Safety Lapses Research Articles

Incivility and Patient Safety: A Longitudinal Study of Rudeness, Protocol Compliance, and Adverse Events

Little is known about the impact of social interactions on iatrogenesis and lapses in patient safety. This field-based experience-sampling study of primarily nurses in a general hospital explored the impact of rudeness on patient safety performance, state depletion (that is, exhaustion of mental energy for reflective behavior), and team processes (for example, information sharing). Objective measures of performance were compliance with hand hygiene and medication preparation protocols, as well as archival reports of adverse events. Data were analyzed by department shift (480 shifts [15 days] in 16 departments). A total of 231 rudeness incidents were reported in 98 shifts, most stemming from a patient or family. Compliance with hand hygiene was significantly lower up to 24 hours after rudeness exposure (p = 0.03). Rudeness significantly increased team members' state depletion (p = 0.002) and was associated with decreased information sharing (p = 0.046) but was not directly associated with adverse events or level of compliance with medication and hand hygiene protocols. However, the adverse indirect effect of shifts' temporal proximity to rudeness on poor compliance with medication preparation and team members' information sharing via state depletion was significant. Rudeness exposure was also associated with increased rate of adverse events in the subsequent 24 hours, although this association was not statistically significant. Rudeness exposure was associated with reduced team member compliance with infection control and medication protocols via greater team member state depletion and diminished information sharing.

Safety Lapses Prior to Initiation of Hemodialysis for Acute Kidney Injury in Hospitalized Patients: A Patient Safety Initiative.

Background: Safety lapses in hospitalized patients with acute kidney injury (AKI) may lead to hemodialysis (HD) being required before renal recovery might have otherwise occurred. We sought to identify safety lapses that, if prevented, could reduce the need for unnecessary HD after AKI; Methods: We conducted a retrospective observational study that included consecutive patients treated with HD for AKI at a large, tertiary academic center between 1 September 2015 and 31 August 2016. Exposures of interest were pre-specified iatrogenic processes that could contribute to the need for HD after AKI, such as nephrotoxic medication or potassium supplement administration. Other outcomes included time from AKI diagnosis to initial management steps, including Nephrology referral; Results: After screening 344 charts, 80 patients were included for full chart review, and 264 were excluded because they required HD within 72 h of admission, were deemed to have progression to end-stage kidney disease (ESKD), or required other renal replacement therapy (RRT) modalities in critical care settings such as continuous renal replacement therapy (CRRT) or sustained low efficiency dialysis (SLED). Multiple safety lapses were identified. Sixteen patients (20%) received an angiotensin converting enzyme inhibitor or angiotensin receptor blocker after AKI onset. Of 35 patients with an eventual diagnosis of pre-renal AKI due to hypovolemia, only 29 (83%) received a fluid bolus within 24 h. For 28 patients with hyperkalemia as an indication for starting HD, six (21%) had received a medication associated with hyperkalemia and 13 (46%) did not have a low potassium diet ordered. Nephrology consultation occurred after a median (IQR) time after AKI onset of 3.0 (1.0–5.7) days; Conclusions: Although the majority of patients had multiple indications for the initiation of HD for AKI, we identified many safety lapses related to the diagnosis and management of patients with AKI. We cannot conclude that HD initiation was avoidable, but, improving safety lapses may delay the need for HD initiation, thereby allowing more time for renal recovery. Thus, development of automated processes not only to identify AKI at an early stage but also to guide appropriate AKI management may improve renal recovery rates.

Community Health and Employee Work Performance in the American Manufacturing Environment

Although better community health has long been assumed to be good for local businesses, evidence demonstrating the relationship between community health and employee performance is quite limited. Drawing on human resources data on 6103 employees from four large US manufacturing plants, we found that employees living in counties with poor community health outcomes had considerably higher rates of absenteeism and tardiness (ABT). For example, in one company, employees living in communities with high rates of children on free or reduced lunch had higher rates of ABT compared to other employees [adjusted odds ratio (OR) 2.76, 95% confidence interval (CI) 2.52–3.04], and employees living in communities with high rates of drug overdose deaths had higher rates of ABT (OR 1.51, 95% CI 1.29–1.77). In one plant, the annual value of lost wages due to ABT was over $1.3 million per year. Employees reported that poor community health (e.g., poverty, caregiving burdens, family dysfunction, drug use) resulted in “mental stress” leading to distraction, poor job performance, and more rarely, lapses in safety. These findings bolster the case for greater private sector investment in community health.

