Patient Safety Activities Research Articles

A multicentered academic medical center experience of a simulated root cause analysis (RCA) for hematology/oncology fellows.

188 Background: Quality improvement and patient safety education is an Accreditation Council for Graduate Medical Education (ACGME) common program requirement for hematology/oncology fellowships. Specifically, the ACGME requires trainee participation in interprofessional clinical patient safety activities, such as root cause analyses. These can be challenging to incorporate into busy schedules and are intimidating to some trainees, but simulated RCAs are a novel way to assure trainees gain important patient safety skills. We report on a multicentered experience utilizing a simulated RCA educational module in an attempt to provide fellows with the tools needed to participate in a live RCA and to increase awareness of the need to analyze patient safety events. Methods: The two-hour module included a didactic session explaining the basics of an RCA including common terminology, effective chart review, and personal interviews. The fellows assessed a patient safety event of a missed coagulopathy and created an event flow map and fishbone analysis. They then formed root cause/contributing factor statements and proposed a solution. Seventeen fellows from two institutions completed pre- and post-session surveys regarding the experience. Results: There was a 47% increase in both the percentage of fellows who felt comfortable participating in live RCAs in the future, and in the number of fellows who felt comfortable with using the tools typically utilized in an RCA. 70.59% of respondents felt that as a result of the mock RCA, they were more likely to report a near miss or adverse event. Conclusions: Mock RCAs are a feasible method of incorporating ACGME-required patient safety activities into hematology/oncology fellow education and are effective in increasing their comfort and understanding of important quality improvement skills

Urology Resident Involvement in Patient Safety and Quality Improvement Activities.

To assess current urology resident engagement in patient safety and quality improvement (PSQI) and how to improve resident involvement in PSQI. Overall urology resident participation in PSQI is low, especially when compared to other non-surgical residency programs. Multiple methods have been successfully implemented to increase resident participation in PSQI. Patient safety and quality improvement are extremely important to the progression of both urology and the healthcare community. True and meaningful participation in PSQI is lacking for many urology residents. However, there are easily adopted methods to improve resident involvement in this area of healthcare. These methods include direct communication and access between residents and hospital PSQI boards, resident-led safety councils, monetary incentives, formal training, and PSQI resident support teams.

Hand Hygiene in the Era of Big Data: We Can Now See What We Have Been Missing

Background: Hand hygiene (HH) has long been a focus in the prevention of healthcare-associated infections. The limitations of direct observation, including small sample size (often 20–100 observations per month) and the Hawthorne effect, have cast doubt on the accuracy of reported compliance rates. As a result, hospitals are exploring the use of automated HH monitoring systems (AHHMS) to overcome the limitations of direct observation and to provide a more robust and realistic estimation of HH behaviors. Methods: Data analyzed in this study were captured utilizing a group-based AHHMS installed in a number of North American hospitals. Emergency departments, overflow units, and units with <1 year of data were excluded from the study. The final analysis included data from 58 inpatient units in 10 hospitals. Alcohol-based hand rub and soap dispenses HH events (HHEs) and room entries and exits (HH opportunities (HHOs) were used to calculate unit-level compliance rates. Statistical analysis was performed on the annual number of dispenses and opportunities using a mixed effects Poisson regression with random effects for facility, unit, and year, and fixed effects for unit type. Interactions were not included in the model based on interaction plots and significance tests. Poisson assumptions were verified with Pearson residual plots. Results: Over the study period, 222.7 million HHOs and 99 million HHEs were captured in the data set. There were an average of 18.7 beds per unit. The average number of HHOs per unit per day was 3,528, and the average number of HHEs per unit per day was 1,572. The overall median compliance rate was 35.2 (95% CI, 31.5%–39.3%). Unit-to-unit comparisons revealed some significant differences: compliance rates for medical-surgical units were 12.6% higher than for intensive care units (P < .0001). Conclusions: This is the largest HH data set ever reported. The results illustrate the magnitude of HHOs captured (3,528 per unit per day) by an AHHMS compared to that possible through direct observation. It has been previously suggested that direct observation samples between 0.5% to 1.7% of all HHOs. In healthcare, it is unprecedented for a patient safety activity that occurs as frequently as HH to not be accurately monitored and reported, especially with HH compliance as low as it is in this multiyear, multicenter study. Furthermore, hospitals relying on direct observation alone are likely insufficiently allocating and deploying valuable resources for improvement efforts based on the scant information obtained. AHHMSs have the potential to introduce a new era in HH improvement.Funding: GOJO Industries, Inc., provided support for this study.Disclosures: Lori D. Moore and James W. Arbogast report salary from GOJO.

