Safety Improvement Initiatives Research Articles

A practical tool for managing change: cross-sectional psychometric assessment of the safe surgery organizational readiness tool.

Strengthening health systems through planned safety and quality improvement initiatives is an imperative to achieve more equitable, resilient, and effective care. And yet, years of organizational behavior research demonstrate that change initiatives often fall short because managers fail to account for organizational readiness for change. This finding remains true especially among surgical safety and quality improvement initiatives in low-income countries and middle-income countries. In this study, our aim was to psychometrically assess the construct validity and internal consistency of the Safe Surgery Organizational Readiness Tool (SSORT), a short survey tool designed to provide change leaders with insight into facility infrastructure that supports learning and readiness to undertake change. To demonstrate generalizability and achieve a large sample size ( n =1706) to conduct exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), a collaboration between seven surgical and anesthesia safety and quality improvement initiatives was formed. Collected survey data from health care workers were divided into pilot, exploration, and confirmation samples. The pilot sample was used to assess feasibility. The exploration sample was used to conduct EFA, while the confirmation sample was used to conduct CFA. Factor internal consistency was assessed using Cronbach's alpha coefficient. Results of the EFA retained 9 of the 16 proposed factors associated with readiness to change. CFA results of the identified 9 factor model, measured by 28 survey items, demonstrated excellent fit to data. These factors (appropriateness, resistance to change, team efficacy, team learning orientation, team valence, communication about change, learning environment, vision for sustainability, and facility capacity) were also found to be internally consistent. Our findings suggest that communication, team learning, and supportive environment are components of change readiness that can be reliably measured prior to implementation of projects that promote surgical safety and quality improvement in low-income countries and middle-income countries. Future research can link performance on identified factors to outcomes that matter most to patients.

“Good Catch” Reporting as a Foundation for Safety Improvement in Cardiopulmonary Bypass

Historically, improvement in safety focuses on incident-related data. Collecting data concerning variation from routine cardiopulmonary bypass (CPB) practice may provide a better foundation for development of safety improvement initiatives. This project aims to: identify whether education on the importance of collecting “Good Catch” data, including variations in practice during CPB, increases safety reporting and the opportunity to guide safety improvement initiatives.

Patient safety culture among healthcare professionals in Bhutan

Introduction: There is dearth of information regarding the status of patient safety culture in Bhutanese healthcare system. The aim of the study was to assess the baseline patient safety culture among the healthcare professionals working in different levels of hospitals in Bhutan. Methods: A cross-sectional study was conducted using the Hospital Survey on Patient Safety, version 2 (HSOPS2) questionnaire in 2021 in six District Hospitals (DHs), two Regional Referral Hospitals (RRHs), and one National Referral Hospital (NRH) in Bhutan. A total of 782 healthcare professionals were recruited into the study. EpiData version 3.0 and Statistical Package for Social Science (SPSS) version 28.0 were used to process data and conduct the statistical analysis on survey data including descriptive statistics and validity and reliability of survey. The internal consistency reliability of each composite measure was assessed by calculating Cronbach’s alpha score. Results: The overall level of patient safety culture was 61.28% (95% CI: 113.26, 115.27) and the percentage scores for the ten patient safety dimensions ranged from 45.13% to 82.65%. The dimension, “Teamwork within the hospital units” had the highest positive score while the dimensions, “Staffing and work pace” and “Reporting patient safety events” had the lowest positive scores. Conclusions: The healthcare professionals working in hospitals in Bhutan had average patient safety culture. To improve patient safety culture, more emphasis should be given on human resource management, patient safety event reporting system, hospital management support for patient safety and quality improvement initiatives and creating an environment that promote just and learning culture.

Hacia la excelencia en la atención farmacéutica al paciente quirúrgico

The perioperative setting is one of the hospital areas with the highest prevalence of medication errors. Despite the wide experience of hospital pharmacists in developing medication safety programs and improvement initiatives, the surgical environment has remained one of the areas in which there is less experience.Clinical pharmacist should be integrated into the multidisciplinary care teams so that they can be involved in the different surgical phases of care, which include from the preoperative assessment to inpatient stay, and finally discharge from hospital. Their work will consist of coordinating and implementing strategies that have been demonstrated to reduce medication errors throughout the perioperative process.The aim of this paper is to introduce a specialized pharmaceutical care program to achieve excellence in the pharmaceutical care of surgical patients. This program is especially aimed at promoting the figure of the clinical pharmacist in the perioperative setting to guarantee the highest quality and safety in pharmacotherapeutic care throughout all the surgical phases of care.

