Preventable Harm Research Articles

Comparison of Metrics Used to Track CLABSIs and CAUTIs Across a Regional Network

Background: The standardized infection ratio (SIR) is the nationally adopted metric used to track and compare catheter-associated urinary tract infections (CAUTIs) and central-line– associated bloodstream infections (CLABSIs). Despite its widespread use, the SIR may not be suitable for all settings and may not capture all catheter harm. Our objective was to look at the correlation between SIR and device use for CAUTIs and CLABSIs across community hospitals in a regional network. Methods: We compared SIR and SUR (standardized utilization ratio) for CAUTIs and CLABSIs across 43 hospitals in the Duke Infection Control Outreach Network (DICON) using a scatter plot and calculated an R2 value. Hospitals were stratified into large (>70,000 patient days), medium (30,000–70,000 patient days), and small hospitals (<30,000 patient days) based on DICON’s benchmarking for community hospitals. Results: We reviewed 24 small, 11 medium, and 8 large hospitals within DICON. Scatter plots for comparison of SIRs and SURs for CLABSIs and CAUTIs across our network hospitals are shown in Figs. 1 and 2. We detected a weak positive overall correlation between SIR and SUR for CLABSIs (0.33; R2 = 0.11), but no correlation between SIR and SUR for CAUTIs (−0.07; R2 = 0.00). Of 15 hospitals with SUR >1, 7 reported SIR <1 for CLABSIs, whereas 10 of 13 hospitals with SUR >1 reported SIR <1 for CAUTIs. Smaller hospitals showed a better correlation for CLABSI SIR and SUR (0.37) compared to medium and large hospitals (0.19 and 0.22, respectively). Conversely, smaller hospitals showed no correlation between CAUTI SIR and SUR, whereas medium and larger hospitals showed a negative correlation (−0.31 and −0.39, respectively). Conclusions: Our data reveal a weak positive correlation between SIR and SUR for CLABSIs, suggesting that central line use impacts CLABSI SIR to some extent. However, we detected no correlation between SIR and SUR for CAUTIs in smaller hospitals and a negative correlation for medium and large hospitals. Some hospitals with low CAUTI SIRs might actually have higher device use, and vice versa. Therefore, the SIR alone does not adequately reflect preventable harm related to urinary catheters. Public reporting of SIR may incentivize hospitals to focus more on urine culture stewardship rather than reducing device utilization.Funding: NoneDisclosures: None

A Toolbox for Detecting and Eliminating Preventable Harm to Patients: Current Progress and the Road Ahead.

A Toolbox for Detecting and Eliminating Preventable Harm to Patients: Current Progress and the Road Ahead.

Prediction of Suicide Attempts Using the Box-Jenkins Model.

Objective: Suicide is a preventable social harm in the field of health. The present study aimed to design a prediction model for suicide incidence based on Box-Jenkins model in Ilam province. Method : Using a retrospective method all completed and attempted suicide data were collected during 1993-2013. Then, using the autoregressive integrated moving average (ARIMA) model, the time series analysis of the Box-Jenkins model was conducted to predict suicide status in the coming years (2014-2015). Results: According to the actual results obtained from the suicide data in 2014, a total of 1078 suicides were recorded and compared to the predicted results, according to the fitted model of the time series, which showed the selected model predicted 931 suicide cases, showing 86% accuracy of prediction. The series’ prediction indicated 931 suicides in 2014 with a negative growth rate of 25.3% compared to 2013 and 969 suicide cases in 2015 with a positive growth rate of 3.93% compared to 2014. Conclusion: The results of this study showed the designed model provides a high diagnostic value to predict suicide rates. These types of models can help to predict suicide in future and plan to control and prevent suicide attempts.

Anesthesiologists' airway management expertise: Identifying subjective and objective knowledge gaps.

