Patient Safety: July 2022

Welcome to the latest key papers and publications focussing mainly on Patient Safety in the nursing profession.

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Medical Error Reduction and Prevention
Abstract: Medical errors are a serious public health problem and a leading cause of death in the United States. It is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimizes the chances of a recurrent event. By recognizing untoward events occur, learning from them, and working toward preventing them, patient safety can be improved.
Part of the solution is to maintain a culture that works toward recognizing safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. Healthcare organizations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers.
All providers know medical errors create a serious public health problem that poses a substantial threat to patient safety. Yet, one of the most challenging unanswered questions is "What constitutes a medical error?" The answer to this basic question has not been clearly established. Due to unclear definitions, “medical errors” are difficult to scientifically measure. A lack of standardized nomenclature and overlapping definitions of medical errors has hindered data analysis, synthesis, and evaluation.
Source: Treasure Island (FL): StatPearls Publishing; 2022 Jan-. [Free Books & Documents]

Exploring and Evaluating Patient Safety Culture in a Community-Based Primary Care Setting
Abstract: Objectives: The primary aim was to measure patient safety culture in two home care services in Belgium (Flanders). In addition, variability based on respondents' profession was examined.
Methods: A cross-sectional study was conducted by administering the SCOPE-Primary Care questionnaire in two home care service organizations.
Results: In total, 1875 valid questionnaires were returned from 2930 employees, representing a response rate of 64%. The highest mean patient safety culture score was found for "organizational learning" (mean [SD] = 3.81 [0.53]), followed by "support and fellowship" (mean [SD] = 3.76 [0.61]), "open communication and learning from error" (mean [SD] = 3.73 [0.64]), and "patient safety management" (mean [SD] = 3.71 [0.60]). The lowest mean scores were found for "handover and teamwork" (mean [SD] = 3.28 [0.58]) and "adequate procedures and working conditions" (mean [SD] = 3.30 [0.56]). Moreover, managers/supervisors scored significantly higher on the dimensions "open communication and learning from error," "adequate procedures and working conditions," "patient safety management," "support and fellowship," and "organizational learning" than clinical and nonclinical staff.
Conclusions: In conclusion, organizational learning is perceived as most positive. However, large gaps remain in the continuity of care as "handover and teamwork" is perceived as the most negative safety culture dimension. With knowledge of the current patient safety culture, organizations can redesign processes or implement improvement strategies to avoid patient safety incidents and patient harm in the future.
Source: Journal of Patient Safety, 2021 Dec 1; 17(8): e1216-e1222
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Differences between professionals' views on patient safety culture in long-term and acute care? A cross-sectional study
Abstract: Purpose: This paper aims to assess how patient safety culture and incident reporting differs across different professional groups and between long-term and acute care. The Hospital Survey on Patient Safety Culture (HSPOSC) questionnaire was used to assess patient safety culture. Data from the organizations' incident reporting system was also used to determine the number of reported patient safety incidents.
Design/methodology/approach: Patient safety culture is part of the organizational culture and is associated for example to rate of pressure ulcers, hospital-acquired infections and falls. Managers in health-care organizations have the important and challenging responsibility of promoting patient safety culture. Managers generally think that patient safety culture is better than it is.
Findings: Based on statistical analysis, acute care professionals' views were significantly positive in 8 out of 12 composites. Managers assessed patient safety culture at a higher level than other professional groups. There were statistically significant differences (p = 0.021) in frequency of events reported between professional groups and between long-term and acute care (p = 0.050). Staff felt they did not get enough feedback about reported incidents.
Originality/value: The study reveals differences in safety culture between acute care and long-term care settings, and between professionals and managers. The staff felt that they did not get enough feedback about reported incidents. In the future, education should take these factors into consideration.
Source: Leadership in Health Services (Bradford, England), 2021 Sep 8; (ahead-of-print): 499-511

Patients' and Families' Experiences Regarding Disclosure of Patient Safety Incidents
Abstract: In South Korea, disclosure of patients' safety incidents is not common in health care settings. Thus, this study identified patients' and families' experiences regarding disclosure of patient safety incidents. Data were collected through in-depth individual interviews from May 25, 2020, to June 23, 2020, and analyzed using Colaizzi's phenomenological method. The participants consisted of 15 patients and their families who had experienced patient safety incidents in hospitals. It is essential to form a base of mutual understanding to enable disclosure and promote follow-up management systems that can ethically and responsibly handle patient safety incidents. Concrete protocols and policies need to be developed to protect patients and their families from physical/psychological injury and the stress experienced due to patient safety incidents. The patients and their families desired changes to improve protocols for proper disclosure, help health care professionals adopt an ethical and mature attitude, and develop professional health care policies regarding patients' safety incidents.
Source: Qualitative Health Research, 2021 Nov; 31(13): 2502-2511
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Evaluation of the Green Cross Method Regarding Patient Safety Culture and Incidence Reporting
Abstract: Objectives: The Green Cross (GC) method is a visual method for health service staff to recognize risks and preventable adverse events (PAEs) on a daily basis. The aim was to compare patient safety culture and the number of reported PAEs in units using the GC method with units that do not.
Methods: This study has a retrospective cross-sectional design in the setting of psychiatric and somatic care departments in a Swedish hospital. In total, 1476 staff members from 62 different units participate in the study.
Results: Units who had implemented the GC method scored higher than non-GC units in overall quality. The dimensions Feedback and communication about error, Nonpunitive response to errors, Organizational learning-continuous improvement, Handoffs and transitions between units and shifts, and Teamwork within units scored significantly higher in GC units. More risks were reported in the incident reporting system in GC units than in non-GC units, but the number of PAEs was similar. Units with nursing staff who used the GC method scored higher on patient safety culture than those who did not use the method. This difference was not seen in physician units.
Conclusions: The implementation of the GC method has a positive impact on patient safety culture and PAE reporting. However, the method does not seem to have the same impact in physician units as in units with nursing staff, which calls for further investigation.
Source: Journal of Patient Safety, 2022 Jan 1; 18(1): e18-e25

