Patient Safety System Research Articles

System Factors Affecting Intraoperative Risk and Resilience: Applying a Novel Integrated Approach to Study Surgical Performance and Patient Safety.

To identify and categorize system factors in complex laparoscopic surgery that have the potential to either threaten patient safety or support system resilience. The operating room is a uniquely complex sociotechnical work system wherein surgical successes prevail despite pervasive safety threats. Holistically characterizing intraoperative factors that thus support system resilience in addition to those that threaten patient safety using contextual methodologies is critical for optimizing surgical safety overall. In this prospective descriptive interdisciplinary study, 19 audio/video recordings of complex laparoscopic general surgical procedures were directly observed and transcribed. Using a qualitative systems-based approach, intraoperative human factors with the potential to impact patient safety, either as a safety threat or as a support for resilience, were identified. Adverse events were further assessed for shared threats and supports. Data collection was guided by the Systems Engineering Initiative for Patient Safety 2.0 work system model. A total of 1083 relevant observations were made over 39.8 hours of operative time, enabling the identification of 79 distinct safety threats and 67 resilience supports within the surgical system. Safety threats associated with the physical environment, tasks, organization, and equipment were prevalent and observed in equal measure, whereas supports for resilience were predominantly attributed to clinician behaviors, including proactive team management and skills coaching. Two subclinical adverse events were identified; shared safety threats included suboptimal technology design, whereas shared resilience supports included calm clinician behavior and redundant intraoperative resourcing. Safety threats and resilience supports were found to be systematic in the surgical setting. Identified safety threats should be prioritized for remediation, and clinician behaviors that contribute to fostering resilience should be valued and protected.

From skepticism to assurance and control; Implementation of a patient safety system at a pediatric hospital in Sweden

BackgroundThe use of evidence-based practice among healthcare professionals directly correlates to better outcomes for patients and higher professional satisfaction. Translating knowledge in practice and mobilizing evidence-based clinical care remains a continuing challenge in healthcare systems across the world.PurposeTo describe experiences from the implementation of an Early Detection and Treatment Program for Children (EDT-C) among health care professionals at a pediatric hospital in Sweden.Design and methodsSixteen individual interviews were conducted with physicians, nurses and nurse assistants, which of five were instructors. Data were analyzed with qualitative content analysis.ResultsAn overarching theme was created: From uncertainty and skepticism towards assurance and control. The theme was based on the content of eight categories: An innovation suitable for clinical practice, Differing conditions for change, Lack of organizational slack, Complex situations, A pragmatic implementation strategy, Delegated responsibility, Experiences of control and Successful implementation.ConclusionsSuccessful implementation was achieved when initial skepticism among staff was changed into acceptance and using EDT-C had become routine in their daily work. Inter-professional education including material from authentic patient cases promotes knowledge about different professions and can strengthen teamwork. EDT-C with evidenced-based material adapted to the context can give healthcare professionals a structured and objective tool with which to assess and treat patients, giving them a sense of control and assurance.

Investigation on patient safety culture in standardized training for resident doctors

Objective To investigate the cognition on patient safety culture of resident doctors re-ceiving standardized training in two affiliated hospitals, analyze the effectiveness of publicity and education in patient safety culture and put forward suggestions for improvements. Methods A total of 913 resident doctors receiving standardized training in the two affiliated hospitals during 2014 to 2016 were enrolled. Their cognition on patient safety culture were investigated using questionnaire surveys from May to October in 2016, and the main factors influencing the cognition on patient safety culture in standardized training were put forward through expert interviews. All statistical analyses were performed with SPSS 17.0 software with Chi-square test. Results The response rate of the questionnaire was 87.62% (800/913). Three factors were involved in the patient safety system, including the hospital security objectives, security feedback channels, and adverse event warning mechanism. The cognitiive level of A hospital (68.96%, 62.52%, 62.81%) was higher than that of B hospital (52.99%, 46.16%, 47.01%), and the difference was statistically significant (P<0.05). The publicity of pre-service training, education in the department, and encouragement from teachers (82.13%, 84.48%, 78.33%) was better in A hospital than in B hospital (68.38%, 71.8%, 62.39%) (P<0.05). The reporting rate of adverse events in A hospital was higher than that in B hospital (P <0.05). Conclusion It is necessary for hospitals to further intensify the publicity and education on patient safety culture. We can improve students' cognition on patient safety culture to reduce medical errors by cre-ating a favorable atmosphere, establishing standardized admission education and training system, improving teachers' teaching ability, and strengthening the training for clinical skills. Key words: Patient safety culture; Resident; Standardized training; Postgraduate students

Creating a Radiology Quality and Safety Program: Principles and Pitfalls.

