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Tsamasiotis C, Fiard G, Bouzat P, François P, Fond G, Boyer L, Boussat B. From Reporting to Improving: How Root Cause Analysis in Teams Shape Patient Safety Culture. Risk Manag Healthc Policy 2024; 17:1847-1858. [PMID: 39072187 PMCID: PMC11277907 DOI: 10.2147/rmhp.s466852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 07/10/2024] [Indexed: 07/30/2024] Open
Abstract
Background Given the increasing focus on patient safety in healthcare systems worldwide, understanding the impact of Continuous Quality Improvement Programs (QIPs) is crucial. QIPs, including Morbidity and Mortality Conferences (MMCs) and Experience Feedback Committees (EFCs), have been identified as effective strategies for enhancing patient safety culture. These programs engage healthcare professionals in the identification and analysis of adverse events to foster a culture of safety (ie the product of individual and group value, attitudes, and perceptions about quality and safety). This study aimed to determine whether patient safety culture differed regarding care provider participation in MMCs and EFCs activities. Methods A cross-sectional web-only survey was conducted in 2022 using the Hospital Survey on Patient Safety Culture (HSOPS) among 4780 employees at an 1836-bed, university-affiliated hospital in France. We quantified the mean differences in the 12 HSOPS dimension scores according to MMCs and EFCs participation, using Cohen d effect size. We performed a multivariate analysis of variance to examine differences in dimension scores after adjusting for background characteristics. Results Of 4780 eligible employees, 1457 (30.5%) participated in the study. Among the respondents, 571 (39.2%) participated in MMCs or EFCs activities. Participants engaged in MMCs or EFCs reported significantly higher scores in six out of twelve HSOPS dimensions, particularly in "Nonpunitive response to error", "Feedback and communication about error", and "Organizational learning" (Overall effect size = 0.14, 95% confidence interval = 0.11 to 0.17, P<0.001). Notably, involvement in both MMCs and EFCs was associated with higher improvements in patient safety culture compared to non-participation or singular involvement in either program. However, certain dimensions such as "Staffing", "Hospital management support", and "Hospital handoffs and transition" showed no significant association with MMCs or EFCs participation, highlighting broader systemic challenges. Conclusion The study confirms the positive association between participation in MMCs or EFCs and an enhanced culture of patient safety, emphasizing the importance of such programs in fostering an environment conducive to learning, communication, and nonpunitive responses to errors. While MMCs or EFCs are effective in promoting certain aspects of patient safety culture, addressing broader systemic challenges remains crucial for comprehensive improvements in patient safety.
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Affiliation(s)
- Christos Tsamasiotis
- Department of Clinical Epidemiology, Grenoble-Alps University Hospital; Laboratory TIMC-IMAG, UMR 5525 Joint Research Unit, National Center for Scientific Research, Faculty of Medicine, Grenoble Alps University, Grenoble, France
| | - Gaelle Fiard
- Department of Urology, Grenoble Alpes University Hospital, CNRS, Grenoble INP, TIMC, Université Grenoble Alpes, Grenoble, France
| | - Pierre Bouzat
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, University Grenoble Alpes; INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France
| | - Patrice François
- Department of Clinical Epidemiology, Grenoble-Alps University Hospital; Laboratory TIMC-IMAG, UMR 5525 Joint Research Unit, National Center for Scientific Research, Faculty of Medicine, Grenoble Alps University, Grenoble, France
| | - Guillaume Fond
- AP-HM, Aix-Marseille University, School of Medicine - La Timone Medical Campus, UR3279: Health Service Research and Quality of Life Center (CEReSS), Marseille, France
| | - Laurent Boyer
- AP-HM, Aix-Marseille University, School of Medicine - La Timone Medical Campus, UR3279: Health Service Research and Quality of Life Center (CEReSS), Marseille, France
| | - Bastien Boussat
- Department of Clinical Epidemiology, Grenoble-Alps University Hospital; Laboratory TIMC-IMAG, UMR 5525 Joint Research Unit, National Center for Scientific Research, Faculty of Medicine, Grenoble Alps University, Grenoble, France
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