Interprofessional learning about medication safety
Abstract: Background: Safe medication management requires collaboration between health professionals.
Approach: A mixed academic and clinician team co-designed and co-facilitated a 2-h interprofessional medication safety workshop, covering medication history taking, perioperative medication management, discharge planning, incident review and dosing and administration calculations. Three workshop sessions were delivered across three sites during September 2019 at a large metropolitan healthcare network. Senior nursing, medical and pharmacy students were invited to participate in the workshops and evaluation.
Evaluation: We evaluated satisfaction, learning experience and perceived clinical application for medical, pharmacy and nursing students. Surveys were conducted immediately after each workshop and at 4 weeks. Quantitative data was analysed descriptively and qualitative data analysed using thematic analysis. Forty-five students participated in the evaluative component of the workshops. Mean student response scores demonstrated a high level of satisfaction with the workshop's relevance and utility to their learning. Students expressed strong agreement that the workshop promoted communication across professions for medication safety. Analysis of the qualitative data identified seven key themes, with consistently positive responses provided in each: interactions within the interprofessional team; recognising the importance of teams; learning the process of medication use; acknowledging and working with difference; role playing; thinking patient safety; and authenticity.
Implications: A 2-h interprofessional workshop about medication safety provided positive learning experiences with high satisfaction to medical, nursing and pharmacy students, and had strong perceived applicability to their future clinical practice.
Source: The Clinical Teacher, 2021 Dec; 18(6): 656-661

Speaking up or remaining silent about patient safety concerns in rehabilitation: A cross-sectional survey to assess staff experiences and perceptions
Abstract: Background and aims: Patient safety incidents may be prevented if healthcare workers speak up to voice their concerns when they observe hazardous clinical situations. This study aims to investigate the frequency of speaking up and healthcare workers' perception of organizational climate in rehabilitation clinics.
Methods: An online survey was conducted in five rehabilitation clinics. An existing survey instrument (Speaking Up About Patient Safety Questionnaire [SUPS-Q]) was adapted for this purpose. The instrument includes items on self-reported speak-up-related behavior (perceived safety concerns, withholding voice, and speaking up), anticipated speak-up behavior, barriers to speaking up, and speak-up-related climate measures (psychological safety, encouraging environment, and resignation). Data analysis included descriptive statistics, one-way analysis of variance for differences between groups, multiple regression, and measures for validity and reliability of the scales.
Results: Four hundred seventy-one individuals participated in the survey (response rate of 32%). In the 4 weeks preceding the survey, 81% of respondents had specific concerns about patient safety, 83% performed speak up and 41% remained silent in one or more instances. Expected differences between professional groups were confirmed, but surprisingly, we found no effect of hierarchical level on speaking up behavior and perception of the speak-up climate. Factors that most frequently prevented healthcare workers from speaking up were ineffectiveness (38%), presence of patients (26%), and unpredictability of the actor's reaction (25%). The psychometric evaluation of the adapted SUPS-Q showed acceptable results for validity and reliability.
Conclusions: Healthcare workers in rehabilitation clinics frequently perceive safety concerns. The study underlines the importance of promoting a culture of safety and speaking up. The short survey instrument SUPS-Q can be used by rehabilitation clinics to initiate discussions related to facilitators and barriers to speaking up and to identify areas for improvement within the organization.
Keywords: communication; hospitals; organizational culture; patient safety; rehabilitation; surveys and questionnaires.
Source: Health Science Reports, 2022 Apr 28; 5(3): e631

