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Khan A, Farooq A, Elfallal W, Gandhi R, Vinas F, Boquet AJ. Application of broken windows theory to identify flow disruptions in neurosurgery procedure. J Healthc Risk Manag 2024; 43:7-15. [PMID: 38291324 DOI: 10.1002/jhrm.21565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/04/2024] [Indexed: 02/01/2024]
Abstract
Addressing flow disruptions (FDs) in neurosurgery requires a multifaceted approach. Strategies like improved communication protocols, minimizing interruptions, improving coordination among team, optimizing operating room layout, and promoting user-centered design can help mitigate the challenges and enhance the overall flow and safety of neurosurgical procedures. Thirty neurosurgery cases were observed at two tertiary care facilities. The data collected were from wheels into the operating room to wheels out from the operating room. Data points were categorized using a human factors taxonomy known as RIPCHORD-TWA (Realizing Improved Patient Care Through Human-Centered Operating Room Design for Threat Window Analysis). Of the 541 total disruptions observed, coordination issues were the most prevalent (26.25%), followed by layout issues (26.06%), issues related to interruption (22.55%), communication (22.37%), equipment issues (2.40%) and usability issues (0.37%) comprised the remainder of the observations. This translated into one disruption every 2.7 min. Instead of focusing exclusively on errors and adverse events, we propose conceptualizing the accumulation of disruptions as "threat windows" to analyze potential threats to the integrity of the care system. This perspective allows for the improved identification of system weaknesses or threats, affording us the ability to address these inefficiencies and intervene before errors and adverse events may occur.
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Affiliation(s)
- Asfandyar Khan
- Embry Riddle Aeronautical University, Daytona Beach, Florida, USA
| | - Aimen Farooq
- AdventHealth Gastroenterology Fellow, AdventHealth, Orlando, Florida, USA
| | - Wissam Elfallal
- AdventHealth Medical Group Neurosurgery, Neurosurgeon AdventHealth, Daytona Beach, Florida, USA
| | - Ravi Gandhi
- Neurosurgeon AdventHealth Physician Network, Orlando, Florida, USA
| | - Federico Vinas
- AdventHealth Medical Group Neurosurgery, Neurosurgeon AdventHealth, Daytona Beach, Florida, USA
| | - Albert J Boquet
- Embry Riddle Aeronautical University, Daytona Beach, Florida, USA
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Wright B, Baker T, Lennox A, Waxman B, Bragge P. Optimising acute non-critical inter-hospital transfers: A review of evidence, practice and patient perspectives. Aust J Rural Health 2024; 32:5-16. [PMID: 38108541 DOI: 10.1111/ajr.13080] [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: 02/18/2023] [Revised: 07/05/2023] [Accepted: 12/05/2023] [Indexed: 12/19/2023] Open
Abstract
INTRODUCTION Patients who present to hospital with an acute non-critical illness or injury, which is considered outside the capability framework of that hospital to treat, will require inter-hospital transfer (IHT) to a hospital with a higher level of capability for that condition. Delays in IHT can negatively impact patient care and patient outcomes. OBJECTIVE To review and synthesis academic evidence, practitioner insights and patient perspectives on ways to improve IHT from regional to metro hospitals. DESIGN A rapid review methodology identified one review and 14 primary studies. Twelve practitioner interviews identified insights into practice and implementation, and the patient perspectives were explored through a citizen panel with 15 participants. FINDINGS The rapid review found evidence relating to clinician and patient decision factors, protocols, communication practices and telemedicine. Practitioner interviews revealed challenges in making the initial decision, determining appropriate destinations and dealing with pushback. Adequate support and communication were raised as important to improve IHT. The citizen panel found that the main concern with IHT was delays. Citizen panel participants suggested dedicated transfer teams, education and information transfer systems to improve IHT. DISCUSSION AND CONCLUSION Common challenges in IHT include making the initial decision to transfer and communicating with other health services and patients and families. In identifying the appropriateness of transferring acute non-critical patients, clear and effective communication is central to appropriate and timely IHT; this evidence review indicates that education, protocols and information management could make IHT processes smoother.
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Affiliation(s)
- Breanna Wright
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, Clayton, Victoria, Australia
| | - Tim Baker
- Centre for Rural Emergency Medicine, Deakin University, Burwood, Victoria, Australia
| | - Alyse Lennox
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, Clayton, Victoria, Australia
| | - Bruce Waxman
- Bass Coast Health and Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, Clayton, Victoria, Australia
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Weigl M, Heinrich M, Rivas J, Bergmann F, Kurz M, Silbereisen C, Dieterich HJ, Kleine B, Riek S, Olivieri M, Hoffmann F, Lieftüchter V. Teamwork and mental workload in postsurgical pediatric patient handovers: Prospective effect evaluation of an improvement intervention for OR-PICU patient transitions. Eur J Pediatr 2023; 182:5637-5647. [PMID: 37819421 PMCID: PMC10746584 DOI: 10.1007/s00431-023-05241-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/13/2023]
Abstract
Postsurgical handover of pediatric patients from operating rooms (OR) to pediatric intensive care units (PICU) is a critical step. This transition is susceptible to errors and inefficiencies particularly if poor multidisciplinary teamwork occurs. Despite wide adoption of standardized handover interventions, comprehensive investigations into joint effects for patient care and provider outcomes are scarce. We aimed to improve OR-PICU handovers quality and sought to evaluate the intervention with particular attention to patient care effects and provider outcomes. A prospective, before-after-study design with an interrupted-series and a multi-source, mixed-methods evaluation approach was established. Drawing upon a participative plan-do-study-act approach, a standardized, checklist-based handover process was designed and implemented. For effect assessments, we observed OR-PICU handovers on site (pre implementation: n = 31, post: n = 30), respectively, with standardized expert observation and provider self-report tools (n = 111, n = 110). Setting was a tertiary Pediatric University Hospital. Supplementary qualitative, semi-structured interviews were conducted, and a general inductive content analysis approach was used to identify key facilitators and barriers on implementation. Improvement efforts focused on stepwise implementation of (1) standardized handover process and (2) a checklist for multi-professional OR-PICU handover communication. We observed significant increases in team and patient setup (pre: 79.3%, post: 98.6%, p < .01), enhanced team engagement (pre: 50%, post: 81.7%, p < .01), and comprehensive information transfer by the anesthesia sub-team (pre: 78.6%, post: 87.3%, p < .01). Expert-rated teamwork outcomes were consistently higher, yet self-reported teamwork did not change over time. Provider perceived stress and disruptions did not change, mental workload tended to decrease over time (pre: M = 3.2, post: 2.9, p = .08). Comprehensiveness of post-operative patient information reported by PICU physician increased significantly: pre: 65.9%, post: 76.2%, p < .05. After implementation, providers acknowledged the importance of standardized handover practices and associated benefits for facilitation of information transfer and comprehensiveness. Among reported barriers were obstacles during implementation as well as insufficient consideration of professionals' individual workflow after surgery. CONCLUSION A multidisciplinary intervention for postsurgical pediatric patient handovers was associated with improved expert-rated teamwork and fewer omissions of key patient information over time. Inconsistent results were obtained for provider-rated mental workload and teamwork outcomes. The findings contribute to a better understanding concerning the interplay of teamwork and provider cognitions in the course of establishing safe patient transitions in pediatric care. WHAT IS KNOWN • Transfer of critically ill children conveys significant challenges for interprofessional communication and teamwork. Prospective research into interventions for safe and efficient handover practices of OR PICU patient transitions is necessary. • Checklists are assumed to facilitate cognitive load among providers in acute clinical environments. WHAT IS NEW • A standardized, checklist-based handover intervention was associated with improvements in team set-up and information transfer. Provider outcomes such as mental workload and stress did not change over time. • The combination of teamwork and provider assessments allows a more nuanced understanding of implementation barriers and sustainable effects in course of OR-PICU handover interventions.
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Affiliation(s)
- Matthias Weigl
- Institute for Patient Safety, University Hospital, Bonn, 53127, Germany.
- Institute and Clinic for Occupational, Social and Environmental Medicine, LMU University Hospital, LMU Munich, Munich, Germany.
| | - Martina Heinrich
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, LMU University Hospital, LMU Munich, Munich, Germany
| | - Julia Rivas
- Institute and Clinic for Occupational, Social and Environmental Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Florian Bergmann
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, LMU University Hospital, LMU Munich, Munich, Germany
| | - Matthias Kurz
- Department of Anesthesiology, LMU University Hospital Munich, LMU Munich, Munich, Germany
| | - Clemens Silbereisen
- Department of Anesthesiology, LMU University Hospital Munich, LMU Munich, Munich, Germany
| | - Hans-Juergen Dieterich
- Department of Anesthesiology, LMU University Hospital Munich, LMU Munich, Munich, Germany
| | - Beate Kleine
- Department of Pediatrics, Dr. von Hauner Children's Hospital, LMU University Hospital, LMU Munich, Munich, Germany
| | - Susanne Riek
- Department of Pediatrics, Dr. von Hauner Children's Hospital, LMU University Hospital, LMU Munich, Munich, Germany
| | - Martin Olivieri
- Department of Pediatrics, Dr. von Hauner Children's Hospital, LMU University Hospital, LMU Munich, Munich, Germany
| | - Florian Hoffmann
- Department of Pediatrics, Dr. von Hauner Children's Hospital, LMU University Hospital, LMU Munich, Munich, Germany
| | - Victoria Lieftüchter
- Department of Pediatrics, Dr. von Hauner Children's Hospital, LMU University Hospital, LMU Munich, Munich, Germany
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Routly M, Gettis M, Thomas A, Macias J, Cherven B. Transferring critical pediatric patients from emergency department to intensive care: A quality improvement initiative. J Pediatr Nurs 2023; 72:e47-e52. [PMID: 37330276 DOI: 10.1016/j.pedn.2023.06.004] [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: 02/23/2023] [Revised: 05/30/2023] [Accepted: 06/04/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Transfer of care, moving hospitalized patients between care areas, is a critical point of vulnerability for healthcare organizations. Patient information handoff is an essential activity occurring frequently in hospital environments. Poor communication has been linked with adverse events and poor patient outcomes. This evidence-based quality project aimed to enhance the handoff process between the Emergency Department (ED) and Pediatric Intensive Care Unit (PICU) by standardizing transfer of care steps. This was accomplished through customizing a reporting tool to contain all the information the receiving department deemed necessary for safe patient care. METHODS A customized situation, background, assessment, recommendation (SBAR) form handoff tool was developed for ED to PICU transfers. This SBAR tool included information that PICU nurses identified as critical to transfer of care. Nurse perceptions were surveyed pre- and post-implementation. Patient safety event reports were tracked to evaluate events related to transfer of care before and after the practice change. FINDINGS An increased number of PICU nurses agreed the customized handoff tool was complete and organized. Additionally, more nurses agreed that handoff gave all information needed to safely care for critically ill patients transferred from the ED. Lastly, bedside patient checks increased, and patient safety events related to transfer of care decreased. DISCUSSION This project demonstrated that implementation of a standardized transfer of care process coupled with a customized handoff tool increased PICU nurse perceptions that handoff was organized, and all information needed to safely care for critically ill patients was conveyed. APPLICATION TO PRACTICE Transfer of care processes between the ED and PICU should be standardized. The use of customized tools may improve information exchange between nurses and ensure that all vital patient information is communicated.
