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McGlacken-Byrne SM, Murphy NP, Barry S. A realist synthesis of multicentre comparative audit implementation: exploring what works and in which healthcare contexts. BMJ Open Qual 2024; 13:e002629. [PMID: 38448042 PMCID: PMC10916097 DOI: 10.1136/bmjoq-2023-002629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/20/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Multicentre comparative clinical audits have the potential to improve patient care, allow benchmarking and inform resource allocation. However, implementing effective and sustainable large-scale audit can be difficult within busy and resource-constrained contemporary healthcare settings. There are little data on what facilitates the successful implementation of multicentre audits. As healthcare environments are complex sociocultural organisational environments, implementing multicentre audits within them is likely to be highly context dependent. OBJECTIVE We aimed to examine factors that were influential in the implementation process of multicentre comparative audits within healthcare contexts-what worked, why, how and for whom? METHODS A realist review was conducted in accordance with the Realist and Meta-narrative Evidence Syntheses: Evolving Standards reporting standards. A preliminary programme theory informed two systematic literature searches of peer-reviewed and grey literature. The main context-mechanism-outcome (CMO) configurations underlying the implementation processes of multicentre audits were identified and formed a final programme theory. RESULTS 69 original articles were included in the realist synthesis. Four discrete CMO configurations were deduced from this synthesis, which together made up the final programme theory. These were: (1) generating trustworthy data; (2) encouraging audit participation; (3) ensuring audit sustainability; and (4) facilitating audit cycle completion. CONCLUSIONS This study elucidated contexts, mechanisms and outcomes influential to the implementation processes of multicentre or national comparative audits in healthcare. The relevance of these contextual factors and generative mechanisms were supported by established theories of behaviour and findings from previous empirical research. These findings highlight the importance of balancing reliability with pragmatism within complex adaptive systems, generating and protecting human capital, ensuring fair and credible leadership and prioritising change facilitation.
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Affiliation(s)
| | - Nuala P Murphy
- Department of Paediatric Endocrinology, Children's Health Ireland at Temple Street, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Sarah Barry
- RCSI School of Population Health, Dublin, Ireland
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Sumera K, Ilczak T, Bakkerud M, Lane JD, Pallas J, Martorell SO, Sumera A, Webster CA, Quinn T, Sandars J, Niroshan Siriwardena A. CPR Quality Officer role to improve CPR quality: A multi-centred international simulation randomised control trial. Resusc Plus 2024; 17:100537. [PMID: 38261942 PMCID: PMC10796959 DOI: 10.1016/j.resplu.2023.100537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/10/2023] [Accepted: 12/11/2023] [Indexed: 01/25/2024] Open
Abstract
Background An out-of-hospital cardiac arrest requires early recognition, prompt and quality clinical interventions, and coordination between different clinicians to improve outcomes. Clinical team leaders and clinical teams have high levels of cognitive burden. We aimed to investigate the effect of a dedicated Cardio-Pulmonary Resuscitation (CPR) Quality Officer role on team performance. Methods This multi-centre randomised control trial used simulation in universities from the UK, Poland, and Norway. Student Paramedics participated in out-of-hospital cardiac arrest scenarios before randomisation to either traditional roles or assigning one member as the CPR Quality Officer. The quality of CPR was measured using QCPR® and Advanced Life Support (ALS) elements were evaluated. Results In total, 36 teams (108 individuals) participated. CPR quality from the first attempt (72.45%, 95% confidence interval [CI] 64.94 to 79.97) significantly increased after addition of the CPR Quality role (81.14%, 95% CI 74.20 to 88.07, p = 0.045). Improvement was not seen in the control group. The time to first defibrillation had no significant difference in the intervention group between the first attempt (53.77, 95% CI 36.57-70.98) and the second attempt (48.68, 95% CI 31.31-66.05, p = 0.84). The time to manage an obstructive airway in the intervention group showed significant difference (p = 0.006) in the first attempt (168.95, 95% CI 110.54-227.37) compared with the second attempt (136.95, 95% CI 87.03-186.88, p = 0.1). Conclusion A dedicated CPR Quality Officer in simulated scenarios improved the quality of CPR compressions without a negative impact on time to first defibrillation, managing the airway, or adherence to local ALS protocols.
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Affiliation(s)
- Kacper Sumera
- East Midlands Ambulance Service NHS Trust, Education, Nottingham NG11 8NS, UK
- European Pre-hospital Research Network, United Kingdom
| | - Tomasz Ilczak
- Department of Emergency Medicine, Faculty of Health Sciences, University of Bielsko-Biała, Poland
- European Pre-hospital Research Network, United Kingdom
| | - Morten Bakkerud
- Oslo Metropolitan University, Department of Nursing and Health Promotion, Pilestredet 32, 0166 Oslo, Norway
- European Pre-hospital Research Network, United Kingdom
| | - Jon Dearnley Lane
- Edge Hill University, Allied Health, Social Work & Wellbeing, Ormskirk L39 4QP, UK
| | - Jeremy Pallas
- John Hunter Hospital, Emergency Department, NSW 2305, Australia
| | - Sandra Ortega Martorell
- Liverpool John Moores University, School of Computer Science and Mathematics, Liverpool L3 5UX, UK
| | - Agnieszka Sumera
- University of Chester, Faculty of Health, Medicine & Society, Chester CH1 1SL, UK
- European Pre-hospital Research Network, United Kingdom
| | - Carl A. Webster
- Nottingham Trent University, Institute of Health and Allied Professions, Nottingham NG11 8NS, UK
- European Pre-hospital Research Network, United Kingdom
| | - Tom Quinn
- Kingston University & St George’s, University of London, Centre for Health and Social Care Research, London KT2 7LB, UK
- European Pre-hospital Research Network, United Kingdom
| | - John Sandars
- Edge Hill University, Allied Health, Social Work & Wellbeing, Ormskirk L39 4QP, UK
| | - A. Niroshan Siriwardena
- University of Lincoln, School of Health and Social Care, Lincoln LN6 7TS, UK
- European Pre-hospital Research Network, United Kingdom
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Ladell MM, Shafer G, Ziniel SI, Grubenhoff JA. Comparative Perspectives on Diagnostic Error Discussions Between Inpatient and Outpatient Pediatric Providers. Am J Med Qual 2023; 38:245-254. [PMID: 37678302 PMCID: PMC10484186 DOI: 10.1097/jmq.0000000000000148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Diagnostic error remains understudied and underaddressed despite causing significant morbidity and mortality. One barrier to addressing this issue remains provider discomfort. Survey studies have shown significantly more discomfort among providers in discussing diagnostic error compared with other forms of error. Whether the comfort in discussing diagnostic error differs depending on practice setting has not been previously studied. The objective of this study was to assess differences in provider willingness to discuss diagnostic error in the inpatient versus outpatient setting. A multicenter survey was sent out to 3881 providers between May and June 2018. This survey was designed to assess comfort level of discussing diagnostic error and looking at barriers to discussing diagnostic error. Forty-three percent versus 22% of inpatient versus outpatient providers (P = 0.004) were comfortable discussing short-term diagnostic error publicly. Similarly, 76% versus 60% of inpatient versus outpatient providers (P = 0.010) were comfortable discussing short-term diagnostic error privately. A higher percentage of inpatient (64%) compared with outpatient providers (46%) (P = 0.043) were comfortable discussing long-term diagnostic error privately. Forty percent versus 24% of inpatient versus outpatient providers (P = 0.018) were comfortable discussing long-term error publicly. No difference in barriers cited depending on practice setting. Inpatient providers are more comfortable discussing diagnostic error than their outpatient counterparts. More study is needed to determine the etiology of this discrepancy and to develop strategies to increase outpatient provider comfort.