A Framework for Managing Team Processes in Healthcare Delivery

Relevant to the conference theme, we explore team processes in this symposium proposal to improve patient well-being. Specifically, interactions among team members play a fundamental role in the delivery of healthcare services. An understanding of interactions in critical events (Klein et al., 2006), such as medical trauma teams, which tend to be task-focused, will provide relevant and pragmatic insights to improving communications. Although patients are increasingly participating in their own care, including them in team- based care is fraught with ethical tensions in terms of respect for patient autonomy, beneficence, and justice. We explore ways in which healthcare providers can balance these principles to shape the information they convey to patients and improve shared decision making. In addition to the importance of communication in patient safety, coordination among team members to complete tasks is another important dynamic in team process. Coordination is most challenged in multidisciplinary ad hoc medical teams that involve individuals from different disciplines with fluid memberships. We discuss a conceptual framework of coordination for multidisciplinary ad hoc teams that face different task requirements and situational demands. Finally, as healthcare becomes more specialized, resulting in more inter-disciplinary handoffs in patient transfers where different units require different information with differing levels of fidelity, handoffs have become a high-risk factor for lapses in patient safety. We explore the use of Machine Learning (ML) to understand the factors that make electronic handoff systems (in)effective clinical tools for team-based inpatient care. We conclude with theoretical and practical suggestions to better manage teams. Does being nice matter in a crisis? Civility during trauma team activations Presenter: Sandy Lim; National U. of Singapore Presenter: Jeremy Choon Peng We; Singapore General Hospital Presenter: Ting Hway Wong; Singapore General Hospital Presenter: Seo Kiat Goh; Singapore General Hospital Presenter: Yew Kwan Tong; National U. of Singapore Presenter: Jeremy Chung Fai Ng; Singapore General Hospital Presenter: Marcus Eng Hock Ong; Singapore General Hospital Social Preferences in Healthcare Dilemmas Presenter: Sebastiano Massaro; U. of Warwick Improving Coordination in Ad hoc Multidisciplinary Hospital Teams Presenter: Soo-Hoon Lee; Old Dominion U. Predicting Safe Clinical Handoffs Using Machine Learning Presenter: Phillip Phan; Johns Hopkins U.

Samuel W. Buell, Capital Offenses: Business Crime and Punishment in America's Corporate Age.

We live in an age of extraordinary corporate power and frequent corporate scandals: malfeasance at American defense contractors, savings and loans, and health-care companies in the 1980s and 1990s; grossly manipulated financial statements at major companies in the 1990s and early 2000s; blatant schemes of tax evasion in the same decades, conjured up by leading law and accounting firms; major safety lapses at Toyota, General Motors, and British Petroleum; rampant bribery of foreign officials by Siemens; and widespread deceptions/manipulations associated with the securitized mortgage markets, emissions standards by automakers such as Volkswagen, the setting of interbank interest rates, and the creation of unauthorized accounts at Wells Fargo.

Perspective of Nurses toward the Patient Safety Culture in Neonatal Intensive Care Units

Background: Infants hospitalized in neonatal intensive care units (NICUs) are often severely ill, highly prone to various diseases, and exposed to complex and prolonged intensive care interventions. Consequently, they are susceptible to the lapses in teamwork and patient safety. Patient safety culture a fundamental step to improve patient safety. The present study aimed to evaluate the perspective of NICU nurses toward the patient safety culture. Methods: This cross-sectional study was conducted in 2016. Participants were selected via census sampling, including 156 nurses working in the NICU of the teaching hospitals affiliated to Isfahan University of Medical Sciences in Isfahan, Iran. Data were collected using a demographic questionnaire and Hospital Survey on Patient Safety Culture (HSOPSC). Data analysis was performed in SPSS version 16 (SPSS Inc, Chicago, IL, USA) using descriptive statistics (mean and standard deviation). Results: Among the 12 dimensions of the patient safety culture, the highest scores were observed in the ‘teamwork within units’ (98.5%),’organizational learning-continuous development’ (87.8%), ‘feedback and communication about errors’ (80.3%), and ‘frequency of events reported’ (78.8%). The lowest scores belonged to the dimensions of ‘handoffs and transitions’ (15.3%), ‘non-punitive response to error’ (21.5%), and ‘staffing’ (37.1%). Conclusion: According to the results, adherence to the dimensions of the patient safety culture was poor in the studied hospitals. Therefore, the patient safety culture requires special attention by providing proper facilities, adequate staff, developing checklists for handoffs and transitions, and surveillance and continuous monitoring by healthcare centers. Furthermore, a system-based approach should be implemented to deal with errors, while a persuasive reporting approach is needed to promote the patient safety culture in the NICUs of these hospitals.