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Affiliation(s)
- Maia Routly
- Children's Healthcare of Atlanta, Atlanta, GA, United States of America.
| | - Margaret Gettis
- Children's Healthcare of Atlanta, Atlanta, GA, United States of America; Nursing Research & Evidence Based Practice Department at Children's Healthcare of Atlanta, Atlanta, GA, United States of America
| | - Amy Thomas
- Children's Healthcare of Atlanta, Atlanta, GA, United States of America
| | - Jennifer Macias
- Children's Healthcare of Atlanta, Atlanta, GA, United States of America
| | - Brooke Cherven
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Atlanta, GA, United States of America; Nursing Research & Evidence Based Practice Department at Children's Healthcare of Atlanta, Atlanta, GA, United States of America; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States of America
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Lane-Fall MB, Koilor CB, Givan K, Klaiman T, Barg FK. Patient- and Team-Level Characteristics Associated with Handoff Protocol Fidelity in a Hybrid Implementation Study: Results from a Qualitative Comparative Analysis. Jt Comm J Qual Patient Saf 2023; 49:356-364. [PMID: 37208240 PMCID: PMC10524533 DOI: 10.1016/j.jcjq.2023.04.003] [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: 09/02/2022] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Standardization is an evidence-based approach to improve handoffs. The factors underpinning fidelity (that is, adherence) to standardized handoff protocols are not well specified, which hampers implementation and sustainability efforts. METHODS The Handoffs and Transitions in Critical Care (HATRICC) study (2014-2017) involved the creation and implementation of a standardized protocol for operating room (OR)-to-ICU handoffs in two mixed surgical ICUs. The present study used fuzzy-set qualitative comparative analysis (fsQCA) to characterize combinations of conditions associated with fidelity to the HATRICC protocol. Conditions were derived from postintervention handoff observations yielding quantitative and qualitative data. RESULTS Sixty handoffs had complete fidelity data. Four conditions from the SEIPS 2.0 model were used to explain fidelity: (1) whether the patient was newly admitted to the ICU; (2) presence of an ICU provider; (3) observer ratings of attention-paying by the handoff team; and (4) whether the handoff took place in a quiet environment. None of the conditions were singly necessary or sufficient for high fidelity. Three combinations of conditions were sufficient for fidelity: (1) presence of the ICU provider and high attention ratings; (2) a newly admitted patient, presence of the ICU provider, and quiet environment; and (3) a newly admitted patient, high attention ratings, and quiet environment. These three combinations explained 93.5% of the cases demonstrating high fidelity. CONCLUSION In a study of OR-to-ICU handoff standardization, multiple combinations of contextual factors were associated with handoff protocol fidelity. Handoff implementation efforts should consider multiple fidelity-promoting strategies that support these combinations of conditions.
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Starmer AJ, Michael MM, Spector ND, Riesenberg LA. Improving Handoffs in the Perioperative Environment: A Conceptual Framework of Key Theories, System Factors, Methods, and Core Interventions to Ensure Success. Jt Comm J Qual Patient Saf 2023:S1553-7250(23)00130-7. [PMID: 37423813 DOI: 10.1016/j.jcjq.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Patient handoffs involve the transition of information and responsibility for care from one health care provider to another. They occur frequently during a patient's perioperative care continuum, potentially introducing communication errors that could result in harmful, even fatal consequences. The perioperative environment poses distinct challenges to team communication and patient safety, which in turn leaves the surgical patient uniquely vulnerable to adverse events. CONCEPTUAL FRAMEWORK The best way to achieve safe, coordinated handoffs throughout the perioperative continuum has yet to be established. However, a variety of theoretical principles, methods, and interventions have been used successfully in operative and nonoperative contexts among multiple disciplines. Informed by a literature review, the authors describe a conceptual framework for the development, implementation, and sustainment of a multimodal perioperative handoff improvement bundle. The conceptual framework presented here begins with overarching objectives for patient-centered handoff improvement efforts. The article outlines theoretical principles that could be used to guide and inform future multimodal interventions, as well as health care system factors to consider. Further, the authors propose employing data-driven quality improvement and research methodologies to conduct, measure, achieve, and sustain long-term success. Finally, this report describes essential evidence-based interventional components to employ. IMPLICATIONS Future efforts to improve handoff safety in the perioperative environment will require a comprehensive evidence-based approach. The authors believe the conceptual framework presented here outlines essential components for success. It integrates proven theoretical frameworks, consideration of system factors, data-driven iterative methods, and synergistic patient-centered interventions.
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Al Baker AS, Ibrahim F, Obaid LM, Obdamen FR, Dimaocor A. Evaluating Psychometric Properties of the Sultan Bin Abdulaziz Humanitarian City (SBAHC) Nurses' Electronic Handover Tool. Cureus 2023; 15:e40026. [PMID: 37425565 PMCID: PMC10323703 DOI: 10.7759/cureus.40026] [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] [Accepted: 06/05/2023] [Indexed: 07/11/2023] Open
Abstract
INTRODUCTION Handover is crucial during the transfer of patient care between healthcare professionals.Successful handover maintains patients' safety and high-quality care. The electronic handover of patients' information is achievable, feasible, and potentially improves the quality of patient care. However, the introduction of the electronic handover is relatively recent and challenging for healthcare providers, especially nurses. OBJECTIVES Since Sultan Bin Abdulaziz Humanitarian City (SBAHC) has recently implemented an electronic handover system among nurses, the main aim of the current study was to develop a tool to assess the perception and barriers to electronic handover systems among nurses working at SBAHC and evaluate its psychometric properties. METHODS The tool content and face validity were assessed by the content validity ratio (CVR). Exploratory and confirmatory factor analysis were used as validity methods, while the test-retest and inter-item consistency were used as reliability measures. The sample size was planned as five times the number of questions and a total of 200 nurses participated in the study. RESULTS The criteria required for factor analysis were met as indicated by the results of the Kaiser-Mayer-Olkin test and Bartlett's test of sphericity. The reliability results showed a Cronbach's alpha coefficient ranging from 0.858 to 0.910 for the perception subscale and from 0.564 to 0.789 for the barrier subscale, and an overall interclass correlation of 0.986, p<0.001. CONCLUSIONS The developed SBAHC electronic handover tool was valid and reliable, and it is advisable to consider it at the initial stages of implanting an electronic handover system to identify obstacles that are faced by the staff to be considered and addressed by the higher management.
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Affiliation(s)
- Ahmad S Al Baker
- Department of Nursing, Sultan Bin Abdulaziz Humanitarian City, Riyadh, SAU
| | - Fatima Ibrahim
- Department of Nursing, Sultan Bin Abdulaziz Humanitarian City, Riyadh, SAU
| | - Lina M Obaid
- Department of Nursing, Sultan Bin Abdulaziz Humanitarian City, Riyadh, SAU
| | - Febee Rose Obdamen
- Department of Nursing, Sultan Bin Abdulaziz Humanitarian City, Riyadh, SAU
| | - Ashraff Dimaocor
- Department of Nursing, Sultan Bin Abdulaziz Humanitarian City, Riyadh, SAU
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Keebler JR, Lynch I, Ngo F, Phelps E, Huang N, Guttman O, Preble R, Minhajuddin AT, Gamez N, Wanat-Hawthorne A, Landgraf K, Minnis E, Gisick L, McBroom M, Ambardekar A, Olson D, Greilich PE. Leveraging the Science of Teamwork to Sustain Handoff Improvements in Cardiovascular Surgery. Jt Comm J Qual Patient Saf 2023:S1553-7250(23)00120-4. [PMID: 37357132 DOI: 10.1016/j.jcjq.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Improving the reliability of handoffs and care transitions is an important goal for many health care organizations. Increasing evidence shows that human-centered design and improved teamwork can lead to sustainable care transition improvements and better patient outcomes. This study was conducted within a cardiovascular service line at an academic medical center that performs more than 600 surgical procedures annually. A handoff process previously implemented at the center was poorly adopted. This work aimed to improve cardiovascular handoffs by applying human factors and the science of teamwork. METHODS The study's quality improvement method used Plan-Do-Study-Act cycles and participatory design and ergonomics to develop, implement, and assess a new handoff process and bundle. Trained observers analyzed video-recorded and live handoffs to assess teamwork, leadership, communication, coordination, cooperation, and sustainability of unit-defined handoff best practices. The intervention included a teamwork-focused redesign process and handoff bundle with supporting cognitive aids and assessment metrics. RESULTS The study assessed 153 handoffs in multiple phases over 3 years (2016-2019). Quantitative and qualitative assessments of clinician (teamwork) and implementation outcomes were performed. Compared with the baseline, the observed handoffs demonstrated improved team leadership (p < 0.0001), communication (p < 0.0001), coordination (p = 0.0018), and cooperation (p = 0.007) following the deployment of the handoff bundle. Sustained improvements in fidelity to unit-defined handoff best practices continued 2.3 years post-deployment of the handoff bundle. CONCLUSION Participatory design and ergonomics, combined with implementation and safety science principles, can provide an evidence-based approach for sustaining complex sociotechnical change and making handoffs more reliable.
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Conn Busch J, Wu J, Anglade E, Peifer HG, Lane-Fall MB. So Many Ways to Be Wrong: Completeness and Accuracy in a Prospective Study of OR-to-ICU Handoff Standardization. Jt Comm J Qual Patient Saf 2023:S1553-7250(23)00115-0. [PMID: 37316396 DOI: 10.1016/j.jcjq.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 04/30/2023] [Accepted: 05/09/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Studies focused on improving handoffs often measure the quality of information exchange using information completeness without reporting on accuracy. The present investigation aimed to characterize changes in the accuracy of transmitted patient information after standardization of operating room (OR)-to-ICU handoffs. METHODS Handoffs and Transitions in Critical Care (HATRICC) was a mixed methods study conducted in two US ICUs. From 2014 to 2016, trained observers captured the nature and content of information transmitted during OR-to-ICU handoffs, comparing this to the electronic medical record. Inconsistencies were compared before and after handoff standardization. Semistructured interviews initially conducted for implementation were reanalyzed to contextualize quantitative findings. RESULTS A total of 160 OR-to-ICU handoffs were observed-63 before and 97 after standardization. Across seven categories of information, including allergies, past surgical history, and IV fluids, two types of inaccuracy were observed: incomplete information (for example, providing only a partial list of allergies) and incorrect information. Before standardization, an average of 3.5 information elements per handoff were incomplete, and 0.11 were incorrect. After standardization, the number of incomplete information elements per handoff decreased to 2.4 (-1.1, p < 0.001), and the number of incorrect items was similar, at 0.16 (p = 0.54). Interviews revealed that the familiarity of a transporting OR provider (for example, surgeon, anesthetist) with the patient's case was considered an important factor affecting information exchange. CONCLUSION Handoff accuracy improved after standardizing OR-to-ICU handoffs in a two-ICU study. The improvement in accuracy was due to improved completeness rather than a change in the transmission of inaccurate information.
