Identify Patient Safety Issues Research Articles

The influence of supervisory support on clinical learning as experienced by Czech Nursing and health professional students in the context of patient safety events: A qualitative study

AimTo explore the influence of supervisory and mentoring relationships on the clinical learning experiences of Czech Nursing and health professional students in the context of patient safety events BackgroundClinical experience is integral to healthcare education, shaping skills, behaviours, values and professional identity. During clinical placements, students may encounter memorable patient safety events and experience varied reactions from mentors/supervisors/others. Some research has highlighted challenges faced by students on clinical placement. Few studies involve multiple professions, most emanating from Western Europe, the UK, the USA and Australia with little relating to central European countries such as the Czech Republic. DesignTwo stage interpretivist qualitative study based in social constructionism MethodsConvenience sample across 13 undergraduate and 18 postgraduate health professions courses. Stage 1 (2022): using SLIPPS Learning Event Recording Tool translated into Czech. 20 students’ (Midwifery=11, Nursing=1, Paramedic=1, Occupational therapy =7) submitted 21 patient safety learning event narratives. Stage 2 (2022): Focus group with 2 nursing and nine midwifery students. Phased thematic analysis involving multiple researchers. ResultsThree themes illustrate the circumstances and impact of placement mentoring/supervision experiences, conceptualised as: ‘Clinical and Emotional Companionship’, ‘Clinical and Emotional Abandonment’ and ‘Sense of agency - Professional and personal growth’. ‘Companionship’ reflected the students’ feelings of being welcomed, respected, heard, trusted and supported. Conversely ‘abandonment’ emerged from feelings of being unheard, vulnerable, humiliated, afraid, leaving students feeling abandoned, lonely and ‘useless’. Notwithstanding these conditions, students showed the ability to identify patient safety issues with agency evident in reactions such as stepping-in to try to ameliorate a situation, rather than speaking-up. Professional and personal growth was also apparent in their narratives and a conceptual diagram illustrates the students’ learning journeys in a patient safety context. ConclusionThe findings and new conceptualisations around abandonment and companionship emerging from this study expand the evidence base regarding the profound impact of clinical experience and mentorship/supervision on learning and students’ emotional wellbeing. A sense of companionship appears to play a buffering role even in challenging circumstances of involvement in or witnessing compromised patients’ safety. Allowing students a sense of belonging, to vent, grow, feel supported and safe to ask/learn - contributing to ‘emotional safety for learning’, promotes students’ behaviour that may prevent/minimize hazards or ameliorate the aftermath. However, we must not simply blame mentors/supervisors, staff, or the students themselves- they are simply part of a much larger complex environment of professional education encompassing hidden curriculums, power dynamics and professional socialisation.

What do parents think about the quality and safety of care provided by hospitals to children and young people with an intellectual disability? A qualitative study using thematic analysis.

Children with intellectual disability experience patient safety issues resulting in poor care experiences and health outcomes. This study sought to identify patient safety issues that pertain to children aged 0-16 years with intellectual disability admitted to two tertiary state-wide children's hospitals and a children's palliative care centre; to describe and understand these factors to modify the Australian Patient Safety Education Framework to meet the particular needs for children and young people with intellectual disability. Parents of children with intellectual disability from two paediatric hospitals and a palliative care unit participated in semi-structured interviews to elicit their experiences of their child's care in the context of patient safety. Thirteen interviews were conducted with parents from various backgrounds with children with intellectual, developmental and medical diagnoses. Eight themes about safety in hospital care for children and young people with intellectual disability emerged from thematic analyses: Safety is not only being safe but feeling safe; Negative dismissive attitudes compromise safety, quality and care experience; Parental roles as safety advocates involve being heard, included and empowered; Need for purposeful and planned communication and care coordination to build trust and improve care; Systems, processes and environments require adjustments to prevent patient safety events; Inequity in care due to lack of resources and skills, Need for training in disability-specific safety and quality issues and Core staff attributes: Kindness, Patience, Flexibility and Responsiveness. Parents highlighted the dilemma of being dismissed when raising concerns with staff and being required to provide care with little support. Parents also reported a lack of comprehensive care coordination services. They noted limitations within the healthcare system in accommodating reasonable adjustments for a family and child-centred context. The development of an adapted Patient Safety Education Framework for children with intellectual disability should consider ways for staff to transform attitudes and reduce bias which leads to adaptations for safer and better care. In addition, issues that apply to quality and safety for these children can be generalised to all children in the hospital. Parent advocates in the project advisory team were shown the questions to determine their appropriateness for the interviews.