Second victim phenomenon after patient safety incidents among Korean nursing students: A cross-sectional study
Abstract: Background: Perfectionism in the medical field turns healthcare professionals into second victims of patient safety incidents. They suffer physically and psychologically, which makes them consider changing occupations. Nursing students may also have similar negative experiences during clinical practice.
Objective: To describe the second victim phenomenon among nursing students after patient safety incidents during their clinical practice.
Design: A descriptive cross-sectional study using an online questionnaire.
Setting and participants: Fourth-year nursing students (n = 354) who encountered patient safety incidents directly or indirectly during clinical practice. Participants were recruited through convenience and snowball sampling methods using personal contacts, professional networks, and online platforms.
Methods: The questionnaire addressed the characteristics of patient safety incidents and physical and psychological responses after the most significant patient safety incident. Descriptive statistics and a chi-square test were performed for data analysis.
Results: Of the participants, 22.6% were directly involved in patient safety incidents and 77.4% had indirectly encountered patient safety incidents, such as witnessing incidents with colleagues or other healthcare professionals. After patient safety incidents, of those, 67.8% experienced shock at the time of the incident, 47.2% feared experiencing a similar incident, and 28.2% were still affected although time had passed. Additionally, 26.3% reported experiencing long-term embitterment; of them, 7.3% were experiencing severe embitterment. Furthermore, 31.9% and 27.1% of the students experienced sleeping and eating difficulties, respectively, and these rates were higher when incidents were encountered directly rather than indirectly.
Conclusions: Nursing students may become second victims of patient safety incidents during clinical practice. Therefore, nursing education institutions need to develop comprehensive support strategies to help nursing students cope with experiencing the second victim phenomenon.
Source: Nurse Education Today, 2021 Dec; 107: 105115
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Suicide Risk, Changing Jobs, or Leaving the Nursing Profession in the Aftermath of a Patient Safety Incident
Abstract: Background: Nursing retention is a concern for healthcare systems, hospital administrators, and nurses who have spent considerable time and money to achieve educational goals. Nearly, 33% of nurses will drop out in the 2 years practice. Those who stay in practice face an increased risk of suicide when compared the general population.
Aims: To examine the relationship between nurse sociodemographic data and unique study variables with potential morally injurious outcomes (i.e., dropping out variables: changing jobs, intention to leave the profession, or suicidal thinking).
Methods: A descriptive, correlational study design was used to characterize the relationship between the sociodemographic data of 216 registered nurses (RNs) and patient safety and the suicidal behavioral questionnaire.
Results: RNs involved in a patient safety incident (PSI) considered changing jobs when the degree of harm was death (p < .001) or was unknown (p < .05) when compared with no harm. RNs were more likely to consider leaving the profession when the degree of harm to the patient was permanent (p < .01) or the patient died (p < .05) when compared with having no harm. RNs future suicidal thinking (i.e., their self-reported likelihood of future suicidal behavior) was statistically significant when degree of harm to the patient was death (p < .05) as a result of a PSI (95% CI [1.11, 8.71]) when compared with no harm. The RNs who had suicidal thoughts over the past year compared with those without and the RNs with future suicidal thinking compared with those without, may respond differently in the aftermath of a PSI.
Linking evidence to action: This study served as a pioneering effort to the current understanding between nurse characteristics and patient harm and "dropping out" outcomes in RNs involved in PSIs. RNs involved with PSIs that led to more harm were more likely to change jobs, consider leaving the profession, or contemplate future suicide. These findings have important implications for nurses, administrative managers in healthcare organizations, and researchers.
Source: Worldviews on Evidence-Based Nursing, 2021 Oct; 18(5): 264-272

Patient-safety incidents during COVID-19 health crisis in France: An exploratory sequential multi-method study in primary care
Abstract: Background: The COVID-19 pandemic has resulted in the rapid reorganisation of health and social care services. Patients are already at significant risk of healthcare-associated harm and the wholesale disruption to service delivery during the pandemic stood to heighten those risks.
Objectives: We explored the type and nature of patient safety incidents in French primary care settings during the COVID-19 first wave to make tentative recommendations for improvement.
Methods: A national patient safety incident reporting survey was distributed to General Practitioners (GPs) in France on 28 April 2020. Reports were coded using a classification system aligned to the WHO International Classification for Patient Safety (incident types, contributing factors, incident outcomes and severity of harm). Analysis involved data coding, processing, iterative generation of data summaries using descriptive statistical analysis. Clinicaltrials.gov: NCT04346121.
Results: Of 132 incidents, 58 (44%) related to delayed diagnosis, assessments and referrals. Cancellations of appointments, hospitalisations or procedures was reported in 22 (17%) of these incidents. Home confinement-related incidents accounted for 13 (10%) reports and inappropriate medication stopping for five (4%). Patients delayed attending or did not consult their general practitioner or other healthcare providers due to their fear of contracting COVID-19 infection at an in-person visit in 26 (10%) incidents or fear of burdening their GPs in eight (3%) incidents.
Conclusion: Constraints from the first wave of the COVID-19 pandemic have contributed to patient safety incidents during non-COVID-19 care. Lessons from these incidents pinpoint where primary care services in France can focus resources to design safer systems for patients.
Source: The European Journal of General Practice, 2021 Dec; 27(1): 142-151