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Affiliation(s)
- Meagan M. Ladell
- Department of Pediatric (Section of Emergency Medicine), Children’s Wisconsin and Medical College of Wisconsin, Milwaukee, WI
| | - Grant Shafer
- Department of Pediatrics (Section of Neonatology), Children’s Hospital of Orange County and University of California Irvine, Orange, CA
| | - Sonja I. Ziniel
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Joseph A. Grubenhoff
- Department of Pediatrics (Section of Emergency Medicine), University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
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Yeung AWK, Kletecka-Pulker M, Klager E, Eibensteiner F, Doppler K, El-Kerdi A, Willschke H, Völkl-Kernstock S, Atanasov AG. Patient Safety and Legal Regulations: A Total-Scale Analysis of the Scientific Literature. J Patient Saf 2022; 18:e1116-e1123. [PMID: 35617635 DOI: 10.1097/pts.0000000000001040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of the study was to quantitatively analyze the scientific literature landscape covering legal regulations of patient safety. METHODS This retrospective bibliometric analysis queried Web of Science database to identify relevant publications. The identified scientific literature was quantitatively evaluated to reveal prevailing study themes, contributing journals, countries, institutions, and authors, as well as citation patterns. RESULTS The identified 1295 publications had a mean of 13.8 citations per publication and an h-index of 57. Approximately 78.8% of them were published since 2010, with the United States being the top contributor and having the greatest publication growth. A total of 79.2% (n = 1025) of the publications were original articles, and 12.5% (n = 162) were reviews. The top authors (by number of publications published on the topic) were based in the United States and Spain and formed 3 collaboration clusters. The top institutions by number of published articles were mainly based in the United States and United Kingdom, with Harvard University being on top. Internal medicine, surgery, and nursing were the most recurring clinical disciplines. Among 4 distinct approaches to improve patient safety, reforms of the liability system (n = 91) were most frequently covered, followed by new forms of regulation (n = 73), increasing transparency (n = 67), and financial incentives (n = 38). CONCLUSIONS Approximately 78.8% of the publications on patient safety and its legal implications were published since 2010, and the United States was the top contributor. Approximately 79.2% of the publications were original articles, whereas 12.5% were reviews. Healthcare sciences services was the most recurring journal category, with internal medicine, surgery, and nursing being the most recurring clinical disciplines. Key relevant laws around the globe were identified from the literature set, with some examples highlighted from the United States, Germany, Italy, France, Sweden, Poland, and Indonesia. Our findings highlight the evolving nature and the diversity of legislative regulations at international scale and underline the importance of healthcare workers to be aware of the development and latest advancement in this field and to understand that different requirements are established in different jurisdictions so as to safeguard the necessary standards of patient safety.
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Affiliation(s)
| | | | - Elisabeth Klager
- From the Ludwig Boltzmann Institute for Digital Health and Patient Safety (LBIDHPS), Medical University of Vienna, Vienna, Austria
| | | | - Klara Doppler
- From the Ludwig Boltzmann Institute for Digital Health and Patient Safety (LBIDHPS), Medical University of Vienna, Vienna, Austria
| | - Amer El-Kerdi
- From the Ludwig Boltzmann Institute for Digital Health and Patient Safety (LBIDHPS), Medical University of Vienna, Vienna, Austria
| | | | - Sabine Völkl-Kernstock
- From the Ludwig Boltzmann Institute for Digital Health and Patient Safety (LBIDHPS), Medical University of Vienna, Vienna, Austria
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Myren BJ, de Hullu JA, Bastiaans S, Koksma JJ, Hermens RPMG, Zusterzeel PLM. Disclosing Adverse Events in Clinical Practice: The Delicate Act of Being Open. HEALTH COMMUNICATION 2022; 37:191-201. [PMID: 33045852 DOI: 10.1080/10410236.2020.1830550] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Practicing a "safe" disclosure of adverse events remains challenging for healthcare professionals. In addition, knowledge on how to deliver a disclosure is still limited. This review focuses on how disclosure communication may be practiced based on the perspectives of patients and healthcare professionals. Empirical studies conducted between September 2008 and October 2019 were included from the databases PubMed, Web of Science and Psychinfo. After full text analysis and quality appraisal this scoping review included a total of 23 studies out of 2537 studies. As a first step, the needs of patients and the challenges of healthcare professionals with the practice of providing an effective disclosure were extracted from the empirical literature. Based on these findings, the review demonstrates that specific disclosure communication strategies on the level of interpersonal skills, organization, and supportive factors may facilitate healthcare professionals to provide optimal disclosure of adverse events. These may be relevant to provide patients with a tailored approach that accompanies their preferences for information and recognition. In conclusion, healthcare professionals may need training in interpersonal (verbal and nonverbal) communication skills. Furthermore, it is important to develop an open (organizational) culture that supports the communication of adverse events and disclosure as a standard practice.