The Influence of Patient Safety Culture and Patient Safety Error Experience on Safety Nursing Activities of Emergency Nurses in South Korea

IntroductionThe unique nature of the space and environment of emergency departments is a threat to patient safety. Enhancing patient safety and minimizing safety-related issues are important tasks for ED health care staff. The purpose of this study was to examine the relationships among patient safety culture, patient safety error, and safety nursing activities of emergency nurses in South Korea. MethodsA convenience sample of 200 emergency nurses working in 12 general hospitals in South Korea were surveyed for safety nursing activities using the Hospital Survey of Patients’ Safety Culture, a 4-item questionnaire for patient safety error and ED safety management items in the Guidelines for Patient Safety (seventh revision). ResultsHierarchical regression analysis revealed that the potential factors associated with safety nursing activities were safety training experience (β = 0.180, P=.01), organizational learning–continuous improvement (β = 0.170, P=.04), age (β = 0.160, P=.02), and implementation of domestic and foreign accreditation (β = 0.147, P=.03). DiscussionTo improve patient safety, it is essential to identify problems in medical institutions, determine areas of improvement, and improve the organization’s patient safety activity system on the basis of patient safety error experience reports. After training the emergency nurses for continuous improvement, the effect of patient safety activities must be analyzed.

Community Pharmacy-based Patient Safety Activities: Focused on the Regional Patient Safety Center of the Korean Pharmaceutical Association

Community Pharmacy-based Patient Safety Activities: Focused on the Regional Patient Safety Center of the Korean Pharmaceutical Association

Establishing a Multi-Institutional Quality and Patient Safety Consortium: Collaboration Across Affiliates in a Community-Based Medical School.

The landscape of health care delivery and medical education is evolving. Institutions must continually reassess priorities, strategies, and partnerships to align the knowledge and skills of the health care workforce with the delivery of quality, socially accountable, collaborative health care that meets the needs of diverse populations in communities. This article describes the development, implementation, and early outcomes of the University of Missouri-Kansas City's Health Care Quality and Patient Safety Consortium. Inspired by an actual patient safety event, the consortium aimed to improve patient outcomes by establishing quality improvement and patient safety (QIPS) education and scholarship as foundational within its unique, horizontal-matrix academic health center, which comprises 6 affiliated hospitals and 4 university-based health sciences schools. The consortium established a governance structure with leaders who, collectively, represent the diverse members and stakeholders of the consortium. The members share a common agenda and mutual goals. The consortium measures success by applying published conceptual frameworks for evaluating the outcomes of educational programs on learners (Kirkpatrick) and patients (Bzowyckyj and colleagues). Consortium learner and patient outcomes span all levels of these frameworks. Undergraduate and graduate QIPS-based projects with meaningful health system or improved individual health outcomes signify a Level 4 outcome (the highest level) for learners and patients alike. Factors critical to success include a financial gift, leadership buy-in and support, a clear champion, shared goals and a united vision, a willingness to collaborate across health systems with varied strengths and priorities, and a stable communication platform. Aspirational goals of the consortium include increasing involvement across health professional schools, incorporating simulation into QIPS activities, and aligning the consortium's projects with broader community needs.

