Learning from incident reports in the Australian medical imaging setting: handover and communication errors

Development of minimum data set and dashboard for monitoring adverse events in radiology departments

Background

To reduce the risk of errors, patient safety monitoring in the medical imaging department is crucial. Interventions are required and these can be provided as a framework for documenting, reporting, evaluating, and recognizing events that pose a threat to patient safety. The aim of this study was to develop minimum data set and dashboard for monitoring adverse events in radiology departments.

Material and methods

This developmental research was conducted in multiple phases, including content determination using the Delphi technique; database designing using SQL Server; user interface (UI) building using PHP; and dashboard evaluation in three aspects: the accuracy of calculating; UI requirements; and usability.

Results

This study identified 26 patient safety (PS) performance metrics and 110 PS-related significant data components organized into 14 major groupings as the system contents. The UI was built with three tabs: pre-procedure, intra-procedure, and post-procedure. The evaluation results proved the technical feasibility of the dashboard. Finally, the dashboard's usability was highly rated (76.3 out of 100).

Conclusion

The dashboard can be used to supplement datasets to obtain a more accurate picture of the PS condition and to draw attention to characteristics that professionals might otherwise overlook or undervalue.

Provision of Safe Anesthesia in Magnetic Resonance Environments: Degree of Compliance with International Guidelines in Saudi Arabia

BACKGROUND

The lack of local guidelines and regulations for the administration of anesthesia in magnetic resonance imaging (MRI) units presents a potential risk to patient safety in Saudi Arabia. Hence, this study aimed to evaluate the extent to which hospitals in Saudi Arabia follow international guidelines and recommendations for the safe and effective administration of anesthesia in an MRI environment.

METHODS

This study used a questionnaire that was distributed to 31 medical facilities in Saudi Arabia that provided anesthesia in MRI units.

RESULTS

The findings of the study revealed that the mean compliance with the 17 guidelines across the 31 sites was 77%; 5 of the 31 sites (16.1%) had a compliance rate of less than 50% with the recommended guidelines. Only 19.4% of the institutes provided general safety education. Communication breakdowns between anesthesia providers and MRI teams were reported.

CONCLUSIONS

To conclude, this survey highlights the status of anesthesia standards in Saudi Arabian MRI units and emphasizes areas that require better adherence to international guidelines. The results call for targeted interventions, including the formulation of specific national anesthesia guidelines for MRI settings. Communication breakdowns between anesthesia providers and MRI teams were reported at a rate of 83.9% during the administration of a gadolinium contrast agent. There were additional breakdowns, particularly for high-risk patients with implants, such as impaired respirators (74.2%), thus requiring further investigation due to potential safety incidents during MRI procedures. While considering the limitations of this study, such as potential biases and the low response rate, it provides a valuable foundation for refining protocols and promoting standardized practices in Saudi Arabian healthcare.

MRI and the Critical Care Patient: Clinical, Operational, and Financial Challenges

Neuroimaging in conjunction with a neurologic examination has become a valuable resource for today's intensive care unit (ICU) physicians. Imaging provides critical information during the assessment and ongoing neuromonitoring of patients for toxic-metabolic or structural injury of the brain. A patient's condition can change rapidly, and interventions may require imaging. When making this determination, the benefit must be weighed against possible risks associated with intrahospital transport. The patient's condition is assessed to decide if they are stable enough to leave the ICU for an extended period. Intrahospital transport risks include adverse events related to the physical nature of the transport, the change in the environment, or relocating equipment used to monitor the patient. Adverse events can be categorized as minor (e.g., clinical decompensation) or major (e.g., requiring immediate intervention) and may occur in preparation or during transport. Regardless of the type of event experienced, any intervention during transport impacts the patient and may lead to delayed treatment and disruption of critical care. This review summarizes the commentary on the current literature on the associated risks and provides insight into the costs as well as provider experiences. Approximately, one-third of patients who are transported from the ICU to an imaging suite may experience an adverse event. This creates an additional risk for extending a patient's stay in the ICU. The delay in obtaining imaging can negatively impact the patient's treatment plan and affect long-term outcomes as increased disability or mortality. Disruption of ICU therapy can decrease respiratory function after the patient returns from transport. Because of the complex care team needed for patient transport, the staff time alone can cost $200 or more. New technologies and advancements are needed to reduce patient risk and improve safety.