Novel Telephone-Based Interactive Voice Response System for Incident Reporting
Abstract: Background: The voluntary reporting of medical errors and near misses is a well-established patient safety reporting mechanism. However, studies suggest that these incident reporting systems (IRSs) detect less than 10% of all adverse events. Improving the process of reporting can facilitate more informative and timely data capture while providing more opportunities to improve healthcare quality and safety. The purpose of this study was to understand the barriers to incident reporting via the existing Web-based IRS and develop solutions to increase the ease and efficiency of reporting.
Methods: A survey of staff in a diagnostic imaging department in St. Catharines, Ontario was performed to identify barriers to incident reporting. Based on the barriers identified, two methods of incident reporting were tested in successive phases: (1) a phone-based voice message mailbox, in the computed tomography suite; and (2) a phone-based structured interactive voice response system (IVRS), across the entire department. We measured the rate of incident reports/day and time required to complete reports.
Outcomes: The three most common barriers to reporting identified were lack of time, complexity of reporting system, and lack of feedback. There was a significant difference in reports per day for the IVRS (mean [M] = 3.43, standard deviation [SD] = 2.71) compared to the IRS (M = 0.99, SD = 0.55); t(31) = 4.58, p ≤ 0.00001. There was also a significant difference in the average time to make a report for the IVRS (M = 97 seconds [s], SD = 30 s) compared to the IRS (M = 644 s, SD = 90 s); t(4) =13.55, p = 0.00025.
Conclusion: IVRS is an innovative approach to incident reporting that may prove to be more efficient than Web-based approaches and encourage higher reporting rates.
Source: Joint Commission Journal on Quality and Patient Safety, 2021 Dec; 47(12): 809-813
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Peer support by interprofessional health care providers in aftermath of patient safety incidents: A cross-sectional study
Abstract: Aim: To investigate the health care professionals' preferences pertaining to support in the aftermath of patient safety incidents and potential variation thereof depending on the degree of harm.
Background: Peer support systems are available to support health care professionals in the aftermath of patient safety incidents. It is unclear which type of support is best offered by whom.
Methods: A cross-sectional study in 32 Dutch hospitals.
Results: In total, 2,362 nurses and 1,404 doctors indicated they were involved in patient safety incidents at any time during their career (86%). Less than 10% of health care providers had spoken with professional support, and less than 20% admitted a need to do so. They used different support. A higher degree of harm related to higher odds of desiring support. Respondents mainly wanted to understand what happened and how it can be prevented.
Conclusion: The desired support of health care professionals in the aftermath of patient safety incidents depends on the level of harm.
Implication for nursing management: Health care professionals seem to mostly rely on persons they are close with, and they mainly desire information related to the aftermath of patient safety incidents. This should be taken into account when support programmes are set up.
Source: Journal of Nursing Management, 2021 Oct; 29(7): 2270-2277.

Hospital work environments affect the patient safety climate: A longitudinal follow-up using a logistic regression analysis model
Abstract: Background: Occupational worker wellness and safety climate are key determinants of healthcare organizations' ability to reduce medical harm to patients while supporting their employees. We designed a longitudinal study to evaluate the association between work environment characteristics and the patient safety climate in hospital units.
Methods: Primary data were collected from Norwegian hospital staff from 970 clinical units in all 21 hospitals of the South-Eastern Norway Health Region using the validated Norwegian Work Environment Survey and the Norwegian version of the Safety Attitudes Questionnaire. Responses from 91,225 surveys were collected over a three year period. We calculated the factor mean score and a binary outcome to measure study outcomes. The relationship between the hospital unit characteristics and the observed changes in the safety climate was analyzed by linear and logistic regression models.
Results: A work environment conducive to safe incident reporting, innovation, and teamwork was found to be significant for positive changes in the safety climate. In addition, a work environment supportive of patient needs and staff commitment to their workplace was significant for maintaining a mature safety climate over time.
Conclusions: A supportive work environment is essential for patient safety. The characteristics of the hospital units were significantly associated with the unit's safety climate scores, hence improvements in working conditions are needed for enhancing patient safety.
Source: PLoS One, 2021 Oct 15; 16(10): e0258471

Medication administration errors: Causes and reporting behaviours from nurses perspectives
Abstract: Evaluation of nurses' perceptions towards medication administration errors (MAEs) reporting is a key aspect for improving patient safety, and prevention of errors repetition. Thus, this study has evaluated nurses' behaviour towards MAEs reporting practice, and factors contributing to their under-reporting of errors. This is a cross-sectional survey-based study that was conducted during February 2021. During the study period, a convenience sample of nurses working at Jordan university hospital was invited to voluntarily participate in the study and to fill an online questionnaire uploaded on an electronic data collection platform. The questionnaire assessed nurses MAEs reporting practice, their perception towards factors contributing to MAEs, factors associated with under-reporting of MAEs, and their perception towards MAEs preventive measures. A total of 150 nurses responded to the electronic questionnaire, with 54.0% of them (n = 81) were males and the majority had a bachelor's degree in nursing (n = 138, 92.0%). Regarding MAE reporting's practice, 78% of them (n = 117) indicated that they are always/often report MAEs even if it is not possible to improve the patient's health status. With regard to factors contributing to MAEs, results showed that "insufficient staffing" was the most common reason contributing to MAEs occurrence reported by nurses (n = 114, 94.0%). Personal fear from nursing administration was the primary cause of MAEs under-reporting (n = 98, 65.3%), while 94.0% of nurses (n = 141) agreed/strongly agreed that following the six rights is a way to prevent MAEs occurrence. This study indicates a positive reporting attitude towards MAEs. Nursing administration concerns were considered the main reason associated with the under-reporting of MAEs. This study shed the light on the deep need for continuous education programmes about the importance of the right MAEs reporting. As well, the need for effective and restricted rules in a non-punitive environment to prevent MAEs incidences.
Source: International Journal of Clinical Practice, 2021 Oct; 75(10): e14541

