Association between use of clinical governance systems at the frontline and patient safety: a pre-post study

This section includes detailed findings from the second set of visits (2015–2017) of the Clinical Learning Environment Review (CLER) Program. The findings in the 6 CLER Focus Areas1 are based on site visits to the major participating clinical sites (ie, hospitals and medical centers) for 287 Accreditation Council for Graduate Medical Education (ACGME)-accredited Sponsoring Institutions (SIs) with 3 or more core residency programs.23 These clinical sites serve as clinical learning environments (CLEs) for the SIs.Collectively, the 287 SIs oversee 9167 ACGME-accredited residency and fellowship programs, with a median of 20 programs per SI. These larger SIs account for 87.1% of all residents and fellows in ACGME-accredited programs—with a range of 17 to 2156 trainees per SI (median = 246).Approximately 28% of the CLEs were located in the Northeast region of the United States, 30.3% in the South, 26.5% in the Midwest, and 14.6% in the West. The sites ranged in size from 107 to 2654 acute care beds (median = 528). The majority (67.2%) were nongovernment, not-for-profit organizations; 23.3% were government, nonfederal; 5.9% were investor-owned, for-profit; and 3.5% were government, federal. Although the CLER teams spent the majority of their time at inpatient settings, they also sometimes visited affiliated ambulatory care practices in close proximity.In total, the CLER teams interviewed more than 1600 members of executive leadership (including chief executive officers), 9262 residents and fellows, 8164 core faculty members, and 6034 program directors of ACGME-accredited programs in group meetings. Additionally, the CLER teams interviewed the CLEs' leadership in patient safety and health care quality and thousands of residents, fellows, faculty members, nurses, pharmacists, social workers, and other health care professionals while on walking rounds in the clinical areas.As previously described in the CLER National Report of Findings 2016,4 these findings are based on a mixed methods approach to data gathering and analysis to improve the accuracy of the findings by combining quantitative, descriptive, and qualitative evidence in a complementary manner. As such, some of the findings are represented quantitatively while others are described qualitatively.The combination of methodologies and varied representation of findings should be considered when interpreting the results, making comparisons, or drawing conclusions. Both supporting and conflicting evidence may be presented to explain or qualify findings. For example, results from the group interviews may appear more positive than information gathered on walking rounds. Alternatively, practices reported during group interviews may have been verified on walking rounds.During the group interviews with residents and fellows, faculty members, and program directors, an electronic audience response system (ARS; Keypoint Interactive version 2.6.6, Innovision Inc, Commerce Township, MI) was used to collect anonymous responses to closed-ended questions. The results from the ARS were analyzed at both the individual (eg, residents and fellows) and the CLE levels.At the individual level of analysis, results are presented as percentages of the total number of individuals surveyed. For example:At the CLE level of analysis, individual responses were aggregated at the CLE level and results are presented as median and interquartile range (IQR) percentages. For example:Statistically significant differences (ie, P ≤ .05) in responses due to resident and fellow characteristics (eg, residency year) and CLE characteristics (eg, bed size) are also reported. Of note, statistical significance does not always imply practical significance. For example, differences in responses by residency year may be statistically significant but the differences may not be meaningful or large enough to have practical relevance or implications.As described in the Methodology section,5 this report contains a specific set of descriptive terms that summarize quantitative results from both the ARS and specific findings that were quantified from the site visit reports. These terms and their corresponding quantitative ranges are as follows:Besides the quantitative data, this report contains qualitative data from a number of open-ended questions that CLER Site Visitors asked during group interviews and walking rounds. This information, by design, was not intended to be enumerated. For these questions, the site visit teams made an assessment of the relative magnitude of observations at each individual site. To prevent confusion, these results are presented in the report using a set of descriptive terms different from the previously described terms used for quantitative data. The qualitative descriptive terms, which are intended to approximate the quantitative terms above, are as follows:Finally, this section follows approximately the same structure as the individual CLER Site Visit reports received by participating institutions. This structure is intended to facilitate easy comparison between data from an individual site and that of this report, which aggregates results from all 287 SIs. Those who seek additional detail may consult the Appendices (p. 81–124). Appendix A contains additional information on the SIs, sites visited, and groups interviewed, Appendix B contains selected aggregated quantitative results from the group interviews with residents and fellows, and Appendix C contains qualitative information from the group interviews and walking rounds.The CLER Program explored several aspects of resident and fellow engagement in patient safety with emphasis on 5 major topics: culture of safety, use of the patient safety event reporting system, knowledge of patient safety principles and methods, inclusion in patient safety event investigations, and disclosure of patient safety events. Generally across CLEs, members of the executive leadership team identified patient safety as their highest priority area for improvement.The patient safety and quality leaders in many CLEs indicated that they periodically conduct a culture of safety survey that includes residents, fellows, and faculty members. Overall, 97.7% of the residents and fellows in the group interviews reported that their CLE provides a safe and nonpunitive environment for reporting errors.Across CLEs, physicians and other staff members also reported use of the patient safety event reporting system to report on individual behaviors. This use included reporting on behaviors in a retaliatory fashion or in a manner that could be perceived as punitive.Given this and based on the collective findings from the site visits, it is unclear as to whether residents, fellows, and other staff members perceived a safe and nonpunitive culture for reporting patient safety events.Overall, CLEs had 1 or more mechanisms for reporting patient safety events, including an online or paper-based