Radiographers' experience of preventing patient safety incidents in the context of radiological examinations

AIM

To describe factors that prevent patient safety incidents in connection with the radiological examination from the radiographer's perspective.

BACKGROUND

Radiology plays an important role in the care chain and involves diagnostic examinations and treatments using various radiation sources and different techniques. Risks for patient safety incidents exist in every phase of a radiological examination. Appropriate use of medical imaging requires a multidisciplinary approach involving staff of different categories to meet the medical objectives and the patient's care needs. In accordance with a Safety-II approach, it is therefore important to understand why things go right and ensure that they do by supporting the conditions for right things to happen.

DESIGN

A qualitative study with a descriptive design.

METHODS

Semi-structured interviews were conducted with 17 radiographers. The data were analysed using theoretical thematic analysis based on the Systems Engineering Initiative for Patient Safety model.

RESULTS

The analysis yielded 20 sub-themes, which describe different success factors contributing to patient safety.

CONCLUSION

Proactive work should focus on collaboration and sharing the necessary knowledge, internally and externally, for care in connection with the radiological examination. The radiological and peri-radiographic knowledge should include monitoring the patient's safety needs before, during and after the radiological examination. The referring clinician has a central role in writing relevant referrals and the radiographer's competence is crucial in monitoring the patient's safety needs. A good patient safety culture is required and working with standards is important.

Detecting Patient Safety Errors by Characterizing Incidents Reported by Medical Imaging Staff

The objectives of the study were to characterize events related to patient safety reported by medical imaging personnel in Finland in 2007–2017, the number and quality of reported injuries, the risk assessment, and the planned improvement of operations. The information was collected from a healthcare patient safety incident register system. The data contained information on the nature of the patient safety errors, harms and near-misses in medical imaging, the factors that lead to the events, the consequences for the patient, the level of risks, and future measures. The number of patient safety incident reports included in the study was 7,287. Of the incident reports, 75% concerned injuries to patients and 25% were near-misses. The most common consequence of adverse events and near-misses were minor harm (37.2%) related to contrast agent, or no harm (27.9%) related to equipment malfunction. Supervisors estimated the risks as low (47.7%) e.g., data management, insignificant (35%) e.g., verbal communication or moderate (15.7%) e.g., the use of contrast agent. The most common suggestion for learning from the incident was discussing it with the staff (58.1%), improving operations (5.7%) and submitting it to a higher authority (5.4%). Improving patient safety requires timely, accurate and clear reporting of various patient safety incidents. Based on incident reports, supervisors can provide feedback to staff, develop plans to prevent accidents, and monitor the impact of measures taken. Information on the development of occupational safety should be disseminated to all healthcare professionals so that the same mistakes are not repeated.

A Mixed-Methods Systematic Review of the Effectiveness and Experiences of Quality Improvement Interventions in Radiology

OBJECTIVE

This study aimed to compile and synthesize evidence regarding the effectiveness of quality improvement interventions in radiology and the experiences and perspectives of staff and patients.

METHODS

Databases searched for both published and unpublished studies were as follows: EMBASE, MEDLINE, CINAHL, Joanna Briggs Institute, Cochrane Central Register of Controlled Trials, PsycINFO, Scopus, Web of Science, Mednar, Trove, Google Gray, OCLC WorldCat, and Dissertations and Theses. This review included both qualitative and quantitative studies of patients undergoing radiological examinations and/or medical imaging health care professionals; a broad range of quality improvement interventions including introduction of health information technology, effects of training and education, improved reporting, safety programs, and medical devices; the experiences and perspectives of staff and patients; context of radiological setting; a broad range of outcomes including patient safety; and a result-based convergent synthesis design.

