Implementation of a critical care outreach team in a children's hospital

Introduction

Proactive surveillance by a critical care outreach team (CCOT) can promote early recognition of deterioration in hospitalized patients but is uncommon in pediatric rapid response systems (RRSs). After our children's hospital introduced a CCOT in 2019, we aimed to characterize early implementation outcomes. We hypothesized that CCOT rounding would identify additional children at risk for deterioration.

Methods

The CCOT, staffed by a dedicated critical care nurse (RN), respiratory therapist, and attending, conducts daily in-person rounds with charge RNs on medical-surgical units, to screen RRS-identified high-risk patients for deterioration. In this prospective study, observers tracked rounds discussion content, participation, and identification of new high-risk patients. We compared 'identified-patient-discussions' (IPD) about RRS-identified patients, and 'new-patient-discussions' (NPD) about new patients with Fisher's exact test. For new patients, we performed thematic analysis of clinical data to identify deterioration related themes.

Results

During 348 unit-rounds over 20 days, we observed 383 discussions - 35 (9%) were NPD. Frequent topics were screening for clinical concerns (374/383, 98%), active clinical concerns (147/383, 39%), and watcher activation (66/383, 17%). Most discussions only included standard participants (353/383, 92%). Compared to IPD, NPD more often addressed active concerns (74.3% vs 34.8%, p < 0.01) and staffing resource concerns (5.7% vs 0.6%, p < 0.04), and more often incorporated extra participants (25.7% vs 6%, p < 0.01). In thematic analysis of 33 new patients, most (29/33, 88%) had features of deterioration.

Conclusion

A successfully implemented CCOT enhanced identification of clinical deterioration not captured by existing RRS resources. Future work will investigate its impact on operational safety and patient-centered outcomes.

Building Cultures of High Reliability: Lessons from the High Reliability Organization Paradigm

Safety models from disciplines outside of health care have begun to diffuse into the health care safety arena. This article explores high reliability organizing (HRO) theory, which privileges culture as means to adaptively learn and reliably perform. A brief history of the HRO paradigm and factors that contribute to cultures of high reliability is provided, followed by review of existing research to discern which HRO ideas have diffused into research on anesthesiology and perioperative care. High reliability research is growing and concepts seem useful; but there is a long way to go before the benefits of HRO are fully realized.

Relationships among psychological safety, the principles of high reliability, and safety reporting intentions in pediatric nursing

PURPOSE

The purpose of this study was to explore relationships among psychological safety, the principles of high reliability, and safety reporting intentions in pediatric nursing. Patient safety events are underreported and costly. To promote reporting, many healthcare organizations have adopted the high reliability framework with strategies to foster team psychological safety.

DESIGN

A web-based survey was distributed through the Society of Pediatric Nurses and the National Pediatric Nurse Scientist Collaborative. Data were collected from 244 pediatric nurses using a demographic form, Safety Organizing Scale, Team Psychological Safety Scale, and Intention to Report Safety Events Scale. Data were analyzed using logistic and linear regression.

RESULTS

Psychological safety and perception of working in a high reliability organization (HRO) showed positive statistically significant relationships with reporting intentions (p = 0.034). Odds of nurses achieving highest reporting intention scores increased by a factor of 0.3 with each practice year.

CONCLUSIONS

Psychological safety was found to be a predictor for intention to report safety events among pediatric nurses. Findings also demonstrated that nurses' perceptions of whether they worked in a high reliability setting also profoundly affect their attitude towards reporting.

PRACTICE IMPLICATIONS

Focusing organizational efforts on cultivating psychological safety and embedding the high reliability framework into professional practice may significantly affect attitudes towards safety event reporting.

Stressors in forensic organizations: Risks and solutions

Stressors of many types occur in forensic laboratories, with detrimental effects for individuals, laboratory systems, and casework outcomes. These stressors may be general, affecting the entire laboratory or all cases, or specific, affecting individual examiners or single cases. Stressors affecting individual examiners include: vicarious trauma associated with details of worked cases, nonstandard working hours, fatigue, the monotony of repetitious tasks, fear of errors, and severe backlogs. Policies and laboratory cultures can be put in place to minimize the effects of stressors; however, current forensic organizational responses to these stressors may vary from punitive to collaborative approaches. This article presents several models and case studies that can help inform the creation of positive laboratory policies. A system of discipline-wide centralized error reporting, similar to systems used to reduce fatal mistakes in medicine and aviation, could have the potential to identify areas of concern within forensic science practices.