patient safety event reporting system, a chain-of-command system that allowed events to be reported to an immediate supervisor (eg, a more senior resident or faculty member), and a mechanism to verbally report events to the patient safety staff (eg, hotline).In general, residents and fellows appeared to be aware of their CLE's process for reporting patient safety events such as adverse events, near misses/close calls, and unsafe conditions. During walking rounds, the CLER Site Visit teams also asked nurses about their CLE's patient safety event reporting system. Across nearly all CLEs (97.2%), nurses appeared to be familiar with their CLE's system for reporting patient safety events.Approximately 78% of CLEs were able to provide information on the number of patient safety event reports submitted by residents and fellows (see Appendix C1), and 70.7% were able to provide the number of patient safety event reports submitted by attending physicians. The remaining CLEs indicated that their system did not track such information. Whereas CLEs occasionally provided the Graduate Medical Education Committee and their governing body with information on the number or percentage of patient safety event reports submitted by residents and fellows, it was less common for them to routinely report the number or percentage of patient safety event reports submitted by faculty members to these same groups.Generally across CLEs, the residents and fellows interviewed on walking rounds appeared to lack understanding and awareness of the range of reportable patient safety events, including what defines a near miss/close call. In most CLEs (83.6%), nurses' understanding of reportable patient safety events also varied (see Appendix C2).Across CLEs, residents, fellows, and nurses appeared to focus on reporting sentinel events, medication errors, patient falls, and other events with harm; they did not appear to recognize near misses/close calls, unsafe conditions, events without harm, unexpected deteriorations, or known procedural complications as reportable patient safety events. Residents, fellows, and nurses appeared to have little awareness of the importance of reporting these events and how such reporting can provide valuable information for identifying system failures, addressing vulnerabilities in the system, reducing risks, and improving patient safety.Overall, 72.7% of the residents and fellows in the group interviews indicated that they had experienced an adverse event, near miss/close call, or unsafe condition while at their CLE. This experience varied by gender, year of training, and specialty grouping (see Appendix B1).Of the residents and fellows who reported that they had experienced an adverse event, near miss/close call, or unsafe condition, 49.8% indicated that they had personally reported the patient safety event using the CLE's patient safety event reporting system. Responses varied by gender, year of training, and specialty grouping. Across CLEs, the median (IQR) finding was 50.0% (37.5%–66.7%) and varied by region, CLE bed size, and type of ownership (see Appendix B2). For those who did not personally enter the patient safety event into the system, 13.6% indicated that they relied on a nurse to submit the patient safety event report, 24.4% indicated that they relied on a physician supervisor, and 12.1% indicated that they cared for the patient and chose not to submit a report.When faculty members and program directors in the group interviews were asked what process residents and fellows most frequently followed when reporting a patient safety event, 57.9% of the faculty members and 53.7% of the program directors indicated that they believed residents and fellows most often reported the event themselves using the CLE's patient safety event reporting system.In a separate query, 23.6% of the residents and fellows in the group interviews indicated that they had reported a near miss/close call event while at the CLE; responses varied by gender, year of training, and specialty grouping (FIGURE 1). Across CLEs, this finding ranged from 0% to 100%, with a median (IQR) of 23.1% (15.2%–33.3%); responses varied by region and type of ownership (see Appendix B3).On walking rounds, residents and fellows in many CLEs mentioned that they often report patient safety events locally or through their chain of command while also indicating familiarity with the patient safety event reporting system and its use. When they delegated or relied on others to report, it was unclear if these reports were formally captured in the CLE's centralized patient safety event reporting system. Residents and fellows mentioned the cumbersome process of submitting a report, the time needed to enter a report, fears of repercussion, and the uncertainty of receiving feedback as reasons for not reporting. The collective information from the site visits indicated that in 70.6% of the CLEs, resident and fellow reporting of patient safety events into the CLE's patient safety event reporting system was varied or infrequent (see Appendix C3).In the group interviews, the CLER teams also explored faculty members' and program directors' use of the CLE's patient safety event reporting system. Approximately 36% of the faculty members reported that they had personally reported an adverse event, near miss/close call, or unsafe condition in the past year (median [IQR], 35.7% [26.0%–46.6%] across CLEs). Among the program directors, 35.9% reported that they had personally reported an adverse event, near miss/close call, or unsafe condition in the past year (5.5% had no clinical responsibilities at the site). Across CLEs, the median (IQR) finding was 36.0% (27.3%–50.0%). In both groups, responses varied by CLE bed size and type of ownership.In the group interviews, the CLER teams asked residents and fellows whether they received feedback on patient safety event reports. Of those who had experienced an adverse event, near miss/close call, or unsafe condition and who had personally submitted a patient safety event report or relied on a nurse or supervisor to submit the report, 46.1% reported that they received feedback on the outcome of the report. Responses varied by gender, specialty grouping, and year of training (FIGURE 2; see also Appendix B4).Residents and fellows often mentioned receiving an e-mail acknowledging receipt of the patient safety event report. They also noted receiving requests for additional information as part of a formal patient safety event investigation. It was uncommon for residents to mention receiving information on the outcome of the investigation, including recommended actions to address vulnerabilities in the system and to improve patient safety. Across CLEs, residents, fellows, nurses, and other clinical staff expressed a strong desire to receive feedback in response to submitting a patient safety event report.Overall, CLEs varied in their processes for reviewing and prioritizing patient safety events. Residents and fellows also varied in their knowledge