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Soares DRA, Rodrigues D, Carmona F. Implementation of a standardized handoff system (I-PASS) in a tertiary care pediatric hospital. REVISTA PAULISTA DE PEDIATRIA : ORGAO OFICIAL DA SOCIEDADE DE PEDIATRIA DE SAO PAULO 2023; 41:e2022123. [PMID: 36921182 PMCID: PMC10014024 DOI: 10.1590/1984-0462/2023/41/2022123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 11/20/2022] [Indexed: 03/17/2023]
Abstract
OBJECTIVE The handoff is the act of transferring information and responsibility among healthcare providers, and it is critical for the patient safety and the quality of service. The aim of this study was to evaluate the implementation of a standardized medical handoff system [I-PASS (Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver)] and assess the effect on the amount and quality of the information transmitted during medical handoffs in a pediatric ward. METHODS In a prospective intervention study, physicians (staff and residents) who work in 12- or 24-h shifts in the pediatric ward of a single tertiary care Brazilian hospital were eligible. Those who agreed to participate were trained in an online session (lecture plus simulation). Medical handoffs were recorded pre- and post-intervention (training) to compare the amount and quality of information transmitted in handoffs. RESULTS The handoff standardization significantly increased the number of relevant information delivered for 12 out of the 16 items assessed without increasing, in seconds, the handoff duration (45.9 vs. 48.0; p=0.349). The protocol training and the following discussion about communication resulted in greater focus and attention among participants during transfers, decreasing time spent with interruptions and communication unrelated to the patient (18 vs. 2.7%). Regarding the I-PASS elements, there was an increase in the number of action lists and contingency plans reported (31 vs. 81% and 16 vs. 73%, respectively; p<0.001 for both). CONCLUSION Standardization brought greater efficiency and objectivity to handoffs. It increased the quantity and quality of the information transmitted while successfully drawing attention to the most important points.
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Affiliation(s)
| | - Dalma Rodrigues
- Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Fabio Carmona
- Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil
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Keebler JR, Lazzara E, Griggs A, Tannenbaum S, Fernandez R, Greilich P, Salas E. Holistic strategy for promoting effective handoffs. BMJ LEADER 2022:leader-2022-000639. [DOI: 10.1136/leader-2022-000639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 12/19/2022] [Indexed: 12/31/2022]
Abstract
BackgroundHandoffs are ubiquitous in modern healthcare practice, and they can be a point of resilience and care continuity. However, they are prone to a variety of issues. Handoffs are linked to 80% of serious medical errors and are implicated in one of three malpractice suits. Furthermore, poorly performed handoffs can lead to information loss, duplication of efforts, diagnosis changes and increased mortality.MethodsThis article proposes a holistic approach for healthcare organisations to achieve effective handoffs within their units and departments.ResultsWe examine the organisational considerations (ie, the facets controlled by higher-level leadership) and local drivers (ie, the aspects controlled by the individuals working in the units and providing patient care).ConclusionWe propose advice for leaders to best enact the processes and cultural change necessary to see positive outcomes associated with handoffs and care transitions within their units and hospitals.
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Draganović Š, Offermanns G. Patient safety culture in Austria and recommendations of evidence-based instruments for improving patient safety. PLoS One 2022; 17:e0274805. [PMID: 36251643 PMCID: PMC9576070 DOI: 10.1371/journal.pone.0274805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/03/2022] [Indexed: 11/05/2022] Open
Abstract
This study aimed to investigate the patient safety culture in Austria. We identified factors that contributed to a higher degree of patient safety and subsequently developed evidence-based suggestions on how to improve patient safety culture in hospitals. Moreover, we examined differences in the perception of patient safety culture among different professional groups. This study used a cross-sectional design in ten Austrian hospitals (N = 1,525). We analyzed the correlation between ten patient safety culture factors, three background characteristics (descriptive variables), and three outcome variables (patient safety grade, number of adverse events reported, and influence on patient safety). We also conducted an analysis of variance to determine the differences in patient safety culture factors among the various professional groups in hospitals. The findings revealed that all ten factors have considerable potential for improvement. The most highly rated patient safety culture factors were communication openness and supervisor/manager’s expectations and actions promoting safety; whereas, the lowest rated factor was non-punitive response to error. A comparison of the various professional groups showed significant differences in the perception of patient safety culture between nurses, doctors, and other groups. Patient safety culture in Austria seems to have considerable potential for improvement, and patient safety culture factors significantly contribute to patient safety. We determined evidence-based practices as recommendations for improving each of the patient safety factors.
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Affiliation(s)
- Šehad Draganović
- Department of Organization, Human Resources, and Service Management, Faculty of Management and Economics, University of Klagenfurt, Klagenfurt am Wörthersee, Austria
- * E-mail:
| | - Guido Offermanns
- Department of Organization, Human Resources, and Service Management, Faculty of Management and Economics, University of Klagenfurt, Klagenfurt am Wörthersee, Austria
- Karl Landsteiner Society, Institute for Hospital Organization, Vienna, Austria
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Hebballi NB, Gupta VS, Sheppard K, Kubanda A, Salley D, Ostovar-Kermani T, Bryndzia C, Khan AM, Wadhwa N, Tsao K, Jain R, Kawaguchi AL. Standardization of Pediatric Noncardiac Operating Room to Intensive Care Unit Handoffs Improves Communication and Patient Care. J Patient Saf 2022; 18:e1021-e1026. [PMID: 35985048 DOI: 10.1097/pts.0000000000000986] [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: 11/26/2022]
Abstract
OBJECTIVES Handoffs are critical points in transitioning care between multidisciplinary teams, yet data regarding intensive care unit (ICU) handoffs in pediatric noncardiac surgical patients are lacking. We hypothesized that standardized handoffs from the pediatric operating room (OR) to the ICU would improve physician presence, communication, and patient care parameters. METHODS This quality improvement initiative was performed at a tertiary children's hospital. Stakeholders (anesthesiologists, nurses, intensivists, and surgeons) developed a standardized OR to pediatric and neonatal ICU handoff process based on common goals and outcomes of interest. Baseline data were collected before intervention. Implementation was carried out in 2 phases, phase 1 with a written handoff and Phase 2 with a scripted handoff process. Data collected by trained observers included handoff attendance, distractions, and transfer of essential patient information. As a surrogate for outcomes, patient care parameter data were collected for 6 hours after transfer. RESULTS After phase 1, surgery and ICU physician attendance increased significantly, distractions decreased, and communication of essential patient data improved. In phase 2 (scripted handoff), attendance continued to rise, distractions remained decreased, and transfer of essential information was still improved compared with baseline. Mean handoff duration did not significantly change throughout the study. Certain patient care parameters (escalation of respiratory support, additional laboratory studies, vasopressor administration, antibiotic administration and timing) remained unchanged compared with baseline. However, the need for resuscitative fluid bolus or blood products significantly decreased after implementation phase 2. CONCLUSIONS Standardized handoffs for pediatric noncardiac surgical patients from the OR to the ICU can improve provider attendance and communication.
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Affiliation(s)
- Nutan B Hebballi
- From the Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston
| | - Vikas S Gupta
- From the Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston
| | - Kyle Sheppard
- From the Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston
| | | | | | - Tiffany Ostovar-Kermani
- From the Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston
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Quality Improvement in Neurocritical Care: a Review of the Current Landscape and Best Practices. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00734-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Purpose of Review
The field of neurocritical care (NCC) has grown such that there is now a substantial body of literature on quality improvement specific to NCC. This review will discuss the development of this literature over time and highlight current best practices with practical tips for providers.
Recent Findings
There is tremendous variability in patient care models for NCC patients, despite evidence showing that certain structural elements are associated with better outcomes. There now also exist evidence-based recommendations for neurocritical care unit (NCCU) structure and processes, as well as NCC-specific performance measure (PM) sets; however, awareness of these is variable among care providers. The evidence-based literature on NCC structure, staffing, training, standardized order sets and bundles, transitions of care including handoff, prevention of bounce backs, bed flow optimization, and inter-hospital transfers is growing and offers many examples of successful performance improvement initiatives in NCCUs.
Summary
NCC providers care for patients with life-threatening conditions like intracerebral and subarachnoid hemorrhages, ischemic stroke, and traumatic brain injury, which are associated with high morbidity, complexity of treatment, and cost. Quality improvement initiatives have been successful in improving many aspects of NCC patient care, and NCC providers should continue to update and standardize their practices with consideration of this data. More research is needed to continue to identify high-risk and high-cost NCCU structures and processes and strategies to optimize them, validate current NCC PMs, and encourage clinical adoption of those that prove to be associated with improved outcomes.
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Lazzara EH, Simonson RJ, Gisick LM, Griggs AC, Rickel EA, Wahr J, Lane-Fall MB, Keebler JR. Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes. ERGONOMICS 2022; 65:1138-1153. [PMID: 35438045 DOI: 10.1080/00140139.2021.2020341] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 12/12/2021] [Indexed: 06/14/2023]
Abstract
Anaesthesia handoffs are associated with negative outcomes (e.g. inappropriate treatments, post-operative complications, and in-hospital mortality). To minimise these adverse outcomes, federal bodies (e.g. Joint Commission) have mandated handoff standardisation. Due to the proliferation of handoff interventions and research, there is a need to meta-analyze anaesthesia handoffs. Therefore, we performed meta-analyses on the provider, patient, organisational, and handoff outcomes related to post-operative anaesthesia handoff protocols. We meta-analysed 41 articles with post-operative anaesthesia handoffs that implemented a standardised handoff protocol. Compared to no standardisation, a standardised post-operative anaesthesia handoff changed provider outcomes with an OR of 4.03 (95% CI 3.20-5.08), patient outcomes with an OR of 1.49 (95% CI 1.32-1.69), organisational outcomes with an OR of 4.25 (95% CI 2.51-7.19), handoff outcomes with an OR of 8.52 (95% CI 7.05-10.31). Our meta-analyses demonstrate that standardised post-operative anaesthesia handoffs altered patient, provider, organisational, and handoff outcomes. Practitioner Summary: We conducted meta-analyses to assess the effects of post-operative anaesthesia handoff standardisation on provider, patient, organisational, and handoff outcomes. Our findings suggest that standardised post-operative anaesthesia handoffs changed all listed outcomes in a positive direction. We discuss the implications of these findings as well as notable limitations in this literature base.
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Affiliation(s)
- Elizabeth H Lazzara
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Richard J Simonson
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Logan M Gisick
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Andrew C Griggs
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Emily A Rickel
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Joyce Wahr
- Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Meghan B Lane-Fall
- David E. Longnecker Associate Professor of Anesthesiology and Critical Care, Department of Anesthesiology and Critical Care, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph R Keebler
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
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16
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Webster KL, Keebler JR, Lazzara EH, Chaparro A, Greilich P, Fagerlund A. Handoffs & Teamwork: A Framework for Care Transition Communication. Jt Comm J Qual Patient Saf 2022; 48:343-353. [DOI: 10.1016/j.jcjq.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 03/25/2022] [Accepted: 04/05/2022] [Indexed: 11/30/2022]
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17
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Fingrut WB, Chen AC, Green M, Weiss JT, Mercer D, Allan D. Development and evaluation of checklists to support the recruitment of committed hematopoietic stem cell donors. Transfusion 2022; 62:887-896. [PMID: 35182432 DOI: 10.1111/trf.16827] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/06/2022] [Accepted: 02/07/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Checklists are memory recall tools used across healthcare to improve outcomes. Here, we describe the development and evaluation of checklists to support recruitment of committed allogeneic hematopoietic stem cell donors. STUDY DESIGN AND METHODS Checklists were developed with the following objectives: (1) improve best-practice adherence; (2) reduce errors; and (3) support standardization at stem cell drives. Topics included: recruiting needed donors; securing informed consent; maintaining good-documentation practices; and supervising registration and tissue sample collection. Checklists were iteratively revised with input from stakeholders. We evaluated the checklists by examining recruitment outcomes and errors (i.e., preventing registrants from being listed as donors) pre- (11/2011-8/2016) and post- (9/2016-11/2019) implementation by the Canadian donor recruitment organization Stem Cell Club. Quantitative and qualitative methods were employed to analyze recruiters' perspectives on the checklists. RESULTS The checklists supported recruitment of donors from needed demographic groups as Stem Cell Club expanded its recruitment effort from 4118 registrants (60% male, 58% non-European) pre-implementation to 10,621 (52% male, 56% non-European) post-implementation. Checklist implementation was associated with a marked reduction in errors (from 13.2% to 1.9%) and a three-fold increase in the match rate of recruited donors (from 0.024% to 0.075%). Qualitative and quantitative analysis of recruiter feedback supported that the checklists' objectives were realized from the recruiter perspective. DISCUSSION We developed checklists to support donor recruitment and showed that their implementation was valued by recruiters and associated with both reduced errors and improved donor recruitment outcomes. The checklists are relevant to donor recruitment organizations worldwide.