Laboratory-acquired infections of Salmonella enterica serotype Typhi in South Africa: phenotypic and genotypic analysis of isolates

BackgroundWorkers in clinical microbiology laboratories are exposed to a variety of pathogenic microorganisms. Salmonella species is among the most commonly reported bacterial causes of laboratory-acquired infections. We report on three cases of laboratory-acquired Salmonella enterica serotype Typhi (Salmonella Typhi) infection which occurred over the period 2012 to 2016 in South Africa.MethodsLaboratory investigation included phenotypic and genotypic characterization of isolates. Phenotypic analysis included standard microbiological identification techniques, serotyping and antimicrobial susceptibility testing. Genotypic analysis included the molecular subtyping methodologies of pulsed-field gel electrophoresis analysis, multilocus sequence typing and whole-genome sequencing (WGS); with WGS data analysis including phylogenetic analysis based upon comparison of single nucleotide polymorphism profiles of isolates.ResultsAll cases of laboratory-acquired infection were most likely the result of lapses in good laboratory practice and laboratory safety. The following critical issues were highlighted. There was misdiagnosis and misreporting of Salmonella Typhi as nontyphoidal Salmonella by a diagnostic laboratory, with associated public health implications. We highlight issues concerning the importance of accurate fluoroquinolone susceptibility testing and interpretation of results according to updated guidelines. We describe potential shortcomings of a single disk susceptibility screening test for fluoroquinolone susceptibility and suggest that confirmatory minimum inhibitory concentration testing should always be performed in cases of invasive Salmonella infections. These antimicrobial susceptibility testing issues resulted in inappropriate ciprofloxacin therapy which may have been responsible for failure in clearance of pathogen from patients. Salmonella Typhi capsular polysaccharide vaccine was not protective in one case, possibly secondarily to a faulty vaccine.ConclusionsMolecular subtyping of isolates proved effective to investigate the genetic relatedness of isolates. Molecular subtyping data interpreted together with epidemiological data allowed us to pinpoint the most likely sources for our cases of laboratory-acquired infection.

When risks cannot be seen: Regulating uncertainty in emerging technologies

Commercializing an emerging technology that employs an immature production process can be challenging, particularly when there are many different sources of uncertainty. In industries with stringent safety requirements, regulatory interventions that ensure safety while maintaining incentives for innovation can be particularly elusive. We use the extreme case of metal additive manufacturing (an emerging technology with many sources of process uncertainty) in commercial aviation (an industry where lapses in safety can have catastrophic consequences) to unpack how the characteristics of a technology may influence the options for regulatory intervention. Based on our findings, we propose an adaptive regulatory framework in which standards are periodically revised and in which different groups of companies are regulated differently as a function of their technological capabilities. We conclude by proposing a generalizable framework for regulating emerging process-based technologies in safety-critical industries in which the optimal regulatory configuration depends on the industry structure (number of firms), the performance and safety requirements, and the sources of technological uncertainty.

Antecedents and Consequences of Medical Students' Moral Decision Making during Professionalism Dilemmas.

Medical students often experience professionalism dilemmas (which differ from ethical dilemmas) wherein students sometimes witness and/or participate in patient safety, dignity, and consent lapses. When faced with such dilemmas, students make moral decisions. If students' action (or inaction) runs counter to their perceived moral values-often due to organizational constraints or power hierarchies-they can suffer moral distress, burnout, or a desire to leave the profession. If moral transgressions are rationalized as being for the greater good, moral distress can decrease as dilemmas are experienced more frequently (habituation); if no learner benefit is seen, distress can increase with greater exposure to dilemmas (disturbance). We suggest how medical educators can support students' understandings of ethical dilemmas and facilitate their habits of enacting professionalism: by modeling appropriate resistance behaviors.

New graduate registered nurses' knowledge of patient safety and practice: A literature review.