of these processes and often used the term "black box," indicating that these processes were unclear. Many residents and fellows appeared to be unaware of how their CLEs use the reporting of adverse events, near misses/close calls, or unsafe conditions to improve care both broadly and at the individual departmental level. Residents and fellows were rarely involved in their CLE's process for reviewing and prioritizing patient safety events that required further investigation.On walking rounds, the CLER teams explored resident and fellow participation in the time-out process as part of patient safety practices (eg, ambulatory and bedside procedures). Across many CLEs, residents, fellows, nurses, and other health care professionals interviewed on walking rounds indicated that residents and fellows do not consistently conduct standardized time-outs before performing bedside procedures.Across most CLEs (91.6%), residents and fellows appeared to have limited knowledge of fundamental patient safety principles and methods (eg, Swiss cheese model of system failure, root cause analysis, fishbone diagrams; see Appendix C4).When asked to identify their skills in applying patient safety principles, the majority of the faculty members indicated that they were either proficient or expert (62.7% and 25.1%, respectively) in applying these skills. Similarly, most of the program directors reported themselves as proficient or expert (63.6% and 21.9%, respectively).Of the residents and fellows in the group interviews, 36.3% reported that they had participated in a structured interprofessional simulation activity related to patient safety. Responses varied by gender, year of training, and specialty grouping. Across CLEs, the median (IQR) finding was 37.1% (26.3%–50.0%), with responses varying by region and type of ownership.In many CLEs, the patient safety and quality leaders indicated that they did not track resident and fellow participation in patient safety event investigations (eg, root cause analysis). A limited number of CLEs provided the Graduate Medical Education Committee and the governing body with information regarding the number of residents and fellows who had participated in formal patient safety event investigations.The CLER teams also asked the program directors in the group interviews if they measured resident and fellow participation in patient safety event investigations. Approximately 42% of the program directors reported tracking resident and fellow involvement (median [IQR], 44.4% [30.0%–66.7%] across CLEs). Responses varied by region, CLE bed size, and type of ownership.In the group interviews, 37.6% of the residents and fellows who were postgraduate year 3 (PGY-3) and higher indicated that they had participated in an interprofessional investigation of a patient safety event that included components such as analysis of system issues, development and implementation of an action plan, and monitoring for continuous improvement. Reponses varied by specialty grouping (FIGURE 3). Across CLEs, the median (IQR) finding was 37.6% (28.6%–50.0%), with responses varying by region, CLE bed size, and type of ownership (see Appendix B5).The CLER teams also asked faculty members about their involvement in interprofessional patient safety event investigations. Approximately 64% of the faculty members in the group interviews reported that they had participated in an investigation of a patient safety event that involved physicians, nurses, administrators, and other health care professionals (median [IQR], 63.3% [53.0%–73.2%] across CLEs).Overall, the format and process of investigating patient safety events varied both across and within CLEs. It was uncommon for residents and fellows to describe involvement in comprehensive systems-based approaches to patient safety event investigations aimed at preventing future adverse events and sustaining improvements in patient safety. In general, residents and fellows described experiences that lacked the attributes of a formal patient safety event investigation with very little or no interprofessional or interdisciplinary engagement. Residents and fellows varied widely in their perceptions of what constituted a formal investigation of a patient safety event. Across many CLEs, case conferences, morbidity and mortality conferences, and grand rounds continued to be the major approach to patient safety event investigations.Faculty members and program directors indicated that departmental mortality conferences, case conferences, and online modules were other informal approaches to model elements of a patient safety event investigation.In the group interviews, 66.0% of the residents and fellows indicated that they had received training on disclosing medical errors to patients and/or families (4.5% reported that such training was not applicable). Responses varied by year of training. Across CLEs, the median (IQR) finding was 68.2% (57.1%–79.3%), with responses varying by region and CLE bed size. Of those who received training, 10.1% indicated that the training was primarily simulation based; 69.8%, didactic and/or online; 15.1%, informal; and 5.0%, other.Approximately 82% of the residents and fellows in the group interviews indicated that they knew of CLE resources to assist them in coping with a major patient safety event that resulted in a patient death (median [IQR], 85.8% [74.7%–93.0%] across CLEs; see Appendix B6 for information on variability). Of those familiar with the resources, most indicated that they would be somewhat (39.8%) or very comfortable (44.7%) in using these resources.The CLER Program explored resident and fellow engagement in improving health care quality within the context of 6 major areas: involvement in developing and implementing the CLE's strategies for health care quality, awareness of the CLE's health care quality priorities, knowledge of health care quality terminology and methods, engagement in quality improvement (QI) projects, access to quality metrics data, and engagement in CLE efforts to address health care disparities.As part of understanding the CLE's approach to improving health care quality, the CLER Site Visit teams reviewed the organization's strategic plan for quality and interviewed both executive and patient safety and quality leaders. Overall, a limited number of CLEs appeared to integrate QI within the organization as part of a system-wide, comprehensive approach to promote experiential learning and to improve quality and safety across the organization.Across CLEs, resident and fellow involvement in strategic planning for QI was uncommon. Residents and fellows often served as implementers of CLE-wide QI activities (eg, hand hygiene, reducing hospital-acquired infections, reducing 30-day readmissions).A limited number of CLEs had instituted resident and fellow committees aimed at increasing resident and fellow engagement in QI; few of these committees were integrated into the CLE's formal QI processes. In many CLEs, resident and fellow participation in institutional