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Affiliation(s)
- B J Myren
- Department of Gynaecology, Radboud University Medical Center
| | - J A de Hullu
- Department of Gynaecology, Radboud University Medical Center
| | - S Bastiaans
- Department of Gynaecology, Radboud University Medical Center
| | - J J Koksma
- Health Academy, Radboud University Medical Center
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Khan G, Kagwanja N, Whyle E, Gilson L, Molyneux S, Schaay N, Tsofa B, Barasa E, Olivier J. Health system responsiveness: a systematic evidence mapping review of the global literature. Int J Equity Health 2021; 20:112. [PMID: 33933078 PMCID: PMC8088654 DOI: 10.1186/s12939-021-01447-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The World Health Organisation framed responsiveness, fair financing and equity as intrinsic goals of health systems. However, of the three, responsiveness received significantly less attention. Responsiveness is essential to strengthen systems' functioning; provide equitable and accountable services; and to protect the rights of citizens. There is an urgency to make systems more responsive, but our understanding of responsiveness is limited. We therefore sought to map existing evidence on health system responsiveness. METHODS A mixed method systemized evidence mapping review was conducted. We searched PubMed, EbscoHost, and Google Scholar. Published and grey literature; conceptual and empirical publications; published between 2000 and 2020 and English language texts were included. We screened titles and abstracts of 1119 publications and 870 full texts. RESULTS Six hundred twenty-one publications were included in the review. Evidence mapping shows substantially more publications between 2011 and 2020 (n = 462/621) than earlier periods. Most of the publications were from Europe (n = 139), with more publications relating to High Income Countries (n = 241) than Low-to-Middle Income Countries (n = 217). Most were empirical studies (n = 424/621) utilized quantitative methodologies (n = 232), while qualitative (n = 127) and mixed methods (n = 63) were more rare. Thematic analysis revealed eight primary conceptualizations of 'health system responsiveness', which can be fitted into three dominant categorizations: 1) unidirectional user-service interface; 2) responsiveness as feedback loops between users and the health system; and 3) responsiveness as accountability between public and the system. CONCLUSIONS This evidence map shows a substantial body of available literature on health system responsiveness, but also reveals evidential gaps requiring further development, including: a clear definition and body of theory of responsiveness; the implementation and effectiveness of feedback loops; the systems responses to this feedback; context-specific mechanism-implementation experiences, particularly, of LMIC and fragile-and conflict affected states; and responsiveness as it relates to health equity, minority and vulnerable populations. Theoretical development is required, we suggest separating ideas of services and systems responsiveness, applying a stronger systems lens in future work. Further agenda-setting and resourcing of bridging work on health system responsiveness is suggested.
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Affiliation(s)
- Gadija Khan
- School of Public Health and Family Medicine, Health Policy and Systems Division, University of Cape Town, Cape Town, South Africa
| | - Nancy Kagwanja
- Kenya Medical Research Institute (KEMRI)-Wellcome-Trust Research Programme, Kilifi, Kenya
| | - Eleanor Whyle
- School of Public Health and Family Medicine, Health Policy and Systems Division, University of Cape Town, Cape Town, South Africa
| | - Lucy Gilson
- School of Public Health and Family Medicine, Health Policy and Systems Division, University of Cape Town, Cape Town, South Africa
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Sassy Molyneux
- Kenya Medical Research Institute (KEMRI)-Wellcome-Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Center for Tropical medicine and Global Health, University of Oxford, Oxford, UK
| | - Nikki Schaay
- University of the Western Cape, School of Public Health, Cape Town, South Africa
| | - Benjamin Tsofa
- Kenya Medical Research Institute (KEMRI)-Wellcome-Trust Research Programme, Kilifi, Kenya
| | - Edwine Barasa
- Kenya Medical Research Institute (KEMRI)-Wellcome-Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Center for Tropical medicine and Global Health, University of Oxford, Oxford, UK
| | - Jill Olivier
- School of Public Health and Family Medicine, Health Policy and Systems Division, University of Cape Town, Cape Town, South Africa
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Shepherd L, Gauld R, Cristancho SM, Chahine S. Journey into uncertainty: Medical students' experiences and perceptions of failure. MEDICAL EDUCATION 2020; 54:843-850. [PMID: 32078164 DOI: 10.1111/medu.14133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 02/06/2020] [Accepted: 02/11/2020] [Indexed: 06/10/2023]
Abstract
CONTEXT Having succeeded in being selected for medical school, medical students are not always familiar with failure and yet they are expected to graduate prepared to effectively function in the failure-burdened arena of clinical medicine. Lacking in the developing literature on learners and failure is an exploration of how this transformation is accomplished. The purpose of this study was to examine how medical students perceive and experience failure during their medical school training. METHOD We used a qualitative description methodology to probe the failure experiences of medical students attending a Canadian medical school. Participants were provided with the broad definition of failure used in this research: 'deviation from expected and desired results.'In total, 12 students were sampled, three from each of the 4 years of study, and participated in individual, semi-structured interviews that were analysed using thematic analysis to identify and describe core themes. RESULTS At the start of medical school, students admitted limited experience with failure; their early descriptions were self-centred and binary. Personal stories recounted by preceptors encouraged students and helped them understand that physicians are human and that failure is inevitable. Students felt relatively protected from failures that could impact patients. Both witnessing and participating in a failure event were distressing and sometimes at odds with their expectations. Students expressed a desire to talk about the experience. CONCLUSIONS Medical students described examples of experiencing failure during medical school that transported them from the more certain black and white beginnings of their classroom into the uncertain shades of grey of clinical medicine. What the participants heard, saw and experienced suggests opportunities for classroom teachers to better prepare pre-clinical students for the inevitability of failure in clinical medicine and opportunities for clinical teachers to engage in open, inclusive conversations surrounding failures that occur on their watch.
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Affiliation(s)
- Lisa Shepherd
- Division of Emergency Medicine, Department of Medicine, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ryan Gauld
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Sayra M Cristancho
- Department of Surgery, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Faculty of Education, Western University, London, Ontario, Canada
| | - Saad Chahine
- Faculty of Education, Queens University, Kingston, Ontario, Canada
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Duthie EA, Fischer IC, Frankel RM. Blame and its consequences for healthcare professionals: response to Tigard. JOURNAL OF MEDICAL ETHICS 2020; 46:339-341. [PMID: 31649111 DOI: 10.1136/medethics-2019-105525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 08/01/2019] [Accepted: 08/07/2019] [Indexed: 06/10/2023]
Abstract
Tigard (2019) suggests that the medical community would benefit from continuing to promote notions of individual responsibility and blame in healthcare settings. In particular, he contends that blame will promote systematic improvement, both on the individual and institutional levels, by increasing the likelihood that the blameworthy party will 'own up' to his or her mistake and apologise. While we agree that communicating regret and offering a genuine apology are critical steps to take when addressing patient harm, the idea that medical professionals should continue to 'take the blame' for medical errors flies in the face of existing science and threatens to do more harm than good. We contrast Dr Tigard's approach with the current literature on blame to promote an alternative strategy that may help to create lasting change in the face of unfortunate error.