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Affiliation(s)
- Warren B Fingrut
- Stem Cell Club, Toronto, ON, Canada.,Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Angela C Chen
- Stem Cell Club, Toronto, ON, Canada.,Faculty of Health, University of Waterloo, Waterloo, Ontario, Canada
| | - Meagan Green
- Canadian Blood Services, Ottawa, Ontario, Canada
| | | | - Dena Mercer
- Canadian Blood Services, Ottawa, Ontario, Canada
| | - David Allan
- Canadian Blood Services, Ottawa, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology & Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
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18
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Gräff I, Pin M, Ehlers P, Seidel M, Hossfeld B, Dietz-Wittstock M, Rossi R, Gries A, Ramshorn-Zimmer A, Reifferscheid F, Reinhold T, Band H, Kuhl KH, König MK, Kasberger J, Löb R, Krings R, Schäfer S, Wienen IM, Strametz R, Wedler K, Mach C, Werner D, Schacher S. Empfehlungen zum strukturierten Übergabeprozess in der zentralen Notaufnahme. Notf Rett Med 2022. [DOI: 10.1007/s10049-020-00810-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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19
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Golling M, Behringer W, Schwarzkopf D. Assessing the quality of patient handovers between ambulance services and emergency department – development and validation of the emergency department human factors in handover tool. BMC Emerg Med 2022; 22:10. [PMID: 35045828 PMCID: PMC8772155 DOI: 10.1186/s12873-022-00567-y] [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: 09/12/2021] [Accepted: 12/01/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Patient handover between prehospital care and the emergency department plays a key role in patient safety. Therefore, we aimed to create a validated tool for measuring quality of communication and interprofessional relations during handover in this specific setting.
Methods
Based on a theoretical framework a comprehensive item pool on information transfer and human factors in emergency department handovers was created and refined in a modified Delphi survey involving clinical experts. Based on a pre-test, items were again revised. The resulting Emergency Department Human Factors in Handover tool (ED-HFH) was validated in a field test at the emergency department of a German university hospital from July to December 2017. The ED-HFH was completed by emergency department and ambulance service staff participating in handovers and by an external observer. Description of item characteristics, exploratory factor analysis, analyses on internal consistency and interrater reliability by intraclass-correlation. Construct validity was analysed by correlation with an overall rating on quality of the handover.
Results
The draft of the ED-HFH contained 24 items, 90 of 102 eligible staff members participated in the field test completing 133 questionnaires on 38 observed handovers. Four items were deleted after analysis of item characteristics. Factor analysis supported a single factor explaining 39% of variance in the items. Therefore, a sum-score was calculated with a possible range between 14 and 70. The median value of the sum-score in the sample was 61.5, Cronbach’s α was 0.83, intraclass-correlation was 0.52, the correlation with the overall rating of hand-over quality was ρ = 0.83 (p ≤ 0.001).
Conclusions
The ED-HFH showed its feasibility, reliability and validity as a measure of quality of information transfer and human factors in handovers between ambulance services and the emergency department. It promises to be a useful tool for quality assurance and staff training.
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20
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Keebler JR, Rosen MA, Sittig DF, Thomas E, Salas E. Human Factors and Ergonomics in Healthcare: Industry Demands and a Path Forward. HUMAN FACTORS 2022; 64:250-258. [PMID: 35000407 DOI: 10.1177/00187208211073623] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This article reviews three industry demands that will impact the future of Human Factors and Ergonomics in Healthcare settings. These demands include the growing population of older adults, the increasing use of telemedicine, and a focus on patient-centered care. Following, we discuss a path forward through improved medical teams, error management, and safety testing of medical devices and tools. Future challenges are discussed.
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Affiliation(s)
- Joseph R Keebler
- Department of Human Factors and Behavioral Neurobiology, 2830Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Michael A Rosen
- Department of Anesthesiology, Armstrong Institute for Patient Safety, Johns Hopkins University, Baltimore, MD, USA
| | - Dean F Sittig
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Eric Thomas
- UT Health Memorial Center for Healthcare Quality and Safety, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Eduardo Salas
- Department of Psychological Sciences, Rice University, Houston, TX, USA
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21
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Aso Escario J. Litigabilidad y defendibilidad en neurología y neurocirugía. Un modelo «terapéutico» para el manejo de reclamaciones por mala praxis asistencial. Neurocirugia (Astur) 2022. [DOI: 10.1016/j.neucir.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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22
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Aso Escario J. Litigability and defensibility in neurology and neurosurgery. A "therapeutic" model for handling claims for malpractice care. NEUROCIRUGIA (ENGLISH EDITION) 2022; 33:22-30. [PMID: 34920981 DOI: 10.1016/j.neucie.2021.10.001] [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: 08/19/2021] [Accepted: 10/10/2021] [Indexed: 06/14/2023]
Abstract
Despite its indisputable importance, there are not many official data on claims for malpractice at the national level in Spain, mainly due to transfers from Health to the Autonomous Communities. This lack of unified information, together with other variables related to modern Healthcare Medicine (type of healthcare system, ethical aspects, consent, patients' rights, new technologies, etc.), complicates the healthcare professional's response to claims, and could not guarantee adequate protection of this against possible liability. This article analyzes the current situation in Spain and emphasizes aspects such as defensibility and liability in malpractice claims, taking as a model the Neurosurgery Specialty, one of the most prone to this type of situation. Prevention and action guidelines are offered, through a model aimed at reinforcing defensibility and reducing liability. This approach, which we call a "therapeutic model", considers the problem analogously to a disease, providing the basis for its prevention and management. We believe that this approach can be useful both to the Neurosurgeon and to any healthcare provider at a time, such as today, when there is some confusion on these issues and some reluctance of insurance companies to provide coverage in some cases.
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23
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Guttman OT, Lazzara EH, Keebler JR, Webster KLW, Gisick LM, Baker AL. Dissecting Communication Barriers in Healthcare: A Path to Enhancing Communication Resiliency, Reliability, and Patient Safety. J Patient Saf 2021; 17:e1465-e1471. [PMID: 30418425 DOI: 10.1097/pts.0000000000000541] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT Suboptimal exchange of information can have tragic consequences to patient's safety and survival. To this end, the Joint Commission lists communication error among the most common attributable causes of sentinel events. The risk management literature further supports this finding, ascribing communication error as a major factor (70%) in adverse events. Despite numerous strategies to improve patient safety, which are rooted in other high reliability industries (e.g., commercial aviation and naval aviation), communication remains an adaptive challenge that has proven difficult to overcome in the sociotechnical landscape that defines healthcare. Attributing a breakdown in information exchange to simply a generic "communication error" without further specification is ineffective and a gross oversimplification of a complex phenomenon. Further dissection of the communication error using root cause analysis, a failure modes and effects analysis, or through an event reporting system is needed. Generalizing rather than categorizing is an oversimplification that clouds clear pattern recognition and thereby prevents focused interventions to improve process reliability. We propose that being more precise when describing communication error is a valid mechanism to learn from these errors. We assert that by deconstructing communication in healthcare into its elemental parts, a more effective organizational learning strategy emerges to enable more focused patient safety improvement efforts. After defining the barriers to effective communication, we then map evidence-based recovery strategies and tools specific to each barrier as a tactic to enhance the reliability and validity of information exchange within healthcare.
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Affiliation(s)
| | - Elizabeth H Lazzara
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, Florida
| | - Joseph R Keebler
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, Florida
| | - Kristen L W Webster
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Logan M Gisick
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, Florida
| | - Anthony L Baker
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, Florida
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24
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Lived Experiences of an Elite Performance Management Team Through Injury Rehabilitation: An Interpretative Phenomenological Analysis. J Sport Rehabil 2021; 31:199-210. [PMID: 34784584 DOI: 10.1123/jsr.2021-0072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/25/2021] [Accepted: 08/18/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Injury is a common and challenging experience for many athletes, and return-to-sport outcomes have been persistently poor despite advancements in research and practice. To ameliorate this challenge and to bridge a gap that exists in the sport injury literature between theoretical conceptualization and intervention design, research is needed to explore team-based approaches to professional practice. The current study aimed to begin this work through exploration of a single performance management team (PMT) through 2 injury and rehabilitation cases leading into and across the 2014 Olympic Winter Games. DESIGN Qualitative, interpretative phenomenological analysis. METHOD Interviews were conducted with the 5 members of the PMT (coach, physiotherapist, sport psychology consultant, case manager, and athlete) involved in both injury cases. Lower-order and higher order themes were identified and interpreted through the extent literature. RESULTS Results indicate that 3 higher order themes interacted to impact the lived experiences of the PMT members across the 2 injury cases. Participants described the sociocultural context that surrounded the team, the individual struggles they faced, and the functioning of the team as the primary contributors to their lived experiences as well as observed rehabilitation outcomes. CONCLUSIONS Findings of this study mirror previous research in team science within the general health care domain, and prompt ongoing exploration of how to improve the experiences for PMT members as well as rehabilitation and return-to-sport outcomes for athletes.