QI committees was uncommon; often, roles and expectations for participation were undefined or unclear. The clinical sites also appeared to have insufficient structure to allow residents and fellows to attend committee meetings regularly and to participate in meaningful ways. Additionally, residents and fellows in many CLEs were not included in the governing body's patient safety and quality committees.In general, priorities for improving health care quality varied across CLEs. However, some common themes included alignment with broad national priorities such as Centers for Medicare & Medicaid Services value-based purchasing, Core Measures, or publicly reported performance measures. Many were also highly focused on meeting specific criteria such as reducing 30-day readmissions or improving performance on metrics related to pneumonia, chronic heart failure, and surgical care improvement project measures.In the group interviews, 78.8% of the residents and fellows (PGY-2 and above) reported knowing their CLE's priorities for improving health care quality (see Appendix B7 for additional information on variability). When asked the same question, 84.4% of the faculty members and 86.7% of the program directors reported knowing the priorities. Often, the physician groups focused on departmental activities and did not describe priorities that aligned with those identified by the CLE's executive leadership or the patient safety and quality leaders. When the physicians identified priorities aligned with those of executive leadership, they were most commonly around nationally recognized measures, especially those related to programs with financial incentives such as measures from the Centers for Medicare & Medicaid Services.In 55.1% of the CLEs, the residents and fellows appeared to have limited knowledge or understanding of basic QI terminology and methods such as Lean, Plan-Do-Study-Act, and Six Sigma (FIGURE 4, see also Appendix C5). A limited number of residents and fellows could articulate the QI approach employed by their CLE in designing and implementing QI activities to improve patient care.In general, the approach to educating residents and fellows about health care QI varied both within and between CLEs. Although some type of education was common as part of new resident and fellow orientation, a limited number of CLEs aimed to provide ongoing training for all residents and in health care QI appeared to primarily within or medical education programs, and the methods, and appeared to of the CLEs, the patient safety and quality leaders indicated that they resident and fellow QI the group interviews with residents and fellows (PGY-2 and reported they had participated in a QI project of their design, or by their program or Of this reported that their QI project was to 1 or more of the CLE's 23.3% were Of those who reported their QI were to the CLE's reported their involved interprofessional Appendices and provide detailed information on the group interviews and on walking rounds, the CLER teams asked residents and fellows to describe their QI Overall, residents and fellows varied in their of these It was uncommon for residents and fellows to describe that aligned with their CLE's priorities. In most CLEs few described that included the components of a QI (ie, (FIGURE see also Appendix Often, resident and fellow participation was limited to planning and implementing a QI For many residents and fellows, their QI did not formally and designing actions to and ongoing QI was also uncommon for residents and fellows to describe involvement in interprofessional QI During the interviews on walking rounds, a limited number of nurses and other health care professionals indicated that they were involved in interprofessional QI that included residents and the CLER teams faculty members in the group interviews about their engagement in interprofessional QI projects, 72.7% reported that they had participated in a QI project with nurses, pharmacists, and other members of the health care team (median [IQR], across the group interviews, of the program directors reported that their residents and fellows have access to for and data for the of health clinical and or national quality were often reported as common of QI data. Residents and fellows often mentioned the (eg, in specific reports from these data Many faculty members noted that residents and fellows had limited for data When it was often a departmental The type and of to residents and fellows varied both within and across of the residents and fellows in the group interviews reported receiving aggregated or QI data on their Responses varied by gender, year of training, and specialty grouping. Across CLEs, the median (IQR) finding was with responses varying by region, CLE bed size, and type of ownership (FIGURE see also Appendix the patient safety and quality leaders indicated that residents and fellows receive QI data to the care of their patients with others served by their clinical many CLEs, executive leaders were aware of of health their Many described to improve access to care and or care and for the often by residents and fellows from a few core (eg, and A limited number of residents and fellows from other specialty and programs reported in these limited number of executive leaders to health care within their or medical Overall, less than of executive leaders described a specific set of strategies or a approach to and in the care provided to or the clinical of their patient at for health care In approximately of the CLEs, the executive faculty members, or program directors indicated that some were data or related to health care specific patient many of these efforts were reported as the group interviews, 55.1% of the residents and fellows reported that they knew their CLE's priorities in addressing in health responses varied by year of training and specialty grouping. Across CLEs, this finding ranged from to (median [IQR], Responses varied by region, CLE bed size, and type of ownership (see Appendix In of the faculty members and of the program directors reported that they knew their CLE's priorities with to health care residents, fellows, faculty members, and program directors interviewed in the group interviews were able to describe at for health care at their clinical the group interviews, of the residents and fellows reported that they had received training that was specific to at for health care at their clinical reported receiving training that was not specific to the CLE's patient reported receiving training that was primarily informal while clinical and indicated that they had not received training at their CLEs, a median (IQR) of of the residents and fellows indicated that they had received training that was specific to at for health care at their clinical site. Responses varied by region, CLE bed size, and type of ownership (FIGURE see also Appendix interviews on walking rounds, many residents and fellows described education and training in that was and not specific to the