RESULTS

Eighteen studies were selected from 4846 identified by a systematic literature search. Five groups of interventions were identified: health information technology (n = 6), training and education (n = 6), immediate and critical reporting (n = 3), safety programs (n = 2), and the introduction of mobile radiography (n = 1), with demonstrated improvements in outcomes, such as improved operational and workflow efficiency, report turnaround time, and teamwork and communication.

CONCLUSIONS

The findings were constrained by the limited range of interventions and outcome measures. Further research should be conducted with study designs that might produce findings that are more generalizable, examine the other dimensions of quality, and address the issues of cost and risk versus benefit.

Engineering and clinical use of artificial intelligence (AI) with machine learning and data science advancements: radiology leading the way for future

Over the years, many clinical and engineering methods have been adapted for testing and screening for the presence of diseases. The most commonly used methods for diagnosis and analysis are computed tomography (CT) and X-ray imaging. Manual interpretation of these images is the current gold standard but can be subject to human error, is tedious, and is time-consuming. To improve efficiency and productivity, incorporating machine learning (ML) and deep learning (DL) algorithms could expedite the process. This article aims to review the role of artificial intelligence (AI) and its contribution to data science as well as various learning algorithms in radiology. We will analyze and explore the potential applications in image interpretation and radiological advances for AI. Furthermore, we will discuss the usage, methodology implemented, future of these concepts in radiology, and their limitations and challenges.

Experiences of radiographers working alone in remote locations: A Far North Queensland non-participant observational study

INTRODUCTION

Radiographers employed in remote locations such as Far North Queensland (FNQ) can face unique sets of challenges as they often perform radiographic and sonographic diagnostic imaging without onsite radiologists' services. Additionally, the majority of patients presenting to these sites are Indigenous for whom English may be their third language. This non-participant observational study observed two FNQ radiographers' interactions with patients and interprofessional staff, and the radiographers' ability to fit into the Indigenous community during routine radiographic and sonographic examinations which to date have received little attention.

METHODS

Non-participant observations and semi-structured interviews with radiographers were held at two FNQ hospitals. Consecutive radiographer-patient interactions were observed and recorded on checklists. Interviews were audio recorded and transcribed for thematic analysis.

RESULTS

Across both remote sites, 24 patients were observed as they underwent diagnostic imaging examinations, with the majority being Aboriginal or Torres Strait Islanders (n = 17/24 (70.8%). In total, eleven general radiography and sixteen ultrasound examinations were observed. Semi-structured interviews highlighted complex issues such as the need for radiographer communication in local dialect, ongoing interprofessional collaborations, overcoming the lack of radiologists' onsite support by providing radiographic reports directly to referring doctors and midwives, and isolation with regard to professional development opportunities.

CONCLUSIONS

Radiographers working in remote hospitals need to be culturally competent, navigate local indigenous languages and possess excellent interprofessional skills as well as thorough knowledge of imaging pathology to convey findings to referring doctors and allied health professionals. These findings have implications for the entry to practice curriculum.

IMPLICATIONS FOR PRACTICE

This study provides evidence that culturally competent radiographers are capable of undertaking reporting roles to facilitate patient management in the absence of timely radiologists' reports at remote sites.

Factors that Influence the Communication of Adverse Findings in Obstetrics: A Survey of Current Sonographer Practices in Australia

Objective:

To identify factors influencing sonographers’ practices in communicating adverse obstetric findings and to understand their views on the need for standardized national policies and guidelines.

Methods:

Qualified and trainee sonographers who currently perform obstetric sonography were invited to complete a survey through the Australasian Sonographers Association. Closed-ended questions sought information on the demographic profile of the participants and their experiences on a range of issues related to workplace practices and policies. Open-ended questions allowed respondents to elaborate on workplace interactions and their views on the communication roles of sonologists (radiologists and obstetricians) and sonographers.

Results:

The practice setting, the background of the sonologist, the type of adverse finding, and the trimester in which a patient is scanned have an impact on the level of difficulty for sonographers in obstetric communication. These findings highlight a lack of uniformity of sonographer and sonologist communication with patients due to limited training, lack of formalized departmental policies, inadequate support, and communication practices by radiologists. As a result, respondents strongly supported the development of a standardized national policy.