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David-Tchouda S, Foote A, Bosson JL. The Incident Feedback Committee (IFC): A Useful Tool to Investigate Errors in Clinical Research. Healthcare (Basel) 2022; 10:healthcare10071354. [PMID: 35885880 PMCID: PMC9317103 DOI: 10.3390/healthcare10071354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/10/2022] [Accepted: 07/14/2022] [Indexed: 11/16/2022] Open
Abstract
In clinical practice, an objective of safety management is to identify preventable causes of adverse events to avoid the incidents from recurring. Likewise, in the field of clinical research adequate methods to investigate incidents that impair the quality of a clinical trial are needed. Understanding the causes of errors and undesirable incidents can help guarantee participant safety, improve the practices of research coordinators, investigators, and clinical research assistants and help to minimize research costs. Here, we present the main features of our Incident Feedback Committees (IFC) in clinical research, with outcomes over 5 years. Methods: The IFC has adapted the ALARM and ORION post-event methods with investigations focused on ‘the incidents’ occurring during research studies. It sought the root causes contributing to these incidents and proposed corrective actions. Results: Since our IFC was set up in 2015 it has examined 52 incidents from nine studies. The most frequent causes mainly concerned the working environment (54%). Most incidents had two or more causes. Some corrective actions were planned for ongoing or future studies. Conclusion: IFCs provide a useful and much-appreciated method of analysing incidents in the performance of clinical research. A multicentre study is needed to evaluate the effect of IFCs on the quality of an establishment’s clinical research, at the individual level (patient safety) and also at the system level (changes in the organization of tasks).
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Affiliation(s)
- Sandra David-Tchouda
- Pôle Santé Publique, CHU Grenoble Alpes, F-38000 Grenoble, France;
- TIMC-Imag UMR 5525, Université Grenoble Alpes, F-38000 Grenoble, France
- CIC 1406 Grenoble, INSERM, F-38000 Grenoble, France
- Correspondence:
| | - Alison Foote
- Pôle Recherche, CHU Grenoble Alpes, F-38000 Grenoble, France;
| | - Jean-Luc Bosson
- Pôle Santé Publique, CHU Grenoble Alpes, F-38000 Grenoble, France;
- TIMC-Imag UMR 5525, Université Grenoble Alpes, F-38000 Grenoble, France
- CIC 1406 Grenoble, INSERM, F-38000 Grenoble, France
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Svensson J. Patient Safety Strategies in Psychiatry and How They Construct the Notion of Preventable Harm: A Scoping Review. J Patient Saf 2022; 18:245-252. [PMID: 34347739 PMCID: PMC9359776 DOI: 10.1097/pts.0000000000000885] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The literature on patient safety in psychiatry has not been explored systematically in terms of what interventions are used, how they are used, and what type of (preventable) harm is targeted. The aims of this scoping review are to explore patient safety strategies used in psychiatry and determine how they construct the notion of preventable harm. METHOD A scoping review of literature on patient safety in psychiatry published in English between 2000 and 2019 was conducted using Scopus, MEDLINE, PsycInfo, and CINAHL. Keywords of patient safety strategies and possible outcomes were coded from the results, discussion, or conclusion. Patient safety strategies were inductively categorized into themes according to the focus of the strategy. RESULTS The review introduces 7 focus areas of patient safety strategies identified within the psychiatric literature: "risk management," "healthcare practitioners," "patient observation," "patient involvement," "computerized methods," "admission and discharge," and "security." The result shows that patient safety strategies mainly aim to reduce suicide, self-harm, violence, and falls and present a large diversity of measures, often aimed at reducing variability while increasing standardization. CONCLUSIONS The strategies that are supported in the literature to achieve safer psychiatry mainly arise from linear cause-effect models and rely on staff performance, competence, and compliance. Contemporary safety science acknowledges the performance variability of everyday normal work and sees risk as the dynamic migration of these daily activities. The field of psychiatry has not yet included this view of safety in the strategic actions to reduce preventable harm.