Adverse events in anesthesia: Analysis of claims against anesthetists affiliated to an insurance fund in Colombia. Cross-sectional study

Introduction: Prevention, identification, analysis and reduction of adverse events (AEs) are all activities designed to increase safety of care in the clinical setting. Closed claims reviews are a strategy that allows to identify patient safety issues. This study analyzes adverse events resulting in malpractice lawsuits against anesthesiologist affiliated to an insurance fund in Colombia between 2013-2019.
 Objective: To analyze adverse events in closed medicolegal lawsuits against anesthesiologist affiliated to an insurance fund between 2013-2019.
 Methods: Cross-sectional observational study. Convenience sampling was used, including all closed claims in which anesthesiologist affiliated to an insurance fund in Colombia were sued during the observation period. Variables associated with the occurrence of AEs were analyzed.
 Results: Overall, 71 claims were analyzed, of which 33.5% were due to anesthesia-related AEs. Adverse events were found more frequently among ASA I-II patients (78.9%), and in surgical procedures (95.8%). The highest number of adverse events occurred in plastic surgery (29.6%); the event with the highest proportion was patient death (43.7%). Flaws in clinical records and failure to comply with the standards were found in a substantial number of cases.
 Conclusions: When compared with a previously published study in the same population, an increase in ethical, disciplinary and administrative claims was found, driven by events not directly related to anesthesia. Most of the anesthesia-related events occurred in the operating theater during surgical procedures in patients and procedures categorized as low risk, and most of them were preventable.

Using Systems Thinking to Identify Staff and Patient Safety Issues in Infectious Disease Simulation Scenarios

BackgroundSimulation scenarios can be used to identify staff and patient safety issues in healthcare services. MethodsA systems thinking approach was used to analyze qualitative data from five simulation reports and five interviews with facilitators and participants in a hospital setting. ResultsInfection prevention measures created delays in providing timely patient care due to altered roles for staff and constraints imposed by hospital equipment and physical structure. ConclusionsSystems thinking can be used to analyze the outcomes of simulation scenarios and may help healthcare professionals better understand and work with the affordances and constraints of their healthcare service.

Patient safety superheroes in training: using a comic book to teach patient safety to residents

ProblemMedical errors are a health burden. Residents must be aware of patient safety threats and have confidence reporting concerns. Creative modalities for teaching such content (eg, simulation) are resource intensive,...

Health Information Technology Use and Patient Safety: Study of Pharmacists in Nebraska.

This study aimed to describe the impact of 13 different health information technologies (HITs) on patient safety across pharmacy practice settings from the viewpoint of the working pharmacist. A cross-sectional mixed methods survey of all licensed practicing pharmacists in 2008 in Nebraska (n = 2195) was developed, pilot-tested and IRB approved. One-fourth responded (24.4%). A database of pharmacists’ responses to closed-ended quantitative questions and in vivo qualitative responses to open-ended questions was built. Qualitative data was coded and thematically analyzed, transformed to quantitative data and descriptive and relational statistics performed. One-third were involved in an error of any kind in the six months preceding the survey, and half observed an error or “near miss”. Most errors or near misses were attributed to workload. When asked specifically about the 13 HITs, these participants reported 3252 observations about the types of errors that were associated with each. These were reports about either error types reduced or eliminated by integration of HIT (n = 1908) or occurring in association with a specific technology’s use (n = 1344). Integration of HIT into pharmacy practice also introduced new error types such as excessive alert programming in the pharmacy computer systems clinical information support causing pharmacists to experience alert fatigue and ignore warnings or bar code scanners mismatching NDC codes of products resulting in wrong drug product identification. Continued vigilance is essential to identifying patient safety issues and implementing safety strategies specific to each HIT.

