The Role for Leaders of Health Care Organizations in Patient Safety

Standardizing Patient Safety Event Reporting between Care Delivered or Purchased by the Veterans Health Administration (VHA)

BACKGROUND

Increasing community care (CC) use by veterans has introduced new challenges in providing integrated care across the Veterans Health Administration (VHA) and CC. VHA's well-recognized patient safety program has been particularly challenging for CC staff to adopt and implement. To standardize VHA safety practices across both settings, VHA implemented the Patient Safety Guidebook in 2018. The authors compared national- and facility-level trends in VHA and CC safety event reporting post-Guidebook implementation.

METHODS

In this retrospective study using patient safety event data from VHA's event reporting system (2020-2022), the research team examined trends in patient safety events, adverse events, close calls (near misses), and recovery rates (ratio of close calls to adverse events plus close calls) in VHA and CC using linear regression models to determine whether the average changes in VHA and CC safety events at the national and facility levels per quarter were significant.

RESULTS

A total of 499,332 safety events were reported in VHA and CC. Although VHA patient safety event trends were not significant (p > 0.05), there was a significant negative trend for adverse events (p = 0.02) and positive trends for close calls (p = 0.003) and recovery rates (p = 0.004). In CC there were significant negative trends for patient safety events and adverse events (p = 0.02) and a significant positive trend for recovery rates (p = 0.03). There was less variation in VHA than in CC facilities with significant decreases (for example, interquartile ranges in VHA and CC were 0.03 vs. 0.05, respectively).

CONCLUSION

Fluctuations in different safety events over time were likely due to the disruption of care caused by COVID-19 as well as organizational factors. Notably, the increases in recovery rates reflect less staff focus on harmful events and more attention to close calls (preventable events). Although safety practice adoption from VHA to CC was feasible, additional implementation strategies are needed to sustain standardized safety reporting across settings.

Efficacy of Aromatherapy at Relieving the Work-Related Stress of Nursing Staff from Various Hospital Departments during COVID-19

This study aimed to evaluate the efficacy of aromatherapy in relieving the stress of nursing staff working in different departments during COVID-19. A total of 26 nursing staff from Taiwan were recruited for this study. Bergamot essential oil was diffused for over a four-week period in four different hospital departments. We assessed heart rate variability indicators, Nurse Stress Checklist, and Copenhagen Burnout Inventory before and after the intervention. The results of the analysis showed that during a high workload period, aromatherapy had no significant effect on regulating physical stress. Subjective measurements showed a significant impact on work concern and personal fatigue. Moreover, there were large differences among the four departments; the aromatherapy treatment had a weak effect on those with a heavy workload, whereas those with a lighter workload showed a stronger effect. Finally, this study provides practical results about aromatherapy stress reduction applied during the pandemic on first-line medical staff.

Supporting a culture of patient safety: Resident-led patient safety event reviews in a pathology residency training program

Patient safety is a critical component of quality patient care at any healthcare institution. In order to support a culture of patient safety, and in the context of a hospital-wide patient safety initiative at our institution, we have created and implemented a new patient safety curriculum within our training program. The curriculum is embedded in an introductory course for first-year residents, in which residents gain an understanding of the multifaceted role of the pathologist in patient care. The patient safety curriculum is a resident-centered event review process and includes 1) identification and reporting of a patient safety event, 2) event investigation and review, and 3) presentation of findings to the residency program including core faculty and safety champions for the consideration of implementation of the identified systems solution. Here we discuss the development of our patient safety curriculum, which was trialed over a series of seven event reviews conducted between January 2021 and June 2022. Resident involvement in patient safety event reporting and patient safety event review outcomes were measured. All event reviews conducted thus far have resulted in the implementation of the solutions discussed during event review presentations based on cause analysis and identification of strong action items. Ultimately this pilot will serve as the basis by which we implement a sustainable curriculum in our pathology residency training program centered on supporting a culture of patient safety, and in line with ACGME requirements.

Staying ahead of the curve: avigating changes and maintaining gains in patient safety culture - a mixed-methods study

OBJECTIVES

This study examines how the results of the Hospital Survey on Patient Safety Culture changed between 2012 and 2019 and identifies organisational factors affecting these changes.

DESIGN

The study combined the use of quantitative surveys of staff and qualitative interviews with hospital leadership. Secondary data analysis was performed for previous surveys.

SETTING

This study was conducted in a tertiary care teaching multisite hospital in Riyadh, Saudi Arabia.

PARTICIPANTS

One thousand hospital staff participated in the survey. Thirty-one executive board members and directors and four focus groups of frontliners were qualitatively interviewed.

PRIMARY AND SECONDARY OUTCOME MEASURES

Twelve safety culture dimensions were assessed to study the patient safety culture as perceived by the healthcare professionals. An additional semi-structured interview was conducted to identify organisational factors, changes, and barriers affecting the patient safety culture. Furthermore, suggestions to improve patient safety were proposed.

RESULTS

Comparing the results revealed a general positive trend in scores from 2012 to 2019. The areas of strength included teamwork within and across units, organisational learning, managerial support, overall perception of safety and feedback and communication about error. Non-punitive response to error, staffing and communication and openness consistently remain the lowest-scoring composites. Interview results revealed that organisational changes may have influenced the answers of the participants on some survey composites.

CONCLUSIONS

Patient safety is a moving target with areas for improvement that are continuously identified. Effective quality improvement initiatives can lead to visible changes in the patient safety culture in a hospital, and consistent leadership commitment and support can maintain these improvements.