All radiology departments are now expected to create organized and comprehensive quality and safety (QS) programs. No matter the department size, there are fundamental principles that should be at the core of each program. "Just culture" and culture of safety are essential principles in establishing effective programs. Physician leaders of QS programs must involve stakeholders, define program goals, and develop an effective program structure. QS programs should establish reliable quality assurance and patient safety systems. Integrating continuous quality improvement and learning into the department and prioritizing patient and referring clinician experiences will enhance outcomes. Physician QS leaders will face common obstacles in program development and management. Heightened awareness of these obstacles and understanding potential solutions will help programs succeed. Leveraging resources offered by professional societies and engaging in radiology QS community networks will provide ongoing support for program leaders. ©RSNA, 2018.

Implementation and operation of incident learning across a newly-created health system.

PurposeThe purpose of this work is to describe our experience launching an expanded incident learning system for patient safety and quality that takes into account aspects beyond therapeutic dose delivery, specifically imaging/simulation incidents, medical care incidents, and operational issues.MethodsOur ILS was designed for a newly created health system comprised of a midsized academic hospital and two smaller community hospitals. The main design goal was to create a highly sensitive system to capture as much information throughout the department as possible. Reports were classified according to incidents and near misses involving therapeutic radiation, imaging/simulation, and patient care (not involving radiation), unsafe conditions, operational issues, and accolades/suggestions. Reports were analyzed according to impact on various steps in the process of care. Actions made in response to reports were assessed and characterized by intervention reliability.ResultsA total of 1125 reports were submitted in the first 23 months. For all three departments, therapeutic radiation incidents and near misses consisted of less than one‐third of all reports submitted. For the midsized academic department, operational issues and unsafe conditions comprised the largest percentage of reports (70%). Although the majority of reports impacted steps related to the technical aspects of treatment (simulation, planning, and treatment delivery), 20% impacted other steps such as scheduling or clinic visits. More than 160 actions were performed in response to reports. Of these actions, 63 were quality improvement interventions to improve practices, while 97 were learning actions for raising awareness.ConclusionsWe have developed an ILS that identifies issues related to the entire process of care delivery in radiation oncology, as evidenced by frequent and varied reported events. By identifying a broad spectrum of issues in a department, opportunities for improvement can be identified.

Description and Factors Associated With Missed Nursing Care in an Acute Care Community Hospital.

The aims of this study are to describe and evaluate the factors associated with missed nursing care in an acute care community hospital. Despite RNs' accountability for high-quality patient care in hospitals, missed nursing care is widespread, jeopardizing patient safety and health system costs. Better understanding of the factors associated with missed nursing care may provide nurse leaders with opportunities for improvement. Using a cross-sectional correlational study design, 138 RNs were randomly sampled during May-June 2017. The extent of missed nursing care is consistent with other studies, was greater on medical-surgical and telemetry units compared with specialty units, and was negatively associated with staffing/resources, satisfaction with current position, and collegial nurse-physician relationships. Findings suggest urgent nurse leader action and future research.