The electronic health record: An essential tool for advancing patient safety

The Overarching Themes From the CLER National Report of Findings 2018.

To audit written medical discharge summary procedure and practice against Standard Six (clinical handover) of the Australian National Safety and Quality Health Service Standards at a major regional Victorian health service. Department heads were invited to complete a questionnaire about departmental discharge summary practices. Twenty-seven (82%) department heads completed the questionnaire. Seven (26%) departments had a documented discharge summary procedure. Fourteen (52%) departments monitored discharge summary completion and 13 (48%) departments monitored the timeliness of completion. Seven (26%) departments informed the patient of the content of the discharge summary and six (22%) departments provided the patient with a copy. Seven (26%) departments provided training for staff members on how to complete discharge summaries. Completing discharge summaries was usually delegated to the medical intern. The introduction of the National Service Standards prompted an organisation-wide audit of discharge summary practices against the external criterion. There was substantial variation in the organisation's practices. The Standards and the current audit results highlight an opportunity for the organisation to enhance and standardise discharge summary practices and improve communication with general practice.

To evaluate whether implementing the Comprehensive Assessment and Risk Evaluation (CARE) record, developed to operationalise Standard 5: Comprehensive Care of the Australian National Safety and Quality Health Service Standards was associated with improvements in patient safety and quality of care. A secondary objective was to explore staff and patient experiences of implementation. Mixed-methods pre-post evaluation combining quantitative analysis of routinely collected hospital data with staff surveys and patient interviews. A metropolitan hospital network in Melbourne, Victoria, Australia PARTICIPANTS: Quantitative analysis included 88 041 admissions pre-implementation and 23 765 post implementation. Staff surveys were completed by 117 staff (84% nurses, 60% with >5 years at the service). Structured interviews were conducted with 39 patients (mean age 65.6 years, 64% male). The CARE record was a structured record embedding validated risk assessments (STRATIFY, Braden Scale, Malnutrition Screening Tool, Confusion Assessment Method/4 'A's Test, Broset Violence Checklist, Columbia-Suicide Severity Rating Scale) and care planning into routine workflows, to meet requirements of Standard 5. Primary outcomes were the incidence of falls and pressure injuries. Secondary outcomes were completion of the CARE record, staff and patient experiences, and documentation of other hospital-acquired complications (HACs) (delirium, malnutrition, violence and aggression, suicide and self-harm). Data were compared for two time periods: 1 January 2016 to 28 February 2019 (before CARE record implementation) and 1 March 2019 to 30 March 2020 (after CARE record implementation but before COVID-19). Post implementation, overall falls decreased (OR 0.85; 95% CI 0.78 to 0.93), though severe falls increased (OR 1.89; 95% CI 1.17 to 3.07). Pressure injuries decreased in coded data (OR 0.41; 95% CI 0.23 to 0.73) and incident reports (OR 0.79; 95% CI 0.68 to 0.92). Documentation of delirium (OR 2.02), malnutrition (OR 2.03), aggression/violence (OR 2.09) and suicide/self-harm (OR 1.92) increased. Half of the staff (50.4%) felt they knew more about patients, but 61.2% reported more time to admit patients. Communication between nursing and allied health improved (65.8%). Patients were generally satisfied, though 50% repeated information frequently and 20% felt unprepared for discharge. CARE record implementation, mandated by the Australian Commission on Safety and Quality in Health Care's Standard 5, was associated with fewer pressure injuries and overall falls (though there was an increase in falls resulting in serious injury), and greater documentation of other complications. Staff and patient experiences highlighted some benefits but also documentation time challenges. Findings provide lessons for the national implementation of Standard 5 and the need to balance structured processes with clinical judgement.

