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Mark Waltzman
- Boston Children’s Hospital, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Amir A Kimia
- Boston Children’s Hospital, MA, USA
- Harvard Medical School, Boston, MA, USA
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Shah F, Falconer EA, Cimiotti JP. Does Root Cause Analysis Improve Patient Safety? A Systematic Review at the Department of Veterans Affairs. Qual Manag Health Care 2022; 31:231-241. [PMID: 35170581 DOI: 10.1097/qmh.0000000000000344] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES While root cause analysis (RCA) is used to analyze medical errors with a systems approach, evidence demonstrating its effectiveness in reducing patient harm remains sparse. The heterogeneity of the RCA methodology at different health care organizations has posed challenges to studying its value. The Department of Veterans Affairs (VA) has an established and standardized RCA approach, making it an ideal context to study RCA's impact. This review assessed whether implemented interventions recommended by RCAs were effective in mitigating preventable adverse events at the VA. METHODS PubMed, Web of Science, CINAHL and Business Source were searched for studies on RCAs performed at the VA that evaluated effectiveness of interventions and were published between 2010 and 2020. The Appraisal Tool for Cross-sectional Studies (AXIS) was used to assess bias of bias. RESULTS The majority of studies eliminated during our eligibility process reported on RCAs without attention to their specific impact on patient safety. Ten retrospective studies met inclusion criteria and were part of the final review. Studies were grouped into adverse events related to incorrect surgical/invasive procedures, suicides, falls with injury, and all-cause adverse events. Six studies reported on effectiveness by demonstrating quantitative changes in adverse events over time or by location following a specific intervention. Four studies reported on the effectiveness of implemented interventions using a facility-based rating of "much better" or "better." CONCLUSIONS Of the studies included in this review, all reported improvements following interventions implemented after RCAs, but with variability in study definitions and methodology to assess effectiveness. Increased reporting of outcomes following RCAs, with an emphasis on quantitative patient-related outcome measures, is needed to demonstrate the impact and value of the RCA.
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Affiliation(s)
- Freny Shah
- Department of Education, Atlanta VA Health Care System, Decatur, Georgia (Drs Shah and Falconer); Departments of Medicine (Dr Shah) and Surgery (Dr Falconer), Emory University School of Medicine, Atlanta, Georgia; and Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia (Dr Cimiotti)
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Stayt LC, Merriman C, Bench S, Price A, Vollam S, Walthall H, Credland N, Gerber K, Calovski V. ‘Doing the best we can’: Registered Nurses' experiences and perceptions of patient safety in intensive care during
COVID
‐19. J Adv Nurs 2022; 78:3371-3384. [PMID: 35986583 PMCID: PMC9538018 DOI: 10.1111/jan.15419] [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: 05/31/2022] [Revised: 07/16/2022] [Accepted: 08/03/2022] [Indexed: 11/27/2022]
Abstract
Aims To explore registered nurses' experiences of patient safety in intensive care during COVID‐19. Design A qualitative interview study informed by constructivism. Method Semi‐structured interviews were conducted and audio‐recorded with 19 registered nurses who worked in intensive care during COVID‐19 between May and July 2021. Interviews were transcribed verbatim and thematically analysed utilizing framework. Results Two key themes were identified. ‘On a war footing’—an unprecedented situation which describes the situation nurses faced, and the actions are taken to prepare for the safe delivery of care. ‘Doing the best we can’—Safe Delivery of Care which describes the ramifications of the actions taken on short‐ and long‐term patient safety including organization of care, missed and suboptimal care and communication. Both themes were embedded in the landscape of Staff Well‐being and Peer Support. Conclusion Nurses reported an increase in patient safety risks which they attributed to the dilution of skill mix and fragmentation of care. Nurses demonstrated an understanding of the holistic and long‐term impacts on patient safety and recovery from critical illness. Impact This study explored the perceived impact of COVID‐19 on patient safety in intensive care from a nursing perspective. Dilution of skill mix, where specialist critical care registered nurses were diluted with registered nurses with no critical care experience, and the fragmentation of care was perceived to lead to reduced quality of care and increased adverse events and risk of harm which were not consistently formally reported. Furthermore, nurses demonstrated a holistic and long‐term appreciation of patient safety. These findings should be considered as part of future nursing workforce modelling and patient safety strategies by intensive care leaders and managers. No public or patient contribution to this study. The study aims and objectives were developed in collaboration with health care professionals.
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Affiliation(s)
| | | | | | - Ann Price
- Canterbury Christ Church University Canterbury UK
| | - Sarah Vollam
- Nuffield Department of Clinical Neurosciences University of Oxford Oxford UK
- NIHR Oxford Biomedical Research Centre Oxford UK
| | - Helen Walthall
- Oxford University Hospitals NHS Foundation Trust and Oxford Biomedical Research Centre Oxford UK
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Mele F, Buongiorno L, Montalbò D, Ferorelli D, Solarino B, Zotti F, Carabellese FF, Catanesi R, Bertolino A, Dell'Erba A, Mandarelli G. Reporting Incidents in the Psychiatric Intensive Care Unit: A Retrospective Study in an Italian University Hospital. J Nerv Ment Dis 2022; 210:622-628. [PMID: 35394976 PMCID: PMC10860884 DOI: 10.1097/nmd.0000000000001504] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT To evaluate the characteristics of the reported workplace violence in a psychiatric intensive care unit (PICU) by analyzing an electronic hospital incident reporting system (IRS). One hundred thirty reports were retrieved from January 2017 to June 2020, referring to assaults committed by patients (71% males) with an average age of 29.8 years (SD, 14.9). The most frequent psychiatric diagnosis was a neurodevelopmental disorder (33%). Physical aggression (84%) was more frequent than the other types of aggression. Nurses and unlicensed assistive personnel were the most frequent victims (65%). Aggressions were more frequent on Friday (18%) and between 4 p.m. and 8 p.m. (35%). A total of 64.9% of the incidents happened in the first 5 days of hospitalization. A significant association between physical aggression and diagnosis of neurodevelopmental disorder emerged. IRS could be helpful to identify high-risk patient groups and develop clinical strategies to reduce adverse events in clinical practice.