Failure in airway management continues to cause preventable patient harm, and the recommended continuing education is challenged by anesthesiologists' unknown knowledge gaps. This study aimed to identify anesthesiologists' subjective and objective knowledge gaps as well as areas where anesthesiologists are incorrect and unaware. An adaptive E-learning program with 103 questions on adult airway management was used for subjective and objective assessment of anesthesiologists' knowledge. All anesthesiologists in the Capital Region of Denmark were invited to participate. The response rate was 67% (191/285). For preoperative planning, participants stated low confidence (subjective assessment) regarding predictors of difficult airway management in particular (69.1%-79.1%). Test scores (objective assessment) were lowest for obstructive sleep apnea as a predictor of difficult airway management (28.8% correct), with participants being incorrect and unaware in 33.5% of the answers. For optimization of basic techniques, the lowest confidence ratings related to patient positioning and prediction of difficulties (57.4%-83.2%), which agreed with the lowest test scores. Concerning advanced techniques, videolaryngoscopy prompted the lowest confidence (72.4%-85.9%), while emergency cricothyrotomy resulted in the lowest test scores (47.4%-67.8%). Subjective and objective assessments correlated and lower confidence was associated with lower test scores: preoperative planning [r=-.58, P<.001], optimization of basic techniques [r=-.58, P=.002], and advanced techniques [r=-.71, P<.001]. We identified knowledge gaps in important areas of adult airway management with differing findings from the subjective and objective assessments. This underlines the importance of objective assessment to guide continuing education.

Measuring and monitoring perioperative patient safety: a basic approach for clinicians.

Purpose of reviewRecent research points to considerable rates of preventable perioperative patient harm and anaesthesiologists’ concerns about eroding patient safety. Anaesthesia has always been at the forefront of patient safety improvement initiatives. However, factual local safety improvement requires local measurement, which may be afflicted by barriers to data collection and improvement activities. Because many of these barriers are related to mandatory reporting, the focus of this review is on measurement methods that can be used by practicing anaesthesiologists as self-improvement tools, even independently from mandatory reporting, and using basic techniques widely available in most institutions.Recent findingsFour mutually complementary measurement approaches may be suited for local patient safety learning: incident and rate-based measurements, staff surveys and patient surveys. Reportedly, individual methods have helped to tailor problem solutions and to reduce patient harm, morbidity, and mortality.SummaryConsidering the potential for perioperative patient safety measurements to improve patient outcomes, the absence of a generally accepted measurement standard and manifold barriers to reporting, a pragmatic approach to locally measuring patient safety appears advisable.

Community-based maternal health workers’ perspectives on heat risk and safety: a pilot qualitative study

In this study the authors examined how maternal health workers (MHWs) perceive the health risks of extreme heat exposure to pregnant women and fetuses. The authors conducted interviews with 12 MHWs (including midwives and doulas) in El Paso, Texas. Using qualitative analysis, the researchers identified numerous themes. Although heat was not communicated as a major health risk, participants expressed some concern with growing heat exposure and communicated standard protective measures. While all participants were familiar with some heat illness symptoms, they were generally unaware of their clients’ vulnerability. MHWs’ minimal heat-risk knowledge leaves pregnant women and developing fetuses at risk of preventable harm.

Issues of patient safety in the context of preventing medical errors&#x0D; (analytical review)

Introduction. Patient safety is the absence of preventable harm to the patient in the course of medical care and the reduction of the risk of unnecessary harm associated with medical care to an acceptable minimum. Over the past two decades, the problem of patient safety has become the object and target area of public health for specific efforts to improve it. The study aims to analyze modern scientific literature to consider problems related to clinical safety, the global burden of harming patients. Material and methods. In the context of studying the problem, the results of modern research were used to identify the causes of medical errors and to find ways to prevent them. Results. The desire to improve the level of safety and the quality of medical care is growing in the world. Consequently, significant measures to evaluate the safety of medical care and its quality will be of paramount importance. To date, there is no gold standard or established array of quality indices (QI) for measuring the quality and safety of medical care. However, many indices have been developed, and some have even been tested to measure specific aspects of patient quality and safety. Such studies are in demand to achieve a clinically significant reduction in the incidence of medical errors. Conclusion. Despite the growing recognition of the role of human medical error in medicine, to prevent or mitigate their consequences requires the search for adequate ways both at the individual and systemic levels.

Exploring Safety Aspects in Dental School Clinics Including Droplet Infection Prevention

BACKGROUND: Health-care safety focuses on improving patient’s and worker’s safety in a safe working clinics’ environment and prevent infection transmission including droplet infections as seasonal influenza and novel coronavirus (COVID-19). Dental health-care personnel (DHCP) are the target of safety measures and are themselves responsible for elimination of preventable harm. Dental schools are expected to demonstrate the model for quality safe care.&#x0D; AIM: This study aims to achieve high-quality safe dental care at dental clinics, Faculty of Dentistry, Cairo University.&#x0D; METHODS: A cross-sectional survey study was conducted at two Dental Outpatient Clinics, Cairo University. Disk review of policies, observation checklists for practices and awareness questionnaires of DHCP were used.&#x0D; RESULTS: DHCP showed good awareness for most of infection control (IC) and X-ray safety items. However, there are no policies or procedures to control droplet infections in the clinics. The clinics were closed in the current COVID-19 pandemic. There were poor patient safety practices, hand hygiene compliance, and personal protective equipment (PPE) use except for protecting clothes and disposable gloves. Students showed better compliance for patient safety guidelines. Other safety policies were poorly communicated.&#x0D; CONCLUSION: There should be preparedness plan to deal with any droplet infection outbreak, epidemic or pandemic as COVID-19 in all dental settings. There is a need to initiate dental safety unit in dental schools to implement, communicate, train, and supervise all dental safety practices including infection control.