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25
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Michael M, Griggs AC, Shields IH, Sadighi M, Hernandez J, Chan C, McHugh M, Nichols BE, Joshi K, Testa D, Raj S, Preble R, Lazzara EH, Greilich PE. Improving handover competency in preclinical medical and health professions students: establishing the reliability and construct validity of an assessment instrument. BMC MEDICAL EDUCATION 2021; 21:518. [PMID: 34600497 PMCID: PMC8487478 DOI: 10.1186/s12909-021-02943-x] [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: 06/25/2021] [Accepted: 09/15/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND As part of the worldwide call to enhance the safety of patient handovers of care, the Association of American Medical Colleges (AAMC) requires that all graduating students "give or receive a patient handover to transition care responsibly" as one of its Core Entrustable Professional Activities (EPAs) for Entering Residency. Students therefore require educational activities that build the necessary teamwork skills to perform structured handovers. To date, a reliable instrument designed to assess teamwork competencies, like structured communication, throughout their preclinical and clinical years does not exist. METHOD Our team developed an assessment instrument that evaluates both the use of structured communication and two additional teamwork competencies necessary to perform safe patient handovers. This instrument was utilized to assess 192 handovers that were recorded from a sample of 229 preclinical medical students and 25 health professions students who participated in a virtual course on safe patient handovers. Five raters were trained on utilization of the assessment instrument, and consensus was established. Each handover was reviewed independently by two separate raters. RESULTS The raters achieved 72.22 % agreement across items in the reviewed handovers. Krippendorff's alpha coefficient to assess inter-rater reliability was 0.6245, indicating substantial agreement among the raters. A confirmatory factor analysis (CFA) demonstrated the orthogonal characteristics of items in this instrument with rotated item loadings onto three distinct factors providing preliminary evidence of construct validity. CONCLUSIONS We present an assessment instrument with substantial reliability and preliminary evidence of construct validity designed to evaluate both use of structured handover format as well as two team competencies necessary for safe patient handovers. Our assessment instrument can be used by educators to evaluate learners' handoff performance as early as their preclinical years and is broadly applicable in the clinical context in which it is utilized. In the journey to optimize safe patient care through improved teamwork during handovers, our instrument achieves a critical step in the process of developing a validated assessment instrument to evaluate learners as they seek to accomplish this goal.
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Affiliation(s)
- Meghan Michael
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Mail Code 9068, Dallas, TX 75390 USA
| | - Andrew C. Griggs
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, 1 Aerospace Blvd, Daytona Beach, FL 32114 USA
| | - Ian H. Shields
- Office of Quality, Safety, and Outcomes Education, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
| | - Mozhdeh Sadighi
- Department of Undergraduate Medical Education, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
| | - Jessica Hernandez
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
| | - Chrissy Chan
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
| | - Mary McHugh
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
| | - Blake E. Nichols
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Mail Code 9063, Dallas, TX 75390 USA
| | - Kavita Joshi
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
| | - Daniel Testa
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
| | - Sonika Raj
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
| | - Richard Preble
- Office of Quality, Safety, and Outcomes Education, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390 USA
| | - Elizabeth H. Lazzara
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, 1 Aerospace Blvd, Daytona Beach, FL 32114 USA
| | - Philip E. Greilich
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Mail Code 9068, Dallas, TX 75390 USA
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26
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Schmidt RF, Vibbert MD, Vernick CA, Mendelson AM, Harley C, Labella G, Houser J, Becher P, Simko E, Jabbour PM, Tjoumakaris SI, Gooch MR, Sharan AD, Farrell CJ, Harrop JS, Rosenwasser RH, Jaffe RC, Jallo J. Standardizing postoperative handoffs using the evidence-based IPASS framework through a multidisciplinary initiative improves handoff communication for neurosurgical patients in the neuro-intensive care unit. J Clin Neurosci 2021; 92:67-74. [PMID: 34509265 DOI: 10.1016/j.jocn.2021.07.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 07/13/2021] [Accepted: 07/25/2021] [Indexed: 11/25/2022]
Abstract
Errors in communication are a major source of preventable medical errors. Neurosurgical patients frequently present to the neuro-intensive care unit (NICU) postoperatively, where handoffs occur to coordinate care within a large multidisciplinary team. A multidisciplinary working group at our institution started an initiative to improve postoperative neurosurgical handoffs using validated quality improvement methodology. Baseline handoff practices were evaluated through staff surveys and serial observations. A formalized handoff protocol was implemented using the evidence based IPASS format (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, Synthesis by receiver). Cycles of objective observations and surveys were employed to track practice improvements and guide iterative process changes over one year. Surveys demonstrated improved perceptions of handoffs as organized (17.1% vs 69.7%, p < 0.001), efficient (27.0% vs. 72.7%, p < 0.001), comprehensive (17.1% vs. 66.7%, p < 0.001), and safe (18.0% vs. 66.7%, p < 0.001), noting improved teamwork (31.5% vs. 69.7%, p < 0.001). Direct observations demonstrated improved communication of airway concerns (47.1% observed vs. 92.3% observed, p < 0.001), hemodynamic concerns (70.6% vs. 97.1%, p = 0.001), intraoperative events (52.9% vs. 100%, p < 0.001), neurological examination (76.5% vs. 100%, p < 0.001), vital sign goals (70.6% vs. 100%, p < 0.001), and required postoperative studies (76.5% vs. 100%, p < 0.001). Receiving teams demonstrating improved rates of summarization (47.1% vs. 94.2%, p = 0.005) and asking questions (76.5% vs 98.1%, p = 0.004). The mean handoff time during long-term follow-up was 4.4 min (95% confidence interval = 3.9-5.0 min). Standardization of handoff practices yields improvements in communication practices for postoperative neurosurgical patients.
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Affiliation(s)
- Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States.
| | - Matthew D Vibbert
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - Coleen A Vernick
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Andrew M Mendelson
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Caitlin Harley
- Department of Nursing, Thomas Jefferson University, Philadelphia, PA, United States
| | - Giuliana Labella
- Department of Nursing, Thomas Jefferson University, Philadelphia, PA, United States
| | - Jessica Houser
- Department of Nursing, Thomas Jefferson University, Philadelphia, PA, United States
| | - Patrick Becher
- Department of Nursing, Thomas Jefferson University, Philadelphia, PA, United States
| | - Erin Simko
- Department of Nursing, Thomas Jefferson University, Philadelphia, PA, United States
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | | | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - Ashwini D Sharan
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - Christopher J Farrell
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - James S Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - Rebecca C Jaffe
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, United States
| | - Jack Jallo
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
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Lavoie P, Clausen C, Purden M, Emed J, Frunchak V, Clarke SP. Nurses' experience of handoffs on four Canadian medical and surgical units: A shared accountability for knowing and safeguarding the patient. J Adv Nurs 2021; 77:4156-4169. [PMID: 34414589 DOI: 10.1111/jan.14997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/15/2021] [Accepted: 07/24/2021] [Indexed: 11/30/2022]
Abstract
AIMS To explore nurses' experience and describe how they manage various contextual factors affecting the nurse-to-nurse handoff at change of shift. DESIGN Qualitative descriptive study. METHODS A convenience sample of 51 nurses from four medical and surgical care units at a university-affiliated hospital in Montreal, Canada, participated in one of the 19 focus group interviews from November 2017 to January 2018. Data were analysed through a continuous and iterative process of thematic analysis. RESULTS Analysis of the data generated a core theme of 'sharing accountability for knowing and safeguarding the patient' that is achieved through actions related to nurses' role in the exchange. Specifically, the outgoing nurse takes actions to ensure continuity of care when letting go, and the incoming nurse takes actions to provide seamless care when taking over. In both roles, nurses navigate each handoff juncture by mutually adjusting, ensuring attentiveness, managing judgements, keeping on track, and venting and debriefing. Handoff is also shaped by contextual conditions related to handoff norms and practices, the nursing environment, individual nurse attributes and patient characteristics. CONCLUSIONS This study generated a conceptualization of nurses' roles and experience that details the relationship among the elements and conditions that shape nurse-to-nurse handoffs. IMPACT Nursing handoff involves the communication of patient information and relational behaviours that support the exchange. Although many factors are known to influence handoffs, little was known about nurses' experience of dealing with these at the point of care. This study contributed a comprehensive conceptualization of nursing handoff that could be useful in identifying areas for quality improvement and guiding future educational efforts.
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Affiliation(s)
- Patrick Lavoie
- Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada.,Montreal Heart Institute Research Centre, Montreal, Quebec, Canada
| | - Christina Clausen
- Centre for Nursing Research, Jewish General Hospital, Montreal, Quebec, Canada.,Ingram School of Nursing, McGill University, Montreal, Quebec, Canada.,Department of Nursing, Jewish General Hospital, Montreal, Quebec, Canada
| | - Margaret Purden
- Centre for Nursing Research, Jewish General Hospital, Montreal, Quebec, Canada.,Ingram School of Nursing, McGill University, Montreal, Quebec, Canada
| | - Jessica Emed
- Ingram School of Nursing, McGill University, Montreal, Quebec, Canada.,Department of Nursing, Jewish General Hospital, Montreal, Quebec, Canada
| | - Valerie Frunchak
- Ingram School of Nursing, McGill University, Montreal, Quebec, Canada.,Department of Nursing, Jewish General Hospital, Montreal, Quebec, Canada
| | - Sean P Clarke
- Rory Meyers College of Nursing, New York University, New York, New York, USA
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Jakonen A, Mänty M, Nordquist H. Safety Checklists for Emergency Response Driving and Patient Transport: Experiences from Emergency Medical Services. Jt Comm J Qual Patient Saf 2021; 47:572-580. [PMID: 34183282 DOI: 10.1016/j.jcjq.2021.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Emergency response driving (ERD) is considered one of the most significant occupational risk factors affecting both patient and traffic safety in emergency medical services (EMS). The majority of the risk factors in ERD are crew related and could be affected positively with crew resource management (CRM). The aim of this study was to examine how the safety checklists developed for ERD and patient transport are experienced in practical work in EMS by paramedics. METHODS Safety checklists for ERD and patient transport were developed and then piloted in practical work among 30 paramedics in five different EMS areas around Finland for a two-month period in fall 2019. Afterward, semistructured thematic interviews were performed with the pilot participants, and the material was analyzed using inductive content analysis. RESULTS Paramedics experienced that use of ERD and patient transport safety checklists improved safety, and deployment of the checklists required systematic planning. Use of the safety checklists was seen as changing the mindset of the ERD drivers to a more safety critical stance and increasing a systematic approach to ERD. Paramedics also stated that when deploying the checklists in EMS, their use should be standardized as a nationwide operating model and that service-dependent fine-tuning is required. CONCLUSION This study's findings support the use of ERD and patient transport safety checklists in practical work in EMS for promoting safety. In addition to safety checklists, other sections of CRM and its applications to EMS should also be studied.
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Abstract
Zusammenfassung
Hintergrund
Die Weitergabe von Informationen in einer stressbesetzten, hoch dynamischen Arbeitsumgebung wie der zentralen Notaufnahme (ZNA) stellt eine Risikoquelle für die Entstehung von Behandlungsfehlern dar und ist somit mortalitätsbeeinflussend.
Ziel der Arbeit
In der Arbeit wird untersucht, welchen Stellenwert dem Übergabeprozess durch die beteiligten Berufsgruppen beigemessen wird und welche strukturellen Merkmale bzw. Rahmenbedingungen dem Übergabeprozess von diesen zugeschrieben werden.
Material und Methoden
Bei der vorliegenden Studie handelte es sich um eine anonyme, freiwillige, webbasierte (Online‑)Umfrage, die mittels eines strukturierten elektronischen Fragebogens durchgeführt wurde.
Ergebnisse
Insgesamt haben 2728 Teilnehmer an der Onlineumfrage teilgenommen. Nahezu alle Teilnehmer-/innen benennen die Übergabe als outcomerelevanten Parameter für die Patienten, allerdings sehen 3 von 4 Teilnehmern den Übergabeprozess als verbesserungswürdig an. Bei der Selbsteinschätzung meinen 4 von 5 Teilnehmer-/innen, die Übergabe zu beherrschen. Es lässt sich unter den Teilnehmern kein favorisiertes Übergabeschema erkennen, die Mehrheit benutzt entweder ein eigenes oder gar kein Übergabeschema. Eine hohe Übereinstimmung zwischen Rettungsdienst und ZNA-Mitarbeitern liegt in Bezug auf Kerninhalte und Rahmenbedingungen der Übergabe vor. Mit großer Mehrheit zeigt sich der Wunsch nach einem einheitlichen Übergabeschema sowie nach Integrierung in Aus- und Fortbildungskonzepte.