Who Applies an Intervention to Influence Cultural Attributes in a Quality Improvement Collaborative?

OBJECTIVES

Organizational culture change has been recognized as one of the promising ways to reduce error and increase safety. However, it is still unclear what factors support health care teams implementing interventions aimed to influence the cultural attributes that bolster continuous quality improvement. This study aimed to identify factors related to teams' adoption of the Comprehensive Unit-based Safety Program (CUSP), an approach to improving patient safety culture among intensive care units (ICUs) participating in a bloodstream infection reduction collaborative.

METHODS

We analyzed data from the 103 ICUs participating in the Keystone ICU project. We conducted logistic regressions to assess baseline factors associated with ICU teams' use of CUSP. Predictors included safety climate scales (teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management, and working conditions) as measured by the Safety Attitudes Questionnaire, central line-associated bloodstream infection rates, bloodstream infection prevention intervention phase, ICU type, hospital bed size, and hospital teaching status.

RESULTS

Intensive care units with lower perceived safety climate, greater stress recognition, higher perceptions of management, and better working conditions were more likely to adopt CUSP. Intensive care units that implemented the infection prevention interventions late were less likely to adopt CUSP. Mixed ICUs and ICUs in large hospitals were also less likely to use CUSP.

CONCLUSIONS

Staff-perceived safety climate, ICU type, and hospital size were related to ICUs' implementation of CUSP. Better baseline safety climate or lower perceived organizational support reduced uptake. The findings can help hospital leaders and collaborative experts identify units that are less likely to implement cultural interventions.

Challenges and Priorities in Responding to COVID-19 in Inpatient Psychiatry

This Open Forum focuses on specific challenges, contingency planning considerations, and downstream impacts of COVID-19 on inpatient psychiatric care. COVID-19 is a novel coronavirus that has been declared a pandemic. Challenges for inpatient psychiatry include risky close contact among staff and patients, space constraints, and structural barriers in care delivery. Nuanced considerations of five contingency planning strategies in response to COVID-19 are described, including COVID-19-specific precautions, visitor restrictions, physician workforce considerations, operational adjustments, and group therapy changes. Organized leadership and clear communication are identified as early priorities in pandemic response to minimize misinformation and address immediate challenges.

Combined SNA and LDA methods to understand adverse medical events

OBJECTIVE

To compare primary medical adverse event keywords from reporters (e.g. physicians and nurses) and harm level perspectives to explore the underlying behaviors of medical adverse events using social network analysis (SNA) and latent Dirichlet allocation (LDA) leading to process improvements.

DESIGN

Used SNA methods to explore primary keywords used to describe the medical adverse events reported by physicians and nurses. Used LDA methods to investigate topics used for various harm levels. Combined the SNA and LDA methods to discover common shared topic keywords to better understand underlying behaviors of physicians and nurses in different harm level medical adverse events.

SETTING

Maccabi Healthcare Community is the second largest healthcare organization in Israel.

DATA

17,868 medical adverse event data records collected between 2000 and 2017.

METHODS

Big data analysis techniques using social network analysis (SNA) and latent Dirichlet allocation (LDA).

RESULTS

Shared topic keywords used by both physicians and nurses were determined. The study revealed that communication, information transfer, and inattentiveness were the most common problems reported in the medical adverse events data.

CONCLUSIONS

Communication and inattentiveness were the most common problems reported in medical adverse events regardless of healthcare professional reporting or harm levels. Findings suggested that an information-sharing and feedback mechanism should be implemented to eliminate preventable medical adverse events. Healthcare institutions managers and government officials should take targeted actions to decrease these preventable medical adverse events through quality improvement efforts.

An Investigation of Healthcare Worker Perception of Their Workplace Safety and Incidence of Injury

Background: Managing the safety climate in health care is a promising tool for improving employee and patient safety in the health care work environment. Gaps in the theoretical and conceptual underpinnings of safety climate, as well as the evidence base for its practical application in health care remain. The purpose of this study was to evaluate the number of work injuries occurring in health care work units and associated safety climate beliefs. Methods: A retrospective analysis was conducted utilizing organizational staff survey data collected by a large medical hospital in the Midwest in 2015. Employees (n = 32,327) were invited to identify safety climate perceptions via survey. Injuries, days restricted, and days absent were identified through the Hospital's Occupational Safety and Health Administration (OSHA) log. Zero inflated negative binomial regressions used injuries as dependent variables and safety climate perceptions as independent variables. Findings: In all, 23,599 employees completed the survey (73% response rate) across 1,805 employee work units which were defined as groupings of employees reporting to a single supervisor. We found that there was an association between fewer injuries and health care workers indicating that they share responsibility for compliance with safety rules and procedures (relative risk [RR] = 0.98, 95% confidence interval [CI] = [0.98, 0.99]). Conclusion/Application to Practice: This study supports the use of a safety climate measure to assess working units' perceptions of employee safety. A continued focus on the health and safety of employees who interact directly with patients is warranted, as well as employees who do not provide direct patient care.

Safety Culture at Primary Healthcare Level: A Cross-Sectional Study Among Employees with a Leadership Role

Introduction

An effective leadership is critical to the development of a safety culture within an organization. With this study, the authors wanted to assess the self-perceived level of safety culture among the employees with a leadership function in the Ljubljana Community Health Centre.