You Have Control: aviation communication application for safety-critical times in surgery.

High-risk organisations (HRO), including aviation, undergo formal communication training, with emphasis on safety-critical moments. Such training is not widespread or mandatory in healthcare, and while there are many differences both share the ‘human element’ with circumstances leading to an increased risk of harm. A typical operating theatre consists of an operating surgeon, and an assisting surgeon, roles that may change throughout the course of a procedure. Similarly, a training aircraft or multi-crew cockpit (flight deck) has a pilot in control, or ‘pilot flying’, and a ‘pilot not flying’. Both interact with wider teams, for example the scrub team and air traffic controllers, respectively. Surgical error is the second most prevalent cause of preventable harm to patients after drug errors. Every year in the UK National Health Service (NHS), there are typically 500 never events, 21,000 serious incidents, and many more episodes of physical or psychological harm. Ineffective communication (46%) is the most common behavioural factor leading to a never event. In this review, we examine the concept of ‘sterile cockpit’, use of unambiguous terminology, callsigns, important information readback, sharing of mental models, and the mini-brief, and how these may be used to reduce patient harm during safety-critical moments.

COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada

Healthcare resources have been strained to previously unforeseeable limits as a result of the COVID-19 pandemic of 2020. This has prompted the emergence of critical just-in-time COVID-19 education, including rapid simulation preparedness, evaluation and training across all healthcare sectors. Simulation has been proven to be pivotal for both healthcare provider learning and systems integration in the context of testing and integrating new processes, workflows, and rapid changes to practice (e.g., new cognitive aids, checklists, protocols) and changes to the delivery of clinical care. The individual, team, and systems learnings generated from proactive simulation training is occurring at unprecedented volume and speed in our healthcare system. Establishing a clear process to collect and report simulation outcomes has never been more important for staff and patient safety to reduce preventable harm. Our provincial simulation program in the province of Alberta, Canada (population = 4.37 million; geographic area = 661,848 km2), has rapidly responded to this need by leading the intake, design, development, planning, and co-facilitation of over 400 acute care simulations across our province in both urban and rural Emergency Departments, Intensive Care Units, Operating Rooms, Labor and Delivery Units, Urgent Care Centers, Diagnostic Imaging and In-patient Units over a 5-week period to an estimated 30,000 learners of real frontline team members. Unfortunately, the speed at which the COVID-19 pandemic has emerged in Canada may prevent healthcare sectors in both urban and rural settings to have an opportunity for healthcare teams to participate in just-in-time in situ simulation-based learning prior to a potential surge of COVID-19 patients. Our coordinated approach and infrastructure have enabled organizational learnings and the ability to theme and categorize a mass volume of simulation outcome data, primarily from acute care settings to help all sectors further anticipate and plan. The goal of this paper is to share the unique features and advantages of using a centralized provincial simulation response team, preparedness using learning and systems integration methods, and to share the highest risk and highest frequency outcomes from analyzing a mass volume of COVID-19 simulation data across the largest health authority in Canada.

Opioid Use Disorder and Overdose in Older Adults With Breast, Colorectal, or Prostate Cancer.