Professional and interprofessional differences in electronic health records use and recognition of safety issues in critically ill patients

ABSTRACTDuring interprofessional intensive care unit (ICU) rounds each member of the interprofessional team is responsible for gathering and interpreting information from the electronic health records (EHR) to facilitate effective team decision-making. This study was conducted to determine how each professional group reviews EHR data in preparation for rounds and their ability to identify patient safety issues. Twenty-five physicians, 29 nurses, and 20 pharmacists participated. Individual participants were given verbal and written sign-out and then asked to review a simulated record in our institution’s EHR, which contained 14 patient safety items. After reviewing the chart, subjects presented the patient and the number of safety items recognised was recorded. About 40%, 30%, and 26% of safety issues were recognised by physicians, nurses, and pharmacists, respectively (p = 0.0006) and no item recognised 100% of the time. There was little overlap between the three groups with only 50% of items predicted to be recognised 100% of the time by the team. Differential recognition was associated with marked differences in EHR use, with only 3/152 EHR screens utilised by all three groups and the majority of screens used exclusively only by one group. There were significant and non-overlapping differences in individual profession recognition of patient safety issues in the EHR. Preferential identification of safety issues by certain professional groups may be attributed to differences in EHR use. Future studies will be needed to determine if shared decision-making during rounds can improve recognition of safety issues.

Low-Fidelity Simulation to Enforce Patient Safety

BackgroundLiterature is limited regarding low-fidelity simulation related to patient safety. A low-fidelity simulation was implemented to assess prelicensure students' ability to detect patient safety issues and their perceptions of the simulation. MethodA descriptive design was used with a convenience sample of students enrolled in associate, bachelor, or accelerated bachelor degree programs. ResultsParticipants were not successful in identifying all the patient safety issues. However, they perceived themselves as being successful. Participants valued the learning experience and felt it increased their confidence in identifying patient safety issues. ConclusionsNurse educators need to examine their nursing curriculum related to how patient safety concepts are taught and reinforced throughout the curriculum.

Establishing research priorities for patient safety in emergency medicine: a multidisciplinary consensus panel.

BackgroundPatient safety in the context of emergency medicine is a relatively new field of study. To date, no broad research agenda for patient safety in emergency medicine has been established. The objective of this study was to establish patient safety-related research priorities for emergency medicine. These priorities would provide a foundation for high-quality research, important direction to both researchers and health-care funders, and an essential step in improving health-care safety and patient outcomes in the high-risk emergency department (ED) setting.MethodsA four-phase consensus procedure with a multidisciplinary expert panel was organized to identify, assess, and agree on research priorities for patient safety in emergency medicine. The 19-member panel consisted of clinicians, administrators, and researchers from adult and pediatric emergency medicine, patient safety, pharmacy, and mental health; as well as representatives from patient safety organizations. In phase 1, we developed an initial list of potential research priorities by electronically surveying a purposeful and convenience sample of patient safety experts, ED clinicians, administrators, and researchers from across North America using contact lists from multiple organizations. We used simple content analysis to remove duplication and categorize the research priorities identified by survey respondents. Our expert panel reached consensus on a final list of research priorities through an in-person meeting (phase 3) and two rounds of a modified Delphi process (phases 2 and 4).ResultsAfter phases 1 and 2, 66 unique research priorities were identified for expert panel review. At the end of phase 4, consensus was reached for 15 research priorities. These priorities represent four themes: (1) methods to identify patient safety issues (five priorities), (2) understanding human and environmental factors related to patient safety (four priorities), (3) the patient perspective (one priority), and (4) interventions for improving patient safety (five priorities).ConclusionThis study established expert, consensus-based research priorities for patient safety in emergency medicine. This framework could be used by researchers and health-care funders and represents an essential guiding step towards enhancing quality of care and patient safety in the ED.Electronic supplementary materialThe online version of this article (doi:10.1186/s12245-014-0049-9) contains supplementary material, which is available to authorized users.

The challenges in monitoring and preventing patient safety incidents for people with intellectual disabilities in NHS acute hospitals: evidence from a mixed-methods study.

