Targeted Staff Education Research Articles

Strategies used to detect and mitigate system-related errors over time: A qualitative study in an Australian health district

BackgroundElectronic medical record (EMR) systems provide timely access to clinical information and have been shown to improve medication safety. However, EMRs can also create opportunities for error, including system-related errors or errors that were unlikely or not possible with the use of paper medication charts. This study aimed to determine the detection and mitigation strategies adopted by a health district in Australia to target system-related errors and to explore stakeholder views on strategies needed to curb future system-related errors from emerging.MethodsA qualitative descriptive study design was used comprising semi-structured interviews. Data were collected from three hospitals within a health district in Sydney, Australia, between September 2020 and May 2021. Interviews were conducted with EMR users and other key stakeholders (e.g. clinical informatics team members). Participants were asked to reflect on how system-related errors changed over time, and to describe approaches taken by their organisation to detect and mitigate these errors. Thematic analysis was conducted iteratively using a general inductive approach, where codes were assigned as themes emerged from the data.ResultsInterviews were conducted with 25 stakeholders. Participants reported that most system-related errors were detected by front-line clinicians. Following error detection, clinicians either reported system-related errors directly to the clinical informatics team or submitted reports to the incident information management system. System-related errors were also reported to be detected via reports run within the EMR, or during organisational processes such as incident investigations or system enhancement projects. EMR redesign was the main approach described by participants for mitigating system-related errors, however other strategies, like regular user education and minimising the use of hybrid systems, were also reported.ConclusionsInitial detection of system-related errors relies heavily on front-line clinicians, however other organisational strategies that are proactive and layered can improve the systemic detection, investigation, and management of errors. Together with EMR design changes, complementary error mitigation strategies, including targeted staff education, can support safe EMR use and development.

Sugar Sickness in Aboriginal & Torres Strait Islander Cardiology Patients—Hitting the Sweet Spot

We aimed to evaluate improvement in diabetes screening, medication use, and GP clinical handover in Indigenous Australian cardiology patients at Princess Alexandra Hospital. Following the initial audit, the multifaceted interventions in 2018 were increased pathology testing of HbA1c from 6 to 7 days a week, targeted staff education, systematic HbA1c screening for patients under the care of Better Cardiac Care (BCC), Coronary Care Unit, and Cardiac Rehabilitation Team.

Knowledge, Attitudes, and Practices of Pediatric Long-term Care Facility Staff Regarding Infection Control for Acute Respiratory Infections and Influenza Vaccination

We surveyed clinical staff and on-site teachers working at pediatric long-term care facilities regarding prevention and control of acute respiratory infections and influenza in staff and residents. We uncovered knowledge gaps, particularly among teachers and clinical staff working <5 years at sites, thereby elucidating areas for targeted staff education.

Implementation of an opioid weaning protocol to improve pain management, and to prevent or decrease iatrogenic withdrawal syndrome in the neonatal intensive care.

The aim of this evidence implementation project was to improve pain assessment and management of the neonate receiving an opioid infusion, and to prevent or decrease the incidence of iatrogenic withdrawal syndrome (IWS). The current project was carried out in two intensive care areas of a 79 bed tertiary Neonatal Unit in Australia. A pre/postaudit design was utilized. Patient charts were reviewed to collect baseline audit data on pain assessments and titration of opioids. A weaning protocol was developed and implemented along with targeted staff education to align current practice with best practice recommendations. A postimplementation audit was then conducted to evaluate changes in practice. A total of 32 charts (13 pre/19 post) were reviewed to evaluate pain assessment, titration of opioids, and the identification of any signs and symptoms of IWS. The results demonstrated an improvement in the completion of pain assessments by 34%, and 100% compliance to withdrawal assessment following the introduction of an IWS assessment tool. For neonates receiving analgesics for less than 4 days, adherence to the weaning schedule occurred in 75%. No clinical signs of IWS were seen in this cohort. For neonates receiving analgesics for greater than 4 days, adherence to the weaning schedule occurred in only 55%. Of those neonates where the protocol was not followed, 67% developed clinical signs of IWS. Although this project demonstrated improvements in pain assessment and the identification of IWS, lack of adherence to the pain management policy and weaning tool has increased awareness of the importance of collaboration within the multidisciplinary team to improve outcomes. Several barriers were identified prior to implementation and various methods were employed to overcome these. Despite this, consistency of practice and change-management remain a challenge in clinical care.

Implementation of a survivorship clinic in a medically underserved comprehensive community cancer center.