Methods

This was a cross-sectional study in the largest community health centre in Slovenia. We sent an invitation to all employees with a leadership role (N=211). The Slovenian version of the SAQ - Short Form as a measurement of a safety culture was used. The data on demographic characteristics (gender, age, role, work experience, working hours, and location of work) were also collected. An electronic survey was used.

Results

The final sample consisted of 154 (69.7%) participants, out of which 136 (88.3%) were women. The mean age and standard deviation of the sample was 46.2±10.5 years. The average scores for the safety culture domains on a scale from 1 to 5 were 4.1±0.6 for Teamwork Climate, Safety Climate, and Working Conditions and Satisfaction, 3.7±0.5 for Perception of Management, 3.6±0.4 for Communication, and 3.5±0.6 for Stress Recognition.

Conclusion

The safety culture among leaders in primary healthcare organizations in Slovenia is perceived as positive. There is also a strong organizational culture. Certain improvements are needed, especially in the field of communication and stress recognition with regards to safety culture.

Non-clinical rounds in hospital settings: a scoping review

PURPOSE

The purpose of this paper is to systematically describe the types of non-clinical rounds implemented in hospital settings.

DESIGN/METHODOLOGY/APPROACH

This scoping review was conducted and reported in accordance with the PRISMA. The review followed the four stages of conducting scoping review as defined by Arskey and O'Malley (2005).

FINDINGS

Initially, 978 articles were identified through database search from which only 24 studies were considered relevant and included in the final review. Overall, eight types of non-clinical rounds were identified (death rounds, grand rounds, morbidity and mortality conferences, multidisciplinary rounds, patient safety rounds, patient safety huddles, walkarounds and Schwartz rounds) that independently of their format, goal, participants and type of outcomes aimed to enhance patient safety and improve quality of healthcare delivery in hospital settings, either by focusing on physician, patient or organizational system.

ORIGINALITY/VALUE

To the authors' knowledge this is the first review that aims to provide a comprehensive summary to the types of non-clinical rounds that has been applied in clinical settings.

Preoccupation with failure and adherence to shared baselines: Measuring high-reliability organizational culture

OBJECTIVE

To create, administer, and psychometrically examine a survey to measure two new organizational culture factors - preoccupation with failure and adherence to shared baselines - in healthcare settings.

METHOD

Direct care providers (n = 4484) from a large healthcare system in the Southern United States completed a survey as part of their annual safety culture assessment.

RESULTS

We provide evidence about the internal consistency (Cronbach's alpha ranged from .80 to .89) factor structure, concurrent validity (correlation with overall patient safety grade ranged from .60 to .67, p <.05), and discriminant validity (correlations less than .85 with safety and teamwork culture) of these two factors.

CONCLUSIONS

We established evidence for internal consistency and validity of two new factors that measure aspects of organizational culture - preoccupation with failure and adherence to shared baselines - that are distinct from safety culture and teamwork culture.

Developing patient safety system using WHO tool in hospitals in Oman

Objective

Oman is progressively implementing the Patient Safety Friendly Hospital Initiative (PSFHI), a tool formulated by the World Health Organization (WHO) to achieve optimal patient safety in hospitals. This paper describes its implementation in selected government and private hospitals in Oman and analyses the performance of four hospitals whose implementations of PSFHI were assessed by WHO.

Design

The PSFHI initiative was launched in 11 hospitals in Oman during 2016. The enrolled hospitals implemented a 1-year plan composed of several steps such as formation of steering committees, working groups, full orientation about the standards, training of staff, documents development and community involvement. One year later, four hospitals which were the earliest to join the initiative were subjected to WHO assessment.

Setting

Secondary level government and private hospitals.

Intervention(s)

The WHO-PSFHI standards.

Main Outcome Measure

Hospitals' adherence to the standards.

Results

Three of the four hospitals (one government and two private) scored level two. One government hospital scored level three, earning it the distinction of being the first hospital in the Eastern Mediterranean Region to reach level three in the very first assessment.

Conclusions

Implementation of PSFHI in selected hospitals of Oman had successful outcomes in improving patient's safety.

Reducing Serious Safety Events and Priority Hospital-Acquired Conditions in a Pediatric Hospital with the Implementation of a Patient Safety Program

BACKGROUND

A freestanding children's hospital evaluated the impact of a patient safety program on serious safety events (SSEs) and hospital-acquired conditions (HACs).

METHODS

The No Harm Patient Safety Program was developed throughout the organization using a multifaceted approach that included safety moments, leadership rounding, cause analysis changes, event reporting enhancements, error prevention training, leadership training, identifying priority HACs, Eye on Safety Campaign, and safety coaches. The organization set strategic goals for improvement of SSEs and priority HACs.

RESULTS

The rate of SSEs decreased from 0.19 in 2014 to 0.09 in 2015. The rate significantly declined from 2015 to 2016 to a rate of 0.00, for a rate difference of -0.00009 (95% confidence interval [CI]: -0.00016, -0.00002; p = 0.012). The organization reached two years without an SSE in July 2017. The central line-associated bloodstream infection rate significantly declined from 2.8 per 1,000 line-days in 2015 to 1.6 in 2016, for a difference of -0.00118 (95% CI: -0.002270, -0.00008; p = 0.036). Surgical site infection rates declined from a 2015 rate of 3.8 infections per 100 procedures to a 2016 rate of 2.6 (p = 0.2962), and catheter-associated urinary tract infection rates declined from a 2015 rate of 2.7 per 1,000 catheter-days to a 2016 rate of 1.4 (p = 0.2770).