Translated article] Achieving excellence in the pharmaceutical care of the surgical patient

The perioperative setting is one of the hospital areas with the highest prevalence of medication errors. Despite the wide experience of hospital pharmacists in developing medication safety programs and improvement initiatives, the perioperative setting has remained one of the areas in which there is less experience.Clinical pharmacist should be integrated into the multidisciplinary care team so that they can be involved in the different surgical phases of care, which include from the preoperative assessment to inpatient stay, and finally discharge from hospital. Their work will consist of coordinating and implementing strategies that have been demonstrated to reduce medication errors during the perioperative process.The aim of this paper is to introduce a specialized pharmaceutical care program to achieve excellence in the pharmaceutical care of surgical patients. This program is especially aimed at promoting the figure of the clinical pharmacist in the perioperative setting to guarantee the highest quality and safety in pharmacotherapeutic care throughout all the surgical phases of care.

Optimizing neuromuscular blockade management for improving patient safety and peri-operative outcomes: a pilot phase of a quality improvement initiative.

Although quantitative monitoring of neuromuscular blockade (NMB) is recommended, it is not routinely used in daily practice. The optimizing NMB management to improve patient safety and perioperative outcomes (OBISPO) quality improvement (QI) initiative intends to address this issue and change clinicians' behaviors. A pilot phase of the prospective QI intervention was conducted. The primary objective was implement clinical practice change that emphasizes improving NMB monitoring in patients undergoing elective cardiac surgery who are eligible for fast-track extubation between February 2021 and December 2021. The secondary objective was to reduce the train-of-four ratio (TOFR) < 0.9 incidence before tracheal extubation to less than 20%. The intervention included educational sessions for teams. A total of 859 patients underwent elective cardiac surgery, 40% were eligible for fast-track extubation. From our cohort of fast-track cardiac cases, 69% had reported TOFR; 47% of them had residual paralysis (TOFR < 0.9) on arrival to PACU, 22% persisted with residual paralysis after extubation, and 27% were extubated without monitoring. The survey identified cognitive biases, knowledge gaps, unfamiliarity, and lack of trust in quantitative monitoring devices. Workflow disruptions imposed by COVID and changes in NMB monitoring devices have negatively affected our initiative. Our study showed that changes in clinician behavior are among the most challenging issues in perioperative medicine. Continuous teaching and QI initiatives, focused on quantitative NMB monitors and adequate reversal agent use, are mandatory to improve perioperative outcomes. Therefore, new proposals are required to promote changes in current practices.

An Asset-Based Quality Improvement Tool for Health Care Organizations: Cultivating Organizationwide Quality Improvement and Health Care Professional Engagement.

In the United States, health care organizations are often biased toward deficit-based quality and safety improvement techniques, such as incident reporting and peer review. However, deficit-based techniques may elicit negative sentiments from frontline health care professionals, causing disengagement and adverse event underreporting. To complement deficit-based quality improvement, our institution developed an organizationwide asset-based quality improvement tool. Inspired by asset-based quality improvement methodologies such as appreciative inquiry, Safety-II, and positive deviance, this tool facilitates the identification and analysis of clinical excellence. Resultant best practices and quality improvement projects are then propagated throughout our organization. Ultimately, asset-based quality improvement tools are logistically and technologically feasible for organizationwide deployment, and they potentially improve care quality and team culture. Health care organizations should consider adding these tools to their quality and safety improvement initiatives.

Quality and safety indicators for home care recipients in Australia: development and cross-sectional analyses

ObjectivesTo develop and examine the prevalence of quality and safety indicators to monitor care of older Australians receiving home care packages (HCPs), a government-funded aged care programme to support individuals to live at home independently.DesignCross-sectional.SettingHome care recipients, Australia.Participants90 650 older individuals (aged ≥65 years old and ≥50 years old for people of Aboriginal or Torres Strait Islander descent) who received a HCP between 1 January 2016 and 31 December 2016 nationally were included.Primary and secondary outcome measuresThe Registry of Senior Australians developed 15 quality and safety indicators: antipsychotic use, high sedative load, chronic opioid use, antimicrobial use, premature mortality, home medicines reviews, chronic disease management plan, wait-time for HCP, falls, fractures, medication-related adverse events, weight loss/malnutrition, delirium/dementia-related hospitalisations, emergency department (ED) presentations and pressure injuries. Risk adjusted prevalence (%, 95% CI) and geographical area (statistical level 3) variation during 2016 were examined.ResultsIn 2016, a total of 102 590 HCP episodes were included for 90 650 individuals, with 66.9% (n=68 598) level 1–2 HCP episodes (ie, for basic care needs) and 33.1% (n=33 992) level 3–4 HCP (ie, higher care needs). The most prevalent indicators included: antibiotic use (52.4%, 95% CI 52.0 to 52.7), chronic disease management plans (38.1%, 95% CI 37.8 to 38.4), high sedative load (29.1%, 95% CI 28.8 to 29.4) and ED presentations (26.4%, 95% CI 25.9 to 26.9). HCP median wait time was 134 days (IQR 41–406). Geographical variation was highest in chronic disease management plans and ED presentations (20.7% of areas outside expected range).ConclusionA comprehensive outcome monitoring system to monitor the quality and safety of care and variation for HCP recipients was developed. It provides a pragmatic, efficient and low burden tool to support evidence-based quality and safety improvement initiatives for the aged care sector.