Patient Safety Organizations Ready for Action

Research Aim: In response to the noted rationale, this structured literature review sought to investigate the impact of the SBAR communication and handover tool when used by nurses upon patient safety outcomes. Background: In nursing practice, effective communication is the most primitive and fundamental trait that has direct influence over the provision of care and thus, care quality and patient safety. Indeed, a wider range of evidence and serious case reviews have shown that deficits in communication and clinical handover can lead to patient harm and even death and thus, utilising tools to optimise communication quality and sufficiency represents an opportunity to prevent such adverse outcomes. The Situation, Background, Assessment and Recommendations (SBAR) framework is one of the most common communication tools used in nursing practice but little is known about its specific direct impact upon measures of patient safety. Thus, there is a need to address this important knowledge gap to help inform current and future nursing communication and handover practices. Methods: A structured literature review was designed using the PRISMA criteria for systematic reviews to enhance credibility. A search for literature relevant to the research aim was undertaken in February 2021 using the databases of MEDLINE, CINAHL, EMBASE and Google Scholar. Search terms were constructed using the research question, modified with syntax and combined with Boolean logic to optimise search precision. Articles eligible for review were restricted to English language, peer-review and publication since the year 2010. All studies were appraised using the principles of CASP and data was analysed via narrative synthesis due to limited homogeneity across studies that precluded meta-analysis. Results/Discussion: A total of 12 studies were eligible for review, which comprised eight quasi-experimental before-and-after studies, three cohort studies and one randomised controlled trial. The overall risk of bias was moderate to high for most studies given the detection of issues associated with non-response, recall, confounding and outcome ascertainment biases. Applicability to the UK context also varied due to issues of sample size and representativeness. Narrative synthesis revealed that the use of SBAR by nurses to guide inter-professional communication and clinical handover was consistently positive in optimising patient safety when compared to non-structured communication controls or baseline. Specific improvements in safety outcomes included: reductions in the number of care omissions, the incidence of near-miss and patient safety events, falls, adverse drug events, restraint use and nosocomial infections and even mortality. Moreover, some studies explored the impact of SBAR upon indirect patient safety measures, which included perceptions that the tool optimised patient safety, as well as inducing improvements to care quality and culture through enhancing communication and documentation quality and sufficiency. These findings were supported by the wider literature and this derived some key implications for nursing practice and handover guidelines. Conclusion: Overall, this review that was based on the most relevant and best available evidence showed that SBAR can be used to enhance patient safety within varied health contexts and for patients of differing age groups. It is strongly recommended that SBAR is employed with routine nursing practice to guide inter-professional communication and handover, although this may require supplementation with more extensive information exchange in situations of clinical complexity. Moreover, it is important that the current NICE guidelines for structured handover better emphasise the value of SBAR in optimising communication and in reducing the risk of communication errors that can compromise patient safety. Through wider adoption and use of SBAR, it is hoped that the findings of this review will promote marked improvements in patient safety across national and international health systems. Future research, that can account for biases detected among the current evidence, is needed to re-explore the value of SBAR upon patient safety such to validate the findings herein. Key Words: Handover tool, SBAR, Communication errors, ISBAR, Adverse outcomes and Patient safety.