Our first review: an evaluation of effectiveness of root cause analysis recommendations in Hong Kong public hospitals

BackgroundTo evaluate the effectiveness of root cause analysis (RCA) recommendations and propose possible ways to enhance its quality in Hong Kong public hospitals.MethodsA retrospective cross-sectional study was performed across 43 public hospitals and institutes in Hong Kong, reviewing RCA reports of all Sentinel Events and Serious Untoward Events within a two-year period. The incident nature, types of root causes and strengths of recommendations were analysed. The RCA recommendations were categorised as ‘strong’, ‘medium’ or ‘weak’ strengths utilizing the US’s Veteran Affairs National Center for Patient Safety action hierarchy.ResultsA total of 214 reports from October 2016 to September 2018 were reviewed. These reports generated 504 root causes, averaging 2.4 per RCA report, and comprising 249 (49%) system, 233 (46%) staff behavioural and 22 (4%) patient factors. There were 760 recommendations identified in the RCA reports with an average of 3.6 per RCA. Of these, 18 (2%) recommendations were rated strong, 116 (15%) medium and 626 (82%) weak. Most recommendations were related to ‘training and education’ (466, 61%), ‘additional study/review’ (104, 14%) and ‘review/enhancement of policy/guideline’ (39, 5%).ConclusionsThis study provided insights about the effectiveness of RCA recommendations across all public hospitals in Hong Kong. The results showed a high proportion of root causes were attributed to staff behavioural factors and most of the recommendations were weak. The reasons include the lack of training, tools and expertise, appropriateness of panel composition, and complicated processes in carrying out large scale improvements. The Review Team suggested conducting regular RCA training, adopting easy-to-use tools, enhancing panel composition with human factors expertise, promoting an organization-wide safety culture to staff and aggregating analysis of incidents as possible improvement actions.

Amino Acid Supplementation Is Associated with Reduced Mortality and Complications Following Acute Fracture Fixation: Results of a Prospective, Randomized Controlled Trial

Abstract Objectives Acute musculoskeletal trauma patients experience immobilization and under-nutrition resulting in catabolic skeletal muscle wasting and compromised wound healing. We conducted a prospective RCT to assess the effect of supplementation with conditionally essential amino acids (CEAA) on postoperative outcomes in patients with acute orthopedic trauma. We hypothesized that supplementation with CEAA would decrease postoperative complications. Methods Adults with operative pelvis or long bone fractures, excluding distal radius fractures, were prospectively enrolled in this single-blinded RCT. Patients were assigned by stratified by injury severity and randomized to standard preoperative nutrition (control) or standard nutrition with oral supplement containing CEAA for two weeks after surgery (CEAA). Subjects with minimum 6-months follow up were included in this analysis. Postoperative complication rates were analyzed with X,2 using intention-to-treat analysis. Results 243 patients met inclusion criteria (Control: 117, CEAA: 126). Median supplement compliance in CEAA patients was 84% of 28 prescribed CEAA servings with no reported supplement-related adverse events. 7 of 117 patients within the control group died during follow up vs. 1 of 126 in CEAA group (P = 0.031). Total complication rate was 55% control patients and 41% CEAA patients (P = 0.040). Surgical site infection (SSI) rates were 24% in control vs. 14% in CEAA (P = 0.055). Medical complication rates were 35% in control vs. 23% in CEAA (P = 0.039). Nonunion rates were 3% in control vs. 5% in CEAA (P = 0.751). Conclusions Patients receiving CEAA supplementation following acute fracture fixation had significantly lower mortality, overall complications, and medical complications. There was a trend toward decreased surgical site infections among patients receiving CEAA, although this did not reach statistical significance. Postoperative oral supplementation with CEAA is a low-cost, low-risk intervention associated with reductions in postoperative mortality and complications. Further work is warranted to improve preoperative risk stratification and further define which individuals receive greatest benefit from this intervention. Funding Sources American Academy of Orthopaedic Surgeons, Board of Specialty Societies Quality and Patient Safety Action Fund.