54 Background: Historically, preparation of Survivorship Care Plans (SCPs) had been a cumbersome challenge that resulted in a limited number of plans delivered to eligible patients. In 2015, eleven breast SCPs were prepared and delivered by an RN. Upon review, it was determined the process of preparation and delivery of SCPs required refinement. Methods: Initially, we identified the barriers to our practice, which included limited knowledge, process, personnel, and software interfacing. We implemented a quality improvement project with the goal of delivery of SCPs to an increased number of cancer survivor patients. The project targeted staff education to identify eligible patient populations, create awareness of the Commission on Cancer accreditation requirements, and the knowledge necessary to create a SCP. We coordinated with the information technology department to attempt interfacing software programs, track the delivery of plans, and use provider notes to export data. We increased communication between departments to identify eligible patient populations. A nurse practitioner was assigned the responsibility for preparation and delivery of the document during a scheduled appointment, which focused on review and education in relation to the patient’s diagnosis, treatment plan, sequelae and recommended surveillance. Results: Through close coordination of interdisciplinary teams, we were able to implement strategies to develop a streamlined process to create and deliver SCPs. These interventions resulted in the Survivorship Clinic going from 11 breast cancer SCPs delivered in 2015 to 98 and counting, of all types of cancer, delivered in 2016. Patients requested follow up visits to the Survivorship clinic. Conclusions: We have successfully developed a Survivorship Clinic within a federally designated medically underserved community setting. Implementation of best practices resulted in nine-fold increase in delivery of SCPs. Most importantly, we have increased patient education and satisfaction. Our practices can be replicated by other programs and thereby curb the disparity of cancer survivorship care in rural areas.

G569(P) Patient safety improvement project. prescription of intravenous fluids for administration in children

Context The prescription of IV fluids is a commonplace task on the paediatric ward and its importance is often underestimated. National Patient Safety Agency (NPSA) has issued an alert in 2007 advising clinicians about the risk of hyponatraemia in children receiving intravenous (IV) fluids. Accurate prescription of IV fluids and careful monitoring are crucial in preventing fluid induced hyponatraemia in children. Hence, a local IV fluid prescription guideline was developed and a patient safety improvement project was set up to ensure that the guideline is adhered to. Problem A prospective audit was performed in November 2012, looking at all children who were admitted to a busy district general children hospital and prescribed IV fluids over a 2 week period. Prescription of IV fluid rate, type of fluid used, potassium content as well as monitoring of patient’s renal function, fluid balance and daily weight were audited. Assessment of problem and analysis of its causes The results of this audit show that type of fluid, rate of fluid and daily monitoring of UEs are done relatively well. Weight monitoring and fluid balance was poorly done. Intervention We took few actions to improve the outcome. Further education of junior doctors, nurses and allied health care professionals was provided. Fluid prescription chart was updated to act as a visual cue and to enable accurate calculation of fluid rate and renal function monitoring. Strategy for change Our strategy to improve the compliance to the standards was by focussing on the targeted education package for both medical and nursing team. We designed an IV fluid teaching booklet with assessments to be carried out by all junior doctors during the departmental induction followed by a seminar every few months. Awareness regarding the standards was created among nursing colleagues. Measurement of improvement A similar prospective reaudit was performed in November 2013 on all children admitted over a 2 week period in the same hospital. Effects of changes The prescription of type of fluid, rate of fluid and daily monitoring of UEs are done relatively well. Prescription of potassium containing fluids, monitoring of daily weights and fluid balance which were badly done on the initial audit with compliance rate of 40%, 40% and 58% respectively improved to 71%, 71% and 61% during the reaudit. Lessons learnt This project highlights the importance of education and enhanced training for staff. We are highlighting the results to all clinician as well as nursing staff during departmental meetings to raise awareness and identify solutions to barriers identified on a regular basis. Message for others Targeted staff education and training are paramount important in improving the quality of care. These can be cost effective and by effective organisation, can successfully implement locally.

G38(P) The challenge of change

IntroductionGastroenteritis poses a major burden for health services. National Accident Emergency Medical guidelines for acute gastroenetritis in children provide a clear, safe guideline to instruct assessment and treatment of acute...

Preoperative fasting: current practice and areas for improvement

Preoperative fasting aims to increase patient safety by reducing the risk of adverse events during general anaesthesia. However, prolonged fasting may be associated with dehydration, hypoglycaemia and electrolyte imbalance as well as patient discomfort. We aimed to examine compliance with the current best practice guidelines in a large surgical unit and to identify areas for improvement. Adult patients undergoing elective and emergency general, orthopaedic, gynaecology and vascular surgery procedures in the Royal Infirmary of Edinburgh were surveyed over a 3-month period commencing November 2011. A standardised questionnaire was used to collect information on the duration of preoperative fasting and the advice administered by medical and nursing staff. 292 patients were included. Median fast from solids was 13.5h for elective patients (IQR 11.5-16) and 17.38h for emergency patients (IQR 13.68-28.5h). Similarly, the median fast from fluids was 9.36h for elective patients (IQR 5.38-12.75h) and 12.97h for emergency patients (IQR 8.5-16.22h). The instructions that elective patients received contributed to prolonged fasting times. The median fast for elective patients fully compliant with fasting advice would be 10h for solids (IQR 8.75-12h) and 6.25h (IQR 3.83-9.25h) for clear fluids. Elective patients fasted for longer than recommended confirming that clinical practice is slow to change. The use of universal fasting instructions and patient choice are factors that unnecessarily prolong preoperative fasting, which however appears to be multifactorial. Service improvement by abbreviation of the observed fasting periods will rely on targeted staff education and effective clinical communication by provision of written information for both elective and emergency surgical patients. The routine use of preoperative nutritional supplements may need to be re-examined when further evidence is available.