Despite high rates of opioid therapy, evidence about the risk of preventable opioid harms among cancer survivors is underdeveloped. Our objective was to estimate the odds of opioid use disorder (OUD) and overdose following breast, colorectal, or prostate cancer diagnosis among Medicare beneficiaries. We conducted a retrospective cohort study using 2007-2014 Surveillance, Epidemiology, and End Results-Medicare data for cancer survivors with a first cancer diagnosis of stage 0-III breast, colorectal, or prostate cancer at age 66-89 years between 2008 and 2013. Cancer survivors were matched to up to 2 noncancer controls on age, sex, and Surveillance, Epidemiology, and End Results region. Using Firth logistic regression, we estimated adjusted 1-year odds of OUD or nonfatal opioid overdose associated with a cancer diagnosis. We also estimated adjusted odds of OUD and overdose separately and by cancer stage, prior opioid use, and follow-up time. Among 69 889 cancer survivors and 125 007 controls, the unadjusted rates of OUD or nonfatal overdose were 25.2, 27.1, 38.9, and 12.4 events per 10 000 patients in the noncancer, breast, colorectal, and prostate samples, respectively. There was no association between cancer and OUD. Colorectal survivors had 2.3 times higher odds of opioid overdose compared with matched controls (adjusted odds ratio = 2.33, 95% confidence interval = 1.49 to 3.67). Additionally, overdose risk was greater in those with more advanced disease, no prior opioid use, and preexisting mental health conditions. Opioid overdose was a rare, but statistically significant, outcome following stage II-III colorectal cancer diagnosis, particularly among previously opioid-naïve patients. These patients may require heightened screening and intervention to prevent inadvertent adverse opioid harms.

Paediatric Focused Triggering Tool (PFTT) To Assess the Harm and its Utilization to Minimize the Levels of Harm among Children at a Tertiary Care Hospital

Abstract: Objectives: Very few paediatric trigger tools have been developed to assess harm in children. Hence, a Paediatric-focused trigger tool has been developed, assess its utility to measure the levels of harm, categorize and minimize them further. Methodology: The final 40 trigger tool developed by modifying IHI-GTT adult care, was prospectively tested for structural review of records (n=520) of paediatric population of a tertiary care hospital for incidence of adverse events (AE’s) with associated harm and categorized using modified NCCMERP (National Coordinating Council for Medication Error Reporting and Prevention) index from E-I. Results: Among 292 male and 228 female children, the incidence of AEs was 35%, more in the category of 1-5 years of age with harm assessment events. Out of 182 AEs identified, 107(58.80%) were found to be of E-category, 43(23.62%) were of category F, 22(12.08%) with category G, 9(4.95%) with category H and 1(0.55%) was category I. Two third of the paediatric population of category E and F (82.4%) had temporary harm and remaining (17.6%) were of non- preventable harm, category G-I. One example of AE identified with harm was, decrease in 25% in Haemoglobin or Haematocrit and number of blood transfusions. Further action was taken to strictly monitor and minimize further harm. Conclusion: The present study highlights on the harm assessment among the paediatric population with the help of developed Paediatric-Focused Trigger Tool (PFTT) modified by using IHI-GTT adult trigger tool. This helps paediatric set ups to assess its usefulness and further develop strategies to mitigate the harm. Key words: Paediatric, Trigger tool, AEs, NCCMERP Index, Harm.

Picking Up the Pieces: Healthcare Quality in a Post-COVID-19 World.

Picking Up the Pieces: Healthcare Quality in a Post-COVID-19 World.

Access to Care for Individuals with Opioid Use Disorder

The United States is currently facing two severe public health emergencies: COVID-19 and the continuing epidemic of preventable opioid-related harm. While these epidemics share some similarities, there is one key difference: while there are currently no approved pharmaceutical treatments for the novel coronavirus, highly effective medications to treat opioid use disorder (OUD) have existed for decades. Despite their proven efficacy, access to these medications has long been limited by federal and state laws, limitations that disproportionately impact those who are made particularly vulnerable by structural factors including economic injustice and structural racism. In response to the COVID-19 epidemic, the U.S. Drug Enforcement Administration and other federal agencies have taken steps to temporarily remove some legal and regulatory barriers to these medications. These changes are not comprehensive, and most are tied to the COVID-19 public health emergency declaration. The epidemic of opioid-related harm will not end when the new coronavirus is controlled or the related emergency declaration expires. Indeed, it seems likely that steps taken to attempt to control the virus’ spread may result in an even more unhealthy risk environment for people with OUD, with a resulting increase in treatment need. This Chapter briefly highlights the potential positive impact of increased access to OUD treatment, current changes to increase access to that treatment, and recommendations for making those changes permanent.This paper was prepared as part of Assessing Legal Responses to COVID-19, a comprehensive report published by Public Health Law Watch in partnership with the de Beaumont Foundation and the American Public Health Association.