To critically appraise available literature and summarise evidence pertaining to the patient safety knowledge and practices of new graduate registered nurses. Responsibility for patient safety should not be limited to the practice of the bedside nurses, rather the responsibility of all in the healthcare system. Previous research identified lapses in safety across the health care, more specifically with new practitioners. Understanding these gaps and what may be employed to counteract them is vital to ensuring patient safety. A focused review of research literature. The review used key terms and Boolean operators across a 5-year time frame in CINAHL, Medline, psycINFO and Google Scholar for research articles pertaining to the area of enquiry. Eighty-four articles met the inclusion criteria, 39 discarded due to irrelevant material and 45 articles were included in the literature review. This review acknowledges that nursing has different stages of knowledge and practice capabilities. A theory-practice gap for new graduate registered nurses exists, and transition to practice is a key learning period setting new nurses on the path to becoming expert practitioners. Within the literature, there was little to no acknowledgement of patient safety knowledge of the newly registered nurse. Issues raised in the 1970s remain a concern for today's new graduate registered nurses. Research has recognised several factors affecting transition from nursing student to new graduate registered nurse. These factors are leaving new practitioners open to potential errors and risking patient safety. Understanding the knowledge of a new graduate registered nurse upon entering clinical practice may assist in organisations providing appropriate clinical and theoretical support to these nurses during their transition.

The effects of power, leadership and psychological safety on resident event reporting.

Although the reporting of adverse events is a necessary first step in identifying and addressing lapses in patient safety, such events are under-reported, especially by frontline providers such as resident physicians. This study describes and tests relationships between power distance and leader inclusiveness on psychological safety and the willingness of residents to report adverse events. A total of 106 resident physicians from the departments of neurosurgery, orthopaedic surgery, emergency medicine, otolaryngology, neurology, obstetrics and gynaecology, paediatrics and general surgery in a mid-Atlantic teaching hospital were asked to complete a survey on psychological safety, perceived power distance, leader inclusiveness and intention to report adverse events. Perceived power distance (β = -0.26, standard error [SE] 0.06, 95% confidence interval [CI] -0.37 to 0.15; p < 0.001) and leader inclusiveness (β = 0.51; SE 0.07, 95% CI 0.38-0.65; p < 0.001) both significantly predicted psychological safety, which, in turn, significantly predicted intention to report adverse events (β = 0.34; SE 0.08, 95% CI 0.18-0.49; p < 0.001). Psychological safety significantly mediated the direct relationship between power distance and intention to report adverse events (indirect effect: -0.09; SE 0.02, 95% CI -0.13 to 0.04; p < 0.001). Psychological safety also significantly mediated the direct relationship between leader inclusiveness and intention to report adverse events (indirect effect: 0.17; SE 0.02, 95% CI 0.08-0.27; p = 0.001). Psychological safety was found to be a predictor of intention to report adverse events. Perceived power distance and leader inclusiveness both influenced the reporting of adverse events through the concept of psychological safety. Because adverse event reporting is shaped by relationships and culture external to the individual, it should be viewed as an organisational as much as a personal function. Supervisors and other leaders in health care should ensure that policies, procedures and leadership practices build psychological safety and minimise power distance between low- and high-status members in order to support greater reporting of adverse events.

Patient Safety Reporting: Lessons From the Blind Men and the Elephant

Keywords: editorial / personal viewpoint; organ procurement and allocation; organ transplantation in general; business / management; United Network for Organ Sharing (UNOS); quality of care / care delivery; patient safety

No Harm, No Foul, and No Hospital Readmissions

No Harm, No Foul, and No Hospital Readmissions

Burnout in Radiology

Burnout is a psychological syndrome that arises in the setting of prolonged work-related stress. Although its specific manifestations are highly variable, the core features of burnout include emotional exhaustion, callousness or apathy towards patients or peers, and feelings of personal inadequacy. Burnout can have profound consequences for the affected physician, his or her patients, and the health care system at large. Increased rates of substance abuse, depression, and suicide have been linked to physician burnout, as have medical errors and lapses in patient safety. Disruptive workplace behaviors, such as presenteeism (which is reduced productivity due to physical or emotional dysfunction), absenteeism (which is nonparticipation in work), high employment turnover, and early retirement also have been linked to physician burnout and depression. In this article, we review causes, preventive measures and possible solutions for physician burnout.

Designing highly reliable adverse-event detection systems to predict subsequent claims.