LETHAL MEANS RESTRICTION FOR SUICIDE PREVENTION: BELIEFS AND BEHAVIORS OF EMERGENCY DEPARTMENT PROVIDERS

We sought to examine the beliefs and behaviors of emergency department (ED) providers related to preventing suicide by reducing suicidal patients' access to lethal methods (means restriction) and identify characteristics associated with asking patients about firearm access. Physicians and nurses at eight EDs completed a confidential, voluntary survey. The response rate was 79% (n = 631); 57% of respondents were females and 49% were nurses. Less than half believed, "most" or "all" suicides are preventable. More nurses (67%) than physicians (44%) thought "most" or "all" firearm suicide decedents would have died by another method had a firearm been unavailable (P < .001). The proportion of providers who reported they "almost always" ask suicidal patients about firearm access varied across five patient scenarios: suicidal with firearm suicide plan (64%), suicidal with no suicide plan (22%), suicidal with nonfirearm plan (21%), suicidal in past month but not today (16%), and overdosed but no longer suicidal (9%). In multivariable logistic regression, physicians were more likely than nurses to "almost always" or "often" ask about a firearm across all five scenarios, as were older providers and those who believed their own provider type was responsible for assessing firearm access. Many ED providers are skeptical about the preventability of suicide and the effectiveness of means restriction, and most do not assess suicidal patients' firearm access except when a patient has a firearm suicide plan. These findings suggest the need for targeted staff education concerning means restriction for suicide prevention.

Adoption of an Electronic Observation Chart With an Integrated Early Warning Scoring System on Pilot Wards

The charting of physiological variables in hospital inpatients allows for recognition and treatment of deteriorating patients. The use of electronic records to capture patients' vital signs is still in its infancy in the United Kingdom. The main objective of this article was to describe the adoption of an electronic observation charting function integrated into an established bedside e-prescribing record system on acute wards in a large English university hospital. This new function also has the capability of contacting Critical Care Outreach and clinical staff when patients deteriorate. Data captured over a 4-month period from the pilot wards showed that 80% of observation sets were completed sufficiently to produce early warning scores over the time period. A daily average of 419 Standardized Early Warning Score produced 74 alerts to clinical staff, and two critical alarms per day were e-mailed to the Outreach team. The wards showed different levels of completeness of observations (from 69% to 92%). Although a good overall rate of completeness of physiological data was found, traditional gaps in observation recording documented in the literature (eg, recording of respiratory rate) were still apparent. This system can be used for audit for targeted staff education and to evaluate the Critical Care Outreach service.

Family communication coordination: a program to increase organ donation

To improve organ donation performance, the Medical College of Virginia Hospitals implemented a comprehensive family support and communication program, consisting of a standard family communications protocol, a hospital-based team from the Department of Pastoral Care, targeted staff education, and an ongoing quality assurance measuring and monitoring system. The 3 best-demonstrated request practices, private setting, "decoupling," and collaboration in the request between the organ procurement organization and hospital staff, were incorporated into the program. Improvement in the consent and donation rate was evident in the second calendar year of the program; the consent rate was 72% and the donation rate was 50%. During the second year, there was also a positive correlation between "decoupling," appropriate requestor, and the consent rate. Implementation of a hospital-based team and a standard protocol facilitated the clarification of roles and responsibilities toward clearer and more consistent family communication and support. Data suggest that staff experience is a major contributor to a positive donation outcome.

Family Communication Coordination: A Program to Increase Organ Donation

To improve organ donation performance, the Medical College of Virginia Hospitals implemented a comprehensive family support and communication program, consisting of a standard family communications protocol, a hospital-based team from the Department of Pastoral Care, targeted staff education, and an ongoing quality assurance measuring and monitoring system. The 3 best-demonstrated request practices, private setting, “decoupling,” and collaboration in the request between the organ procurement organization and hospital staff, were incorporated into the program. Improvement in the consent and donation rate was evident in the second calendar year of the program; the consent rate was 72% and the donation rate was 50%. During the second year, there was also a positive correlation between “decoupling,” appropriate requestor, and the consent rate. Implementation of a hospital-based team and a standard protocol facilitated the clarification of roles and responsibilities toward clearer and more consistent family communication and support. Data suggest that staff experience is a major contributor to a positive donation outcome.