CONCLUSION

The No Harm Patient Safety Program was interwoven into the organization's strategic mission and values, and key messaging was used to purposefully tie the many interventions being implemented back to it. These interventions were associated with improvements in patient safety outcomes.

Incorporation of Leadership Rounds in CAUTI Prevention Efforts

Leadership engagement is an important aspect of integrating best practices at the bedside. The catheter-associated urinary tract infection (CAUTI) prevention workgroup at our academic medical center implemented leadership rounding in partnership with clinical staff to increase participation in CAUTI prevention initiatives on inpatient units. There was an associated decrease in urinary catheter utilization and CAUTI rates. Implementation of leadership rounds should be considered as a part of comprehensive CAUTI prevention efforts in health care settings.

The safety attitudes questionnaire in Chinese: psychometric properties and benchmarking data of the safety culture in Beijing hospitals

Background

In China, increasing attention has been devoted to the patient safety culture within health administrative departments and healthcare organizations. However, no official version of a patient safety culture assessment tool has been published or is widely used, and little is known about the status of the safety culture in Chinese hospitals. The aims of this study were to examine the reliability and validity of the Safety Attitudes Questionnaire in Chinese and to establish benchmark data on the safety culture in Beijing.

Methods

Across-sectional survey on patient safety culture was conducted from August to October 2014 using the Safety Attitudes Questionnaire in Chinese. Using a stratified random sampling method, we investigated departments from five integrative teaching hospitals in Beijing; frontline healthcare workers in each unit participated in the survey on a voluntary basis. The internal consistency and reliability were tested via Cronbach’s alpha, and the structural validity of the questionnaire was tested using a correlation analysis and confirmatory factor analysis. The patient safety culture in the five hospitals was assessed and analyzed.

Results

A total of 1663 valid questionnaires were returned, for a response rate of 87.9%. Cronbach’s alpha of the total scale was 0.945, and Cronbach’s alpha for the six dimensions ranged from 0.785 to 0.899. The goodness-of-fit indices in the confirmatory factor analysis showed an acceptable but not ideal model fit. The safety attitude score of healthcare workers in the five hospitals was 69.72, and the positive response rate was 38.57% overall. The positive response rates of the six dimensions were between 20.80% and 59.31%.

Conclusions

The Safety Attitudes Questionnaire in Chinese has good internal consistency, and the structural validity and reliability are acceptable. This questionnaire can be used to assess the safety culture in Beijing hospitals, but some items require further refinement. The patient safety culture in Beijing hospitals must be improved in certain key areas.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2543-2) contains supplementary material, which is available to authorized users.

Status of patient safety culture in Arab countries: a systematic review

OBJECTIVES

To explore the status of patient safety culture in Arab countries based on the findings of the Hospital Survey on Patient Safety Culture (HSPSC).

DESIGN

Systematic review.

METHODS

We performed electronic searches of the MEDLINE, EMBASE, CINAHL, ProQuest and PsychINFO, Google Scholar and PubMed databases, with manual searches of bibliographies of included articles and key journals. We included studies that were conducted in the Arab countries that were focused on patient safety culture. 2 reviewers independently verified that the studies met the inclusion criteria and critically assessed the quality of the studies.

RESULTS

18 studies met our inclusion criteria. The review identified that non-punitive response to error is seen as a serious issue which needs to be improved. Healthcare professionals in the Arab countries tend to think that a 'culture of blame' still exists that prevents them from reporting incidents. We found an overall similarity between the reported composite score for dimension of teamwork within units in all of the reviewed studies. Teamwork within units was found to be better than teamwork across hospital units. All of the reviewed studies reported that organisational learning and continuous improvement was satisfactory as the average score of this dimension for all studies was 73.2%. Moreover, the review found that communication openness seems to be a concerning issue for healthcare professionals in the Arab countries.

CONCLUSIONS

There is a need to promote patient safety culture as a strategy for improving the patient safety in the Arab world. Improving patient safety culture should include all stakeholders, like policymakers, healthcare providers and those responsible for medical education. This review was limited only to English language publications. The varied settings in which the HSPSC was used may have influenced the areas of strengths and weaknesses as healthcare workers' perception of safety culture may differ.

Workarounds in the Workplace: A Second Look

Nursing workarounds have garnered increased attention over the past 15 years, corresponding with an increased focus on patient safety and evidence-based practice and a rise in the use of health information technologies (HITs). Workarounds have typically been viewed as deviations from best practice that put patients at risk for poor outcomes. However, this narrow view fails to take into consideration the multifactorial origins of workarounds. The authors explore the ways in which evidence-based protocols and HIT, designed to improve patient safety and quality, can have an unintended consequence of increasing the likelihood of nurses engaging in workarounds. The article also examines workarounds considering the ethical obligations of both nurses and administrative leaders to optimize patient safety and quality.

Design and Testing of the Safety Agenda Mobile App for Managing Health Care Managers' Patient Safety Responsibilities

Background

Adverse events are a reality in clinical practice. Reducing the prevalence of preventable adverse events by stemming their causes requires health managers’ engagement.

Objective

The objective of our study was to develop an app for mobile phones and tablets that would provide managers with an overview of their responsibilities in matters of patient safety and would help them manage interventions that are expected to be carried out throughout the year.

Methods

The Safety Agenda Mobile App (SAMA) was designed based on standardized regulations and reviews of studies about health managers’ roles in patient safety. A total of 7 managers used a beta version of SAMA for 2 months and then they assessed and proposed improvements in its design. Their experience permitted redesigning SAMA, improving functions and navigation. A total of 74 Spanish health managers tried out the revised version of SAMA. After 4 months, their assessment was requested in a voluntary and anonymous manner.