Assessing patient experience with patient safety in primary care: development and validation of the ASK-ME-questionnaire
Abstract: Objective: To develop and test the validity and reliability of a tool measuring patient experiences with patient safety in ambulatory care that is suitable for routine use in general practitioner and specialist practices.
Design: Instrument development was based on a literature review, a 3-round Delphi survey with a multidisciplinary expert panel and cognitive interviews with patients. The instrument was piloted in 22 practices using a cross-sectional survey. Exploratory (EFA) and confirmatory factor analysis (CFA) were performed to test construct validity. Internal consistency and the ability of the questionnaire to differentiate between selected subgroups and at the level of individual practices was examined.
Setting: General practitioner and specialist practices.
Participants: Patients aged >18 years seeking care in ambulatory care practices between February and June 2020.
Results: The final ASK-ME-questionnaire consisted of 22 items covering 5 theoretical dimensions. A total of 3042 patients (71.1%) completed the questionnaire. Median item non-response rate was 4.2% (IQR 3.4%-4.7%). EFA yielded 3 factors comprising 14 items explaining 64.8% of the variance representing contributing factors to patient safety incidents. CFA confirmed the factorial structure suggested by EFA. The model fit the data satisfactorily (comparative fit index=0.92, root mean square error of approximation=0.08, standardised root mean square residual=0.08). Internal consistency values ranged from 0.7 to 0.9. Discriminant validity was supported by significant differences between patients of different age and differences in self-reported health status. The factors distinguished well between practices.
Conclusion: The ASK-ME-questionnaire showed good psychometric properties. It is suitable for routine use in patient safety measurement and improvement systems in ambulatory care. Further research is required to adequately assess number and type of experienced events in routine measurements.
Source: BMJ Open, 2022 Apr 6; 12(4): e049237

Systematic review: Nurses' safety attitudes and their impact on patient outcomes in acute-care hospitals
Abstract: Aims: The aim of this review was to synthesize the best available evidence on the impact of nurses' safety attitudes on patient outcomes in acute-care hospitals.
Design: Systematic review with a narrative synthesis of the available data.
Data sources: Data sources included MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Scopus and Web of Science Core Collection. Studies published up to March 2021 were included.
Review methods: This review was conducted using guidance from the Joanna Briggs Institute for Systematic Reviews and reported as per the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines.
Results: A total of 3,452 studies were identified, and nine studies met the inclusion criteria. Nurses with positive safety attitudes reported fewer patient falls, medication errors, pressure injuries, healthcare-associated infections, mortality, physical restraints, vascular access device reactions and higher patient satisfaction. Effective teamwork led to a reduction in adverse patient outcomes. Most included studies (N = 6) used variants of the Hospital Survey on Patient Safety Culture to assess nurses' safety attitudes. Patient outcomes data were collected from four sources: coded medical records data, incident management systems, nurse perceptions of adverse events and patient perceptions of safety.
Conclusion: A positive safety culture in nursing units and across hospitals resulted in fewer reported adverse patient outcomes. Nurse managers can improve nurses' safety attitudes by promoting a non-punitive response to error reporting and promoting effective teamwork and good communication.
Source: Nursing Open, 2022 Jan; 9(1): 30-43

Staff perceptions of patient safety in the NHS ambulance services: an exploratory qualitative study
Abstract: Objectives: Most research investigating staff perceptions of patient safety has been based in primary care or hospitals, with little research on emergency services. Therefore, this study aimed to explore staff perceptions of patient safety in the NHS ambulance services.
Design: A stratified qualitative study using semi-structured interviews.
Setting: Three urban or rural ambulance service NHS trusts in England.
Participants: A total of 44 participants from three organisational levels, including executives, managers and operational staff.
Methods: The semi-structured interviews explored the interpretation and definition of patient safety, perceived risks, incident reporting, communication and organisational culture. The framework method of qualitative data analysis was used to analyse the interviews and NVivo software was used to manage and organise the data.
Results: We identified five dominant themes: varied interpretation of patient safety; significant patient safety risks; reporting culture shift; communication; and organisational culture. The findings demonstrated that staff perceptions of patient safety ranged widely across the three organisational levels, while they remained consistent within those levels across the participating ambulance service NHS trusts in England.
Conclusions: The findings suggest that participants from all organisational levels perceive that the NHS ambulance services have become much safer for patients over recent years, which signifies an awareness of the historical issues and how they have been addressed. The inclusion of three distinct ambulance service NHS trusts and organisational levels provides deepened insight into the perceptions of patient safety by staff. As the responses of participants were consistent across the three NHS trusts, the identified issues may be generic and have application in other ambulance and emergency service settings, with implications for health policy on a national basis.
Source: British Paramedic Journal, 2022 Mar 1; 6(4): 18-25
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Staffing, teamwork and scope of practice: Analysis of the association with patient safety in the context of rehabilitation
Abstract: Aims: To describe the organization of nursing services (staffing, scope of practice, teamwork) and its association with medication errors and falls, in rehabilitation units.
Background: The healthcare system is greatly impacted by the ageing population and the complexity of care associated with chronic diseases. It is therefore necessary to have enough staff who are using their full scope of practice and who are operating in a favourable working environment. However, these conditions are not always met, which can lead to threats to patient safety.
Design: A correlational descriptive study.
Methods: Staffing data and reported safety incidents were collected by shift from 01 October 2019 until 15 January 2020 in five rehabilitation units. In addition, a total of 75 nursing staff members responded to a missed care and teamwork survey. Descriptive analysis and logistic regression analysis were performed.
Results: The mean staff hours per patient shift was 1.39 (SD = 0.60). The teams reported a global missed care score as 'rarely missed' at 1.14 (SD = 0.07) and a moderate teamwork score at 3.36 (SD = 0.58) on a five-point scale. The safety incidents decreased 10-fold with a predominance of bachelor compared with technician nurses and decreased by 67% when there was an increase of 1 h of care per patient shift.
Conclusions: This study showed that the organization of nursing services in the observed rehabilitation units is characterized by a moderate staffing intensity, a moderate perception of teamwork level and a relatively low level of missed care. It indicated the key role of the staffing in reducing the risk of occurrence of safety incidents. Future research specific to rehabilitation hospitals are greatly needed to improve patient outcomes in this setting.
Impact: Nurse Managers should consider all the aspects of the organization of nursing services (staffing, scope of practice and teamwork) in their efforts to improve patient safety in rehabilitation settings. A central finding of this study is that the staffing intensity, the proportion of bachelor prepared nurses and the proportion of agency staff were positively associated with a reduction of safety incidents.
Source: Journal of Advanced Nursing, 2022 Jul; 78(7): 2015-2029