Modern Approaches to Identification of Adverse Events in Perinatal Medicine

Introduction. In the past two decades, among the various international initiatives aimed at enhancing the quality of medical care, the greatest number of them is aimed at improving the patient's safety situation. Scientific sources suggest that severe evadable adverse events complicate up to 15% of all hospitalizations, of which approximately 0.7-0.9% of cases can lead to death. It is considered that in perinatal practice, mistakes less frequently lead to adverse events and harm, due to a healthier contingent of patients and the modern paradigm of support for normal and physiological processes, instead of diseases. However, according to scientific literature, up to 1-4% of births are complicated by adverse events, of which up to 2/3 can be considered as preventative.The aim of the research is to determine the content of the major modern organizational tools for identification and registration of adverse events and medical errors in perinatal medicine.Materials and methods. We conducted the content analysis of scientific medical and methodological literature, aimed at identifying the key characteristics and content of organizational instruments for identification and registration of medical errors in perinatal medicine.Research results. Content analysis of printed materials and electronic Internet resources allowed us to determine the main requirements for incident reporting system. The subject of analysis can be any incident of patient safety: a medical error and an adverse event. The review of literature allowed us to reveal the evolution of organizational instruments for registration of adverse events in perinatal medicine. At the lower level, there is the analysis of all cases of deaths of mothers, fetuses and newborns, at the second level – registration of all adverse events with causing harm to the patient; at the third level –registration of near-misses events, the list of which can be personally developed by the department / institution management, adapting the already known tools to their own conditions and to the level of the existing patient safety culture; at the fourth level – registration of the so-called triggers, identification of which in the medical documentation is the basis for its detailed analysis in order to identify the adverse event that occurred during the treatment of patient, and, finally, the fifth level – voluntary reporting of medical errors, occurring at the department. The next, higher level of registration of adverse events and medical errors in perinatal medicine is identification and registration of the so-called uncompleted, timely prevented adverse events. The literature review has shown that most countries have implemented the WHO Maternal Near Miss Tool at the national level. However, it is noted that the main disadvantage of this tool is the lack of registration of uncompleted adverse events associated with the newborn. The standard for detecting adverse medical events was a voluntary incident-reporting system. Yet, these systems in a large number of cases do not reveal the actual frequency of adverse events. Public health researchers found that medical staff volunteered to report only 10-20% of errors, of which from 90 to 95% did not cause any harm to patients. Therefore, hospitals need a more effective way of detecting events that harm patients in order to quantify their degree and severity, as well as determine the effectiveness of the measures taken to improve the patient's safety during the treatment and diagnostic process. In this aspect, the Global Trigger Tool, developed by the Institute for Healthcare Improvement (USA), could be the most effective in assessing the safety of in-patient care provision. This methodology represents a list of triggers (prompts) that are defined for their purpose-oriented search in medical paper / electronic documentation. Perinatal trigger tool includes 8 indicators that may indicate an adverse event associated with pregnancy and childbirth. Currently, the global trigger methodology provides for prospective monitoring of clearly defined indicators online in the application of electronic medical documentation, and retrospective monitoring – in the analysis of medical records after the patient's discharge from the hospital.Conclusions. The latest global trends in the provision of medical care, namely the emphasis on patient safety, require new approaches to address the problem of medical errors and adverse events in perinatal medicine. Incident-reporting systems and the culture of patient safety, essential for their successful operation, should be the key elements of patient safety systems, which are implemented at the hospital, regional and national levels.

Barriers to Self-Reporting Patient Safety Incidents by Paramedics: A Mixed Methods Study

Background: A minimal amount of research exists examining the extent to which patient safety events occur within paramedicine and even fewer studies investigating patient safety systems for self-reporting by paramedics. The purpose of this study was to identify barriers to paramedic self-reporting of patient safety incidents (PSIs). Methods: We randomly distributed paper-based surveys among 1,153 paramedics in an Ontario region in Canada. The survey described one of 5 different PSI clinical scenarios (near miss, adverse event, and minor, major or critical patient care variances) and listed 18 potential barriers to self-reporting PSIs as statements presented for rating on a 5-point Likert scale (very significant = 1 – very insignificant = 5). We invited comments on PSI self-reporting with 2 open-ended questions. We analyzed data with descriptive statistics, chi-square tests and Kruskal-Wallis H test. We used an inductive approach to qualitatively analyze emerging themes. Results: We received responses from 1,133 paramedics (98.3%). Almost one third (28.4%) were Advanced Care Paramedics and 45.1% had >10 years' experience. The top 5 barriers to PSI self-reporting (very significant or significant, %) were the fear of being: punished (81.4%), suspended (79.6%), terminated (79.1%), investigated by Ministry of Health and Long-Term Care (78.4%), and decertified (78.0%). Overall, 64.1% responded they would self-report a given PSI. Intention to self-report a PSI varied according to scenario (22.8% near miss, 46.6% adverse event, 74.4% minor, 92.6% major, 95.6% critical). No association was found between level of training (p = 0.55) or years of experience (p = 0.10) and intention to self-report a PSI. Seven themes to improve PSI self-reporting by paramedics emerged from the qualitative data. Conclusions: A high proportion of fear-based barriers to self-reporting of PSIs exist among this study population. This suggests that a culture change is needed to facilitate the identification of future patient safety threats.