Diskussion
Als Konsequenz der Umfrage sollte zügig auf nationaler Ebene mit allen an der Übergabe beteiligten Strukturen ein standardisiertes Übergabeverfahren etabliert werden. Die Bereitstellung entsprechender finanzieller und personeller Ressourcen für die Umsetzung dieses gesundheitspolitischen Ziels ist allerdings Voraussetzung.
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Gu X, Itoh K. Organizational climate for safe and effective inter-unit handoffs in Japanese hospitals. Int J Health Plann Manage 2021; 36:1153-1165. [PMID: 33797114 DOI: 10.1002/hpm.3162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 11/17/2020] [Accepted: 03/15/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES To extract the organizational climate factors that contribute to safe and effective inter-unit patient handoffs, as well as to capture their crucial characteristics in the context of current Japanese hospitals. METHODS A questionnaire survey was conducted among nursing staff in 31 general hospitals, collecting a total of 5117 valid responses (69% response rate). RESULTS A five-factor model was established to determine the inter-unit handoff climate within hospitals. This comprised information and responsibility-related risk, role understanding, communication, handoff environment, and guidelines and process. Based on nursing staff perceptions, the inter-unit handoff climate in Japanese hospitals were generally found to be moderate or moderate-to-high levels across all five of the factors. Nursing staff's perceptions of all five climate factors differed significantly across hospitals and work units, rather than working conditions (full-time vs. part-time) or professions (nurse vs. nurse assistant). All five handoff factors were verified their significant impacts on patient safety awareness and handoff quality. Furthermore, in hospitals where staff perceptions of handoff climate were more positive, information was transferred more effectively. CONCLUSIONS An inter-unit handoff climate structure was extracted and verified its impact on handoff quality and safety. Due to moderate climate levels in Japanese hospitals, as well as background factors such as low risk awareness among staff and busy situations, promoting a more positive organizational culture is suggested for creating safer and more effective inter-unit handoffs. Improving the current handoff guidelines and processes in hospitals and using non-licensed assistive staff more effectively are also recommended.
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Affiliation(s)
- Xiuzhu Gu
- Department of Industrial Engineering and Economics, School of Engineering, Tokyo Institute of Technology, Tokyo, Japan
| | - Kenji Itoh
- Department of Industrial Engineering and Economics, School of Engineering, Tokyo Institute of Technology, Tokyo, Japan
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Gregory ME, Hughes AM, Benishek LE, Sonesh SC, Lazzara EH, Woodard LD, Salas E. Toward the Development of the Perfect Medical Team: Critical Components for Adaptation. J Patient Saf 2021; 17:e47-e70. [PMID: 33635843 DOI: 10.1097/pts.0000000000000598] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Medical teams play a vital role in the delivery of safe and effective patient care. Toward the goal of becoming a high-reliability health system, the authors posit that the "perfect" medical team is one that develops their attitudes, behaviors, and cognitions (ABCs) to facilitate adaptation. METHODS The authors synthesized the literature (frameworks, measures, and conceptual models) on teamwork in healthcare (k = 161) to develop an evidence-based model of ABCs, which current evidence suggests, are requisite for medical team adaptation. Clinical vignettes were garnered from the media and other sources to illustrate how these ABCs-or failure in using these ABCs-can lead to positive or negative events in healthcare. RESULTS The resulting model contains the most frequently included ABCs in healthcare teamwork models, measures, and frameworks: psychological safety (41, 25.5%), situation assessment (66, 41.0%), shared mental models (56, 34.8%), team leadership behaviors (78, 48.4%), role awareness (64, 39.7%), team decision-making (61, 37.9%) and planning (41, 25.5%), conflict management (51, 31.7%), task coordination (71, 44.1%), adaptation (46, 28.6%), and backup behavior (54, 33.5%). The authors posit that communication and organizational conditions-other highly cited components-(141, 87.6%, and 90, 55.9%, respectively) serve as moderators of these relationships. CONCLUSIONS The authors argue that each of these ABCs is critical for enhancing team adaptation and subsequently increasing patient safety. A list of practical tools and educational strategies that teams and organizations can use to improve their performance on each of these ABCs is provided.
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Affiliation(s)
| | - Ashley M Hughes
- Department of Biomedical and Health Information Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Lauren E Benishek
- Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Elizabeth H Lazzara
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, Florida
| | | | - Eduardo Salas
- Department of Psychological Sciences, Rice University, Houston, Texas
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Ehlers P, Seidel M, Schacher S, Pin M, Fimmers R, Kogej M, Gräff I. Prospective Observational Multisite Study of Handover in the Emergency Department: Theory versus Practice. West J Emerg Med 2021; 22:401-409. [PMID: 33856332 PMCID: PMC7972381 DOI: 10.5811/westjem.2020.9.47836] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/13/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction The handover process in the emergency department (ED) is relevant for patient outcomes and lays the foundation for adequate patient care. The aim of this study was to examine the current prehospital to ED handover practice with regard to content, structure, and scope. Methods We carried out a prospective, multicenter observational study using a specifically developed checklist. The steps of the handover process in the ED were documented in relation to qualification of the emergency medical services (EMS) staff, disease severity, injury patterns, and treatment priority. Results We documented and evaluated 721 handovers based on the checklist. According to ISBAR (Identification, Situation, Background, Assessment, Recommendation), MIST (Mechanism, Injuries, Signs/Symptoms, Treatment), and BAUM (Situation [German: Bestand], Anamnesis, Examination [German: Untersuchung], Measures), almost all handovers showed a deficit in structure and scope (99.4%). The age of the patient was reported 339 times (47.0%) at the time of handover. The time of the emergency onset was reported in 272 cases (37.7%). The following vital signs were transferred more frequently for resuscitation room patients than for treatment room patients: blood pressure (BP)/(all comparisons p < 0.05), heart rate (HR), oxygen saturation (SpO2) and Glasgow Coma Scale (GCS). Physicians transmitted these vital signs more frequently than paramedics BP, HR, SpO2, and GCS. A handover with a complete ABCDE algorithm (Airway, Breathing, Circulation, Disability, Environment/Exposure) took place only 31 times (4.3%). There was a significant difference between the occupational groups (p < 0.05). Conclusion Despite many studies on handover standardization, there is a remarkable inconsistency in the transfer of information. A “hand-off bundle” must be created to standardize the handover process, consisting of a uniform mnemonic accompanied by education of staff, training, and an audit process.
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Affiliation(s)
- Philipp Ehlers
- University Hospital Bonn, Department of Emergency Medicine, Bonn, Germany
| | - Matthias Seidel
- University Hospital Bonn, Department of Emergency Medicine, Bonn, Germany
| | - Sylvia Schacher
- Hospital Köln Kalk, Department of Emergency Medicine, Cologne, Germany
| | - Martin Pin
- Hospital Florence Nightingale Düsseldorf, Department of Emergency Medicine, Düsseldorf, Germany
| | - Rolf Fimmers
- University Hospital Bonn, Institute for Medical Biometry, Informatics and Epidemiology, Bonn, Germany
| | - Monika Kogej
- University Hospital Bonn, Department of Emergency Medicine, Bonn, Germany
| | - Ingo Gräff
- University Hospital Bonn, Department of Emergency Medicine, Bonn, Germany
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Impact of standardized prenatal documentation among newborns with ductal-dependent heart disease. J Perinatol 2020; 40:1531-1536. [PMID: 32398739 DOI: 10.1038/s41372-020-0674-5] [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: 12/23/2019] [Revised: 03/23/2020] [Accepted: 04/24/2020] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Absent risk stratification, variable physiology of ductal-dependent congenital heart disease (DD-CHD) imparts risk of over-medicalization and unnecessary exclusion from early parental bonding. METHODS Single-center retrospective cohort study of term infants with isolated prenatally diagnosed DD-CHD expected to require immediate advanced resuscitation/intervention (2005-2017). Standardized documentation (2015 onward) included diagnosis, expected saturations, and allowability of postnatal parental bonding. RESULTS The study cohort (n = 386) included 289 patients in the pre-standardized documentation era and 97 in the post-era; the groups had similar characteristics. Fewer infants were born by cesarean in the later era (32% vs. 22%; p = 0.049). Decrease in any respiratory intervention (38-26%; p = 0.03) followed standardized documentation. More patients had any bonding time (22-74%; p < 0.0001), without increase in CPAP or intubation in the first two hours of life (6.9% vs. 7.2%; p = 0.92). CONCLUSION Standardized predelivery documentation for neonates with DD-CHD decreased unnecessary respiratory intervention and increased parental bonding.
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Gu X, Itoh K. Inter‐shift handoff: Changes over a 6‐year interval. J Adv Nurs 2020; 76:3418-3428. [DOI: 10.1111/jan.14537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/29/2020] [Accepted: 07/24/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Xiuzhu Gu
- Department of Industrial Engineering and Economics School of Engineering Tokyo Institute of Technology Meguro‐ku Tokyo Japan
| | - Kenji Itoh
- Department of Industrial Engineering and Economics School of Engineering Tokyo Institute of Technology Meguro‐ku Tokyo Japan
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Ayorinde AA, Williams I, Mannion R, Song F, Skrybant M, Lilford RJ, Chen YF. Publication and related bias in quantitative health services and delivery research: a multimethod study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.
Objectives
To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.
Methods
The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).
Results
We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.
Conclusions
This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.
Study registration
This study is registered as PROSPERO CRD42016052333 and CRD42016052366.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Abimbola A Ayorinde
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Iestyn Williams
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, UK
| | - Russell Mannion
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, UK
| | - Fujian Song
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Magdalena Skrybant
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Richard J Lilford
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Yen-Fu Chen
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Venn RA, Golbus JR, Wasfy JH. Handoffs and Fumbles. Circ Cardiovasc Qual Outcomes 2020; 13:e006365. [PMID: 32698632 DOI: 10.1161/circoutcomes.119.006365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rachael A Venn
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.V., J.H.W.)
| | - Jessica R Golbus
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor (J.R.G.)
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (R.A.V., J.H.W.)