The patient's "story": an examination of patient-reported safety incidents in general practice.

Patient safety incidents (PSIs) are typically studied through engagement with healthcare providers, without input from patients despite their privileged viewpoint of care experiences. To examine the potential of the patient viewpoint as a lens for future safety improvement initiatives, by: (i) collecting and analysing patients' accounts of PSIs; and (ii) comparing patient and clinician perceptions of PSIs. Firstly, Critical Incident Technique (CIT) interviews were used to obtain rich descriptions of PSIs, which were then condensed into patient stories. Deductive content analysis was used to code the safety deficiencies described in patient stories using patient-derived safety categories. Secondly, General Practitioners (GPs) and patients individually rated the perceived severity and likelihood of each story. A total of 32 eligible patient stories were obtained from 25 interviews. Stories commonly described deficiencies related to communication, staff performance, and compassion/dignity/respect. There were significant differences in GP (n = 14) and patient (n = 11) severity and likelihood ratings. GPs were significantly more likely to consider stories to be a lower severity, and occurring with a lower frequency than patients. Elicitation of the patient perspective using the CIT allowed for the rich description of safety deficiencies that occur in general practice. Given that patients bring a unique and important viewpoint on safety, there is a need to make greater efforts to include the patient perspective of safety in healthcare.

All in for patient safety: a team approach to quality improvement in our laboratories.

Patient safety and quality improvement initiatives are integral parts of every cytopathology laboratory. The need to revisit our approaches to patient safety are essential in light of the expanding test menu, ancillary studies, comprehensive diagnostic reports, and emergence of new technologies for augmenting cytologic diagnosis. Our interview with Drs. Yael Heher, Adam Seegmiller, and Paul VanderLaan explores recent developments that have shaped their perspectives in patient safety, test usage, and laboratory quality. The practical strategies presented provide tools for enhanced patient safety and improved outcomes in a new era of ancillary and molecular testing and standardized reporting in the cytopathology laboratory.

Systematic Review of Patient Safety and Quality Improvement Initiatives in Breast Reconstruction.

Improving patient care and safety requires high-quality evidence. The objective of this study was to systematically review the existing evidence for patient safety (PS) and quality improvement initiatives in breast reconstruction. A systematic review of the published plastic surgery literature was undertaken using a computerized search and following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Publication descriptors, methodological details, and results were extracted. Articles were assessed for methodological quality and clinical heterogeneity. Descriptive statistics were completed, and a meta-analysis was considered. Forty-six studies were included. Most studies were retrospective (52.2%) and from the third level of evidence (60.9%). Overall, the scientific quality was moderate, with randomized controlled trials generally being higher quality. Studies investigating approaches to reduce seroma (28.3% of included articles) suggested a potential benefit of quilting sutures. Studies focusing on infection (26.1%) demonstrated potential benefits to prophylactic antibiotics and drain use under 21 days. Enhanced recovery after surgery protocols (10.9%) overall did not compromise PS and was beneficial in reducing opioid use and length of stay. Interventions to increase flap survival (10.9%) demonstrated a potential benefit of nitroglycerin on mastectomy skin flaps. Overall, studies were of moderate quality and investigated several worthwhile interventions. More validated, standardized outcome measures are required, and studies focusing on interventions to reduce thromboembolic events and bleeding risk could further improve PS.

Reducing Implicit Bias in Maternity Care: A Framework for Action

Reducing Implicit Bias in Maternity Care: A Framework for Action

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.

Development of prescribing safety indicators related to mental health disorders and medications: Modified e-Delphi study.