BackgroundThere has been evidence in recent years that people with intellectual disabilities in acute hospitals are at risk of preventable deterioration due to failures of the healthcare services to implement the reasonable adjustments they need. The aim of this paper is to explore the challenges in monitoring and preventing patient safety incidents involving people with intellectual disabilities, to describe patient safety issues faced by patients with intellectual disabilities in NHS acute hospitals, and investigate underlying contributory factors.MethodsThis was a 21-month mixed-method study involving interviews, questionnaires, observation and monitoring of incident reports to assess the implementation of recommendations designed to improve care provided for patients with intellectual disabilities and explore the factors that compromise or promote patient safety. Six acute NHS Trusts in England took part. Data collection included: questionnaires to clinical hospital staff (n = 990); questionnaires to carers (n = 88); interviews with: hospital staff including senior managers, nurses and doctors (n = 68) and carers (n = 37); observation of in-patients with intellectual disabilities (n = 8); monitoring of incident reports (n = 272) and complaints involving people with intellectual disabilities.ResultsStaff did not always readily identify patient safety issues or report them. Incident reports focused mostly around events causing immediate or potential physical harm, such as falls. Hospitals lacked effective systems for identifying patients with intellectual disabilities within their service, making monitoring safety incidents for this group difficult.The safety issues described by the participants were mostly related to delays and omissions of care, in particular: inadequate provision of basic nursing care, misdiagnosis, delayed investigations and treatment, and non-treatment decisions and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders.ConclusionsThe events leading to avoidable harm for patients with intellectual disabilities are not always recognised as safety incidents, and may be difficult to attribute as causal to the harm suffered. Acts of omission (failure to give care) are more difficult to recognise, capture and monitor than acts of commission (giving the wrong care). In order to improve patient safety for this group, the reasonable adjustments needed by individual patients should be identified, documented and monitored.

Identifying patient safety problems during team rounds: an ethnographic study

Triggered by the 1999 Institute of Medicine report, To Err is Human, 1 patient safety has become a prominent part of the medicine culture. Hospitals and residency programmes have increased...

Evaluation of the Patient Safety Leadership Walkabout programme of a hospital in Singapore

The Patient Safety Leadership Walkabout (PSLWA) programme is a commonly employed tool in the West, in which senior leaders visit sites within the hospital that are involved in patient care to talk to healthcare staff about patient safety issues. As there is a lack of perspective regarding PSLWA in Asia, we carried out an evaluation of its effectiveness in improving the patient safety culture in Tan Tock Seng Hospital, Singapore. A mixed methods analysis approach was used to review and evaluate all documents, protocols, meeting minutes, post-walkabout surveys, action plans and verbal feedback pertaining to the walkabouts conducted from January 2005 to October 2012. A total of 321 patient safety issues were identified during the study period. Of these, 308 (96.0%) issues were resolved as of November 2012. Among the various categories of issues raised, issues related to work environment were the most common (45.2%). Of all the issues raised during the walkabouts, 72.9% were not identified through other conventional methods of error detection. With respect to the hospital's patient safety culture, 94.8% of the participants reported an increased awareness in patient safety and 90.2% expressed comfort in openly and honestly discussing patient safety issues. PSLWA serves as a good tool to uncover latent errors before actual harm reaches the patient. If properly implemented, it is an effective method for engaging leadership, identifying patient safety issues, and supporting a culture of patient safety in the hospital setting.

Using Four-Phased Unit-Based Patient Safety Walkrounds to Uncover Correctable System Flaws