Communication is a way in which humans make sense of the world around them. Communication takes place as an interactive two-way process or interaction, involving two or more people and can occur by nonverbal, verbal, face-to-face or non-face-to-face methods. Effective communication is described to occur when the sender of a message sends their message in a way that conveys the intent of their message and then is understood by the receiver of the message. As a result of the communication from both the sender and the receiver of the message a shared meaning is created between both parties.Communication can therefore be viewed as a reciprocal process. In the health care literature the terms communication and interaction are used interchangeably.Communication failures between clinicians are the most common primary cause of errors and adverse events in health care. Communication is a significant factor in patient satisfaction and complaints about care. Communication plays an integral role in service quality in all service professions including health care professions.Within healthcare, quality care has been defined by the Institute of Medicine as 'care that is safe, effective, timely, efficient, equitable and patient-centred'. Patient-centered care is defined as 'care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient's values guide all clinical decisions. Patient centered-care encompasses the 'individual experiences of a patient, the clinical service, the organizational and the regulatory levels of health care'. At the individual patient level, patient-centered care is care that is 'provided in a respectful manner, assures open and ongoing sharing of useful information in an ongoing manner and supports and encourages the participation of patients and their families'. Healthcare organizations that are patient-centered engage patients as partners and hold human interactions as a pillar of their service.The deepening evidence base for principles and practice of patient-centered care has resulted in increasing recognition of, and greater focus on, the engagement of patients, and the value and benefit of patient engagement. Contemporary healthcare policy across the globe increasingly supports the engagement of patients as partners in all aspects of their own health care and also in systemic quality improvement. In 2005, the World Health Organization's (WHO) World Alliance for Patient Safety established the Patients for Patient Safety program, to improve patient safety globally in collaboration with patient advocates across the world. As a global initiative, Patients for Patient Safety 'believes that safety will be improved if patients are placed at the center of care and included as full partners'.In 2011 the United States of America Department of Health and Human Services announced its commitment of one billion US dollars of federal funding under The Patient Protection and Affordable Care Act 2010 and launched the Partnership for Patients initiative. The Partnership for Patients public-private consortium, which focuses on patient safety improvements and draws membership from federal government agencies and over 8000 health care providing organizations and individuals, views patients 'as essential partners in improving safety and quality' and 'their participation as active members of their own healthcare team is an essential component of making healthcare safer and reducing readmission'.In Australia, as part of national health care reforms to improve access to care, the efficiency of care and public transparency of the performance and funding of health services, the Australian Health Ministers endorsed the 10 National Safety and Quality Health Service Standards (NSQHSS) in 2011 and the Australian Safety and Quality Goals for Health Care (The Goals) in 2012. The NSQHSS focus on partnerships with health consumers in their own care and treatment and also in health service planning, the design of care and service monitoring and evaluation. Standard 1 - Governance for Safety and Quality, and Standard 2 - Partnering with Consumers, are required to be integrated within all of the other eight Standards.With patient safety and quality being core to the delivery of care the Safety of Care, Appropriateness of Care and Partnering with Consumers goals have been identified as the three areas that will make up the goals over the next five years until 2017. The Australian Commission on Safety and Quality in Health Care, in providing further justification for the focus on these three areas, states:The third priority area of The Goals, Partnering with Consumers, reflects patient-centered care practice by ensuring 'that there are effective partnerships between consumers and healthcare providers and organizations at all levels of healthcare provision, planning and evaluation'. Specifically, 'Consumers and healthcare providers understand each other when communicating about care and treatment and health care organizations are health literate organizations''.As healthcare focuses on providing services that are patient-centered and methods to ensure this occurs, patients' voice and experience of health care provision is increasingly being sought from an organizational quality improvement perspective. Patients are being surveyed on their healthcare experience across interpersonal areas such as being provided the opportunity by their health professional to ask questions, the level of involvement in their own care and whether they were shown courtesy, treated with respect and listened to carefully by their health professional.Surveys of patients' satisfaction with their care are now being superseded by surveys of patient experiences of care. However, current methods used to collect and use information from patients about their care is often retrospective, provides inadequate real time data and is not effective in creating action to produce change at the individual patient level. Methods which focus on including the patient and their information in real-time are considered by many to be crucial to the advancement of improved health outcomes and the reduced costs that are required of health care to be sustainable. One such method is patient-centered communication.The nurse-patient interaction is a core component of nursing science and high quality nursing care. Fleisher et al. contend that 'the main intention of communication and interaction, in the health setting, is to influence the patient's health status or state of well-being'. As a profession, nursing predominately requires communicating with, and relating to, patients at the individual level. In the hospital setting nurses undertake many of their patient related duties in a face-to-face manner with the patient at the bedside and these moments can facilitate effective interaction to occur between the nurse and the patient, which is patient-centered. McCabe et al. state that patient-centered communication as "defined by Langewitz et al. as 'communication that invites and encourages the patient to participate and negotiate in decision-making regarding their own care'.''However, qualitative studies by McCabe and Wellard et al, highlighted that nurses interact with patients only when performing administrative or functional activities and nursing 'practice was predominately task-orientated'. The outcome of these studies are supported by Maurer et al. in their report on the tools and strategies available to support patient and family engagement in the hospital setting. Maurer et al. identified that current strategies 'are not attuned to patient and family member experiences of hospitalization' and that most tools and strategies were 'more reflective of health professional and hospital views and the organization of their work'. The report identified a gap in the initiation of engagement, which is not driven by the patients and families' needs and preferences as they occur but by the 'opportunities that the hospital makes available'.McCabe et al. also argue that nurses' attending behavior, that is their 'accessibility and readiness to listen to patients through the use of non-verbal communication' requires that they have the underpinning elements of 'genuineness, warmth and empathy' all of which are components of patient-centered communication. McCabe et al. observed that 'that nurses do not always communicate in a patient-centered way'.According to Fleischer et al. 'The listening behavior in the way of listening and asking actually is the beginning of the nurse-patient communication relationship' McCabe et al. state that the lack of recognition and support by healthcare organizations of the connection and subsequent importance of patient-centered communication in the provision of high quality care has promulgated a culture averse to patient centered communication and is a significant factor in reducing the value that nurses place on providing patient-centered communication to patients.It is apparent that tensions exist between service quality and patient-centered care principles and practice. The impact of this tension on care and the patient as an individual is reflected in the literature. McCabe et al. claim that the use of non-patient-centered types of communication can negatively affect a patient's sense of well-being and security. Horvey et al. detail patient and family member experiences of not being listened to by their health care providers and describe the resulting consequences to be as severe as the death of the patient during their hospital stay. (ABSTRACT TRUNCATED)

Hospitals recently have experienced greater financial pressures. Whether these financial pressures have led to more patient safety problems is unknown. Using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Data for Florida from 1996 to 2000, this study examines whether financial pressure at hospitals is associated with increases in the rate of patient safety events (e.g., medical errors) for major surgeries. Findings show that patients have significantly higher odds of having adverse patient safety events (nursing-related patient safety events, surgery-related patient safety events, and all likely preventable patient safety events) when hospital profit margins decline over time. The finding that a within-hospital erosion of hospital operating profits increases the rate of adverse patient safety events suggests that any cost-cutting efforts be carefully designed and managed.