Perioperative Nutritional Screening Tools Are Not Associated with Poor Outcomes After Musculoskeletal Trauma

Abstract Objectives Malnutrition is predictive of poor outcomes after trauma. Side effects of both pain and narcotics often limit postoperative dietary intake increasing nutritional deficiencies and limiting wound healing. The purpose of this study was to compare the predictive ability of a dietician nutritional evaluation and a patient reported nutritional screening tool for post-operative complications after musculoskeletal trauma. Methods Adults with operative pelvis or long bone fractures were prospectively enrolled in a single-blinded RCT and included in this analysis. Subjects were evaluated with the Patient Generated Subjective Global Assessment (PG-SGA) survey at baseline. Dietician Nutritional Assessment Screening (NAS) was performed for patients ≥65 years with low Albumin or Vitamin D, or admitted to the ICU. Complication analysis included subjects having minimum 6-month follow-up and/or ≥1 complication within six months. Spearman's Correlation was used to evaluate agreement between screening methods. Comparison using X analysis was done of complications between pre-operative assignment of malnutrition for each screening tool. Results Agreement of NAS and self-reported PG-SGA for 265 subjects demonstrated a weak correlation of rho = 0.23, P = 0.0002. Neither screening method had significant correlation for rates of non-union, mortality, medical, or surgical complications between designations of malnutrition (all P > .05). Among study subjects, incidence of those having a medical or surgical complication not screened by a dietician was 31.3% and 37.7% respectively. Conclusions Results indicate inconsistency in methods for assigning malnutrition in trauma population. Additionally, designation of malnutrition by either method was not associated with post-operative complication rates. The high incidence of those with a complication who were not evaluated by a dietician during initial hospitalization (1/3rd) support the need to develop better methods for screening malnutrition after trauma. Funding Sources American Academy of Orthopaedic Surgeons, Board of Specialty Societies Quality and Patient Safety Action Fund.

Conditionally Essential Amino Acid Supplementation Reduces Postoperative Muscle Wasting in Orthopedic Trauma Patients

Abstract Objectives Increased metabolic demand and inadequate oral intake after musculoskeletal trauma results in catabolic skeletal muscle wasting, which limits potential for functional recovery after injury. This study compared standard perioperative nutrition and oral supplementation with conditionally essential amino acids (CEAA) on changes in lean body mass after operative fixation of acute fractures. Methods Patients sustaining operative pelvis and extremity fractures presenting to a Level 1 trauma center were prospectively enrolled in a single blinded-randomized clinical trial. Demographics, injury classification, and comorbidities were collected at baseline. Fat Free Mass (FFM) was measured within 72 hours of surgery using A-Mode Ultrasound. Patients were randomly chosen to receive standard nutrition (Control) or standard nutrition plus an oral supplement (CEAA) containing 14 g of amino acids to be taken 2x daily for 2 weeks. FFM was re-assessed at 6 weeks and 3 months post-surgery. Statistical analysis was performed comparing Least Squared Mean FFM (P < .05). Results 222 subjects (Control: 112, CEAA: 120) were included in this analysis. There were no differences in age, gender, BMI, or baseline FFM between Control and CEAA subjects (all P > .05). Median supplement compliance was 22/28 servings (78.6%, sd ± 36.9%). At 6 weeks, average change in FFM among Controls was −1.28 kg (P = .004) and -.56 kg among CEAA (P = .19). Changes were not significant between groups (P = .23). At 12 weeks, there were non-significant changes in FFM from baseline in both groups (Controls: -.02 kg P = .96, CEAA: +.36 kg P = .44). From 6–12 weeks, FFM changes were + 1.26 kg (P = .012) and + .91 kg (P = .06) respectively. Conclusions Patients randomized to standard nutrition had significant FFM loss compared to those receiving additional CEAA supplementation 6 weeks after surgery. At 12 weeks, the control group decreased FFM further from baseline while the CEAA group mostly recovered their loss. Although 12-week FFM changes were not significant, results indicate CEAA supplementation prevents FFM loss in the acute post-operative phase. Further investigation is needed to compare FFM changes, clinical outcomes, complication rates, and the impact of baseline nutrition status. Funding Sources American Academy of Orthopaedic Surgeons, Board of Specialty Societies Quality and Patient Safety Action Fund.