A unit-based Patient Safety Leadership Walkrounds (PSWR) model was deployed in six medical/surgical units at The Children's Hospital of Philadelphia to identify patient safety issues in the clinical microsystem. Specific objectives of PSWR were to (1) provide a forum for frontline staff to freely report and discuss patient safety problems with unit local leaders, (2) improve teamwork and communication within and across units, and (3) develop a supportive environment in which staff and leaders brainstorm on potential solutions. Baseline data collection and discussion with leaders and staff from the pilot units were used to create a standard set of safety tools and questions. Through multiple Plan-Do-Study-Act cycles, safety tools and questions were refined, while the process of walkrounds in each of the six pilot units was customized. Leaders in all six pilot units indicated that PSWR helped them to uncover previously unidentified safety concerns. Top-impact areas included nurse-medical team relationship, work-flow flaws, equipment defects, staff education, and medication safety. The project engaged 149 individuals across all disciplines, including 33 physicians, and entailed 34 PSWR in its first year. Information from these pilot units initiated safety changes that spread across multiple units, with identification of hospital-wide quality and patient safety issues. For participating units, the PSWR process is a situational awareness tool that helps management periodically assess new or unresolved vulnerabilities that may affect safety and care quality on the unit. Unit-based PSWR help identify safety concerns at the microsystem level while improving communication about safety events across units and to hospital leaders in the macrosystem.

Quality and strength of patient safety climate on medical—surgical units

Describing the safety climate in hospitals is an important first step in creating work environments where safety is a priority. Yet, little is known about the patient safety climate on medical-surgical units. Study purposes were to describe quality and strength of the patient safety climate on medical-surgical units and explore hospital and unit characteristics associated with this climate. Data came from a larger organizational study to investigate hospital and unit characteristics associated with organizational, nurse, and patient outcomes. The sample for this study was 3,689 RNs on 286 medical-surgical units in 146 hospitals. Nursing workgroup and managerial commitment to safety were the two most strongly positive attributes of the patient safety climate. However, issues surrounding the balance between job duties and safety compliance and nurses' reluctance to reveal errors continue to be problematic. Nurses in Magnet hospitals were more likely to communicate about errors and participate in error-related problem solving. Nurses on smaller units and units with lower work complexity reported greater safety compliance and were more likely to communicate about and reveal errors. Nurses on smaller units also reported greater commitment to patient safety and participation in error-related problem solving. Nursing workgroup commitment to safety is a valuable resource that can be leveraged to promote a sense of personal responsibility for and shared ownership of patient safety. Managers can capitalize on this commitment by promoting a work environment in which control over nursing practice and active participation in unit decisions are encouraged and by developing channels of communication that increase staff nurse involvement in identifying patient safety issues, prioritizing unit-level safety goals, and resolving day-to-day operational problems the have the potential to jeopardize patient safety.

Engaging junior paediatric trainees in patient safety improvement projects

Aims To engage junior paediatric trainees in patient safety projects. To demonstrate that patient safety is everyone9s responsibility, leading to safer paediatric care across the Wessex Deanery. Methods Since 2009 we have been developing a training programme in patient safety for all paediatric ST1 trainees in the Wessex Deanery. This has involved a compulsory training day which includes sessions on human factors, communication, leadership and lessons learnt from industry as well as relevant NPSA alerts. Under the supervision of a regional ‘Paediatric Patient Safety Champion’ the trainees undertake a project, using PDSA cycles where appropriate. The patient safety projects are all a result of discussions about safety issues within their individual departments. The programme culminates in a regional, cross speciality patient safety conference, attended by trainees and regional leaders in patient safety from trusts in the region. Results All paediatric ST1 trainees undertook patient safety projects in 2011. Across all specialities in 2011 there were 77 poster presentations and 15 oral presentations at the patient safety conference. The paediatric projects included ‘Inefficient referrals to medical staff for babies on the postnatal ward’, ‘Weekend care plans for long term patients on paediatric wards’, ‘Safe prescribing among junior doctors for neonates and children in primary and secondary care’, ‘The reorganisation of paediatric handover’ and ‘Creation of departmental Patient Safety Information Boards’. All projects have been very well received, for example one project was invited to present at trust board with a view to rolling out the project across the trust. Conclusion Patient safety training ensures trainees are aware of their role in this very important area. Our programme empowers junior paediatric trainees to identify patient safety issues in their day-to-day work and to produce high quality patient safety improvement projects. The patient safety training and projects have led to improvements in patient care in Wessex. In addition paediatric ST19s in the region are more aware of the importance and relevance of patient safety in everyday practice.

Mainstreaming risk management education into new resident and fellow orientation.