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Affiliation(s)
- Jakob Svensson
- From the Division of Risk Management and Societal Safety, Lund University, Sweden
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Boussat B, François P, Gandon G, Giai J, Seigneurin A, Perneger T, Labarère J. Inconsistencies Between Two Cross-Cultural Adaptations of the Hospital Survey on Patient Safety Culture Into French. J Patient Saf 2021; 17:e1186-e1193. [PMID: 29140887 DOI: 10.1097/pts.0000000000000443] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Two cross-cultural adaptations of the 12-dimension Hospital Survey on Patient Safety Culture (HSOPSC) into French coexist: the Occelli and Vlayen versions. The objective of this study was to assess the psychometric properties of the Occelli version in comparison with those reported for the Vlayen and the original US versions of this instrument. METHODS Using the original data from a cross-sectional study of 5,064 employees at a single university hospital in France, we examined the acceptability, internal consistency, factorial structure, and construct validity of the Occelli version of the HSOPSC. RESULTS The response rate was 76.8% (n = 3888). Our study yielded lower missing value rates (median, 0.4% [range, 0.0%-2.4%] versus 0.8% [range, 0.2%-11.4%]) and lower dimension scores (median, 3.19 [range, 2.67-3.54] versus 3.42 [range, 2.92-3.96]) than those reported for the Vlayen version. Cronbach alphas (median, 0.64; range, 0.56-0.84) compared unfavorably with those reported for the Vlayen (median, 0.73; range, 0.57-0.86) and original US (median, 0.78; range, 0.63-0.84) versions. The results of the confirmatory factor analysis were consistent between the Vlayen and Occelli versions, making it possible to conduct surveys from the 12-dimensional structure with both versions. CONCLUSIONS The inconsistencies observed between the Occelli and Vlayen versions of the HSOPSC may reflect either differences between the translations or heterogeneity in the study population and context. Current evidence does not clearly support the use of one version over the other. The two cross-cultural adaptations of the HSOPSC can be used interchangeably in French-speaking countries.
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Affiliation(s)
| | | | - Gérald Gandon
- From the Quality of Care Unit, Grenoble University Hospital
| | - Joris Giai
- Service de Biostatistique, Hospices Civils de Lyon, Laboratoire de Biométrie et Biologie Evolutive, Lyon, France
| | | | - Thomas Perneger
- Division of Clinical Epidemiology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Boussat B, Seigneurin A, Giai J, Kamalanavin K, Labarère J, François P. Involvement in Root Cause Analysis and Patient Safety Culture Among Hospital Care Providers. J Patient Saf 2021; 17:e1194-e1201. [PMID: 29283910 DOI: 10.1097/pts.0000000000000456] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The experience feedback committee (EFC) is a tool designed to involve medical teams in patient safety management, through root cause analysis within the team. OBJECTIVE The aim of the study was to determine whether patient safety culture, as measured by the Hospital Survey on Patient Safety Culture (HSOPS), differed regarding care provider involvement in EFC activities. METHODS Using the original data from a cross-sectional survey of 5064 employees at a single university hospital in France, we analyzed the differences in HSOPS dimension scores according involvement in EFC activities. RESULTS Of 5064 eligible employees, 3888 (76.8%) participated in the study. Among the respondents, 440 (11.3%) participated in EFC activities. Experience feedback committee participants had a more developed patient safety culture, with 9 of the 12 HSOPS dimension scores significantly higher than EFC nonparticipants (overall effect size = 0.31, 95% confidence interval = 0.21 to 0.41, P < 0.001). A multivariate analysis of variance indicated that all 12 dimension scores, taken together, were significantly different between EFC participants and nonparticipants (P < 0.0001), independently of sex, hospital department, and healthcare profession category. The largest differences in scores related to the "feedback and communication about error," "organizational learning," and "Nonpunitive response to error" dimensions. The analysis of the subgroup of professionals who worked in a department with a productive EFC, defined as an EFC implementing at least five actions per year, showed a higher patient safety culture level for seven of the 12 HSOPS dimensions (overall effect size = 0.19, 95% confidence interval = 0.10 to 0.27, P < 0.001). DISCUSSION AND CONCLUSIONS Participation in EFC activities was associated with higher patient safety culture scores. The findings suggest that root cause analysis in the team's routine may improve patient safety culture.