Effect of Comprehensive Surgical Safety System on Patients' Outcome: A Prospective Clinical Study.

BackgroundPatient safety has become an integral part of hospital management to prevent catastrophic events which adversely affects the patients, care providers and the hospital. Surgical Checklists are an easy and simple way to prevent surgical errors and complications.ObjectiveThis prospective study is to evaluate the effect of SURPASS (Surgical Patient Safety System) checklist on the outcome of the patients who underwent surgery in our hospital.MethodsAll the patients who underwent surgery in the sixth unit of Department of Surgery from April 2014 to May 2015 were included in the study excluding those aged above 13 years and day care surgery cases. For the control group (initial six months) no checklist was implemented whereas for the study group (next six months) SURPASS checklist was implemented. Data collected on age, sex, diagnosis, surgical procedure, type of anaesthesia, number and type of postoperative complications, need of second surgery because of complications, length of hospital stay and outcome (discharge, disability or death). Mann–Whitney U test and Fisher’s exact test were used for analysis.ResultsOf the total 372 patients operated, 200 were before and 172 were after implementation of SURPASS checklist. Before implementation of the checklist, complications were noticed in 66.66% of elective and 77.23% of emergency cases. Whereas after implementation of checklist the complications in elective cases were found to be 51.09% (p-value = 0.008) and 67.50% (p-value = 0.024) in emergency cases.ConclusionImplementation of SURPASS checklist is effective in reducing the rate of postoperative complications in both elective and emergency surgeries.

Neonatal Nurses Experience Unintended Consequences and Risks to Patient Safety With Electronic Health Records.

In this article, we examine the unintended consequences of nurses' use of electronic health records. We define these as unforeseen events, change in workflow, or an unanticipated result of implementation and use of electronic health records. Unintended consequences experienced by nurses while using electronic health records have been well researched. However, few studies have focused on neonatal nurses, and it is unclear to what extent unintended consequences threaten patient safety. A new instrument called the Carrington-Gephart Unintended Consequences of Electronic Health Record Questionnaire has been validated, and secondary analysis using the tool explored the phenomena among neonatal nurses (N = 40). The purposes of this study were to describe unintended consequences of use of electronic health records for neonatal nurses and to explore relationships between the phenomena and characteristics of the nurse and the electronic health record. The most frequent unintended consequences of electronic health record use were due to interruptions, followed by a heavier workload due to the electronic health record, changes to the workflow, and altered communication patterns. Neonatal nurses used workarounds most often with motivation to better assist patients. Teamwork was moderately related to higher unintended consequences including patient safety risks (r = 0.427, P = .007), system design (r = 0.419, P = .009), and technology barriers (r = 0.431, P = .007). Communication about patients was reduced when patient safety risks were high (r = -0.437, P = .003). By determining the frequency with which neonatal nurses experience unintended consequences of electronic health record use, future research can be targeted to improve electronic health record design through customization, integration, and refinement to support patient safety and better outcomes.

Developing patient safety system using WHO tool in hospitals in Oman.