Impact of hospital readiness on patient safety incidents during the COVID-19 pandemic in Indonesia: health worker perceptions
Abstract: OBJECTIVES: This study examined the impact of hospital readiness on patient safety from the healthcare workers' perspective.
DESIGN: The study employed a mixed-methods explanatory sequential design, with the quantitative phase taking precedence. We conducted an online survey of 235 healthcare workers at COVID-19 referral hospitals, followed by an interview with 11 participants from various hospital types.
SETTING: COVID-19 referral hospitals in Indonesia.
PARTICIPANTS: Health workers working at COVID-19 referral hospitals.
MEASURES: Hospital ownership; hospital accreditation status; hospital readiness including incident management system, surge capacity, infection control and prevention, and human resource management; patient safety incident.
RESULTS: According to the survey, 66.4% of the participants worked at a hospital owned by the provincial or district government, and 69.4% worked at a hospital which had received an excellent status accreditation. More than 80% of the hospitals scored well in the categories of the incident management system (86%), surge capacity (80.9%), infection control and prevention (97.9%), and human resource management (84.7%). However, only 50.6% of the hospitals scored well in managing patient safety incidents. Hospital ownership, accreditation status and hospital readiness all have an impact on patient safety incidents, which were reported in all types of hospitals by both studies.
CONCLUSIONS: This study provides significant results for Indonesia in terms of hospital preparedness and patient safety for the COVID-19 pandemic. The accreditation and ownership status of the hospital have aided hospital readiness. Despite the fact that no hospital in the world was prepared for the COVID-19 pandemic, hospital readiness has improved a year later; however, patient safety has not improved. Patient safety incidents occurred regardless of hospital status, with the most common occurrence being delayed treatment. Administrative errors were also recorded in COVID-19 field hospitals that were not accredited. Future research should focus on improving pandemic care quality and implementing initiatives that are applicable to all types of hospitals.
Source: BMJ Open, 2022 Jul 22; 12(7): e061702

Do Patient Engagement IT Functionalities Influence Patient Safety Outcomes? A Study of US Hospitals
Abstract: OBJECTIVE: Patient engagement using health information technology (IT) functionalities can be a powerful tool in managing their own care for better health outcomes. Therefore, this study explores whether patient engagement IT functionalities and electronic health record (EHR) can affect patient safety outcomes.
DESIGN: Using longitudinal study design for general acute care hospitals within the United States, we examine the interaction effects of EHR and patient engagement IT functionalities on patient safety outcomes (adverse incident rate) using a generalized estimating equation.
SETTING: Our national sample consisted of 9759 hospital-year observations from 2014 to 2018. Overall, we found a significant association between adverse incident rate and patient engagement level and EHR adoption level.
RESULTS: On average, as the combined effects of patient engagement level and EHR adoption level increases, the adverse incident rate decreases by approximately 0.49 (P < .01). Incorporating patient engagement functionalities is becoming an essential tool to improve health outcomes and will play an instrumental role in meeting meaningful use standards.
CONCLUSIONS: Our study provides insights into the potential synergy between a hospital's existing EHR maturity and patient engagement health IT functionalities in affecting organizational performance. Organizational culture and capabilities pertinent to adopting patient engagement health IT functionalities infrastructure should be established first to provide the impetus for this synergy.
Source: Journal of Public Health Management & Practice, 2022 Sep-Oct 01; 28(5): 505-512
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Development of a taxonomy for characterising medical oncology-related patient safety and quality incidents: a novel approach
Abstract: In this report, we describe the development of a comprehensive, validated taxonomy for medical oncology-related incidents. We combined qualitative analysis with multiple, rapid cycles of testing at three different healthcare facilities to validate the classification system. Our goal was to create a taxonomy that will be broadly applicable to the practice of medical oncology across different sites of care.
Source: BMJ Open Quality, 2022 Jul; 11(3): p. e001828