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Lavoie P, Clarke SP, Clausen C, Purden M, Emed J, Cosencova L, Frunchak V. Nursing handoffs and clinical judgments regarding patient risk of deterioration: A mixed-methods study. J Clin Nurs 2020; 29:3790-3801. [PMID: 32644241 DOI: 10.1111/jocn.15409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 06/09/2020] [Accepted: 06/21/2020] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To explore how change-of-shift handoffs relate to nurses' clinical judgments regarding patient risk of deterioration. BACKGROUND The transfer of responsibility for patients' care comes with an exchange of information about their condition during change-of-shift handoff. However, it is unclear how this exchange affects nurses' clinical judgments regarding patient risk of deterioration. DESIGN A sequential explanatory mixed-methods study reported according to the STROBE and COREQ guidelines. METHODS Over four months, 62 nurses from one surgical and two medical units at a single Canadian hospital recorded their handoffs at change of shift. After each handoff, the two nurses involved each rated the patient's risk of experiencing cardiac arrest or being transferred to an intensive care unit in the next 24 hr separately. The information shared in handoffs was subjected to content analysis; code frequencies were contrasted per nurses' ratings of patient risk to identify characteristics of information that facilitated or hindered nurses' agreement. RESULTS Out of 444 recorded handoffs, there were 125 in which at least one nurse judged that a patient was at risk of deterioration; nurses agreed in 32 cases (25.6%) and disagreed in 93 (74.4%). These handoffs generally included information on abnormal vital signs, breathing problems, chest pain, alteration of mental status or neurological symptoms. However, the quantity and seriousness of clinical cues, recent transfers from intensive care units, pain without a clear cause, signs of delirium and nurses' knowledge of patient were found to affect nurses' agreement. CONCLUSIONS Nurses exchanged more information regarding known indicators of deterioration in handoffs when they judged that patients were at risk. Disagreements most often involved incoming nurses rating patient risk as higher. RELEVANCE TO CLINICAL PRACTICE This study suggests a need to sensitise nurses to the impact of certain cues at report on their colleagues' subsequent clinical judgments. Low levels of agreement between nurses underscore the importance of exchanging impressions regarding the likely evolution of a patient's situation to promote continuity of care.
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Affiliation(s)
- Patrick Lavoie
- Faculty of Nursing, Université de Montréal, Montreal, QC, Canada.,Montreal Heart Institute Research Center, Montreal, QC, Canada
| | - Sean P Clarke
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Christina Clausen
- Center for Nursing Research, Jewish General Hospital, Montreal, QC, Canada.,Ingram School of Nursing, McGill University, Montreal, QC, Canada.,Department of Nursing, Jewish General Hospital, Montreal, QC, Canada
| | - Margaret Purden
- Center for Nursing Research, Jewish General Hospital, Montreal, QC, Canada.,Ingram School of Nursing, McGill University, Montreal, QC, Canada
| | - Jessica Emed
- Ingram School of Nursing, McGill University, Montreal, QC, Canada.,Department of Nursing, Jewish General Hospital, Montreal, QC, Canada
| | - Lidia Cosencova
- Center for Nursing Research, Jewish General Hospital, Montreal, QC, Canada
| | - Valerie Frunchak
- Ingram School of Nursing, McGill University, Montreal, QC, Canada.,Department of Nursing, Jewish General Hospital, Montreal, QC, Canada
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Tannenbaum SI, Traylor AM, Thomas EJ, Salas E. Managing teamwork in the face of pandemic: evidence-based tips. BMJ Qual Saf 2020; 30:59-63. [DOI: 10.1136/bmjqs-2020-011447] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/13/2020] [Accepted: 05/20/2020] [Indexed: 11/04/2022]
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Lane-Fall MB, Pascual JL, Peifer HG, Di Taranti LJ, Collard ML, Jablonski J, Gutsche JT, Halpern SD, Barg FK, Fleisher LA. A Partially Structured Postoperative Handoff Protocol Improves Communication in 2 Mixed Surgical Intensive Care Units. Ann Surg 2020; 271:484-493. [DOI: 10.1097/sla.0000000000003137] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tacchini-Jacquier N, Hertzog H, Ambord K, Urben P, Turini P, Verloo H. An Evidence-Based, Nursing Handover Standard for a Multisite Public Hospital in Switzerland: Web-Based, Modified Delphi Study. JMIR Nurs 2020; 3:e17876. [PMID: 34345783 PMCID: PMC8279455 DOI: 10.2196/17876] [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: 01/17/2020] [Revised: 04/10/2020] [Accepted: 04/19/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Ineffective communication procedures create openings for errors when health care professionals fail to transfer complete, consistent information. Deficient or absent clinical handovers, or failures to transfer information, responsibility, and accountability, can have severe consequences for hospitalized patients. Clinical handovers are practiced every day, in many ways, in all institutional health care settings. OBJECTIVE This study aimed to design an evidence-based, nursing handover standard for inpatients for use at shift changes or internal transfers between hospital wards. METHODS We carried out a modified, multiround, web-based, Delphi data collection survey of an anonymized panel sample of 264 nurse experts working at a multisite public hospital in Switzerland. Each survey round was built on responses from the previous one. The surveys ended with a focus group discussion consisting of a randomly selected panel of participants to explain why items for the evidence-based clinical nursing handover standard were selected or not selected. Items had to achieve a consensus of ≥70% for selection and inclusion. RESULTS The study presents the items selected by consensus for an evidence-based nursing handover standard for inpatients for use at shift changes or internal transfers. It also presents the reasons why survey items were or were not included. CONCLUSIONS This modified Delphi survey method enabled us to develop a consensus- and evidence-based nursing handover standard now being trialed at shift changes and the internal transfers of inpatients at our multisite public hospital in Switzerland.
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Affiliation(s)
| | | | | | | | | | - Henk Verloo
- Valais Hospital Sion Switzerland
- Haute École Spécialisée Suisse orientale HES-SO Valais / Wallis Sion Switzerland
- Service of Old Age Psychiatry University Hospital of Lausanne Prilly Switzerland
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Lazzara EH, Keebler JR, Simonson RJ, Agarwala A, Lane-Fall MB. Navigating the challenges of performing anesthesia handoffs and conducting anesthesia handoff research. Int Anesthesiol Clin 2019; 58:32-37. [PMID: 31800413 DOI: 10.1097/aia.0000000000000260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Elizabeth H Lazzara
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, Florida
| | - Joseph R Keebler
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, Florida
| | - Richard J Simonson
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, Florida
| | - Aalok Agarwala
- Department of Anesthesiology, Harvard Medical School, Boston, Massachusetts
| | - Meghan B Lane-Fall
- Department of Anesthesiology, Perlemen School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Hoonakker PLT, Wooldridge AR, Hose BZ, Carayon P, Eithun B, Brazelton TB, Kohler JE, Ross JC, Rusy DA, Dean SM, Kelly MM, Gurses AP. Information flow during pediatric trauma care transitions: things falling through the cracks. Intern Emerg Med 2019; 14:797-805. [PMID: 31140061 PMCID: PMC6692560 DOI: 10.1007/s11739-019-02110-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 05/15/2019] [Indexed: 10/26/2022]
Abstract
Pediatric trauma is one of the leading causes of morbidity and mortality in children in the USA. Every year, nearly 10 million children are evaluated in emergency departments (EDs) for traumatic injuries, resulting in 250,000 hospital admissions and 10,000 deaths. Pediatric trauma care in hospitals is distributed across time and space, and particularly complex with involvement of large and fluid care teams. Several clinical teams (including emergency medicine, surgery, anesthesiology, and pediatric critical care) converge to help support trauma care in the ED; this co-location in the ED can help to support communication, coordination and cooperation of team members. The most severe trauma cases often need surgery in the operating room (OR) and are admitted to the pediatric intensive care unit (PICU). These care transitions in pediatric trauma can result in loss of information or transfer of incorrect information, which can negatively affect the care a child will receive. In this study, we interviewed 18 clinicians about communication and coordination during pediatric trauma care transitions between the ED, OR and PICU. After the interview was completed, we surveyed them about patient safety during these transitions. Results of our study show that, despite the fact that the many services and units involved in pediatric trauma cooperate well together during trauma cases, important patient care information is often lost when transitioning patients between units. To safely manage the transition of this fragile and complex population, we need to find ways to better manage the information flow during these transitions by, for instance, providing technological support to ensure shared mental models.
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Affiliation(s)
- Peter Leonard Titus Hoonakker
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, 3124 Engineering Centers Building, 1550 Engineering Drive, Madison, WI, 53706, USA.
| | - Abigail Rayburn Wooldridge
- Department of Industrial & Enterprise Systems Engineering, University of Illinois at Urbana-Champaign, 209A Transportation Building, 104 South Mathews Avenue, Urbana, IL, 61801, USA
| | - Bat-Zion Hose
- Center for Quality and Productivity Improvement, Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 3139 Engineering Centers Building, 1550 Engineering Drive, Madison, WI, 53706, USA
| | - Pascale Carayon
- Center for Quality and Productivity Improvement, Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 3139 Engineering Centers Building, 1550 Engineering Drive, Madison, WI, 53706, USA
| | - Ben Eithun
- American Family Children's Hospital, University of Wisconsin School of Medicine and Public Health, 1675 Highland Avenue, Madison, WI, 53792, USA
| | - Thomas Berry Brazelton
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Jonathan Emerson Kohler
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Joshua Chud Ross
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Deborah Ann Rusy
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Shannon Mason Dean
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Michelle Merwood Kelly
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Ayse Pinar Gurses
- Center for Health Care Human Factors, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, 750 East Pratt Street, 15th Floor, Baltimore, MD, 21202, USA
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Guttman O, Keebler JR, Lazzara EH, Daniel W, Reed G. Rethinking high reliability in healthcare: The role of error management theory towards advancing high reliability organizing. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2019. [DOI: 10.1177/2516043518819952] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
US Healthcare, despite its exceptional technology and innovative treatments, is still unsafe and unreliable. It is estimated that medical errors account for an estimated 254,000 inpatient deaths a year and hold the distinction as the third leading cause of death in the US. Despite an aggressive national campaign set by organizations like the National Academy of Medicine, the Institute for Healthcare Improvement, the National Patient Safety Foundation, and the National Quality Forum, efforts to improve the quality and safety of US Healthcare have been unsuccessful, or at best, unsustainable at eliminating preventable patient harm. Historically, US Healthcare has turned to commercial aviation, nuclear energy, oil and gas, and other high reliability industries for lessons on how to avoid harm. In this paper, we join two pre-existing conceptual models: high reliability organizing and error management theory to propose a strategy for embedding and sustaining a preoccupation with failure and commitment to resilience within healthcare to advance a practical and disciplined focus to advance organizational high reliability.