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Affiliation(s)
| | | | - Joris Giai
- Service de Biostatistique, Hospices Civils de Lyon, Laboratoire de Biométrie et Biologie Evolutive, UMR 5558 CNRS, Lyon
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Kuosmanen A, Tiihonen J, Repo-Tiihonen E, Eronen M, Turunen H. Changes in patient safety culture: A patient safety intervention for Finnish forensic psychiatric hospital staff. J Nurs Manag 2019; 27:848-857. [PMID: 30784144 DOI: 10.1111/jonm.12760] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 01/21/2019] [Accepted: 02/17/2019] [Indexed: 11/29/2022]
Abstract
AIM To evaluate how a 3-year patient safety intervention, more specifically, the implementation of a patient safety incident reporting system, influences patient safety culture. BACKGROUND Positive patient safety culture improves both the quality of health care and patient safety. Nevertheless, nursing managers need tools that can help them develop and evaluate patient safety culture. METHODS The Hospital Survey on Patient Safety Culture was used to evaluate patient safety culture at two Finnish forensic psychiatric hospitals (study and control) over two periods, baseline and follow-up. Data were analysed using Z-score and T test statistics. RESULTS The follow-up results from the study hospital showed that five patient safety culture dimensions exhibited a significantly (p < 0.05) positive change in positive response rates over the 3-year period. Furthermore, nine out of twelve patient safety culture dimensions at the study hospital showed a significant improvement in mean score. At the control hospital, only the dimension of frequency of reporting events showed a significantly positive change (p < 0.05) in mean score. CONCLUSION This research shows that the studied patient safety intervention (implementation of the patient safety incident reporting system) significantly influences patient safety culture. IMPLICATIONS FOR NURSING MANAGEMENT Nursing managers should utilize a variety of patient safety interventions to improve patient safety and focus on leveraging information from patient safety incidents to advance patient safety culture.
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Affiliation(s)
- Anssi Kuosmanen
- Department of Forensic Psychiatry, University of Eastern Finland, Kuopio, Finland.,Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| | - Jari Tiihonen
- Department of Forensic Psychiatry, University of Eastern Finland, Kuopio, Finland.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Eila Repo-Tiihonen
- Department of Forensic Psychiatry, University of Eastern Finland, Kuopio, Finland
| | | | - Hannele Turunen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland.,Kuopio University Hospital, Kuopio, Finland
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Aboumrad M, Neily J, Watts BV. Teaching Root Cause Analysis Using Simulation: Curriculum and Outcomes. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2019; 6:2382120519894270. [PMID: 31897434 PMCID: PMC6920588 DOI: 10.1177/2382120519894270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 11/20/2019] [Indexed: 05/07/2023]
Abstract
BACKGROUND Clinicians are key drivers for improving health care quality and safety. However, some may lack experience in quality improvement and patient safety (QI/PS) methodologies, including root cause analysis (RCA). OBJECTIVE The Department of Veterans Affairs (VA) sought to develop a simulation approach to teach clinicians from the VA's Chief Resident in Quality and Safety program about RCA. We report the use of experiential learning to teach RCA, and clinicians' preparedness to conduct and teach RCA post-training. We provide curriculum details and materials to be adapted for widespread use. METHODS The course was designed to meet the learning objectives through simulation. We developed course materials, including presentations, a role-playing case, and an elaborate RCA case. Learning objectives included (1) basic structure of RCA, (2) process flow diagramming, (3) collecting information for RCA, (4) cause and effect diagramming, and (5) identifying actions and outcomes. We administered a voluntary, web-based survey in November 2016 to participants (N = 114) post-training to assess their competency with RCA. RESULTS A total of 93 individuals completed the survey of the 114 invited to participate, culminating an 82% response rate. Nearly all respondents (99%, N = 92) reported feeling at least moderately to extremely prepared to conduct and teach RCA post-training. Most respondents reported feeling very to extremely prepared to conduct and teach RCA (77%, N = 72). CONCLUSIONS Experiential learning involving simulations may be effective to improve clinicians' competency in QI/PS practices, including RCA. Further research is warranted to understand how the training affects clinicians' capacity to participate in real RCA teams post-training, as well as applicability to other disciplines and interdisciplinary teams.
