Interruption science is thus important in its own right. As importantly, it also provides us with a model...]]>
The under-reporting of medication errors can compromise patient safety. A qualitative study was conducted to enhance the understanding of barriers to medication error reporting in healthcare organisations.
Focus groups (with physicians, pharmacists and nurses) and in-depth interviews (with risk managers) were used to identify medication error reporting beliefs and practices at four community hospitals in Nova Scotia, Canada. Audio tapes were transcribed verbatim and analysed for thematic content using the template style of analysis. The development and analysis of this study were guided by Safety Culture Theory.
Incentives for medication error reporting were thematised into three categories: patient protection, provider protection and professional compliance. Barriers to medication error reporting were thematised into five categories: reporter burden, professional identity, information gap, organisational factors and fear. Facilitators to encourage medication error reporting were classified into three categories: reducing reporter burden, closing the communication gap and educating for success. Participants indicated they would report medication errors more frequently if reporting were made easier, if they were adequately educated about reporting, and if they received timely feedback.
Study results may lead to a better understanding of the barriers to medication error reporting, why these barriers exist and what can be done to successfully overcome them. These results could be used by hospitals to encourage reporting of medication errors and ultimately make organisational changes leading to a reduction in the incidence of medication errors and an improvement in patient safety.
The aim of this systematic review was to develop a ‘contributory factors framework’ from a synthesis of empirical work which summarises factors contributing to patient safety incidents in hospital settings.
A mixed-methods systematic review of the literature was conducted.
Electronic databases (Medline, PsycInfo, ISI Web of knowledge, CINAHL and EMBASE), article reference lists, patient safety websites, registered study databases and author contacts.
Studies were included that reported data from primary research in secondary care aiming to identify the contributory factors to error or threats to patient safety.
1502 potential articles were identified. 95 papers (representing 83 studies) which met the inclusion criteria were included, and 1676 contributory factors extracted. Initial coding of contributory factors by two independent reviewers resulted in 20 domains (eg, team factors, supervision and leadership). Each contributory factor was then coded by two reviewers to one of these 20 domains. The majority of studies identified active failures (errors and violations) as factors contributing to patient safety incidents. Individual factors, communication, and equipment and supplies were the other most frequently reported factors within the existing evidence base.
This review has culminated in an empirically based framework of the factors contributing to patient safety incidents. This framework has the potential to be applied across hospital settings to improve the identification and prevention of factors that cause harm to patients.
Data were used from inpatient, outpatient and accident and emergency surveys in acute trusts in England to examine consistency in patient-reported experience across services, and factors associated with systematic variations in performance.
Standardised mean scores for six domains of patient experience were constructed for each survey for 145 non-specialist acute trusts. Hierarchical cluster analysis was used to investigate whether and how trust performance clusters. Multilevel regression analysis was used to determine trust characteristics associated with performance.
Cluster analysis identified three groups: trusts that performed consistently above (30 trusts) or below (six trusts) average, and those with mixed performance. All the poor performing trusts were in London, none were foundation trusts or teaching hospitals, and they had the highest mean deprivation score and the lowest proportion of white inpatients and response rates. Foundation and teaching status, and the proportion of white inpatients, were positively associated with performance; deprivation and response rates showed less consistent positive associations. No regional effects were apparent after adjusting for independent variables.
The results have significant implications for quality improvement in the NHS. The finding that some NHS providers consistently perform better than others suggests that there are system-wide determinants of patient experience and the potential for learning from innovators. However, there is room for improvement overall. Given the large samples of these surveys, the messages could also have relevance for healthcare systems elsewhere.
The objective of this study was to qualitatively describe the impact of a Rapid Response Team (RRT) at a 944-bed, university-affiliated hospital.
We analysed 49 open-ended interviews with administrators, primary team attending physicians, trainees, RRT attending hospitalists, staff nurses, nurses and respiratory technicians.
Themes elicited were categorised into the domains of (1) morale and teamwork, (2) education, (3) workload, (4) patient care, and (5) hospital administration. Positive implications beyond improved care for acutely ill patients were: increased morale and empowerment among nurses, real-time redistribution of workload for nurses (reducing neglect of non-acutely ill patients during emergencies), and immediate access to expert help. Negative implications were: increased tensions between nurses and physician teams, a burden on hospitalist RRT members, and reduced autonomy for trainees.
The RRT provides advantages that extend well beyond a reduction in rates of transfers to intensive care units or codes but are balanced by certain disadvantages. The potential impact from these multiple sources should be evaluated to understand the utility of any RRT programme.
Subjective workload in healthcare employees is suspected to be important for the performance and safety of healthcare delivery. This study investigates associations between workflow interruptions and hospital doctors' capability to manage their perceived workload in a safe and efficient manner.
To examine the relationship of observed workflow interruptions with hospital doctors' perceived workload during day clinical shifts.
A prospective study of 43 full shift observations with 29 doctors working in internal medicine and surgical specialties. Workflow interruptions were assessed via observation using a previously validated observation instrument. Doctors assessed their workload twice throughout their day shift using three items of the validated NASA-Task Load Index (NASA-TLX; mental demands, effort, frustration).
Hospital doctors were on average disrupted 3.66 times per hour. Most frequent were interruptions by nursing staff, telephone/beeper interruptions and by fellow doctors. Senior doctors reported higher workload than their junior colleagues. Overall workflow interruptions were significantly related to doctors' workload (β=0.22; p=0.03). Further analyses revealed that doctors' workload was associated particularly with interruptions by nursing personnel (β=0.23; p=0.03).