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Affiliation(s)
- Oren Guttman
- Sidney Kimmel Medical College, Philadelphia, PA, USA
| | - Joseph R Keebler
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Elizabeth H Lazzara
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - William Daniel
- Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Gary Reed
- Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
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Agarwala AV, Lane-Fall MB, Greilich PE, Burden AR, Ambardekar AP, Banerjee A, Barbeito A, Bryson TD, Greenberg S, Lorinc AN, Lynch IP, Pukenas E, Cooper JB. Consensus Recommendations for the Conduct, Training, Implementation, and Research of Perioperative Handoffs. Anesth Analg 2019; 128:e71-e78. [DOI: 10.1213/ane.0000000000004118] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Rosen MA, DiazGranados D, Dietz AS, Benishek LE, Thompson D, Pronovost PJ, Weaver SJ. Teamwork in healthcare: Key discoveries enabling safer, high-quality care. ACTA ACUST UNITED AC 2019; 73:433-450. [PMID: 29792459 DOI: 10.1037/amp0000298] [Citation(s) in RCA: 425] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Few industries match the scale of health care. In the United States alone, an estimated 85% of the population has at least 1 health care encounter annually and at least one quarter of these people experience 4 to 9 encounters annually. A single visit requires collaboration among a multidisciplinary group of clinicians, administrative staff, patients, and their loved ones. Multiple visits often occur across different clinicians working in different organizations. Ineffective care coordination and the underlying suboptimal teamwork processes are a public health issue. Health care delivery systems exemplify complex organizations operating under high stakes in dynamic policy and regulatory environments. The coordination and delivery of safe, high-quality care demands reliable teamwork and collaboration within, as well as across, organizational, disciplinary, technical, and cultural boundaries. In this review, we synthesize the evidence examining teams and teamwork in health care delivery settings in order to characterize the current state of the science and to highlight gaps in which studies can further illuminate our evidence-based understanding of teamwork and collaboration. Specifically, we highlight evidence concerning (a) the relationship between teamwork and multilevel outcomes, (b) effective teamwork behaviors, (c) competencies (i.e., knowledge, skills, and attitudes) underlying effective teamwork in the health professions, (d) teamwork interventions, (e) team performance measurement strategies, and (f) the critical role context plays in shaping teamwork and collaboration in practice. We also distill potential avenues for future research and highlight opportunities to understand the translation, dissemination, and implementation of evidence-based teamwork principles into practice. (PsycINFO Database Record
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Affiliation(s)
- Michael A Rosen
- Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine
| | - Deborah DiazGranados
- Office of Assessment and Evaluation Studies, Virginia Commonwealth University School of Medicine
| | - Aaron S Dietz
- Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine
| | - Lauren E Benishek
- Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine
| | - David Thompson
- Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine
| | - Peter J Pronovost
- Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine
| | - Sallie J Weaver
- Health Systems and Interventions Research Branch of the Healthcare Delivery Research Program, National Cancer Institute
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Chaparro A, Keebler JR, Lazzara EH, Diamond A. Checklists: A Review of Their Origins, Benefits, and Current Uses as a Cognitive Aid in Medicine. ERGONOMICS IN DESIGN 2019. [DOI: 10.1177/1064804618819181] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Since its initial introduction in the 1930s, checklists have proven their worth in aviation and have been increasingly promoted in medicine as a cognitive aid that can improve patient outcomes. This article reviews the different types of checklists, how they aid user performance, the barriers to their adoption, and strategies for increasing user acceptance of checklists.
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Stonko DP, Dennis BM, Callcut RA, Betzold RD, Smith MC, Medvecz AJ, Guillamondegui OD. Identifying temporal patterns in trauma admissions: Informing resource allocation. PLoS One 2018; 13:e0207766. [PMID: 30507930 PMCID: PMC6277067 DOI: 10.1371/journal.pone.0207766] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 11/06/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Increased knowledge of the temporal patterns in the distribution of trauma admissions could be beneficial to staffing and resource allocation efforts. However, little work has been done to understand how this distribution varies based on patient acuity, trauma mechanism or need for intervention. We hypothesize that temporal patterns exist in the distribution of trauma admissions, and that deep patterns exist when traumas are analyzed by their type and severity. STUDY DESIGN We conducted a cross-sectional observational study of adult patient flow at a level one trauma center over three years, 7/1/2013-6/30/2016. Primary thermal injuries were excluded. Frequency analysis was performed for patients grouped by ED disposition and mechanism against timing of admission; in subgroup analysis additional exclusion criteria were imposed. RESULTS 10,684 trauma contacts were analyzed. Trauma contacts were more frequent on Saturdays and Sundays than on weekdays (p<0.001). Peak arrival time was centered around evening shift change (6-7pm), but differed based on ED disposition: OR and ICU or Step-Down admissions (p = 0.0007), OR and floor admissions (p<0.0001), and ICU or Step-Down and floor admissions (p<0.0001). Step-Down and ICU arrival times (p = 0.42) were not different. Penetrating injuries peaked later than blunt (p<0.0001). Trauma varies throughout the year; we establish a high incidence trauma season (April to late October). Different mechanisms have varying dependence upon season; Motorcycle crashes (MCCs) have the greatest dependence. CONCLUSION We identify new patterns in the temporal and seasonal variation of trauma and of specific mechanisms of injury, including the novel findings that 1) penetrating trauma tends to present at later times than blunt, and 2) critically ill patients requiring an OR tend to present later than those who are less acute and require an ICU or Step-Down unit. These patients present later than those who are admitted to the floor. Penetrating trauma patients arriving later than blunt may be the underlying reason why operative patients arrive later than other patients.
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Affiliation(s)
- David P. Stonko
- The Johns Hopkins Hospital, Department of Surgery, Baltimore, MD, United States of America
| | - Bradley M. Dennis
- Vanderbilt University Hospital, Division of Trauma and Surgical Critical Care, Nashville, TN, United States of America
| | - Rachael A. Callcut
- Department of Surgery, University of California, San Fransisco, San Fransisco, CA, United States of America
| | - Richard D. Betzold
- Vanderbilt University Hospital, Division of Trauma and Surgical Critical Care, Nashville, TN, United States of America
| | - Michael C. Smith
- Vanderbilt University Hospital, Division of Trauma and Surgical Critical Care, Nashville, TN, United States of America
| | - Andrew J. Medvecz
- Vanderbilt University Hospital, Division of Trauma and Surgical Critical Care, Nashville, TN, United States of America
| | - Oscar D. Guillamondegui
- Vanderbilt University Hospital, Division of Trauma and Surgical Critical Care, Nashville, TN, United States of America
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Rattray NA, Ebright P, Flanagan ME, Militello LG, Barach P, Franks Z, Rehman SU, Gordon HS, Frankel RM. Content counts, but context makes the difference in developing expertise: a qualitative study of how residents learn end of shift handoffs. BMC MEDICAL EDUCATION 2018; 18:249. [PMID: 30390668 PMCID: PMC6215683 DOI: 10.1186/s12909-018-1350-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 10/15/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Handoff education is both formal and informal and varies widely across medical school and residency training programs. Despite many efforts to improve clinical handoffs, little evidence has shown meaningful improvement. The objective of this study was to identify residents' perspectives and develop a deeper understanding on the necessary training to conduct safe and effective patient handoffs. METHODS A qualitative study focused on the analysis of cognitive task interviews targeting end-of-shift handoff experiences with 35 residents from three geographically dispersed VA facilities. The interview data were analyzed using an iterative, consensus-based team approach. Researchers discussed and agreed on code definitions and corresponding case examples. Grounded theory was used to analyze the transcripts. RESULTS Although some residents report receiving formal training in conducting handoffs (e.g., medical school coursework, resident boot camp/workshops, and handoff debriefing), many residents reported that they were only partially prepared for enacting them as interns. Experiential, practice-based learning (i.e., giving handoffs, covering night shift to match common issues to handoff content) was identified as the most suited and beneficial for delivering effective handoff training. Six skills were described as critical to learning effective handoffs: identifying pertinent information, providing anticipatory guidance, applying acquired clinical knowledge, being concise, incorporating delivery strategies, and appreciating the styles/preferences of handoff recipients. CONCLUSIONS Residents identified the immersive performance and the experience of covering night shifts as the most important aspects of learning to execute effective handoffs. Formal education alone can miss the critical role of real-time sense-making throughout the process of handing off from one trainee to another. Interventions targeting senior resident mentoring and night shift could positively influence the cognitive and performance capacity for safe, effective handoffs.
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Affiliation(s)
- Nicholas A. Rattray
- VA HSR&D Center for Health Information and Communication, Roudebush VAMC, Indianapolis, USA
- Department of Anthropology, Indiana University-Purdue University Indianapolis, Indianapolis, USA
- Regenstrief Institute, Inc., Indianapolis, USA
| | | | - Mindy E. Flanagan
- VA HSR&D Center for Health Information and Communication, Roudebush VAMC, Indianapolis, USA
| | | | - Paul Barach
- Wayne State University School of Medicine, Detroit, USA
| | - Zamal Franks
- VA HSR&D Center for Health Information and Communication, Roudebush VAMC, Indianapolis, USA
| | - Shakaib U. Rehman
- Phoenix VA Healthcare Systems, Phoenix, USA
- University of Arizona College of Medicine-Phoenix, Phoenix, USA
| | - Howard S. Gordon
- VA HSR&D Center of Innovation for Complex Chronic Healthcare, Jesse Brown VAMC, Chicago, USA
- University of Illinois at Chicago, Chicago, USA
| | - Richard M. Frankel
- VA HSR&D Center for Health Information and Communication, Roudebush VAMC, Indianapolis, USA
- Regenstrief Institute, Inc., Indianapolis, USA
- Indiana University School of Medicine, Indianapolis, USA
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Zavodnick J, Jaffe R, Altshuler M, Cowan S, Wickersham A, Diemer G. Leveraging Structural Changes in an Electronic Health Record Tool to Standardize Written Handoff. Am J Med Qual 2018; 34:354-359. [PMID: 30345783 DOI: 10.1177/1062860618808018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Miscommunications during patient handoff can lead to harm. The I-PASS bundle has been shown to improve safety outcomes. Although effective training reliably improves verbal handoffs, research has demonstrated a lack of effect on written handoffs. The objective was to compare written handoff before and after integration of a standardized electronic health record (EHR) tool. Interns at a large urban academic medical center underwent I-PASS handoff training. The EHR handoff tool was then revised to prompt the I-PASS components. Handoff documents were obtained before and after the intervention. More handoffs included Illness Severity (33% to 59%, P < .001) and Action List (65% to 83%, P = .005) after the intervention. There was no change in handoffs with miscommunications (12.5% to 10%, P = .566) or omissions (8% to 11%, P = .447). Handoffs including tangential or unrelated information decreased (20% to 4%, P = .001). A written handoff tool can reinforce the effect of training and increase adherence to I-PASS.
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Affiliation(s)
| | | | | | - Scott Cowan
- 1 Thomas Jefferson University, Philadelphia, PA
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Uhm JY, Lim EY, Hyeong J. The impact of a standardized inter-department handover on nurses' perceptions and performance in Republic of Korea. J Nurs Manag 2018; 26:933-944. [PMID: 30209878 DOI: 10.1111/jonm.12608] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2017] [Indexed: 11/30/2022]
Abstract
AIMS To evaluate the impact of a standardized inter-department nursing handover protocol from intensive care units to general wards on the nurses' perceptions and performance. METHODS We developed an inter-department nursing handover protocol based on the situation, background, assessment and recommendation technique. All participating paediatric nurses were trained in this new protocol, which was then implemented for nine months in eight units of a children's hospital in the Republic of Korea. Data were extracted from a questionnaire and handover auditing using audio recording. RESULTS Following the protocol's introduction, nurses' perceptions of handover effectiveness significantly improved (F = 5.17, p = .007), while their experience of handover errors significantly decreased (F = 12.85, p < .001). Furthermore, the prevalence of additive calls per handover decreased from 70.7% to 45.9% (χ2 = 9.88, p = .002), and the prevalence of handover-related errors decreased from 51.2% to 32.4% (χ2 = 5.63, p = .023). Handover accuracy significantly increased (t = -5.12, p < .001) without prolonging the handover duration. CONCLUSIONS The handover protocol positively influenced the nurses' perception of handover and clinical performance. IMPLICATIONS FOR NURSING MANAGEMENT A standardized inter-department handover helped intensive care unit nurses to improve their organisation and to provide ward nurses with sufficient information during handover, which could ensure safer transitions from intensive care units to wards.
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Affiliation(s)
- Ju-Yeon Uhm
- Department of Nursing Science, Daegu Haany University, Gyeongsan-si, Gyeongsangbuk-Do, Korea
| | - Eun Young Lim
- Department of Nursing, Asan Medical Center, Seoul, Korea
| | - Jinju Hyeong
- Department of Nursing, Asan Medical Center, Seoul, Korea
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