Relationship of patient safety culture with factors influencing working environment such as working hours, the number of night shifts, and the number of days off among healthcare workers in Japan: a cross-sectional study

BackgroundPatient safety culture is defined as a product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management. Factors influencing healthcare workers’ working environment such as working hours, the number of night shifts, and the number of days off may be associated with patient safety culture, and the association pattern may differ by profession. This study aimed to examine the relationship between patient safety culture and working environment.MethodsQuestionnaire surveys were conducted in 2015 and 2016. The first survey was conducted in hospitals in Japan to investigate their patient safety management system and activities and intention to participate in the second survey. The second survey was conducted in 40 hospitals; 100 healthcare workers from each hospital answered a questionnaire that was the Japanese version of the Hospital Survey on Patient Safety Culture for measuring patient safety culture. The relationship of patient safety culture with working hours in a week, the number of night shifts in a month, and the number of days off in a month was analyzed.ResultsResponse rates for the first and second surveys were 22.4% (731/3270) and 94.2% (3768/4000), respectively. Long working hours, numerous night shifts, and few days off were associated with low patient safety culture. Despite adjusting the working hours, the number of event reports increased with an increase in the number of night shifts. Physicians worked longer and had fewer days off than nurses. However, physicians had fewer composites of patient safety culture score related to working hours, the number of night shifts, and the number of days off than nurses.ConclusionsThis study suggested a possibility of improving the patient safety culture by managing the working environment of healthcare workers. High number of night shifts may lead to high number of event reports. Working hours, the number of night shifts, and the number of days off may differently influence patient safety culture in physicians and nurses.

Mixed-method investigation of health consumers’ perception and experience of participation in patient safety activities

ObjectivesThis study aimed to examine the factors influencing patient safety behaviours and to explore health customers’ experiences of patient participation in the healthcare system.DesignA mixed-method sequential explanatory design was employed...

Clima de segurança dos profissionais da saúde em um hospital universitário

Analisar os preditores e fatores associados à cultura de segurança do paciente no ambiente hospitalar. Estudo quantitativo com delineamento transversal, realizado com 263 profissionais selecionados aleatoriamente e submetidos à aplicação do Instrumento Safety Attitude Questionnaire. Realizou-se análise estatística descritiva, correlação de Pearson, análise de variância e regressão linear. Nesse contexto, o constructo que obteve a maior média foi o de Satisfação no trabalho, já a menor foi o da Percepção da atuação da gerência da unidade e da organização sob olhar do profissional. Quando comparadas as médias dos constructos, houve significância estatística entre o Clima de trabalho em equipe e a unidade de atuação, bem como o mesmo constructo com a atuação profissional; Percepção e influência do estresse na execução do trabalho e os cargos dos profissionais; Satisfação no trabalho e gênero. Na regressão linear o constructo que mais apresentou impacto foi o da Percepção da atuação da gerência da unidade e da organização sob olhar do profissional. Conclui-se que o fator preditor mais relevante foi a percepção da atuação da gerência da unidade e organização sob olhar do profissional. Tais resultados poderão servir de subsídio para novos estudos que levem em consideração a influência da cultura nas ações de segurança do paciente.

National Patient Safety Consortium: Learning from Large-Scale Collaboration

From 2014 to 2018, the Canadian Patient Safety Institute brought together key partners and established the National Patient Safety Consortium to drive a shared action plan for safer healthcare. With ongoing consensus development on key priorities, an unprecedented level of collaboration and shared leadership with diverse stakeholders and patients and families as full partners, the Consortium and its Integrated Patient Safety Action Plan built a culture of engagement and improvement across Canada.

Patient Engagement in a Large-Scale Change Initiative: "As Safe as Possible, as Soon as Possible".

Patients for Patient Safety Canada (PFPSC) member engagement has evolved from individual stories to having 27 patients and family members actively participating in the National Patient Safety Consortium. PFPSC collaborated with 270 other stakeholders in governance, leadership and action teams to design, implement and evaluate the National Patient Safety Consortium and Integrated Patient Safety Action Plan. There were several key outputs, including a patient engagement guide. This article illustrates how patients were meaningfully engaged in a large-scale change initiative, highlighting the experiences of the patient partners and organizational partners in this transformational change.