The Impact of Psychological Safety Congruence on Safety Citizenship in Healthcare Organizations

Patients continue to experience significant morbidity and mortality from preventable harm in healthcare organizations despite considerable investment, oversight and increased attention to patient safety. This paper explores the impact of psychological safety congruence between supervisors and workers on safety citizenship behaviours as a potential explanation for the stall in healthcare’s safety progress. High reliability organizations are defined and discussed as exemplars of safe and reliable operations. Psychological safety, safety climate and safety citizenship behaviours are explored as important components of safety cultures. A conceptual model which uses Festinger’s cognitive dissonance theory to augment Ajzen’s theory of planned behaviour is outlined and used to illustrate how psychological safety incongruence can affect the performance of safety citizenship behaviours at a unit level. Finally, the theoretical and practical implications of this model and psychological safety congruence are discussed in order to provide directions for future work aimed at developing new mechanisms through which healthcare safety culture can be understood and ultimately, enhanced.

Operational measurement of diagnostic safety: state of the science.

Reducing the incidence of diagnostic errors is increasingly a priority for government, professional, and philanthropic organizations. Several obstacles to measurement of diagnostic safety have hampered progress toward this goal. Although a coordinated national strategy to measure diagnostic safety remains an aspirational goal, recent research has yielded practical guidance for healthcare organizations to start using measurement to enhance diagnostic safety. This paper, concurrently published as an Issue Brief by the Agency for Healthcare Research and Quality, issues a "call to action" for healthcare organizations to begin measurement efforts using data sources currently available to them. Our aims are to outline the state of the science and provide practical recommendations for organizations to start identifying and learning from diagnostic errors. Whether by strategically leveraging current resources or building additional capacity for data gathering, nearly all organizations can begin their journeys to measure and reduce preventable diagnostic harm.

From kamishibai card to key card: a family-targeted quality improvement initiative to reduce paediatric central line-associated bloodstream infections

BackgroundCentral line-associated bloodstream infections (CLABSIs) are major contributors to preventable harm in the inpatient paediatric setting. Despite multiple guidelines to reduce CLABSI, sustaining reliable central line maintenance bundle compliance remains...

Improving Patient Handoffs and Transitions through Adaptation and Implementation of I-PASS Across Multiple Handoff Settings.

Introduction:Communication failures are common root causes of serious medical errors. Standardized, structured handoffs improve communication and patient safety. I-PASS is a handoff program that decreases medical errors and preventable patient harm. The I-PASS mnemonic is defined as illness severity, patient information, action list, situational awareness and contingency plans, and synthesis by receiver. I-PASS was validated for physician handoffs, yet has the potential for broader application. The objectives of this quality improvement initiative were to adapt and implement I-PASS to handoff contexts throughout a pediatric hospital, including those with little or no known evidence of using I-PASS.Methods:We adapted and implemented I-PASS for inpatient nursing bedside report, physician handoff, and imaging/procedures handoff. Throughout the initiative, end-user stakeholders participated as team members and informed the adaptation of the I-PASS mnemonic, handoff processes, written handoff documents, and performance evaluation methods. Peers observed handoffs, scored performance, and provided formative feedback. Adherence to I-PASS was the primary outcome. We also evaluated changes in handoff-related error frequency and clinician attitudes about the effects of I-PASS on personal and overall handoff performance.Results:All 5 elements of the I-PASS mnemonic were used in 87% of inpatient nursing, 76% of physician, and 89% of imaging/procedures handoffs. Inpatient nurses reported reductions in handoff-related errors following I-PASS implementation. Clinicians across most handoff settings reported that using I-PASS improved both general and personal handoff performance.Conclusions:I-PASS is adaptable to many handoff settings, which expands its potential to improve patient safety. Clinicians reported reductions in errors and improvements in handoff performance. We identified broad institutional support, customized written handoff documents, and peer observations with feedback as crucial factors in sustaining I-PASS usage.

Prevention of Central Line-Associated Bloodstream Infections in Children: Current Challenges and Opportunities

No longer are healthcare-acquired conditions considered expected costs of care. Given the lack of randomized controlled trials in children, often we are left with extrapolating from adult literature, recommended prevention bundles, and expert opinion. Additionally, strategies that are considered adjunct to the standard prevention bundles have been examined. Here, we review standard central line-associated bloodstream infection (CLABSI) prevention bundles as well as adjunct prevention strategies. Due to the mortality and morbidity risk, indirect and direct costs, and the inevitable penalties associated with these largely preventable harms, we must reliably implement bundles to avoid these healthcare-acquired infections.

Severe and fatal medication errors in hospitals: findings from the Norwegian Incident Reporting System

BackgroundEven with global efforts to prevent medication errors, they still occur and cause patient harm. Little systematic research has been done in Norway to address this issue.ObjectivesTo describe the frequency,...