BackgroundProblems with achieving the continuum of medicines management are long‐standing. Audits are valuable in improving medication management and the quality and safety of healthcare systems.AimTo evaluate the accuracy and timeliness of electronic discharge summaries (EDS) provided to patients and their primary care providers at discharge. This was a forerunner to the study hospital's National Accreditation Examination and for routine safety and quality evaluation.MethodsThis study was a retrospective audit using an adaptation of the NSW indicator 5.3, ‘Percentage of discharge summaries that include medication therapy changes and explanations for changes’ (National quality use of medicines indicators for Australian Hospitals. ACSQHC, Sydney, NSW, 2014). The additions to the NSW tool included: assessing the completion and timeliness of delivery to primary health care providers, and the accuracy of the information.ResultsIn patients leaving hospital, 75% had a hospital EDS completed, with 46% completed within the recommended 48 h from discharge. For an EDS to be delivered, a primary healthcare provider must be nominated by the patient. This occurred in 53% of our sample. Accuracy of information on what medicines patients should use post‐discharge was also assessed. It indicated 46% accuracy, with the majority of errors being omissions of required medicines. None of the EDSs included documented reasons for changes to medicines, in the provided table, to the primary healthcare provider. In patients on a short‐term therapy, such as antibiotics, 71% of EDSs had documented a plan for short‐term therapies to be completed in the community.ConclusionThe lack of information on the primary care provider recorded in the patient's clinical system and discharge summaries, limited the timely transfer of essential information on post‐discharge medicine management to the patient's primary care provider. Work has commenced on an educational program to improve data entry of the patient's primary care provider when they are admitted, and plans to improve compliance with the EDS policy.

BackgroundConsumer involvement in health research is when patients, their families and caregivers work with researchers on research projects. Despite the growing expectation for health services to facilitate the involvement of consumers in research, the practical integration of this approach is an ongoing process, with limited research conducted into how Australian health services can support this practice. This study explored consumer perspectives on the barriers and solutions to enabling consumer involvement in research within an Australian tertiary hospital and health service, and staff perspectives on the solutions to facilitating consumer involvement. A prior survey had identified barriers to consumer involvement from the staff perspective. The broad aim was to inform the development of a framework to help promote consumer involvement in research within the health service.MethodsA Nominal Group Technique (NGT) was utilised with groups comprised of health service consumers and staff. Three health consumers were co-researchers in the full life-cycle of this study and are included as authors.ResultsTen consumers and 14 staff participated across three sessions ranging from one to three hours. For consumers, barriers to their involvement were grouped into seven domains: (1) lack of connection with researchers/research projects, (2) low research literacy, (3) structural barriers, (4) lack of acknowledgement, (5) implementation challenges, (6) inadequate information provision, and (7) representation concerns. Solutions to enabling involvement were grouped into five domains: (1) support to connect with researchers/research projects, (2) adequate information provision, (3) incentive for involvement, (4) acknowledgement, and (5) balanced representation. Staff ideas for solutions were grouped into five domains: (1) support to connect with consumers, (2) support to involve consumers, (3) access to funds to remunerate consumers, (4) more time to involve consumers, and (5) staff training.ConclusionThrough an NGT methodology, this study delivered a nuanced comprehension of perspectives on involving consumers in research from both health service consumers and staff. These findings serve as a foundation for identifying strategies that foster enhanced and refined relationships between consumers and researchers, advancing the collaborative landscape in health research. The findings from this project offer valuable strategies for researchers to better engage consumers in research and for consumer groups to enhance their involvement. Additionally, these insights could be used by other health services to advocate for essential resources.

Patient safety event (PSE) reports are a useful lens to understand hazards and patient safety risks in healthcare systems. However, patient safety officers and analysts in healthcare systems and safety organizations are challenged to make sense of the ever-increasing volume of PSE reports, including the free-text narratives. As a result, there is a growing emphasis on applying text mining and natural language processing (NLP) approaches to assist in the processing and understanding of these narratives. Although text mining and NLP in healthcare have advanced significantly over the past decades, the utility of the resulting models, ontologies, and algorithms to analyze PSE narratives are limited given the unique difference and challenges in content and language between PSE narratives and clinical documentation. To promote the application of text mining and NLP for PSE narratives, these unique challenges must be addressed. Improving data access, developing NLP resources to practically use contributing factor taxonomies, and developing and adopting shared specifications for interoperability will help create an infrastructure and environment that unlocks the collaborative potential between patient safety, research, and machine learning communities, in the development of reproducible and generalizable methods and models to better understand and improve patient safety and patient care.

Innovation in the education and training of healthcare staff is required to support complementary approaches to learning from patient safety and everyday events in healthcare. Debriefing is a commonly used...

From the Agency for Healthcare Research and Quality, Rockville, Maryland. Correspondence: Dr Clancy is Director of the Agency for Healthcare Research and Quality, 540 Gaither Rd, Rockville, Maryland 20850 (e-mail: [email protected]).

Society Launches Quality Prescribing Campaign