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Affiliation(s)
- Elizabeth A Duthie
- Patient Safety Resource Center, Montefiore Health System, Bronx, New York, USA
| | - Ian C Fischer
- Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana, USA
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Grubenhoff JA, Ziniel SI, Cifra CL, Singhal G, McClead RE, Singh H. Pediatric Clinician Comfort Discussing Diagnostic Errors for Improving Patient Safety: A Survey. Pediatr Qual Saf 2020; 5:e259. [PMID: 32426626 PMCID: PMC7190246 DOI: 10.1097/pq9.0000000000000259] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/22/2020] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Meaningful conversations about diagnostic errors require safety cultures where clinicians are comfortable discussing errors openly. However, clinician comfort discussing diagnostic errors publicly and barriers to these discussions remain unexplored. We compared clinicians' comfort discussing diagnostic errors to other medical errors and identified barriers to open discussion. METHODS Pediatric clinicians at 4 hospitals were surveyed between May and June 2018. The survey assessed respondents' comfort discussing medical errors (with varying degrees of system versus individual clinician responsibility) during morbidity and mortality conferences and privately with peers. Respondents reported the most significant barriers to discussing diagnostic errors publicly. Poststratification weighting accounted for nonresponse bias; the Benjamini-Hochberg adjustment was applied to control for false discovery (significance set at P < 0.018). RESULTS Clinicians (n = 838; response rate 22.6%) were significantly less comfortable discussing all error types during morbidity and mortality conferences than privately (P < 0.004) and significantly less comfortable discussing diagnostic errors compared with other medical errors (P < 0.018). Comfort did not differ by clinician type or years in practice; clinicians at one institution were significantly less comfortable discussing diagnostic errors compared with peers at other institutions. The most frequently cited barriers to discussing diagnostic errors publicly included feeling like a bad clinician, loss of reputation, and peer judgment of knowledge base and decision-making. CONCLUSIONS Clinicians are more uncomfortable discussing diagnostic errors than other types of medical errors. The most frequent barriers involve the public perception of clinical performance. Addressing this aspect of safety culture may improve clinician participation in efforts to reduce harm from diagnostic errors.
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Affiliation(s)
- Joseph A. Grubenhoff
- From the Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Sonja I. Ziniel
- From the Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Christina L. Cifra
- Department of Pediatrics, University of Iowa Carver College of Medicine Stead Family, Iowa City, Iowa
| | - Geeta Singhal
- Department of Pediatrics, Baylor College of Medicine
| | - Richard E. McClead
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
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Zientek D, Bonnell R. When International Humanitarian or Medical Missions Go Wrong: An Ethical Analysis. HEC Forum 2019; 32:333-343. [DOI: 10.1007/s10730-019-09392-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Africa L, Shinners JS. Tracking medical errors and near misses in the new graduate registered nurse. Nurs Forum 2019; 55:174-176. [PMID: 31733104 DOI: 10.1111/nuf.12412] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article provides a narrative that describes the current state of medical errors and near misses in the general health care setting and for new graduate registered nurses specifically. It then proposes a "wild idea" to create a national database for the reporting of errors that would act as a call to action to change our current reporting system to one of transparency and shared information for the purpose of creating needed education in both academic and practice settings.
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Affiliation(s)
| | - Jean S Shinners
- Versant Center for the Advancement of Nursing, Las Vegas, Nevada
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12
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Abstract
Patient safety experts debated accountability in health care at the 2014 annual National Patient Safety Foundation Congress. The debate reflected the struggles organizations are facing with ensuring a responsible workforce committed to patient safety versus the need to redesign flawed systems that are error prone. The question, "is it the systems or the individual?" was at issue. This article proposes that it is the wrong question, and the failure to apply patient safety science in clinical practice is contributing to the ambiguity fueling the debate. To transform accountability from a source of confusion to a powerful tool for fulfilling health care's fiduciary responsibility to protect patients from harm, we need to reframe our approach. This article presents the science and strategies to create clarity that will redirect the dialogue from a debate in which accountability resides to one about learning for improvement when adverse events occur.
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Shepherd L, LaDonna KA, Cristancho SM, Chahine S. How Medical Error Shapes Physicians' Perceptions of Learning: An Exploratory Study. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:1157-1163. [PMID: 30973366 DOI: 10.1097/acm.0000000000002752] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE Error is inevitable in medicine, given its inherent uncertainty and complexity. Errors can teach powerful lessons; however, because of physicians' self-imposed silence and the intricacies of responsibility and blame, learning from medical error has been underexplored. The purpose of this study was to understand how physicians perceived learning from medical errors by exploring the tension between responsibility and blame and factors that affected physicians' learning. METHOD Nineteen physicians participated in semistructured interviews, conducted in 2016-2017 at Western University in Canada, that probed their experiences in learning from medical errors. Data collection and analysis were conducted iteratively, with themes identified through constant comparative analysis. RESULTS Participants felt personal responsibility and blame for their errors. Residency produced particularly salient memories of errors. Participants identified interconnecting cultural factors (normalizing error, peer support and mentorship, formal rounds) and individual factors (emotional response, confidence and experience), which either helped or hindered their perceived learning. CONCLUSIONS Learning from medical error requires navigation through blame and responsibility. The keen responsibility felt by physicians must be acknowledged when enacting a system-based approach to medical error. Adopting a learning culture perspective suggests opportunities to enable and disable features of the learning environment to optimize learning from error as residents learn to become the most responsible physician for all outcomes. A better understanding of the factors that shape learning from error can help make the transition from error to learning more explicit, thereby increasing the opportunity to learn and teach from errors that permeate the practice of medicine.