Results

SAMA is an iOS app that includes 37 predefined tasks that are the responsibility of health managers. Health managers can adapt these tasks to their schedule, add new ones, and share them with their team. SAMA menus are structured in 4 main areas: information, registry, task list, and settings. Of the 74 users who tested SAMA, 64 (86%) users provided a positive assessment of SAMA characteristics and utility. Over an 11-month period, 238 users downloaded SAMA. This mobile app has obtained the AppSaludable (HealthyApp) Quality Seal.

Conclusions

SAMA includes a set of activities that are expected to be carried out by health managers in matters of patient safety and contributes toward improving the awareness of their responsibilities in matters of safety.

Patient safety in organizational culture as perceived by leaderships of hospital institutions with different types of administration

OBJECTIVE

To identify the perceptions of leaderships toward patient safety culture dimensions in the routine of hospitals with different administrative profiles: government, social and private organizations, and make correlations among participating institutions regarding dimensions of patient safety culture used.

METHOD

A quantitative cross-sectional study that used the Self Assessment Questionnaire 30 translated into Portuguese. The data were processed by analysis of variance (ANOVA) in addition to descriptive statistics, with statistical significance set at p-value ≤ 0.05.

RESULTS

According to the participants' perceptions, the significant dimensions of patient safety culture were 'patient safety climate' and 'organizational learning', with 81% explanatory power. Mean scores showed that among private organizations, higher values were attributed to statements; however, the correlation between dimensions was stronger among government hospitals.

CONCLUSION

Different hospital organizations present distinct values for each dimension of patient safety culture and their investigation enables professionals to identify which dimensions need to be introduced or improved to increase patient safety.

OBJETIVO

Identificar percepções das lideranças sobre as dimensões da cultura de segurança do paciente no cotidiano de hospitais de diferentes perfis administrativos: públicos, organizações sociais e privados, e realizar correlação entre as instituições participantes, de acordo com as dimensões da cultura de segurança do paciente utilizadas.

MÉTODO

Estudo transversal de aspecto quantitativo obtido por meio da aplicação do instrumento Self Assessment Questionnaire 30, traduzido para a língua portuguesa. Os dados foram tratados com análise de variância (ANOVA), além das estatísticas descritivas, considerando como de significância estatística valores de p-valor ≤ 0,05.

RESULTADOS

Segundo a percepção dos participantes do estudo, as dimensões significativas para a cultura de segurança do paciente foram Ambiente de Segurança do Paciente e Aprendizado Organizacional, com poder explicativo de 81%. A média de respostas obtidas evidenciou que nas organizações privadas houve maiores valores atribuídos às questões, porém a correlação entre as dimensões foi mais forte nas organizações públicas.

CONCLUSÃO

As dimensões da cultura de segurança do paciente têm valores distintos nas diferentes organizações hospitalares e a sua investigação possibilita identificar quais necessitam ser introduzidas ou aprimoradas para maior segurança do paciente.

Effective board governance of safe care: a (theoretically underpinned) cross-sectioned examination of the breadth and depth of relationships through national quantitative surveys and in-depth qualitative case studies

Background

Recent high-profile reports into serious failings in the quality of hospital care in the NHS raise concerns over the ability of trust boards to discharge their duties effectively.

Objectives

Our study aimed to generate theoretically grounded empirical evidence on the associations between board governance, patient safety processes and patient-centred outcomes. The specific aims were as follows: (1) to identify the types of governance activities undertaken by hospital trust boards in the English NHS with regard to ensuring safe care in their organisation; (2) in foundation trusts, to explore the role of boards and boards of governors with regards to the oversight of patient safety in their organisation; (3) to assess the association between particular hospital trust board oversight activities and patient safety processes and clinical outcomes; (4) to identify the facilitators and barriers to developing effective hospital trust board governance of safe care; and (5) to assess the impact of external commissioning arrangements and incentives on hospital trust board oversight of patient safety.

Methods

The study comprised three distinct but interlocking strands: (1) a narrative systematic review in order to describe, interpret and synthesise key findings and debates concerning board oversight of patient safety; (2) in-depth mixed-methods case studies in four organisations to assess the impact of hospital board governance and external incentives on patient safety processes and outcomes; and (3) two national surveys exploring board management in NHS acute and specialist hospital trusts in England, and relating board characteristics to whole-organisation outcomes.

Results

A very high proportion of trust boards reported the kinds of desirable characteristics and board-related processes that research says may be associated with higher performance. Our analysis of the symbolic aspects of board activities highlights the role and differences in local processes of organising the governance of patient safety. Most boards do allocate a considerable amount of time to discussing patient safety and quality-related issues and were using a wide range of hard performance metrics and soft intelligence to monitor its organisation with regard to patient safety. Although the board of governors is generally perceived to be well-meaning, they were also considered to be being largely ineffective in helping to promote and deliver safer care for their organisations. We did not find any statistically significant relationship between board attributes (self-reported) and processes and any patient safety outcome measures. However, we did find a significant relationship between two dimensions of the Board Self-Assessment Questionnaire and two specific-and-related national staff survey organisational ‘process’ measures: (1) staff feeling safe to raise concerns about errors, near-misses and incidents and (2) staff feeling confident that their organisation would address their concerns, if raised. We also found that contracting and external financial incentives appeared to play only a relatively minor role in incentivising quality and safety improvement.