Understanding patient safety events and causative factors is an important step in reducing preventable adverse events. The University of Michigan's Graduate Medical Education (GME) Office, Department of Risk Management (DRM), and Office of Clinical Affairs (OCA) collaborated to incorporate a video workshop as a formal introduction to patient safety during orientation for new residents and fellows. This workshop reinforced the importance of effective communication and supervision in patient safety. DRM and OCA produced a video depicting an actual, unanticipated outcome that resulted from a constellation of preventable circumstances, which allows the audience to observe communication and supervision issues that lead to a patient death. The video is followed by a discussion of the patient safety issues seen, why they occurred, and strategies for improvement. Trainee perceptions of the value of the experience were surveyed and collected using a qualitative survey. Most responders found the video workshop helpful. Trainees perceived the video and facilitated discussion as an effective way to identify patient safety issues, available resources, and the culture of patient safety at the institution. Trainee comments supported the video workshop as an effective way to highlight the importance of communication and supervision in relation to patient safety. In the future, the DRM, OCA, and GME hope to reinforce this shared vision of patient safety through combined educational efforts.

252 Polyclonal resistance to kinase inhibition in GIST: Mechanisms and therapeutic strategies

A unit-based Patient Safety Leadership Walkrounds™ (PSWR) model was deployed in six medical/surgical units at The Children’s Hospital of Philadelphia to identify patient safety issues in the clinical microsystem. Specific objectives of PSWR were to (1) provide a forum for frontline staff to freely report and discuss patient safety problems with unit local leaders, (2) improve teamwork and communication within and across units, and (3) develop a supportive environment in which staff and leaders brainstorm on potential solutions.Baseline data collection and discussion with leaders and staff from the pilot units were used to create a standard set of safety tools and questions. Through multiple Plan-Do-Study-Act cycles, safety tools and questions were refined, while the process of walkrounds in each of the six pilot units was customized.Leaders in all six pilot units indicated that PSWR helped them to uncover previously unidentified safety concerns. Top-impact areas included nurse-medical team relationship, work-flow flaws, equipment defects, staff education, and medication safety. The project engaged 149 individuals across all disciplines, including 33 physicians, and entailed 34 PSWR in its first year. Information from these pilot units initiated safety changes that spread across multiple units, with identification of hospital-wide quality and patient safety issues.For participating units, the PSWR process is a situational awareness tool that helps management periodically assess new or unresolved vulnerabilities that may affect safety and care quality on the unit. Unit-based PSWR help identify safety concerns at the microsystem level while improving communication about safety events across units and to hospital leaders in the macrosystem.

The University of Texas Medical School at Houston

The University of Texas Medical School at Houston

Quality and strength of patient safety climate on medical-surgical units

Describing the safety climate in hospitals is an important first step in creating work environments where safety is a priority. Yet, little is known about the patient safety climate on medical-surgical units. Study purposes were to describe quality and strength of the patient safety climate on medical-surgical units and explore hospital and unit characteristics associated with this climate. Data came from a larger organizational study to investigate hospital and unit characteristics associated with organizational, nurse, and patient outcomes. The sample for this study was 3,689 RNs on 286 medical-surgical units in 146 hospitals. Nursing workgroup and managerial commitment to safety were the two most strongly positive attributes of the patient safety climate. However, issues surrounding the balance between job duties and safety compliance and nurses' reluctance to reveal errors continue to be problematic. Nurses in Magnet hospitals were more likely to communicate about errors and participate in error-related problem solving. Nurses on smaller units and units with lower work complexity reported greater safety compliance and were more likely to communicate about and reveal errors. Nurses on smaller units also reported greater commitment to patient safety and participation in error-related problem solving. Nursing workgroup commitment to safety is a valuable resource that can be leveraged to promote a sense of personal responsibility for and shared ownership of patient safety. Managers can capitalize on this commitment by promoting a work environment in which control over nursing practice and active participation in unit decisions are encouraged and by developing channels of communication that increase staff nurse involvement in identifying patient safety issues, prioritizing unit-level safety goals, and resolving day-to-day operational problems the have the potential to jeopardize patient safety.

NICE/NPSA Patient Safety Pilot

NICE/NPSA Patient Safety Pilot