Conclusion:

In the current environment of patient-centered care, sonographers are in a challenging position as they do not have policies supporting them as independent health care professionals, autonomously deciding on the best approach to communicate findings with their patients. This may lead to anxiety and stress if they lack control over the interaction. More support from sonologists in a radiology setting is needed. These findings should encourage professional bodies to address these issues by working collaboratively and to recognize the importance of the sonographers’ role and their unique position with pregnant patients.

The variables perceived to be important during patient handover by South African prehospital care providers

Introduction

High-acuity patients are typically transported directly to the emergency centre via ambulance by trained prehospital care providers. As such, the emergency centre becomes the first of many physical transition points for patients, where a change of care provider (or handover) takes place. The aim of this study was to describe the variables perceived to be important during patient handover by a cohort of South African prehospital care providers.

Methods

A purpose-designed questionnaire was used to gather data related to prehospital emergency care provider opinions on the importance of certain patient variables.

Results

We collected 175 completed questionnaires from 75 (43%) BAA, 49 (28%) ANA, 15 (9%) ECT, 16 (9%) ANT and 20 (11%) ECP respondents. Within the ten handover variables perceived to be most important for inclusion in emergency centre handover, five were related to vital signs. Blood pressure was ranked most important, followed by type of major injuries, anatomical location of major injuries, pulse rate, respiration rate and patient history. These were followed by Glasgow Coma Score, injuries sustained, patient priority, oxygen saturations and patient allergies.

Conclusion

This study has provided some interesting results related to which handover elements prehospital care providers consider as most important to include in handover. More research is required to correlate these findings with the opinions of emergency centre staff.

•

There is a paucity of literature related to handover within the African context.

•

Adverse events as a result of poor handover have a significant cost implication that healthcare systems can ill-afford.

•

Identification of the importance of handover variables in emergency centre handover have the potential to improve handover.

Gauging potential risk for patients in pediatric radiology by review of over 2,000 incident reports

BACKGROUND

Incident reporting can be used to inform imaging departments about adverse events and near misses.

OBJECTIVE

To study incident reports submitted during a 5-year period at a large pediatric imaging system to evaluate which imaging modalities and other factors were associated with a greater rate of filed incident reports.

MATERIALS AND METHODS

All incident reports filed between 2013 and 2017 were reviewed and categorized by modality, patient type (inpatient, outpatient or emergency center) and use of sedation/anesthesia. The number of incident reports was compared to the number of imaging studies performed during that time period to calculate an incident report rate for each factor. Statistical analysis of whether there were differences in these rates between factors was performed.

RESULTS

During the study period, there were 2,009 incident reports filed and 1,071,809 imaging studies performed for an incident report rate of 0.19%. The differences in rates by modality were statistically significant (P=0.0001). There was a greater rate of incident reports in interventional radiology (1.54%) (P=0.0001) and in magnetic resonance imaging (MRI) (0.62%) (P=0.001) as compared to other imaging modalities. There was a higher incident report rate for inpatients (0.34%) as compared to outpatient (0.1%) or emergency center (0.14%) (P=0.0001). There was a higher rate of incident reports for patients under sedation (1.27%) as compared to non-sedated (0.12%) (P=0.0001).

CONCLUSION

Using incident report rates as a proxy for potential patient harm, the areas of our pediatric radiology service that are associated with the greatest potential for issues are interventional radiology, sedated patients, and inpatients. The areas associated with the least risk are ultrasound (US) and radiography. Safety improvement efforts should be focused on the high-risk areas.

Radiographers' experience of risks for patient safety incidents in the radiology department

AIMS AND OBJECTIVES

To describe potential risks for patient safety incidents in the radiology department from a radiographer's perspective.

BACKGROUND

A radiology department is a high-tech environment with high communication activity between different healthcare systems in combination with a large patient flow. Risks for patient safety incidents exist in every phase of a radiological examination. Due to the nature of the activity, a radiology department needs to have its own range of measures to prevent risks linked to radiology.

DESIGN

A qualitative descriptive design.

METHODS

Semi-structured interviews were carried out with 17 radiographers during the period September 2015 to February 2016. The data were analysed using conventional content analysis. This study followed the COREQ checklist criteria for the reporting of qualitative research.