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Affiliation(s)
- Maya Aboumrad
- National Center for Patient Safety,
White River Junction, VT, USA
- White River Junction Veterans Affairs
Medical Center, White River Junction, VT, USA
- Maya Aboumrad, Veterans Affairs Medical
Center, 215 North Main Street, White River Junction, VT 05009, USA.
| | - Julia Neily
- National Center for Patient Safety,
White River Junction, VT, USA
- White River Junction Veterans Affairs
Medical Center, White River Junction, VT, USA
| | - Bradley V Watts
- National Center for Patient Safety,
White River Junction, VT, USA
- White River Junction Veterans Affairs
Medical Center, White River Junction, VT, USA
- Department of Psychiatry, Geisel School
of Medicine at Dartmouth, Hanover, NH, USA
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Experience feedback committees: A way of implementing a root cause analysis practice in hospital medical departments. PLoS One 2018; 13:e0201067. [PMID: 30048491 PMCID: PMC6062066 DOI: 10.1371/journal.pone.0201067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 06/04/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The experience feedback committee (EFC) is a tool designed to involve medical teams in patient safety management, through root cause analysis (RCA) within the team. OBJECTIVES To investigate the functioning of EFCs in the departments of a large university-affiliated hospital in France and to consider its potential contribution to the management of patient safety. METHODS Cross-sectional, observational study, based on an analysis of the documents produced by the EFCs for 1 year. Data were collected independently by two investigators in meeting minutes, adverse event reports and event analysis reports. RESULTS The study included all 20 EFCs operating in the hospital's medical departments. During the study year, committees held 164 meetings, reviewed 1707 adverse events, conducted 91 event analyses and decided on 206 corrective actions. The median number of corrective actions adopted by each EFC was five actions (range, 0-62). A root cause analysis (RCA) was present in 76% of the analysis reports, and these analyses were complete in only 23% of the reports. There was also a lack of planning corrective actions: an implementation deadline was only defined in 26% of the actions. CONCLUSIONS Healthcare professionals adhered to the system-based approach to patient safety, but we observed difficulties in holding regular meetings and deviations from the theoretical framework. These findings confirm the difficulties of practicing RCA in the healthcare setting. Nevertheless, EFCs can be vectors of safety culture and teamwork.
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Gibson R, Armstrong A, Till A, McKimm J. Learning from error: leading a culture of safety. Br J Hosp Med (Lond) 2017; 78:402-406. [PMID: 28692361 DOI: 10.12968/hmed.2017.78.7.402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A recent shift towards more collective leadership in the NHS can help to achieve a culture of safety, particularly through encouraging frontline staff to participate and take responsibility for improving safety through learning from error and near misses. Leaders must ensure that they provide psychological safety, organizational fairness and learning systems for staff to feel confident in raising concerns, that they have the autonomy and skills to lead continual improvement, and that they have responsibility for spreading this learning within and across organizations.
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Affiliation(s)
- Russell Gibson
- Academic Clinical Fellow, School of Medicine, Exeter University, Exeter EX1 2LU
| | - Alexander Armstrong
- Plastic Surgery Registrar, Plastic Surgery Department, Queen Alexandra Hospital, Portsmouth; National Medical Director's Clinical Fellow 2016-17
| | - Alex Till
- Psychiatric Core Trainee, School of Psychiatry, Liverpool; Executive Leadership and Management Fellow, Mersey Care NHS Foundation Trust; Honorary Clinical Senior Lecturer, Swansea University Medical School; National Medical Director's Clinical Fellow 2016-17
| | - Judy McKimm
- Professor of Medical Education and Director of Strategic Educational Development, School of Medicine, Swansea University School of Medicine, Swansea
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