Oman is progressively implementing the Patient Safety Friendly Hospital Initiative (PSFHI), a tool formulated by the World Health Organization (WHO) to achieve optimal patient safety in hospitals. This paper describes its implementation in selected government and private hospitals in Oman and analyses the performance of four hospitals whose implementations of PSFHI were assessed by WHO. The PSFHI initiative was launched in 11 hospitals in Oman during 2016. The enrolled hospitals implemented a 1-year plan composed of several steps such as formation of steering committees, working groups, full orientation about the standards, training of staff, documents development and community involvement. One year later, four hospitals which were the earliest to join the initiative were subjected to WHO assessment. Secondary level government and private hospitals. The WHO-PSFHI standards. Hospitals' adherence to the standards. Three of the four hospitals (one government and two private) scored level two. One government hospital scored level three, earning it the distinction of being the first hospital in the Eastern Mediterranean Region to reach level three in the very first assessment. Implementation of PSFHI in selected hospitals of Oman had successful outcomes in improving patient's safety.

Beban Kerja Perawat terhadap Implementasi &lt;i&gt;Patient safety&lt;/i&gt; di Ruang Rawat Inap

One of the goals of patient safety systems is a declining unexpected events which are results of multiple problems included humane resources, inadequate policies and procedures to decline in events that could occur due to several problems and one of them is the problem of human resources, policies and procedures even technical failures of factors that risk for causing infection.  One of them is high nurse’s workload due to insufficient staffs or nurses.  The purpose of this study was to examine the relationship between the nurse’s workload and the implementation of patient safety in the inpatient units at Tugurejo Public Hospital Semarang. A cross sectional study invited 155 nurses to participate. The total sampling technique was applied. Chi Square test tested the hypothesis. The result showed that the nurse’s workload tended to high level (58.7%), while mostly the implementation of patient safety was unfavorable (60.6%). Chi-Square test reported X 2 =6.807 (p= 0.0009). There is a significant relationship between the nurse’s workload and the implementation of patient safety in the hospital inpatient Tugurejo Semarang.

Status and Perception of Risk Management in Radiation Therapy: Survey Among Korean Medical Physicists.

This study was conducted as part of an endeavor to improve the risk management system of radiation therapy departments in the Republic of Korea. An online survey on the status and perception of Korea's medical physicists on risk management in radiation therapy was carried out. A total of 40 domestic radiation oncology departments participated. This survey is divided into three categories: (1) work environment; (2) risk management status; and (3) opinions on how to improve risk management. Based on the results of the survey, the conclusions that can be derived are (1) the majority of respondents have a high interest in the risk management of radiation therapy; (2) the lack of staffing is one cause of risk management difficulties; (3) a risk-related terminology and classification system at the national or professional association level are required; (4) each hospital should create a voluntary reporting system for the handling of incidents; (5) medical physicists should establish incident reporting, analysis and countermeasures; and (6) government should develop education and training programs. It was confirmed that the current risk management system should be changed by education in the hospital and at the national level in order to improve risk management related to radiation therapy. In addition, it was recognized that a dedicated staff and a risk management certification system and organization for patient safety in radiotherapy are needed.

Complications of cardiac catheterization in children with congenital heart disease.

Tokel K, Gümüş A, Ayabakan C, Varan B, Erdoğan İ. Complications of cardiac catheterization in children with congenital heart disease. Turk J Pediatr 2018; 60: 675-683. Catheterization procedures for congenital heart disease include a broad range of procedures with a large spectrum of potential adverse outcomes. We aimed to determine the incidence of various complications during pediatric cardiac catheterizations and to designate the relative risk factors for such complications. All pediatric patients undergoing cardiac catheterizations between January 2005-December 2010 were included. Data are collected prospectively by filling out computerized catheterization reports. Patient records were scanned for potential risk factors retrospectively. Groups were divided based on cardiac diagnosis; type of procedure. Adverse events were categorized into major or minor events. A total of 2662 cardiac catheterizations were performed during this period. The mean age of patients was 53.2±64.3 months. Diagnostic catheterizations were done for 1797 (67.5%) patients, and interventional procedures were done in 865 (32.5%) cases. Adverse events were observed in 688 patients (26%) during 941 procedures. Minor and major events were seen in 21.4% and 7.1% of the procedures respectively. Most frequent major complications were anesthesia related (6%), most frequent minor complications were vascular complications (45.2%). Complications were more frequent in younger patients (p=0.0001), during interventional procedures (p=0.0001). Thirteen patients died after a cardiac catheterization; they were younger and had longer procedures compared to those who survived (p=0.0001). Vascular complications were frequent among younger patients, with prolonged procedure time and vessel access (p < 0.0001). Cyanotic patients had more complications (p < 0.05; OR for major and minor complications: 3.5 and 2 respectively). Minor complications were 2.7 times more likely in ventricular outflow obstructions (p < 0.05). The complication rates of cardiac catheterization in children are low, but not negligible. Defining risk factors will help anticipate adverse events, which will guide in preparation for rescue procedures and improvement of patient safety systems in catheterization laboratories.