A retrospective analysis of peri-operative medication errors from a low-middle income country
Abstract: Identifying medication errors is one method of improving patient safety. Peri operative anesthetic management of patient includes polypharmacy and the steps followed prior to drug administration. Our objective was to identify, extract and analyze the medication errors (MEs) reported in our critical incident reporting system (CIRS) database over the last 15 years (2004-2018) and to review measures taken for improvement based on the reported errors. CIRS reported from 2004 to 2018 were identified, extracted, and analyzed using descriptive statistics and presented as frequencies and percentages. MEs were identified and entered on a data extraction form which included reporting year, patients age, surgical specialty, American Society of Anesthesiologist (ASA) status, time of incident, phase and type of anesthesia and drug handling, type of error, class of medicine, level of harm, severity of adverse drug event (ADE) and steps taken for improvement. Total MEs reported were 311, medication errors were reported, 163 (52%) errors occurred in ASA II and 90 (29%) ASA III patient, and 133 (43%) during induction. During administration phase 60% MEs occurred and 65% were due to human error. ADEs were found in 86 (28%) reports, 58 of which were significant, 23 serious and five life-threatening errors. The majority of errors involved neuromuscular blockers (32%) and opioids (13%). Sharing of CI and a lesson to be learnt e-mail, colour coded labels, change in medication trolley lay out, decrease in floor stock and high alert labels were the low-cost steps taken to reduce incidents. Medication errors were more frequent during administration. ADEs were occurred in 28% MEs.
Source: Scientific Reports, 2022 Jul 20; 12(1): 12404

Differences in the Incidence of Adverse Events in Acute Care Hospitals: Results of a Multicentre Study
Abstract: BACKGROUND: Adverse events are indicators of patient safety and quality of care. Adverse events clearly have negative impacts on healthcare system costs. Organizational and unit characteristics are not very often studied in relation to adverse events. The aim of the study was to find the differences in the incidence of adverse events and healthcare-associated infections in hospitalized patients in Czech acute care hospitals according to type of hospital and type of unit.
METHODS: This cross-sectional multicentre study was conducted in 105 acute care medical and surgical units located in 14 acute care hospitals throughout the Czech Republic. The data on adverse events and healthcare-associated infections were reported monthly by nurse researchers. The data were collected from June 2020 to October 2020.
RESULTS: The incidence of healthcare-associated infections, pressure ulcers, and medication errors was significantly lower in large hospitals. Statistically significant differences have been further found between the incidence of pressure ulcers (<0.001), falls without injury (<0.001), and falls with injury (<0.001) in surgical and medical units. More pressure ulcers, falls without injury, and falls with injury have been reported in surgical units.
CONCLUSION: The type of hospital and type of unit affected the incidence of adverse events at acute care hospitals. To reduce adverse events, a systematic adverse event measurement and reporting system should be promoted.
Source: International Journal of Environmental Research & Public Health, 2022 04 26; 19(9): 5238

Surgical Error Compensation Claims as a Patient Safety Indicator: Causes and Economic Consequences in the Murcia Health
System, 2002 to 2018
Abstract: OBJECTIVES: Compensation claims are a useful source of information on patient safety research. The purpose of this study was to determine the main causes of surgical compensation claims and their financial impact on the health system.
METHODS: A descriptive observational study with analytical components was carried out on compensation claims brought against the surgical area of the Murcia Health System between 2002 and 2018. We analyzed the frequency, causes, consequences, locations and surgical settings of these claims, the time of judicial procedure, and compensation adjusted to the Consumer Price Index.
RESULTS: There were 1172 compensation claims. "orthopedic surgery and traumatology" (27.4%), "gynecology and obstetrics" (25.7%), and "general surgery" (17.2%) were the main surgical settings involved. The most frequent causes were surgical error (42.4%) and treatment error (30.9%). The main sequelae were musculoskeletal (20.0%), neurological (17.7%), and obstetric (17.7%). The average time from incident to resolution of claims was 6.3 years. A total of 20.1% of these claims were successful, particularly those involving retained surgical foreign bodies (71.4% successful claims; P < 0.001). The total compensation paid was 56,338,247 (an average of 17,207 per claim). Compensation was higher in cases with respiratory sequelae (median, 131,600; P = 0.033), death (75,916; P < 0.001), and neurological (60,000; P = 0.024).
CONCLUSIONS: Compensation claims associated with surgical procedures are made on a variety of grounds. They are drawn-out proceedings, and patients are only successful in 20% of cases.
Source: Journal of patient safety, 2022 06 01; 18(4): 276-286