Using Root Cause Analysis and Occupational Safety Research to Prevent Child Sexual Abuse in Schools

Significant progress has been made in the past two decades understanding how child molesters gain access to children and molest them while manipulating others to not get caught. However, incidents of child sexual abuse in schools by educators, and by other children, continue. This manuscript suggests that a comprehensive solution involves two components: (1) using root cause analysis methodology to systematically identify and integrate repetitive causes; (2) to use the findings from voluminous occupational safety research focusing on low-frequency but high-intensity events. Additionally, this manuscript describes eight organizational operations and practices that may reduce the risk of sexual abuse of children by educators or peers in a school setting. These findings were based on existing recommendations and on root cause analysis of thousands of incidents in schools and other youth serving organizations. Finally, the manuscript discusses how a framework drawn from occupational safety research can help schools and other youth serving organizations create environments that will help to create safe environments. Authors have used both components in working with thousands of organizations including faith-based, independent, and urban independent school districts, youth development programs, social service agencies, camps and so on serving diverse populations in 11 countries.

An experience in integrated management of clinical risks

BACKGROUND

Manage clinical risks under the integrated risk management model of the BUPA organization (British United Provident Association).

MATERIALS AND METHODS

BUPA is an international group that provides health insurance and healthcare services. The project has been limited to Europe and Latin America (ELA) and this article presents the results related to hospitals. The integral risk management model was based on a governance structure, a risk management framework and the risk management itself (continuous process of identification, evaluation, management, monitoring and reporting). For the latter, a catalog of potential clinical risks was drawn up, using the Joint Commission International (JCI) standards as a reference and applied to a hospital to identify the risk to which they were exposed in their daily activity. An evaluation was conducted, based on its impact and probability of occurrence and depending on the residual and inherent score obtained, the action on each risk and the effectiveness of the controls were determined. A continuous monitoring of the risk profile and the information to share with the Board was defined.

RESULTS

The catalog consisted of 126 risks and 479 controls, divided by areas of application. In the assessment of the inherent risk, 84% of the risks were at an acceptable and assumable level, and in 16% it was necessary to establish an action plan.

CONCLUSIONS

Under the conditions of the study, we believe the benefits of implementing an integrated management of clinical risk system consisted in providing services that meet the legal requirements and standards of good practice (in our case, the JCI's standards). They allowed us to advance in the organization's management of, improving its efficiency in the allocation of resources for risk management and adaptation to the environment and the patient. In addition, this strategy can facilitate decision-making and encourage the organization's transformation capacity.

Quality and the Health System: Becoming a High Reliability Organization

Since the publication of "To Err is Human" in 1999, substantial efforts have been made within the health care industry to improve quality and patient safety. Although improvements have been made, recent estimates continue to indicate the need for a marked change in approach. In this article, the authors discuss the concepts and characteristics of high reliability organizations, safety culture, and clinical microsystems. The health care delivery system must move beyond current quality and patient safety approaches and fully engage in these new concepts to transform health care system performance.

Nurse-Technology Interactions and Patient Safety

Nurses are the end-users of most technology in intensive care units, and the ways in which they interact with technology affect quality of care and patient safety. Nurses' interactions include the processes of ensuring proper input of data into the technology as well as extracting and interpreting the output (clinical data, technical data, alarms). Current challenges in nurse-technology interactions for physiologic monitoring include issues regarding alarm management, workflow interruptions, and monitor surveillance. Patient safety concepts, like high reliability organizations and human factors, can advance efforts to enhance nurse-technology interactions.

Organizational culture and a safety-conscious work environment: The mediating role of employee communication satisfaction

INTRODUCTION

A safety-conscious work environment allows high-reliability organizations to be proactive regarding safety and enables employees to feel free to report any concern without fear of retaliation. Currently, research on the antecedents to safety-conscious work environments is scarce.

METHOD

Structural equation modeling was applied to test the mediating role of employee communication satisfaction in the relationship between constructive culture and a safety-conscious work environment in several nuclear power plants.

RESULTS

Employee communication satisfaction partially mediated the positive relationships between a constructive culture and a safety-conscious work environment.

CONCLUSIONS

Constructive cultures in which cooperation, supportive relationships, individual growth and high performance are encouraged facilitate the establishment of a safety-conscious work environment. This influence is partially explained by increased employee communication satisfaction.

PRACTICAL APPLICATION

Constructive cultures should be encouraged within organizations. In addition, managers should promote communication policies and practices that support a safety-conscious work environment.