Conclusions

Our research is the first large-scale mixed-methods study of hospital board activity and behaviour related to the oversight of patient safety in the English NHS and the key findings should be used to influence the design of future governance arrangements as well as the training and support of board. Our finding that board governance/competencies appear to be linked to staff feeling safe to raise concerns about patient safety issues, and also their confidence that their organisation would address their concern, is worthy of further and more sustained exploration, particularly in the context of the current focus on improving whistleblowing policies in the NHS.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Patient safety culture in a district hospital in South Africa: An issue of quality

Background

The Nursing Act 33 of 2005 holds nurse practitioners responsible for all acts and omissions in the delivery of quality patient care. But quality patient care is influenced by a number of factors beyond the control of nurse practitioners. Patient safety culture is one such factor and is seldom explored in hospitals in developing countries. This article describes the patient safety culture of a district hospital in South Africa.

Objectives

The study identified and analysed the factors that influence the patient safety culture by using the Manchester Patient Safety Framework at the National District Hospital, Bloemfontein, Free State Province.

Method

A descriptive cross-sectional study was conducted and included the total population of permanent staff; community service health professionals; temporarily employed health professionals and volunteers. The standard Manchester Patient Safety Framework questionnaire was distributed with a response rate of 61%.

Results

Less than half of the respondents (42.4%; n = 61) graded their units as acceptable. Several quality dimensions were statistically significant for the employment profile: overall commitment to quality (p = 0.001); investigating patient incidents (p = 0.031); organisational learning following incidents (p < 0.001); communication around safety issues (p = 0.001); and team working around safety issues (p = 0.005). These same quality dimensions were also statistically significant for the professional profiles. Medical doctors had negative perceptions of all the safety dimensions.

Conclusion

The research measured and described patient safety culture (PSC) amongst the staff at the National District Hospital (NDH). This research has identified the perceived inadequacies with PSC and gives nurse managers a clear mandate to implement change to ensure a PSC that fosters quality patient care.

Electronic clinical safety reporting system: a benefits evaluation

Background

Eastern Health, a large health care organization in Newfoundland and Labrador (NL), started a staged implementation of an electronic occurrence reporting system (used interchangeably with “clinical safety reporting system”) in 2008, completing Phase One in 2009. The electronic clinical safety reporting system (CSRS) was designed to replace a paper-based system. The CSRS involves reporting on occurrences such as falls, safety/security issues, medication errors, treatment and procedural mishaps, medical equipment malfunctions, and close calls. The electronic system was purchased from a vendor in the United Kingdom that had implemented the system in the United Kingdom and other places, such as British Columbia. The main objective of the new system was to improve the reporting process with the goal of improving clinical safety. The project was funded jointly by Eastern Health and Canada Health Infoway.

Objective

The objectives of the evaluation were to: (1) assess the CSRS on achieving its stated objectives (particularly, the benefits realized and lessons learned), and (2) identify contributions, if any, that can be made to the emerging field of electronic clinical safety reporting.

Methods

The evaluation involved mixed methods, including extensive stakeholder participation, pre/post comparative study design, and triangulation of data where possible. The data were collected from several sources, such as project documentation, occurrence reporting records, stakeholder workshops, surveys, focus groups, and key informant interviews.

Results

The findings provided evidence that frontline staff and managers support the CSRS, identifying both benefits and areas for improvement. Many benefits were realized, such as increases in the number of occurrences reported, in occurrences reported within 48 hours, in occurrences reported by staff other than registered nurses, in close calls reported, and improved timelines for notification. There was also user satisfaction with the tool regarding ease of use, accessibility, and consistency. The implementation process encountered challenges related to customizing the software and the development of the classification system for coding occurrences. This impacted on the ability of the managers to close-out files in a timely fashion. The issues that were identified, and suggestions for improvements to the form itself, were shared with the Project Team as soon as they were noted. Changes were made to the system before the rollout.

Conclusions

There were many benefits realized from the new system that can contribute to improved clinical safety. The participants preferred the electronic system over the paper-based system. The lessons learned during the implementation process resulted in recommendations that informed the rollout of the system in Eastern Health, and in other health care organizations in the province of Newfoundland and Labrador. This study also informed the evaluation of other health organizations in the province, which was completed in 2013.

Hospital board oversight of quality and patient safety: a narrative review and synthesis of recent empirical research

CONTEXT

Recurring problems with patient safety have led to a growing interest in helping hospitals' governing bodies provide more effective oversight of the quality and safety of their services. National directives and initiatives emphasize the importance of action by boards, but the empirical basis for informing effective hospital board oversight has yet to receive full and careful review.

METHODS

This article presents a narrative review of empirical research to inform the debate about hospital boards' oversight of quality and patient safety. A systematic and comprehensive search identified 122 papers for detailed review. Much of the empirical work appeared in the last ten years, is from the United States, and employs cross-sectional survey methods.

FINDINGS

Recent empirical studies linking board composition and processes with patient outcomes have found clear differences between high- and low-performing hospitals, highlighting the importance of strong and committed leadership that prioritizes quality and safety and sets clear and measurable goals for improvement. Effective oversight is also associated with well-informed and skilled board members. External factors (such as regulatory regimes and the publication of performance data) might also have a role in influencing boards, but detailed empirical work on these is scant.