RESULTS

The analysis yielded 20 different patient safety incidents that could result in the following six types of healthcare-associated harm: Patients could be exposed to unnecessary radiation; patients could receive an inaccurate diagnosis; patients could incur drug-induced damage; patients could suffer direct physical injury; or, their examination and treatment could be delayed or not carried out; or, their general health condition could deteriorate.

CONCLUSION

Lack of communication and knowledge, both internally and externally, can increase risks for patient safety incidents. The study describes a complex chain of activities that represent risks in the radiology department. It needs to be pointed out that it is not always the activities in the radiology department that cause the harm.

RELEVANCE TO CLINICAL PRACTICE

To carry out preventive patient safety work, a comprehensive analysis of the entire care chain is required. Patient safety work should also focus on improvement in communication both internally, within the radiology department, and externally. Standardised methodological guidelines, consistent prescriptions of method from the radiologist and a good working environment are internal success factors for patient safety at the radiology department.

Improving Communication Delay of Outpatient Sleep Study Results to Pediatric Otolaryngology Patients and Families

Objective

We undertook this quality improvement project to improve communication of outpatient pediatric sleep study results to families in a consistent and timely manner.

Methods

Based on the Institute for Healthcare Improvement quality improvement methodology, multiple key drivers were identified, including standardizing documentation and communication for sleep study results among the otolaryngology department, sleep center, and families. Meaningful interventions included developing standard electronic medical record documentation and utilizing otolaryngology nurses and advanced practice nurses to assist with communication by sending the results from the sleep center to both the referring otolaryngology provider and the triage nurses. The primary outcome measure was the monthly proportion of sleep studies communicated by the otolaryngology department to families within 3 business days.

Results

Average monthly sleep study results communicated to families within 3 business days increased from 31% to 92.9% over the study period ( P < .0001). Sleep study results were personally communicated via telephone and voicemail in 60.88% and 34.0% of cases, respectively. Approximately 50.0% of families receiving voicemails later contacted our department for their children’s study results.

Discussion

Novel documentation strategies and involvement of our entire clinical team (physicians, nurses, and advanced practice nurses), allowed us to significantly improve the consistency and timeliness of our communication of outpatient sleep study results to families in a proactive manner.

Implications for Practice

With time-sensitive clinical test results, such as those from pediatric sleep studies, intra- and interdepartmental collaboration and standardization of the communication process and documentation may allow for more expedient care of children with suspected obstructive sleep apnea.

Identification of quality improvement areas in pediatric MRI from analysis of patient safety reports

BACKGROUND

Analysis of safety reports has been utilized to guide practice improvement efforts in adult magnetic resonance imaging (MRI). Data specific to pediatric MRI could help target areas of improvement in this population.

OBJECTIVE

To estimate the incidence of safety reports in pediatric MRI and to determine associated risk factors.

MATERIALS AND METHODS

In a retrospective HIPAA-compliant, institutional review board-approved study, a single-institution Radiology Information System was queried to identify MRI studies performed in pediatric patients (0-18 years old) from 1/1/2010 to 12/31/2015. The safety report database was queried for events matching the same demographic and dates. Data on patient age, gender, location (inpatient, outpatient, emergency room [ER]), and the use of sedation/general anesthesia were recorded. Safety reports were grouped into categories based on the cause and their severity. Descriptive statistics were used to summarize continuous variables. Chi-square analyses were performed for univariate determination of statistical significance of variables associated with safety report rates. A multivariate logistic regression was used to control for possible confounding effects.

RESULTS

A total of 16,749 pediatric MRI studies and 88 safety reports were analyzed, yielding a rate of 0.52%. There were significant differences in the rate of safety reports between patients younger than 6 years (0.89%) and those older (0.41%) (P<0.01), sedated (0.8%) and awake children (0.45%) (P<0.01), and inpatients (1.1%) and outpatients (0.4%) (P<0.01). The use of sedation/general anesthesia is an independent risk factor for a safety report (P=0.02). The most common causes for safety reports were service coordination (34%), drug reactions (19%), and diagnostic test and ordering errors (11%).