The feasibility of an interactive voice response system (IVRS) for monitoring patient safety after discharge from the ED

BackgroundReturn ED visits are frequent and may be due to adverse events: adverse outcomes related to healthcare received. An interactive voice response system (IVRS) is a technology that translates human...

Surgical safety checklist training: a national study of undergraduate medical and nursing student teaching, understanding and influencing factors

IntroductionUse of the WHO surgical safety checklist is consistently recognised to reduce harm caused by human error during the perioperative period. Inconsistent engagement is considered to contribute to persistence of...

Accreditation of Medical Laboratories - System, Process, Benefits for Labs.

SummaryOne and key of the priorities in laboratory medicine is improvement of quality management system for patient safety. Quality in the health care is tightly connected to the level of excellence of the health care provided in relation to the current level of knowledge and technical development. Accreditation is an effective way to demonstrate competence of the laboratory, a tool to recognize laboratories world-wide, is linked to periodical audits, to stimulate the maintenance and improvement of the quality, which leads to high standard of services for clients (patients, health care providers, etc.). The strategic plans of IFCC and EFLM include focusing on accreditation of labs based on ISO standards and cooperation with European Accreditation and national accreditation bodies. IFCC and EFLM recognised that ISO 15189:2012 Medical laboratories – Requirements for quality and competence, encompasses all the assessment criteria specified in the policy of quality. The last version is oriented to process approach with detailed division and clearly defined requirements. The accreditation of labs improves facilitation of accurate and rapid diagnostics, efficiency of treatment and reduction of errors in the laboratory process. Accreditation is not about who the best is, but who has a system of standard procedures with aim to improve the quality and patient safety. Quality system is about people, with people and for people.

The Value of In Vitro Tests to DiminishDrug Challenges.

Drug hypersensitivity reactions have multiple implications for patient safety and health system costs, thus it is important to perform an accurate diagnosis. The diagnostic procedure includes a detailed clinical history, often unreliable; followed by skin tests, sometimes with low sensitivity or unavailable; and drug provocation testing, which is not risk-free for the patient, especially in severe reactions. In vitro tests could help to identify correctly the responsible agent, thus improving the diagnosis of these reactions, helping the physician to find safe alternatives, and reducing the need to perform drug provocation testing. However, it is necessary to confirm the sensitivity, specificity, negative and positive predictive values for these in vitro tests to enable their implementation in clinical practice. In this review, we have analyzed these parameters from different studies that have used in vitro test for evaluating drug hypersensitivity reactions and estimated the added value of these tests to the in vivo diagnosis.

Key priority areas for patient safety improvement strategy in Libya: a protocol for a modified Delphi study

IntroductionPatient safety is a global public health problem. Estimates and size of the problem of patient safety in low-income and developing countries are scarce. A systems approach is needed for...

Analysis of the safety culture in a Cardiology Unit managed by processes

A cross-sectional observational study was conducted in 2 consecutive years, with all staff completing the Spanish version of the questionnaire, "Hospital Survey on Patient Safety Culture" of the "Agency for Healthcare Research and Quality", with 42 items grouped into 12 dimensions. The percentage of positive responses in each dimension in 2014 and 2015 were compared, as well as national data and United States data, following the established rules. The overall assessment out of a possible 5, was 4.5 in 2014 and 4.7 in 2015. Seven dimensions were identified as strengths. The worst rated were: staffing, management support and teamwork between units. The comparison showed superiority in all dimensions compared to national data, and in 8 of them compared to American data. The safety culture in a Cardiology Unit with an integrated quality and risk management patient safety system is high, and higher than nationally in all its dimensions and in most of them compared to the United States.