CONCLUSIONS

Health policy debates recognize the important role of hospital boards in overseeing patient quality and safety, and a growing body of empirical research has sought to elucidate that role. This review finds a number of areas of guidance that have some empirical support, but it also exposes the relatively inchoate nature of the field. Greater theoretical and methodological development is required if we are to secure more evidence-informed governance systems and practices that can contribute to safer care.

Alarm Fatigue

Research has demonstrated that 72% to 99% of clinical alarms are false. The high number of false alarms has led to alarm fatigue. Alarm fatigue is sensory overload when clinicians are exposed to an excessive number of alarms, which can result in desensitization to alarms and missed alarms. Patient deaths have been attributed to alarm fatigue. Patient safety and regulatory agencies have focused on the issue of alarm fatigue, and it is a 2014 Joint Commission National Patient Safety Goal. Quality improvement projects have demonstrated that strategies such as daily electrocardiogram electrode changes, proper skin preparation, education, and customization of alarm parameters have been able to decrease the number of false alarms. These and other strategies need to be tested in rigorous clinical trials to determine whether they reduce alarm burden without compromising patient safety.

Clinical risk management in hospitals: strategy, central coordination and dialogue as key enablers

OBJECTIVE

The study aims to identify key enablers fostering clinical risk management (CRM) in hospitals to guide health care in this vital area of patient safety.

METHOD

A cross-sectional survey was conducted at the national level in 324 Swiss hospitals in 2007-2008 to assess the relationship between key elements and systematic CRM. Therefore, a comprehensive monitoring instrument for CRM was used for the first time. Organizational factors (e.g. strategy, coordination, resources) and structural conditions (e.g. hospital size) were tested as key elements. CRM was assessed by evaluating its maturity (i.e. the level of CRM development) by 12 theoretically derived indices joining together essential aspects of CRM at the hospital level and the service level. Chi-square measures were used to analyse the relationships between organizational factors or structural conditions and maturity of CRM.

RESULTS

Participation in this voluntary survey was good, with CRM experts of 138 out of 324 hospitals responding (response rate 43%). Three key enablers for CRM were identified: implementing a function for central CRM coordination, assuring dialogue with and between the different hospital services, and developing strategic CRM objectives.

CONCLUSIONS

This study offers, for the first time, an assessment of the maturity of hospitals' CRM and identifies key enablers related to CRM. This is a feasible first step in guiding hospitals to shape their CRM and presents a basis for future studies, for example, linking CRM to outcome data.

Disclosure, apology, and offer programs: stakeholders' views of barriers to and strategies for broad implementation

CONTEXT

The Disclosure, Apology, and Offer (DA&O) model, a response to patient injuries caused by medical care, is an innovative approach receiving national attention for its early success as an alternative to the existing inherently adversarial, inefficient, and inequitable medical liability system. Examples of DA&O programs, however, are few.

METHODS

Through key informant interviews, we investigated the potential for more widespread implementation of this model by provider organizations and liability insurers, defining barriers to implementation and strategies for overcoming them. Our study focused on Massachusetts, but we also explored themes that are broadly generalizable to other states.

FINDINGS

We found strong support for the DA&O model among key stakeholders, who cited its benefits for both the liability system and patient safety. The respondents did not perceive any insurmountable barriers to broad implementation, and they identified strategies that could be pursued relatively quickly. Such solutions would permit a range of organizations to implement the model without legislative hurdles.

CONCLUSIONS

Although more data are needed about the outcomes of DA&O programs, the model holds considerable promise for transforming the current approach to medical liability and patient safety.

Assessment of patient safety culture in Palestinian public hospitals

OBJECTIVE

To assess the prevalent patient safety culture in Palestinian public hospitals.

DESIGN

A cross-sectional design, Arabic translated version of the Hospital Survey on Patient Safety Culture was used.

SETTING

All the 11 general public hospitals in the West Bank.

PARTICIPANTS

A total of 1460 clinical and non-clinical hospital staff.

INTERVENTION(S)

No.

MAIN OUTCOME MEASURES

Twelve patient safety culture composites and 2 outcome variables (patient safety grade and events reported in the past year) were measured.

RESULTS

Most of the participants were nurses and physicians (69.2%) with direct contact with patients (92%), mainly employed in medical/surgical units (55.1%). The patient safety composites with the highest positive scores were teamwork within units (71%), organizational learning and continuous improvement (62%) and supervisor/manager expectations and actions promoting patient safety (56%). The composites with the lowest scores were non-punitive response to error (17%), frequency of events reported (35%), communication openness (36%), hospital management support for patient safety (37%) and staffing (38%). Although 53.2% of the respondents did not report any event in the past year, 63.5% rated patient safety level as 'excellent/very good'. Significant differences in patient safety scores and outcome variables were found between hospitals of different size and in relation to staff positions and work hours.

CONCLUSIONS

This study highlights the existence of a punitive and blame culture, under-reporting of events, lack of communication openness and inadequate management support that are key challenges for patient safe hospital care. The baseline survey results are valuable for designing and implementing the patient safety program and for measuring future progress.

A new leadership role for pharmacists: a prescription for change

OBJECTIVE

Pharmacists can play an important role as leaders to reduce patient safety risks, optimize the safe function of medication management systems, and align pharmacy services with national initiatives that measure and reward quality performance. The objective of this article is to determine the actions that pharmacists can take to create a visible and sustainable safe medication management structure and system in the health care environment.

METHODS

An evidence-based literature search was performed to determine what actions successful pharmacist leaders have taken to improve patient safety.