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Affiliation(s)
- Lisa Shepherd
- L. Shepherd is associate professor, Department of Medicine, Division of Emergency Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; ORCID: https://orcid.org/0000-0001-9551-4546. K.A. LaDonna is assistant professor, Departments of Innovation in Medical Education and Medicine, University of Ottawa, Ottawa, Ontario, Canada. S.M. Cristancho is assistant professor, Department of Surgery and Faculty of Education, and scientist, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. S. Chahine is assistant professor, Department of Medicine and Faculty of Education, and scientist, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; ORCID: https://orcid.org/0000-0003-0488-773X
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Holland K, Sun S, Gackle M, Goldring C, Osmar K. A Qualitative Analysis of Human Error During the DIBH Procedure. J Med Imaging Radiat Sci 2019; 50:369-377.e1. [PMID: 31362870 DOI: 10.1016/j.jmir.2019.06.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 06/11/2019] [Accepted: 06/13/2019] [Indexed: 11/18/2022]
Abstract
INTRODUCTION This quality assurance study analyzed human errors that occurred during the radiation treatment delivery of the deep-inspiration breath hold (DIBH) technique at a tertiary cancer centre. The intention is to recommend solutions and system changes that have the potential to decrease the frequency of errors based on human factors principles. METHODS Eighty-two incident reports from January 2012 to July 2017 were retrieved and analysed to determine theme bins of performance-influencing factors contributing to the error. Performance-influencing factors were generated from the incident reports and from focus group discussions with volunteer radiation therapists in the department. Potential solutions to mitigate the error were sought from incident reports, focus groups, literature search, and an interview with a human factors specialist. The solutions were ranked based on the hierarchy of effectiveness, and recommendations were classified using a priority matrix. RESULTS Eighty-nine percent of the errors captured in the incident reports were defined as a slip or lapse error type, and 11% of the remaining errors were defined as a mistake error type. Treatment-related problem solving and distractions/interruptions were the highest frequency causative factors that contributed to the observed error. Potential solutions that were suggested across sources included implementing a forcing function, such as the real-time position management system, adding reminders, such as a console sign-off, and updating the current task checklist. DISCUSSION The potential solutions generated were summarized into four recommendations that have varying degrees of association with known causative factors. The four recommendations include investing in (1) a forcing function, (2) updating/reinforcing the procedure, (3) managing workload, and (4) updating the checklist. A priority matrix was used to assess both potential effectiveness and cost/effort of each recommendation. Ideally, recommendation 1 would be implemented; however, it is understood that there would be an associated cost. It is therefore suggested that recommendations 2, 3, and 4 are implemented together to increase the effectiveness of the intervention until recommendation 1 can be achieved. CONCLUSION This qualitative study introduced a method that analyzed human factors in a specialized procedure used in the treatment of a specific population of patients with cancer. Recommendations were formulated and proposed to the radiation therapy department in hopes of potentially decreasing the frequency of this specific error in the future.
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Affiliation(s)
- Kennedy Holland
- Radiation Therapy Program, University of Alberta, Edmonton, Alberta, Canada; Radiation Therapy, Tom Baker Cancer Centre, Calgary, Alberta, Canada.
| | - Sarah Sun
- Radiation Therapy Program, University of Alberta, Edmonton, Alberta, Canada; Radiation Therapy, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Marilyn Gackle
- Radiation Therapy, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Claire Goldring
- Human Factors Safety Specialist, Alberta Health Services, Calgary, Alberta, Canada
| | - Kari Osmar
- Radiation Therapy Program, University of Alberta, Edmonton, Alberta, Canada
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Dhawale T, Zech J, Greene SM, Roblin DW, Brigham KB, Gallagher TH, Mazor KM. We need to talk: Provider conversations with peers and patients about a medical error. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2019. [DOI: 10.1177/2516043519863578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Tejaswini Dhawale
- Center for Scholarship in Patient Care, Quality and Safety, University of Washington, Seattle, USA
| | - Jennifer Zech
- Mailman School of Public Health, ICAP at Columbia University, New York, USA
| | | | | | - Karen Berg Brigham
- Center for Scholarship in Patient Care, Quality and Safety, University of Washington, Seattle, USA
| | - Thomas H Gallagher
- Center for Scholarship in Patient Care, Quality and Safety, University of Washington, Seattle, USA
| | - Kathleen M Mazor
- Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, USA
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16
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Can the Treatment Approach of Sepsis With Balanced Crystalloid Fluids Translate Into Therapy for Acute Respiratory Distress Syndrome if Considered as "Lung-Limited Sepsis"? Crit Care Med 2019. [PMID: 28622221 DOI: 10.1097/ccm.0000000000002466] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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17
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Genovese U, Del Sordo S, Pravettoni G, Akulin IM, Zoja R, Casali M. A new paradigm on health care accountability to improve the quality of the system: four parameters to achieve individual and collective accountability. J Glob Health 2019; 7:010301. [PMID: 28567274 PMCID: PMC5441445 DOI: 10.7189/jogh.07.010301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Umberto Genovese
- Healthcare Accountability Lab, University of Milan, Milan, Italy.,Institute of Legal Medicine, University of Milan, Milan, Italy.,Department of Oncology and Hemato-Oncology (DIPO), University of Milan, Milan, Italy
| | - Sara Del Sordo
- Healthcare Accountability Lab, University of Milan, Milan, Italy.,Institute of Legal Medicine, University of Milan, Milan, Italy.,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Gabriella Pravettoni
- Department of Oncology and Hemato-Oncology (DIPO), University of Milan, Milan, Italy.,European Institute of Oncology, Milan, Italy
| | - Igor M Akulin
- Department of Health Organization, Saint Petersburg State University, Saint Petersburg, Russia
| | - Riccardo Zoja
- Institute of Legal Medicine, University of Milan, Milan, Italy.,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Michelangelo Casali
- Healthcare Accountability Lab, University of Milan, Milan, Italy.,Institute of Legal Medicine, University of Milan, Milan, Italy.,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
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Oxtoby C, Mossop L. Blame and shame in the veterinary profession: barriers and facilitators to reporting significant events. Vet Rec 2019; 184:501. [PMID: 30837292 DOI: 10.1136/vr.105137] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 12/21/2018] [Accepted: 01/14/2019] [Indexed: 11/04/2022]
Abstract
Significant event reporting is an important concept for patient safety in human medicine, but substantial barriers to the discussion and reporting of adverse events have been identified. This study explored the factors that influence the discussion and reporting of significant events among veterinary surgeons and nurses. Purposive sampling was used to generate participants for six focus groups consisting of a range of veterinary professionals of different ages and roles (mean N per group=9). Thematic analysis of the discussions identified three main themes: the effect of culture, the influence of organisational systems and the emotional effect of error. Fear, lack of time or understanding and organisational concerns were identified as barriers, while the effect of feedback, opportunity for learning and structure of a reporting system facilitated error reporting. Professional attitudes and culture emerged as both a positive and negative influence on the discussion of error. The results were triangulated against the findings in the medical literature and highlight common themes in clinician's concerns regarding the discussion of professional error. The results of this study have been used to inform the development of the 'VetSafe' tool, a web-based central error reporting system.