To develop a set of prescribing safety indicators related to mental health disorders and medications, and to estimate the risk of harm associated with each indicator. A modified two-stage electronic Delphi. The first stage consisted of two rounds in which 31 experts rated their agreement with a set of 101 potential mental health related prescribing safety indicators using a five-point scale and given the opportunity to suggest other indicators. Indicators that achieved 80% agreement were accepted. The second stage comprised a single round in which 29 members estimated the risk of harm for each accepted indicator by assessing the occurrence likelihood and outcome severity using two five-point scales. Indicators were considered high or extreme risk when at least 80% of participants rated each indicator as high or extreme. Seventy-five indicators were accepted in the first stage. Following the second stage, 42 (56%) were considered to be high or extreme risk for patient care. The 42 indicators comprised different types of hazardous prescribing, including drug-disease interactions (n = 12), drug-drug interactions (n = 9), inadequate monitoring (n = 5), inappropriate duration (n = 4), inappropriate dose (n = 4), omissions (n = 4), potentially inappropriate medications (n = 3) and polypharmacy (n = 1). These indicators also covered different mental health related medication classes, including antipsychotics (n = 14), mood stabilisers (n = 8), antidepressants (n = 6), sedative, hypnotics and anxiolytics (n = 6), anticholinergic (n = 6) and nonspecific psychotropics (n = 2). This study has developed the first suite of prescribing safety indicators related to mental health disorders and medications, which could inform the development of future safety improvement initiatives and interventional studies.

COVID-19 and Racial Disparities: Moving Towards Surgical Equity.

COVID-19 and Racial Disparities: Moving Towards Surgical Equity.

Exploring primary health care professionals' perceptions about a patient feedback intervention to improve patient safety in Spanish primary health care centres: a qualitative study.

Patient feedback interventions are receiving increasing attention given their potential to improve health care provision. However, primary health care (PHC) professionals' acceptability and perceived utility of this type of interventions remain largely unexplored. The aim of this study was to explore PHC professionals' perceptions, opinions and suggestions about a patient feedback intervention currently being designed to improve patient safety in Spanish PHC centres. We conducted an exploratory qualitative study with 43 PHC professionals. Information was obtained from three semi-structured interviews and four focus groups. All data were audio-recorded, transcribed and analyzed using content analysis by three analysts. The patient feedback intervention was acceptable to health care professionals, who perceived it as a useful strategy to improve health care processes and activate patients. A number of factors potentially limiting the acceptability and perceived utility of the intervention were identified (low patient safety culture, low patient-centred care orientation and limited credibility of patient feedback data). Recommendations for designing and implementing the proposed intervention in the Spanish PHC centres were identified in relation to the following areas: 'collection and analysis of feedback data'; 'feedback display'; 'feedback delivery' and; 'implementation of safety improvement initiatives'. Although the proposed intervention was generally perceived as useful and acceptable, our study identified a number of tensions about the practical aspects of using the patient-reported data and the credibility of the data and what actions would arise from its use. The intervention has been adapted to address these tensions before its formal evaluation in a randomized clinical trial.

\u201cWe\u2019ve got the home care data, what do we do with it?\u201d: understanding data use in decision making and quality improvement

BackgroundIn the past decade the provision of home care services in Canada has doubled; with this increase there has been a growing interest in improving quality and safety. National-level data are captured in the Home Care Reporting System (HCRS), using the interRAI-HC tools. Data in the HCRS provide decision-makers and administrators with actionable evidence to inform quality and safety improvement initiatives. The objective of this study was to determine how providers and administrators were using these data, and if there were any opportunities to enhance their use.MethodsWe collaborated with the Canadian Patient Safety Institute to conduct this qualitative study. To understand data use in home care, we recruited participants in management and/or data analysis roles from home care organizations across Canada. We conducted three individual interviews and three focus group interviews with a total of eleven participants from five Canadian provinces. Individual and focus group interviews were audio recorded, transcribed, and analysed using a combination of emergent coding and thematic analysis.ResultsSeveral participants provided powerful examples of how interRAI data have been used to guide patient safety and quality improvement initiatives; however, all participants recognized challenges in using these data. Leveraging interRAI data in the complex home care environment is limited by several factors: the general “newness” of these data in many jurisdictions; the sheer volume of data; limited capacity and resources to interpret and analyse the data; and connectivity issues in rural areas. Participants recognized and appreciated the training that has been provided, and made several recommendations for additional training.ConclusionsMandated clinical datasets, such as the suite of interRAI tools, have the potential to improve quality and inform decision-making. However, in order to utilize these data, home care agencies require additional education, personnel and supports. Additional training and resources for these organizations could improve the use of available data by home care agencies, as well as outcomes for individuals receiving home care services.