RESULTS

There is a growing number of quality and patient safety standards, as well as measures that focus specifically on medication use and education. Health care organizations must be made aware of the valuable resources that pharmacists provide and of the complexity of medication management. There are steps that pharmacist leaders can take to achieve these goals.

CONCLUSIONS

The 10 steps that pharmacist leaders can take to create a visible and sustainable safe medication management structure and system are the following: 1. Identify and mitigate medication management risks and hazards to reduce preventable patient harm. 2. Establish pharmacy leadership structures and systems to ensure organizational awareness of medication safety gaps. 3. Support an organizational culture of safe medication use. 4. Ensure evidence-based medication regimens for all patients. 5. Have daily check-in calls/meetings, with the primary focus on significant safety or quality issues. 6. Establish a medication safety committee. 7. Perform medication safety walk-rounds to evaluate medication processes, and request front-line staff ’s input about medication safe practices. 8. Ensure that pharmacy staff engage in teamwork, skill building, and communication training. 9. Engage in readiness planning for implementation of health information technology (HIT). 10. Include medication history-taking and reviews upon entry into the organization; medication counseling and training during the discharge process; and follow-up after the transition to home.

Patient Safety Friendly Hospital Initiative: from evidence to action in seven developing country hospitals

QUALITY PROBLEM

Recent evidence in the level of patient safety from hospitals in six developing countries in the Eastern Mediterranean Region has demonstrated the high prevalence of adverse events, the excessive rate of death and permanent disability and their high preventability. The Patient Safety Friendly Hospital Initiative (PSFHI) has been launched to respond to these challenges.

INITIAL ASSESSMENT

The principal approach of the PSFHI has been to develop an assessment manual that has 140 patient safety standards across five domains--leadership and management, patients and public involvement, safe evidence-based clinical practices, safe environment and lifelong learning.

CHOICE OF SOLUTION AND IMPLEMENTATION

Ministries of health of seven countries--Egypt, Jordan, Morocco, Pakistan, Sudan, Tunisia and Yemen were asked to nominate one hospital for assessment and then follow-up with an improvement plan.

EVALUATION

The standards are divided into critical (20), core (90) and developmental (30). The range of critical standards, the compulsory standards with which a hospital has to comply, achieved by participating hospitals was 8-78%. Overall, in the domain of leadership and management the highest compliance was 47%, for patients and public involvement 25%, for safe evidence-based clinical practice 53%, for safe environment 64% and for lifelong learning 27%.

LESSONS LEARNED

This is the first systematic multi-country initiative in the Eastern Mediterranean Region, which provides compelling evidence that assessment of patient safety standards is feasible and applicable in resource-poor settings and there are significant opportunities for improving the level of patient safety in these hospitals.

Assessing hospitals' clinical risk management: Development of a monitoring instrument

BACKGROUND

Clinical risk management (CRM) plays a crucial role in enabling hospitals to identify, contain, and manage risks related to patient safety. So far, no instruments are available to measure and monitor the level of implementation of CRM. Therefore, our objective was to develop an instrument for assessing CRM in hospitals.

METHODS

The instrument was developed based on a literature review, which identified key elements of CRM. These elements were then discussed with a panel of patient safety experts. A theoretical model was used to describe the level to which CRM elements have been implemented within the organization. Interviews with CRM practitioners and a pilot evaluation were conducted to revise the instrument. The first nationwide application of the instrument (138 participating Swiss hospitals) was complemented by in-depth interviews with 25 CRM practitioners in selected hospitals, for validation purposes.

RESULTS

The monitoring instrument consists of 28 main questions organized in three sections: 1) Implementation and organizational integration of CRM, 2) Strategic objectives and operational implementation of CRM at hospital level, and 3) Overview of CRM in different services. The instrument is available in four languages (English, German, French, and Italian). It allows hospitals to gather comprehensive and systematic data on their CRM practice and to identify areas for further improvement.

CONCLUSIONS

We have developed an instrument for assessing development stages of CRM in hospitals that should be feasible for a continuous monitoring of developments in this important area of patient safety.

Can outcome prediction data change patient outcomes and organizational outcomes?

PURPOSE OF REVIEW

Intensive care medicine consumes a high share of healthcare costs, and there is growing pressure to use the scarce resources efficiently. Accordingly, organizational issues and quality management have become an important focus of interest in recent years. Here, we will review current concepts of how outcome data can be used to identify areas requiring action.

RECENT FINDINGS

Using recently established models of outcome assessment, wide variability between individual ICUs is found, both with respect to outcome and resource use. Such variability implies that there are large differences in patient care processes not only within the ICU but also in pre-ICU and post-ICU care. Indeed, measures to improve the patient process in the ICU (including care of the critically ill, patient safety, and management of the ICU) have been presented in a number of recently published papers.

SUMMARY

Outcome assessment models provide an important framework for benchmarking. They may help the individual ICU to spot appropriate fields of action, plan and initiate quality improvement projects, and monitor the consequences of such activity.

Computer-related medication errors in neonatal intensive care units

Iatrogenic medication errors in the neonatal ICU (NICU) are reported to occur up to 2.6 times per 100 NICU days. It has been learned during the last decade that well-intended but faulty implementations of technology can increase the frequency of errors and also can give rise to new types. This article compares and discusses iatrogenic medication errors in the NICU that are related to computer entry and computerized physician order entry systems. The authors also propose a possible approach for evaluating technology that is intended to prevent iatrogenic mediation errors in the NICU.