AB033. Construction and validation of content of checklist for patient safety in the administration of medicines in pediatrics

Background: To build and validate a list of patient safety actions in the administration of medicines in pediatrics.

Development of a clinical pathway for enhanced recovery in colorectal surgery: a Canadian collaboration

Enhanced Recovery After Surgery (ERAS) is a model of care that was introduced in the late 1990s by a group of surgeons in Europe. The model consists of a number of evidence-based principles that support better outcomes for surgical patients, including improved patient experience, reduced length of stay in hospital, decreased complication rates and fewer hospital readmissions. A number of Canadian surgical care teams have already adopted ERAS principles and have reported positive outcomes. Arising from the Canadian Patient Safety Institute’s Integrated Patient Safety Action Plan for Surgical Care Safety, and with support from numerous partner organizations from across the country, Enhanced Recovery Canada is leading the drive to improve surgical safety across the country and help disseminate these ERAS principles. We discuss the development of a multidisciplinary clinical pathway for elective colorectal surgery to help guide Canadian clinicians.

Ludic strategy for promoting engagement of parents and caregivers in the safety of pediatric patients.

To evaluate a ludic strategy developed to promote the engagement of parents and caregivers in the pediatric patient safety actions. A qualitative research developed in the action-research modality, using the thematic content analysis method for data treatment, developed with caregivers of children admitted to the pediatric unit of the public hospital of Belo Horizonte, Minas Gerais, between May and October 2018. Three thematic categories emerged: Learning about patient safety through the game; Game evaluation as a ludic strategy in promoting patient safety and; Change of perception and behavior of parents and caregivers in safety promotion actions. The game was deemed as an important tool for patient safety knowledge transfer, motivating parents and caregivers to become more critical and more co-participant as for the hospitalized child care.

Analysis of Subgroups with Lower Level of Patient Safety Perceptions Using Decision-Tree Analysis

This study was aimed to investigate experiences, perceptions, and educational needs related to patient safety and the factors affecting these perceptions. Study design was a descriptive survey conducted in November 2019. A sample of 1,187 Koreans aged 20-80 years participated in the online survey. Based on previous research, the questionnaire used patient safety-related and educational requirement items, and the Patient Safety Perception Scale. Descriptive statistics and a decision tree analysis were performed using SPSS 25.0. The average patient safety perception was 71.71 (± 9.21). Approximately 95.9% of the participants reported a need for patient safety education, and 88.0% answered that they would participate in such education. The most influential factors in the group with low patient safety perceptions were the recognition of patient safety activities, age, preference of certified hospitals, experience of patient safety problems, and willingness to participate in patient safety education. It was confirmed that the vulnerable group for patient safety perception is not aware of patient safety activities and did not prefer an accredited hospital. To prevent patient safety accidents and establish a culture of patient safety, appropriate educational strategies must be provided to the general public.

Video Recording of Nursing Care Activities in Gerontological Nursing to Compare General Units and Comprehensive Nursing Care Units

Purpose: Comprehensive nursing care services are provided for patient-centered nursing care in Korea. This study was conducted to compare differences in the frequency and elapsed time of nursing activities between comprehensive nursing care units and general medical-surgical units. Methods: This is a descriptive study design using direct observation of nursing care activities. A time and motion study on the frequency and elapsed time of nursing activities provided by nurses was conducted in the comprehensive nursing care units and general units of two small-to-medium sized hospitals. Data were collected for 64 hours in each hospital, through a two-way method using a checklist and a camera recorder. Results: The total number of nursing activities, activities provided per patient and patient safety care including clinical assessment and treatment were higher in the comprehensive nursing care units compared to general units. We found similar findings regarding the duration of nursing activities. Conclusion: Comprehensive nursing care units provide patient-centered nursing care and have a broader range of nursing activities for patient safety than general units. Assessments conducted to meet nursing needs and to promote safe nurse staffing should reflect the characteristics of the nursing tasks performed in comprehensive nursing care units.