Quality and Safety Improvement in Spine Surgery.

Study Design:Review article.Objectives:A narrative review of the literature on the current advances and limitations in quality and safety improvement initiatives in spine surgery.Methods:A comprehensive literature search was performed using Ovid MEDLINE focusing on 3 preidentified concepts: (1) quality and safety improvement, (2) reporting of outcomes and adverse events, and (3) prediction model and practice guidelines. The search was conducted under appropriate subject headings and using relevant text words. Articles were screened, and manuscripts relevant to this discussion were included in the narrative review.Results:Quality and safety improvement remains a major research focus attracting investigators from the global spine community. Multiple databases and registries have been developed for the purpose of generating data and monitoring the progress of quality and safety improvement initiatives. The development of various prediction models and clinical practice guidelines has helped shape the care of spine patients in the modern era. With the reported success of exemplary programs initiated by the Northwestern and Seattle Spine Team, other quality and safety improvement initiatives are anticipated to follow. However, despite these advancements, the reporting metrics for outcomes and adverse events remain heterogeneous in the literature.Conclusion:Constant surveillance and continuous improvement of the quality and safety of spine treatments is imperative in modern health care. Although great advancement has been made, issues with reporting outcomes and adverse events persist, and improvement in this regard is certainly needed.

Opioid Overdose in the Hospital Setting: A Systematic Review.

Our objective was to determine the percentage of opioid overdose events among medical and surgical inpatient admissions, and to identify risk factors associated with these events. We searched PubMed and CINAHL databases from inception through July 30, 2017 and identified additional studies from reference lists and other reviews. Articles were included if they reported original research on the rate of opioid overdoses or opioid-related adverse events, and the adverse events occurred in a general medical hospital during an inpatient stay. We extracted information on study population, design, results, and risk for bias using the Newcastle-Ottawa Quality Assessment Scale. We performed this review in accordance with recently suggested standards and report our findings as per the Meta-Analyses and Systematic Reviews of Observational Studies guidelines. Thirteen studies met our eligibility criteria. The percentage of opioid overdoses ranged from 0.06% to 2.50% of hospitalizations. The majority of studies used only 1 method of event detection. Risk factors for overdose included older age, infancy, medical comorbidity, substance use disorder diagnosis, combining opioids with other sedatives, and admission to hospitals with higher opioid-prescribing rates. Opioid overdose in the inpatient setting is a serious preventable harm and is likely underestimated in much of the current literature. Improved detection methods are needed to more accurately measure the rate of inpatient opioid overdose. Refined estimates of opioid overdose should be used to drive safety and quality improvement initiatives in hospitals.

Developing a standardized approach to cancer medication-related infusion reaction prevention and management in Ontario.

255 Background: Cancer medication-related infusion reactions (CMIRs) can lead to treatment delays, switching to less optimal therapy, or discontinuation. Variation in the prevention, management and reporting of CMIRs was identified as a quality and safety gap by Ontario clinicians. This initiative aimed to facilitate a standardized approach to CMIRs in Ontario through the development of user-friendly health-care provider and patient resources. Methods: A multidisciplinary working group of 15 oncology clinicians (oncologists, pharmacists, nurses, administrators) with experience in the management of CMIRs reviewed available literature on CMIR assessment, prevention and management. Recommendations were based on best available evidence and group consensus when only low-level evidence was available. Final guideline content was reviewed and validated by external experts. Complementary patient information was created based on best practices in health literacy and input from patient education experts, patients and caregivers. A mechanism for system-wide reporting to track CMIRs was explored. Results: A CMIR clinical practice guideline was created. Definitions, risk factors, prophylaxis strategies, an acute management algorithm and desensitization protocols are described. A CMIR severity grading system was proposed. A toolkit was developed and contains a table outlining risk factors, mechanism, incidence, symptoms, onset, prophylaxis, acute management and re-challenge by specific drug and a tool for calculating a three-bag 12-step desensitization. Patient-friendly information was also created. A new data element for collection of CMIR incidence and severity was added to the provincial Activity Level Reporting (ALR) data set to track CMIR trends. Conclusions: A review of current evidence and expertise from oncology clinicians resulted in an evidence-informed, consensus-based guideline. This guideline and the accompanying resources can help to facilitate safe and standardized prevention and management of CMIRs across Ontario. The collection of system-wide CMIR data based on the proposed grading system will inform future quality and safety improvement initiatives.