CONCLUSION

The overall rate of safety reports in pediatric MRI is 0.52%. Interventions should focus on vulnerable populations, such as younger patients, those requiring sedation, and those in need of acute medical attention.

Tricks of the trade: time management tips for newly qualified doctors

BACKGROUND

The transition from medical student to doctor is an important milestone. The discovery that their time is no longer their own and that the demands of their job are greater than the time they have available is extremely challenging.

METHODS

At a recent surgical boot camp training programme, 60 first-year surgical trainees who had just completed their internship were invited to reflect on the lessons learnt regarding effective time management and to recommend tips for their newly qualified colleagues. They were asked to identify clinical duties that were considered urgent and important using the time management matrix and the common time traps encountered by newly qualified doctors.

RESULTS

The surgical trainees identified several practical tips that ranged from writing a priority list to working on relationships within the team. These tips are generic and so applicable to all newly qualified medial doctors.

POTENTIAL IMPLICATION

We hope that awareness of these tips from the outset as against learning them through experience will greatly assist newly qualified doctors.

Effectiveness of quality improvement interventions for patient safety in radiology: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to find the best available evidence regarding effectiveness of quality improvement interventions in clinical radiology and the experiences and perspectives of staff and patients. More specifically, the review questions are.

Handover and transport of critically ill children: An integrative review

BACKGROUND

The handover and transport of critically ill pediatric patients requires communication amongst multiple disciplines. Poor communication is a leading cause of sentinel events and human factors affect handover and transport.

OBJECTIVES

To synthesize published data on pediatric handover and transport and identify gaps to provide direction for future investigation.

METHODS

Integrative literature review.

RESULTS

Forty research studies were reviewed and revealed the following themes: risk for patient complications, standardized communication, and specialized teams and teamwork were associated with improved outcomes. No articles were identified regarding transportation of critically ill pediatric patients from the emergency room to the intensive care unit. There was a knowledge gap in best practices in handover and transport within the unique subsets of the pediatric population including neonate, toddler, school-aged, and adolescents.

CONCLUSIONS

Research supported a combined approach of specialized teams using standardized communication in the handover and transport of the pediatric patient to improve outcomes. Further study is warranted on interprofessional (team to team) handover practices, select subsets of the pediatric population, and the handover and transport of critically ill patients from the emergency room to the intensive care unit.

Adverse events and near misses relating to information management in a hospital

Objective:

This study described information management incidents and adverse event reporting choices of health professionals.

Methods:

Hospital adverse events reported in an anonymous electronic reporting system were analysed using directed content analysis and descriptive and inferential statistics. The data consisted of near miss and adverse event incident reports ( n = 3075) that occurred between January 2008 and the end of December 2009.

Results:

A total of 824 incidents were identified. The most common information management incident was failure in written information transfer and communication, when patient data were copied or documented incorrectly. Often patient data were transferred using paper even though an electronic patient record was in use. Reporting choices differed significantly among professional groups; in particular, registered nurses reported more events than other health professionals.

Conclusion:

A broad spectrum of information management incidents was identified, which indicates that preventing adverse events requires the development of safe practices, especially in documentation and information transfer.

Errors in Medical Imaging and Radiography Practice: A Systematic Review

BACKGROUND

Errors in health care can harm patients and undermine public trust, yet many are preventable. In medical imaging and radiography, errors can cause increased radiation dose, misdiagnosis, and clinical mismanagement.

AIM

The purpose of this review was to identify the type and prevalence of errors directly associated with radiography practice and the imaging cycle, with a view to developing recommendations to reduce common errors.

METHOD

A systematic review was undertaken of current literature obtained through the Ovid Medline and PubMed databases. A total of 41 useable articles were analysed into a priori categories of the medical imaging cycle: preprocedural, procedural, and postprocedural.

FINDINGS

This review found that errors may occur during any phase of the cycle and that communication breakdown, especially during handover periods, was the main contributing factor to errors. Although the importance of incident reporting is well recognised, feedback to users is often limited.