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Affiliation(s)
- Federica Mele
- Section of Legal Medicine, Interdisciplinary Department of Medicine
| | - Luigi Buongiorno
- Section of Legal Medicine, Interdisciplinary Department of Medicine
| | | | - Davide Ferorelli
- Section of Legal Medicine, Interdisciplinary Department of Medicine
| | - Biagio Solarino
- Section of Legal Medicine, Interdisciplinary Department of Medicine
| | - Fiorenza Zotti
- Section of Legal Medicine, Interdisciplinary Department of Medicine
| | - Felice Francesco Carabellese
- Section of Criminology and Forensic Psychiatry, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Policlinico di Bari Hospital, Bari, Italy
| | - Roberto Catanesi
- Section of Criminology and Forensic Psychiatry, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Policlinico di Bari Hospital, Bari, Italy
| | | | | | - Gabriele Mandarelli
- Section of Criminology and Forensic Psychiatry, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Policlinico di Bari Hospital, Bari, Italy
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Maeda Y, Suzuki Y, Asada Y, Yamamoto S, Shimpo M, Kawahira H. Training residents in medical incident report writing to improve incident investigation quality and efficiency enables accurate fact gathering. APPLIED ERGONOMICS 2022; 102:103770. [PMID: 35427906 DOI: 10.1016/j.apergo.2022.103770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 06/14/2023]
Abstract
We assessed whether training on writing readable and accurate medical incident reports (IRs) improves the quality of fact description. In this training, 124 residents created fictional IRs. We provided tips, including using When, Where, Who, What, Why, How. We compared the fictional IRs with and without tips, and the trainees' and non-trainees' IRs submitted in the first five months after training. Results indicated that the subject words in IRs were more clarified and the readability was improved. The fictional IRs using tips were more accurate, with increased descriptions of the patient's background, reporter's actions, team members' actions and conversations, safety check procedures, result of the error, and post-incident response. The reporter's actions, work procedures, and environment were more clarified in the trainees' IRs than in the non-trainees' IRs. This training may help analysts comprehend the sequence of and underlying factors for reporter's actions based on IRs.
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Affiliation(s)
- Yoshitaka Maeda
- Medical Simulation Centre, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Yoshihiko Suzuki
- Medical Simulation Centre, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Yoshikazu Asada
- Medical Simulation Centre, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Shinichi Yamamoto
- Centre for Graduate Medical Education, Jichi Medical University Hospital, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Masahisa Shimpo
- Centre for Quality Improvement and Patient Safety, Jichi Medical University Hospital, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
| | - Hiroshi Kawahira
- Medical Simulation Centre, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
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Skoogh A, Bååth C, Hall-Lord ML. Healthcare professionals' perceptions of patient safety culture and teamwork in intrapartum care: a cross-sectional study. BMC Health Serv Res 2022; 22:820. [PMID: 35751067 PMCID: PMC9229856 DOI: 10.1186/s12913-022-08145-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/30/2022] [Indexed: 11/10/2022] Open
Abstract
Background In complex healthcare organizations, such as intrapartum care, both patient safety culture and teamwork are important aspects of patient safety. Patient safety culture is important for the values and norms shared by interprofessional teams in an organization, and such values are principles that guide team members’ behavior. The aim of this study was 1) to investigate differences in perceptions of patient safety culture and teamwork between professions (midwives, physicians, nursing assistants) and between labor wards in intrapartum care and 2) to explore the potential associations between teamwork and overall perceptions of patient safety and frequency of events reported. Methods The design was cross-sectional, using the Swedish version of the Hospital Survey on Patient Safety Culture (14 dimensions) and the TeamSTEPPS® Teamwork Perceptions Questionnaire (5 dimensions). Midwives, physicians, and nursing assistants in three labor wards in Sweden in 2018 were included. Descriptive statistics, the Kruskal–Wallis H test, two-way ANOVA, and standard multiple regression analysis were used. Results The questionnaires were completed by 184 of the 365 healthcare professionals, giving a response rate of 50.4%. Two-way ANOVA showed a significant main effect of profession on two patient safety culture dimensions and one teamwork dimension and a significant main effect of labor ward on four patient safety culture dimensions and four teamwork dimensions. A significant interaction effect of profession and labor ward was found on four patient safety culture dimensions and four teamwork dimensions. The regression analysis revealed that four out of the five teamwork dimensions explained 40% of the variance in the outcome dimension ´Overall perceptions of patient safety´. Conclusions The results of the study indicate that profession and labor ward are important for healthcare professionals' perceptions of patient safety culture and teamwork in intrapartum care. Teamwork perceptions are significant for overall patient safety.
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Affiliation(s)
- Annika Skoogh
- Department of Health Sciences, Faculty of Health, Science and Technology, Karlstad University, S-651 88, Karlstad, Sweden.
| | - Carina Bååth
- Department of Health Sciences, Faculty of Health, Science and Technology, Karlstad University, S-651 88, Karlstad, Sweden.,Faculty of Health, Welfare and Organisation, Østfold University College, P.O. Box 700, 1757, Halden, Norway
| | - Marie Louise Hall-Lord
- Department of Health Sciences, Faculty of Health, Science and Technology, Karlstad University, S-651 88, Karlstad, Sweden.,Department of Health Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Teknologivn. 22, 2815, Gjøvik, Norway
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