Frequent workflow interruptions may be linked with increased workload in doctors. Healthcare environments need to be better designed to reduce unnecessary interruptions and distractions so that hospital doctors can manage clinical work efficiently and safely.
Violations of safety protocols are paths to adverse outcomes that have been poorly addressed by existing safety efforts. This study reports on nurses' self-reported violations in the medication administration process.
To assess the extent of violations in the medication administration process among nurses.
Participants were 199 nurses from two US urban, academic, tertiary care, free-standing paediatric hospitals who worked in a paediatric intensive care unit (PICU), a haematology-oncology-transplant (HOT) unit or a medical-surgical (Med/Surg) unit. In a cross-sectional survey, nurses were asked about violations in routine or emergency situations in three steps of the medication administration process.
Self-reported violations of three medication administration protocols were made using a seven-point 0–6 scale from ‘not at all’ to ‘a great deal’.
Analysis of variance identified that violation reports were highest for emergency situations, rather than for routine operations, highest by HOT unit nurses, followed by PICU nurses and then Med/Surg unit nurses, and highest during patient identification checking, followed by matching a medication to a medication administration record, and then documenting an administration. There was also a significant three-way interaction among violation situation, step in the process, and unit.
Protocol violations occur throughout the medication administration process and their prevalence varies as a function of hospital unit, step in the process, and violation situation. Further research is required to determine whether these violations improve or worsen safety, and for those that worsen safety, how to redesign the system of administration to reduce the need to violate protocol to accomplish job tasks.
To develop a patient safety curriculum and evaluate its impact on medical students' safety knowledge, self-efficacy and system thinking.
This study reports on curriculum development and evaluation of a 3-day, clinically oriented patient safety intersession that was implemented at the Johns Hopkins School of Medicine in January 2011. Using simulation, skills demonstrations, small group exercises and case studies, this intersession focuses on improving students' teamwork and communication skills and system-based thinking while teaching on the causes of preventable harm and evidence-based strategies for harm prevention. One hundred and twenty students participated in this intersession as part of their required second year curriculum. A pre–post assessment of students' safety knowledge, self-efficacy in safety skills and system-based thinking was conducted. Student satisfaction data were also collected.
Students' safety knowledge scores significantly improved (mean +19% points; 95% CI 17.0 to 21.6; p<0.01). Composite system thinking scores increased from a mean pre-intersession score of 60.1 to a post-intersession score of 67.6 (p<0.01). Students had statistically significant increases in self-efficacy for all taught communication and safety skills. Participant satisfaction with the intersession was high.
The patient safety intersession resulted in increased knowledge, system-based thinking, and self-efficacy scores among students. Similar intersessions can be implemented at medical, nursing, pharmacy and other allied health schools separately or jointly as part of required school curricula. Further study of the long-term impact of such education on knowledge, skills, attitudes and behaviours of students is warranted.
Reports of quality improvement (QI) research from low- and middle-income countries (LMICs) remain sparse in the scientific literature. The authors reviewed the published literature to describe the characteristics of such reports.
The authors conducted a systematic search for QI research articles from LMICs catalogued in the PubMed databases prior to December 2011, complemented by recommendations from experts in the field. Articles were categorised based on bibliometric and research characteristics. Twenty papers were randomly selected for narrative analysis regarding strategies used to present the methods and results of interventions.
Seventy-six articles met the inclusion criteria. Publication rate accelerated over time, particularly among observational studies. Most studies did not use a concurrent control group; pre-/post-study designs were most common overall. Four papers were published in top-tier journals, 17 in journals at the top of their specialty and 20 in quality-specific journals. Among the papers selected for narrative analysis, four distinct components were observed in most: a description of the problem state, a description of the improvement processes and tools, a separate description of the interventions tested and a description of the evaluation methods.
The small number of articles identified by this review suggests that publication of QI research from LMICs remains challenging. However, recent increases in publication rates, especially among observational studies, may attest to greater interest in the topic among scientific audiences. Though the authors are not able to compare this sample with unpublished papers, the four components observed by them in the narrative analysis seem to strengthen QI research reports.
Unplanned return to the operating theatre (UROT) is a useful trigger tool that could be used to identify surgical adverse events (SAEs). The present study describes the feasibility of SAE surveillance in neurosurgical patients, based on UROT identification, completed with SAE analysis at a morbidity–mortality conference (MMC) meeting.
For consecutive patients who underwent a neurosurgical procedure between 1 November 2008 and 30 April 2009, return to the operating theatre (ROT) was identified based on the hospital information system associated to prospective payment (HISPP). ROT was classified as planned or unplanned and UROT was further classified as related to the natural history of the disease or related to an adverse event (AE-UROT). MMC meetings were organised to discuss results of UROT surveillance and to analyse AE-UROT.
1006 neurosurgical procedures were included in the surveillance. HISSP identified 152 ROTs, with 73 UROTs related to an SAE (7.3% (5.7% to 9.0%)): infectious SAE (n=24, 2.4% (1.5% to 3.5%)), haemorrhagic SAE (n=23, 2.3% (1.5% to 3.4%)), other cause SAE (n=26, 2.8% (1.9% to 4.0%)), and infectious and other cause SAE (n=2, 0.2% (0.0% to 0.7%)). Identification of AE-UROT through HISSP required a 4 h/month time frame. Eight UROTs related to SAE cases were discussed during MMC meetings, leading to the identification of non-conforming care processes and practical improvement actions.
UROT related to SAE surveillance in neurosurgical patients was considered feasible. The association of surveillance and MMCs allowed staff to concentrate on the analysis of most frequent or most severe AEs and was a practical and useful tool to stimulate improvement. The impact on healthcare quality of SAE surveillance associated with MMC warrants further research.