CONCLUSIONS

A systematic approach to radiographic practice may assist in reducing communication-related errors. Future research is required to determine how extending radiographers' roles or using electronic ordering systems could also help to reduce errors.

Perspectives of clinical handover processes: a multi-site survey across different health professionals

AIMS AND OBJECTIVES

To examine the perspectives of health professionals of different disciplines about clinical handover.

BACKGROUND

Ineffective handovers can cause major problems relating to the lack of delivery of appropriate care.

DESIGN

A prospective, cross-sectional design was conducted using a survey about clinical handover practices.

METHODS

Health professionals employed in public metropolitan hospitals, public rural hospitals and community health centres were involved. The sample comprised doctors, nurses and allied health professionals, including physiotherapists, social workers, pharmacists, dieticians and midwives employed in Western Australia, New South Wales, South Australia and the Australian Capital Territory. The survey sought information about health professionals' experiences about clinical handover; their perceived effectiveness of clinical handover; involvement of patients and family members; health professionals' ability to confirm understanding and to clarify clinical information; role modelling behaviour of health professionals; training needs; adverse events encountered and possibilities for improvements.

RESULTS

In all, 707 health professionals participated (response rate = 14%). Represented professions were nursing (60%), medicine (22%) and allied health (18%). Many health professionals reported being aware of adverse events where they noticed poor handover was a significant cause. Differences existed between health professions in terms of how effectively they gave handover, perceived effectiveness of bedside handover vs. nonbedside handover, patient and family involvement in handover, respondents' confirmation of understanding handover from their perspective, their observation of senior health professionals giving feedback to junior health professionals, awareness of adverse events and severity of adverse events relating to poor handovers.

CONCLUSIONS

Complex barriers impeded the conduct of effective handovers, including insufficient opportunities for training, lack of role modelling, and lack of confidence and understanding about handover processes.

RELEVANCE TO CLINICAL PRACTICE

Greater focus should be placed on creating opportunities for senior health professionals to act as role models. Sophisticated approaches should be implemented in training and education.

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

Background

Hospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms.

Objectives

This study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes.

Design

We used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction.

Setting

Welsh Government and NHS Wales.

Participants

Interviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety.

Main outcome measures

Identification of the contextual factors pertinent to the local implementation of the 1000 Lives+patient safety programme in Welsh NHS hospitals.

Results

An innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme.

Conclusions

Heightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented.

Funding

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

Does e-pain plan improve management of sickle cell disease associated vaso-occlusive pain crisis? a mixed methods evaluation

PURPOSE

There is limited application and evaluation of health information systems in the management of vaso-occlusive pain crises in sickle cell disease (SCD) patients. This study evaluates the impact of digitization of paper-based individualized pain plans on process efficiency and care quality by examining both objective patient data and subjective clinician insights.

METHODS

Retrospective, before and after, mixed methods evaluation of digitization of paper documents in Children's Hospital of Pittsburgh of UPMC. Subjective perceptions are analyzed using surveys completed by 115 clinicians in emergency department (ED) and inpatient units (IP). Objective effects are evaluated using mixed models with data on 1089 ED visits collected via electronic chart review 28 months before and 22 months after the digitization.

RESULTS

Surveys indicate that all clinicians perceived the digitization to improve the efficiency and quality of pain management. Physicians overwhelmingly preferred using the digitized plans, but only 44% of the nurses had the same response. Analysis of patient records indicates that adjusted time from analgesic order to administration was significantly reduced from 35.50 to 26.77 min (p<.05). However, time to first dose and some of the objective quality measures (time from administration to relief, relief rate, admission rate, and ED re-visit rate) were not significantly affected.

DISCUSSION

The relatively simple intervention, high baseline performance, and limited accommodation of nurses' perspectives may account for the marginal improvements in process efficiency and quality outcomes. Additional efforts, particularly improved communication between physicians and nurses, are needed to further enhance quality of pain management.

CONCLUSION

This study highlights the important role of health information technology (HIT) on vaso-occlusive pain management for pediatric patients with sickle cell disease and the critical challenges in accommodating human factor considerations in implementing and evaluating HIT effects.