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Affiliation(s)
- Catherine Oxtoby
- Veterinary Risk Manager, The Veterinary Defence Society, Knutsford, UK
| | - Liz Mossop
- Deputy Vice Chancellor, University of Lincoln, Lincoln, UK
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19
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Tigard DW. Taking the blame: appropriate responses to medical error. JOURNAL OF MEDICAL ETHICS 2019; 45:101-105. [PMID: 30413557 DOI: 10.1136/medethics-2017-104687] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 08/21/2018] [Accepted: 10/22/2018] [Indexed: 06/08/2023]
Abstract
Medical errors are all too common. Ever since a report issued by the Institute of Medicine raised awareness of this unfortunate reality, an emerging theme has gained prominence in the literature on medical error. Fears of blame and punishment, it is often claimed, allow errors to remain undisclosed. Accordingly, modern healthcare must shift away from blame towards a culture of safety in order to effectively reduce the occurrence of error. Against this shift, I argue that it would serve the medical community well to retain notions of individual responsibility and blame in healthcare settings. In particular, expressions of moral emotions-such as guilt, regret and remorse-appear to play an important role in the process of disclosing harmful errors to patients and families. While such self-blaming responses can have negative psychological effects on the individual practitioner, those who take the blame are in the best position to offer apologies and show that mistakes are being taken seriously, thereby allowing harmed patients and families to move forward in the wake of medical error.
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Sanner M, Halford C, Vengberg S, Röing M. The dilemma of patient safety work: Perceptions of hospital middle managers. J Healthc Risk Manag 2018; 38:47-55. [PMID: 29964311 DOI: 10.1002/jhrm.21325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 04/16/2018] [Accepted: 05/04/2018] [Indexed: 11/09/2022]
Abstract
Patient safety continues to be a challenge for health care. Medical errors are not decreasing but continue to show roughly the same patterns in Sweden and other Western countries. This interview study aims to explore how 27 hospital middle managers responsible for patient safety work in a Swedish university hospital perceive this task. A qualitative analysis was performed. A code template was created, and each code was explored in depth and summarized into six categories. We conclude that patient safety work appears to have low priority; hospital top management does not seem to have any real interest in patient safety; incidents are underreported; and the organization of patient safety work seems to be insufficient and carried out insofar as resources are available. These parameters may explain why medical errors remain on a certain level and do not seem to decrease in spite of various support programs.
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Affiliation(s)
- Margareta Sanner
- Department of Public Health and Caring Sciences, Health Services Research, Uppsala University, Uppsala, Sweden
| | - Christina Halford
- Department of Public Health and Caring Sciences, Health Services Research, Uppsala University, Uppsala, Sweden
| | - Sofie Vengberg
- Department of Public Health and Caring Sciences, Health Services Research, Uppsala University, Uppsala, Sweden
| | - Marta Röing
- Department of Public Health and Caring Sciences, Health Services Research, Uppsala University, Uppsala, Sweden
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Redefining Accountability in Quality and Safety at Academic Medical Centers. Qual Manag Health Care 2018; 25:244-247. [PMID: 27749723 DOI: 10.1097/qmh.0000000000000107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Sinclair JE, Austin MA, Bourque C, Kortko J, Maloney J, Dionne R, Reed A, Price P, Calder LA. Barriers to Self-Reporting Patient Safety Incidents by Paramedics: A Mixed Methods Study. PREHOSP EMERG CARE 2018; 22:762-772. [PMID: 29787325 DOI: 10.1080/10903127.2018.1469703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND A minimal amount of research exists examining the extent to which patient safety events occur within paramedicine and even fewer studies investigating patient safety systems for self-reporting by paramedics. The purpose of this study was to identify barriers to paramedic self-reporting of patient safety incidents (PSIs). METHODS We randomly distributed paper-based surveys among 1,153 paramedics in an Ontario region in Canada. The survey described one of 5 different PSI clinical scenarios (near miss, adverse event, and minor, major or critical patient care variances) and listed 18 potential barriers to self-reporting PSIs as statements presented for rating on a 5-point Likert scale (very significant = 1 - very insignificant = 5). We invited comments on PSI self-reporting with 2 open-ended questions. We analyzed data with descriptive statistics, chi-square tests and Kruskal-Wallis H test. We used an inductive approach to qualitatively analyze emerging themes. RESULTS We received responses from 1,133 paramedics (98.3%). Almost one third (28.4%) were Advanced Care Paramedics and 45.1% had >10 years' experience. The top 5 barriers to PSI self-reporting (very significant or significant, %) were the fear of being: punished (81.4%), suspended (79.6%), terminated (79.1%), investigated by Ministry of Health and Long-Term Care (78.4%), and decertified (78.0%). Overall, 64.1% responded they would self-report a given PSI. Intention to self-report a PSI varied according to scenario (22.8% near miss, 46.6% adverse event, 74.4% minor, 92.6% major, 95.6% critical). No association was found between level of training (p = 0.55) or years of experience (p = 0.10) and intention to self-report a PSI. Seven themes to improve PSI self-reporting by paramedics emerged from the qualitative data. CONCLUSIONS A high proportion of fear-based barriers to self-reporting of PSIs exist among this study population. This suggests that a culture change is needed to facilitate the identification of future patient safety threats.