To respond proactively to patient safety events, many healthcare organizations have been enhancing and customizing their event reporting systems. Yet an indiscriminate expansion of the range and number of event reports may reduce, rather than raise, risk managers' ability to detect events that warrant a response. To avoid becoming overwhelmed by too many event reports that have little immediate operational value, risk managers therefore require a concurrent and complementary refinement of their data-processing capabilities. To examine the extent to which adverse event reports can predict subsequent claims. The study sample included all adverse event reports and all records of closed claims that related to patient care episodes between July 1, 2006, and May 31, 2009, at a large hospital system in northern Virginia. After matching closed claims to event reports, we fitted multivariate predictive models to identify event report entries that predict future claims. During the period under study, 20 151 event reports and 94 claims were filed across the health system. We were able to match 60 claims (63.8%) to at least 1 preceding event report, implying that only 0.3% of event reports preceded a subsequent matching claim. The superior prediction model identified 90% of eventual matched claims by retaining only 20% of all event reports. Simple prediction algorithms can supplement expert judgment by screening for reports that are likely to result in a claim, thereby enabling risk managers to evaluate adverse event reports more expeditiously and to identify, and ultimately prevent, serious safety lapses more reliably.

US health agency blasted over lab safety violations

An independent committee concludes that the US Centers for Disease Control and Prevention is “on the way to losing credibility” as a result of safety lapses.

INVESTIGATION Feds cite safety lapses, mechanical failures in fatal DuPont accident in Texas

Mechanical problems and ineffective safety practices were likely factors in the chemical leak that killed four workers last month at DuPont’s complex in La Porte, Texas, federal authorities say. The U.S. Chemical Safety & Hazard Investigation Board (CSB), which investigates chemical accidents, points to problems with the vent system in the building where the release of 23,000 lb of toxic methyl mercaptan originated on Nov. 15. In addition, DuPont “did not effectively implement good safety practices” that require workers to wear air respirators and other protective equipment, CSB alleges in preliminary findings. On the basis of its internal review, DuPont says that CSB’s description of the circumstances “leading to the release of methyl mercaptan from the vent header system is the most likely scenario.” But the company adds that it “does not necessarily agree with other aspects of CSB’s statement.” According to CSB, the leak occurred after an unplanned shutdown ...

The Impact of Food Safety Incidents Across Brands: The Case of the Peter Pan Peanut Butter Recall

The effect of negative publicity on consumer demand for brands is examined in the context of recall of a peanut butter brand as a result of pathogen contamination. The recall was associated with negative impacts for the implicated brand and positive effects on the leading competitor brand. Consumers responded to the foodborne illness outbreak within three weeks. The case demonstrates that consumer response is an incentive for companies to prevent safety lapses and that the problems of one brand do not necessarily harm rivals within the category.

Safety lapses in US government labs spark debate

Head of the Centers for Disease Control and Prevention pledges ‘comprehensive, sweeping change’ after incidents involving influenza and anthrax.

Outbreak of Pseudomonas aeruginosa and Klebsiella pneumoniae bloodstream infections at an outpatient chemotherapy center

Four patients were hospitalized July 2011 with Pseudomonas aeruginosa bloodstream infection (BSI), 2 of whom also had Klebsiella pneumoniae BSI. All 4 patients had an indwelling port and received infusion services at the same outpatient oncology center. Cases were defined by blood or port cultures positive for K pneumoniae or P aeruginosa among patients receiving infusion services at the oncology clinic during July 5-20, 2011. Pulsed-field gel electrophoresis (PFGE) was performed on available isolates. Interviews with staff and onsite investigations identified lapses of infection control practices. Owing to concerns over long-standing deficits, living patients who had been seen at the clinic between January 2008 and July 2011 were notified for viral blood-borne pathogen (BBP) testing; genetic relatedness was determined by molecular testing. Fourteen cases (17%) were identified among 84 active clinic patients, 12 of which involved symptoms of a BSI. One other patient had a respiratory culture positive for P aeruginosa but died before blood cultures were obtained. Available isolates were indistinguishable by PFGE. Multiple injection safety lapses were identified, including overt syringe reuse among patients and reuse of syringes to access shared medications. Available BBP results did not demonstrate iatrogenic viral infection in 331 of 623 notified patients (53%). Improper preparation and handling of injectable medications likely caused the outbreak. Increased infection control oversight of oncology clinics is critical to prevent similar outbreaks.