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Robertson JJ, Long B. Suffering in Silence: Medical Error and its Impact on Health Care Providers. J Emerg Med 2018; 54:402-409. [DOI: 10.1016/j.jemermed.2017.12.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/22/2017] [Accepted: 12/01/2017] [Indexed: 10/18/2022]
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Moffatt-Bruce S, Clark S, DiMaio M, Fann J. Leadership Oversight for Patient Safety Programs: An Essential Element. Ann Thorac Surg 2018; 105:351-356. [DOI: 10.1016/j.athoracsur.2017.11.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/15/2017] [Indexed: 10/18/2022]
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LEE SOOHOON, FISHER DALEA, MAH HEIDI, GOH WEIPING, PHAN PHILLIPH. A qualitative study of sign-out processes between primary and on-call residents: relationships in information exchange, responsibility and accountability. Int J Qual Health Care 2017; 29:646-653. [DOI: 10.1093/intqhc/mzx082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 06/29/2017] [Indexed: 11/12/2022] Open
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Rashkovits S, Drach-Zahavy A. The moderating role of team resources in translating nursing teams’ accountability into learning and performance: a cross-sectional study. J Adv Nurs 2016; 73:1124-1136. [DOI: 10.1111/jan.13200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Sarit Rashkovits
- The Department of Health Systems Management; Max Stern Yezreel Valley Academic College; Israel
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Belela-Anacleto ASC, Pedreira MLG. Patient safety era: time to think about accountability. Nurs Crit Care 2016. [DOI: 10.1111/nicc.12270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Mavilde LG Pedreira
- Department of Pediatric Nursing, School of Nursing; Universidade Federal de São Paulo; São Paulo Brazil
- National Council for Scientific and, Technological Development Researcher; São Paulo Brazil
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Gallagher TH, Etchegaray JM, Bergstedt B, Chappelle AM, Ottosen MJ, Sedlock EW, Thomas EJ. Improving Communication and Resolution Following Adverse Events Using a Patient-Created Simulation Exercise. Health Serv Res 2016; 51 Suppl 3:2537-2549. [PMID: 27790708 DOI: 10.1111/1475-6773.12601] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The response to adverse events can lack patient-centeredness, perhaps because the involved institutions and other stakeholders misunderstand what patients and families go through after care breakdowns. STUDY SETTING Washington and Texas. STUDY DESIGN The HealthPact Patient and Family Advisory Council (PFAC) created and led a five-stage simulation exercise to help stakeholders understand what patients experience following an adverse event. The half-day exercise was presented twice. DATA COLLECTION AND ANALYSIS Lessons learned related to the development and conduct of the exercise were synthesized from planning notes, attendee evaluations, and exercise discussion notes. PRINCIPAL FINDINGS One hundred ninety-four individuals attended (86 Washington and 108 Texas). Take-homes from these exercises included the fact that the response to adverse events can be complex, siloed, and uncoordinated. Participating in this simulation exercise led stakeholders and patient advocates to express interest in continued collaboration. CONCLUSIONS A PFAC-designed simulation can help stakeholders understand patient and family experiences following adverse events and potentially improve their response to these events.
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Affiliation(s)
- Thomas H Gallagher
- Department of Medicine, UW Medicine Center for Scholarship in Patient Care Quality and Safety, University of Washington, Seattle, WA
| | | | | | | | - Madelene J Ottosen
- McGovern Medical School at The University of Texas Health Science Center at Houston, University of Texas - Memorial Hermann Center for Healthcare Quality and Safety, Houston, TX
| | - Emily W Sedlock
- McGovern Medical School at The University of Texas Health Science Center at Houston, University of Texas - Memorial Hermann Center for Healthcare Quality and Safety, Houston, TX
| | - Eric J Thomas
- McGovern Medical School at The University of Texas Health Science Center at Houston, University of Texas - Memorial Hermann Center for Healthcare Quality and Safety, Houston, TX
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29
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Tad-y D, Wald HL. The evolution of morbidity and mortality conferences. BMJ Qual Saf 2016; 26:433-435. [DOI: 10.1136/bmjqs-2016-005817] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2016] [Indexed: 11/03/2022]
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Patient Safety: Disclosure of Medical Errors and Risk Mitigation. Ann Thorac Surg 2016; 102:358-62. [DOI: 10.1016/j.athoracsur.2016.06.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 06/16/2016] [Indexed: 11/18/2022]
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31
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Aveling E, Parker M, Dixon‐Woods M. What is the role of individual accountability in patient safety? A multi-site ethnographic study. SOCIOLOGY OF HEALTH & ILLNESS 2016; 38:216-32. [PMID: 26537016 PMCID: PMC4755229 DOI: 10.1111/1467-9566.12370] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
An enduring debate concerns how responsibility for patient safety should be distributed between organisational systems and individual professionals. Though rule-based, calculus-like approaches intended to support a 'just culture' have become popular, they perpetuate an asocial and atomised account. In this article, we use insights from practice theory--which sees organisational phenomena as accomplished in everyday actions, with individual agency and structural conditions as a mutually constitutive, dynamic duality--along with contributions from the political science and ethics literature as a starting point for analysis. Presenting ethnographic data from five hospitals, three in one high-income country and two in low-income countries, we offer an empirically informed, normative rethinking of the role of personal accountability, identifying the collective nature of the healthcare enterprise and the extent to which patient safety depends on contributions from many hands. We show that moral responsibility for actions and behaviours is an irreducible element of professional practice, but that individuals are not somehow 'outside' and separate from 'systems': they create, modify and are subject to the social forces that are an inescapable feature of any organisational system; each element acts on the other. Our work illustrates starkly the structuring effects of the broader institutional and socioeconomic context on opportunities to 'be good'. These findings imply that one of the key responsibilities of organisations and wider institutions in relation to patient safety is the fostering of the conditions of moral community.
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Affiliation(s)
- Emma‐Louise Aveling
- Department of health SciencesUniversity of LeicesterUK
- Department of Health Policy and Management, Harvard T.H. Chan School of Public HealthBostonUSA
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Stamm JA, Korzick KA, Beech K, Wood KE. Medical Malpractice: Reform for Today's Patients and Clinicians. Am J Med 2016; 129:20-5. [PMID: 26391747 DOI: 10.1016/j.amjmed.2015.08.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 08/04/2015] [Accepted: 08/04/2015] [Indexed: 10/23/2022]
Abstract
The current system of medical malpractice does a poor job of serving the best interests of physicians or patients. Economic and societal forces are shifting the nature of health care from the individual physician to a system of health care professionals, characterized by accountable care organizations. In particular, more physicians are employed, quality and outcomes are routinely measured, and reimbursement is moving to value-based purchasing. Medical malpractice likewise needs to transition to a new model that is consistent with the modern era of patient-centered care. Collective accountability, the concept that patient care is the responsibility of all the members of the health care organization, requires malpractice reform that reflects a systems-based practice of medicine. Enterprise liability, coupled with medical error communication and resolution programs, provides the legal framework necessary for the patient-centered practice of medicine in today's environment.
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Affiliation(s)
- Jason A Stamm
- Department of Medicine, Geisinger Medical Center, Danville, Pa.
| | - Karen A Korzick
- Department of Medicine, Geisinger Medical Center, Danville, Pa
| | - Kristen Beech
- Harvard Medical Faculty Physicians, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Kenneth E Wood
- Department of Medicine, Geisinger Medical Center, Danville, Pa
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Marsteller JA, Wen M, Hsu YJ, Bauer LC, Schwann NM, Young CJ, Sanchez JA, Errett NA, Gurses AP, Thompson DA, Wahr JA, Martinez EA. Safety Culture in Cardiac Surgical Teams: Data From Five Programs and National Surgical Comparison. Ann Thorac Surg 2015; 100:2182-9. [DOI: 10.1016/j.athoracsur.2015.05.109] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 05/15/2015] [Accepted: 05/20/2015] [Indexed: 10/23/2022]
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Davidson JE, Agan DL, Chakedis S, Skrobik Y. Workplace Blame and Related Concepts: An Analysis of Three Case Studies. Chest 2015; 148:543-549. [PMID: 25928049 DOI: 10.1378/chest.15-0332] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Blame has been thought to affect quality by decreasing error reporting. Very little is known about the incidence, characteristics, or consequences of the distress caused by being blamed. Blame-related distress (B-RD) may be related to moral distress, but may also be a factor in burnout, compassion fatigue, lateral violence, and second-victim syndrome. The purpose of this article is to explore these related concepts through a literature review applied to three index critical care clinician cases.
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Affiliation(s)
- Judy E Davidson
- Department of Education, Research and Development, University of California San Diego Health System, San Diego, CA.
| | | | - Shannon Chakedis
- Moore's Cancer Center, University of California San Diego Health System, San Diego, CA
| | - Yoanna Skrobik
- McGill University Department of Medicine, McGill University, Montreal, QC; Critical Care Division, Kingston General Hospital, Queen's University, Kingston, ON, Canada
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Lipira LE, Gallagher TH. Disclosure of adverse events and errors in surgical care: challenges and strategies for improvement. World J Surg 2015; 38:1614-21. [PMID: 24763441 DOI: 10.1007/s00268-014-2564-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The disclosure of adverse events to patients, including those caused by medical errors, is a critical part of patient-centered healthcare and a fundamental component of patient safety and quality improvement. Disclosure benefits patients, providers, and healthcare institutions. However, the act of disclosure can be difficult for physicians. Surgeons struggle with disclosure in unique ways compared with other specialties, and disclosure in the surgical setting has specific challenges. The frequency of surgical adverse events along with a dysfunctional tort system, the team structure of surgical staff, and obstacles created inadvertently by existing surgical patient safety initiatives may contribute to an environment not conducive to disclosure. Fortunately, there are multiple strategies to address these barriers. Participation in communication and resolution programs, integration of Just Culture principles, surgical team disclosure planning, refinement of informed consent and morbidity and mortality processes, surgery-specific professional standards, and understanding the complexities of disclosing other clinicians' errors all have the potential to help surgeons provide patients with complete, satisfactory disclosures. Improvement in the regularity and quality of disclosures after surgical adverse events and errors will be key as the field of patient safety continues to advance.
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Affiliation(s)
- Lauren E Lipira
- Department of Medicine, University of Washington, Seattle, WA, USA,
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Another Surgeon's Error: Must You Tell the Patient? Ann Thorac Surg 2014; 98:396-401. [DOI: 10.1016/j.athoracsur.2014.04.073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 03/07/2014] [Accepted: 04/08/2014] [Indexed: 11/23/2022]
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Turillazzi E, Neri M. Medical error disclosure: from the therapeutic alliance to risk management: the vision of the new Italian code of medical ethics. BMC Med Ethics 2014; 15:57. [PMID: 25023339 PMCID: PMC4108959 DOI: 10.1186/1472-6939-15-57] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 07/10/2014] [Indexed: 11/10/2022] Open
Abstract
Background The Italian code of medical deontology recently approved stipulates that physicians have the duty to inform the patient of each unwanted event and its causes, and to identify, report and evaluate adverse events and errors. Thus the obligation to supply information continues to widen, in some way extending beyond the doctor-patient relationship to become an essential tool for improving the quality of professional services. Discussion The new deontological precepts intersect two areas in which the figure of the physician is paramount. On the one hand is the need for maximum integrity towards the patient, in the name of the doctor’s own, and the other’s (the patient’s) dignity and liberty; on the other is the physician’s developing role in the strategies of the health system to achieve efficacy, quality, reliability and efficiency, to reduce errors and adverse events and to manage clinical risk. Summary In Italy, due to guidelines issued by the Ministry of Health and to the new code of medical deontology, the role of physicians becomes a part of a complex strategy of risk management based on a system focused approach in which increasing transparency regarding adverse outcomes and full disclosure of health- related negative events represent a key factor.
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Affiliation(s)
- Emanuela Turillazzi
- Department of Legal Medicine, University of Foggia, Via degli Aviatori, 1, 71100 Foggia, Italy.
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Delivering the truth: challenges and opportunities for error disclosure in obstetrics. Obstet Gynecol 2014; 123:656-659. [PMID: 24499761 DOI: 10.1097/aog.0000000000000130] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Disclosing harmful medical errors to patients is a prominent component of the patient safety movement. Patients expect it and safety agencies and experts advocate its implementation. Obstetrics presents unique challenges to carrying out disclosure recommendations: childbirth is a life-changing, emotionally charged, and dynamic family event characterized by high expectations and unpredictability, and perinatal care is provided by complex ad hoc teams in a litigious area of medicine. Despite these challenges, transparent communication with parents about unexpected adverse birth outcomes remains critical. We call on clinicians and professional societies to pursue a deeper understanding of the unique challenges of disclosure in obstetrics and prepare themselves to conduct these difficult conversations well.
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Gallagher TH, Mello MM, Levinson W, Wynia MK, Sachdeva AK, Snyder Sulmasy L, Truog RD, Conway J, Mazor K, Lembitz A, Bell SK, Sokol-Hessner L, Shapiro J, Puopolo AL, Arnold R. Talking with patients about other clinicians' errors. N Engl J Med 2013; 369:1752-7. [PMID: 24171522 DOI: 10.1056/nejmsb1303119] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Thomas H Gallagher
- From the Department of Medicine and the Department of Bioethics and Humanities, University of Washington, Seattle (T.H.G.); the Department of Health Policy and Management, Harvard School of Public Health (M.M.M.), the Department of Social Medicine, Harvard Medical School (R.D.T.), the Department of Medicine, Beth Israel Deaconess Medical Center (S.K.B., L.S.-H.), and the Division of Otolaryngology, Brigham and Women's Hospital (J.S.) - all in Boston; the Department of Medicine, University of Toronto, Toronto (W.L.); the Institute for Ethics, American Medical Association (M.K.W.), and the Division of Education, American College of Surgeons (A.K.S.) -both in Chicago; the Center for Ethics and Professionalism, American College of Physicians, Philadelphia (L.S.S.); the Institute for Healthcare Improvement, Cambridge, MA (J.C.); the Department of Medicine, University of Massachusetts Medical School, Worcester (K.M.); COPIC Insurance, Denver (A.L.); CVS Caremark, Woonsocket, RI (A.-L.P.); and the Institute for Doctor-Patient Communication and Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh (R.A.)
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