Evaluating incident learning systems and safety culture in two radiation oncology departments
Abstract: INTRODUCTION: Radiation oncology patient pathways are complex. This complexity creates risk and potential for error to occur. Comprehensive safety and quality management programmes have been developed alongside the use of incident learning systems (ILSs) to mitigate risks and errors reaching patients. Robust ILSs rely on the safety culture (SC) within a department. The aim of this study was to assess perceptions and understanding of SC and ILSs in two closely linked radiation oncology departments and to use the results to consider possible quality improvement (QI) of department ILSs and SC.
METHODS: A survey to assess perceptions of SC and the currently used ILSs was distributed to radiation oncologists, radiation therapists and radiation oncology medical physicists in the two departments. The responses of 95 staff were evaluated (63% of staff). The findings were used to determine any areas for improvement in SC and local ILSs.
RESULTS: Differences were shown between the professional cohorts. Barriers to current ILS use were indicated by 67% of respondents. Positive SC was shown in each area assessed: 69% indicated the departments practised a no-blame culture. Barriers identified in one department prompted a QI project to develop a new reporting system and process, improve departmental learning and modify the overall ILS.
CONCLUSION: An understanding of SC and attitudes to ILSs has been established and used to improve ILS reporting, feedback on incidents, departmental learning and the QA program. This can be used for future comparisons as the systems develop.
Source: Journal of Medical Radiation Sciences, 2022 Jun; 69(2): 208-217

Perceptions and knowledge of nurses on incident reporting systems: Exploratory study in three Northeastern Italian Departments
Abstract: Reporting of adverse clinical events (IRs) is believed to be an effective methodology for optimizing health care safety, however, only 1%-3% of incidents are reported by healthcare professionals, lack of information resulting from errors/adverse events/near misses limits the development of safety and improvement measures. This study aimed to identify barrier factors/incentives to report adverse events and find possible improvement strategies and possible
correlations between the population under examination and the willingness to report through Incident Reporting. An ad hoc questionnaire was used and administered to 122 nurses belonging to three different departments of an Italian hospital. The frequency with which improvement interventions are noted following an IR report (p = 0.014) and the support received from their managers (p = 0.014) in reporting are among the factors that can have the greatest impact on
the use of IR among the respondents. The no-blame policies and the attention that nursing managers place on clinical risk management can influence the culture of safety among nurses. Involving nurse managers in the dissemination of the IR can represent a possible strategy to be undertaken by corporate clinical risk managers in order to increase the culture of safety among nurses.
Source: Journal of Healthcare Risk Management; 2022 Jul, 42(1): 16-23

Patient falls in the operating room setting: An analysis of reported safety events
Abstract: INTRODUCTION: Patient falls are a preventable public health problem, and they are among the most reported safety incidents in the hospital. We used a hospital safety reporting system to examine the nature of reported falls in the perioperative setting at an academic tertiary center.
METHODS: In this retrospective study, reports of perioperative safety events listed as "Falls" between 2014 and 2020 were analyzed for severity level and specific event type.
RESULTS: Out of 8337 safety reports from 2014 to 2020, 86 were "fall" related (1%). The most common "fall" event type was "ambulating with assistance and the severity level reported was mainly level 1 (no harm, did reach patient, 63%) followed by level 2 (temporary or minor harm, 28%). One of the most frequently reported types of perioperative falls was from a bed or stretcher (15% of falls)".
CONCLUSIONS: Our safety data reporting system identified falls as a safety event that causes patient harm in the perioperative setting that could be preventable with a multifaceted interdisciplinary approach. Risk managers can use these data to implement strategies to reduce falls such as creating screening protocols to identify high-risk patients, educating and training healthcare personnel, and optimizing operating room, hospital, and equipment design.
Source: Journal of Healthcare Risk Management, 2022 Jul; 42(1): 9-14

Competency expectations of nurses in rapid response teams: an interview-based qualitative study
Abstract: BACKGROUND: The rapid response teams (RRTs) are early intervention Teams made up of physicians, nurses, and/or other designated personnel that conduct early assessment and intervention of patients with changing conditions outside the intensive care unit (ICU) in order to reduce ICU admissions and prevent further deterioration or promote early admission to the ICU in critically ill patients. Numerous studies have shown that RRT can effectively reduce the incidence of
cardiac arrest and accidental death in patients. Nurses are the most indispensable members of multidisciplinary teams (MDT), and their ability is closely related to the success rate of RRT.
METHODS: Using the phenomenological method of qualitative research, we conducted semi-structured interviews with 16 non-nurse members of RRT, including 6 doctors, 5 anesthesiologists and 5 respiratory therapists, in a third class a general hospital in Shanghai. Colaizzi content analysis was used for data analysis.
RESULTS: After analysis and collation, three themes were extracted: professional theoretical knowledge, professional practical skills, and personality traits. Professional theoretical knowledge includes basic medical knowledge and knowledge of rapid response system. Professional practical skills include quick reaction capability, ability to assess illness, first aid skills and communication skills; Personality traits include imperturbable and cooperative spirit of group.
CONCLUSIONS: Non-nurse members of the RRT expect the response team nurses to possess solid professional theoretical knowledge, skilled professional practical skills, and good personality qualities. Nursing managers should pay attention to the training of professional theoretical knowledge, professional practical skills and personality quality when carrying out the training practice of nurses' competency in RRT, so as to truly improve the success rate of RRT operation and further promote patient safety.
Source: Annals of Palliative Medicine, 2022 Jun; 11(6): 2043-2049

The relationship between attitude of nurses toward the patient safety and missed nursing care: A predictive study
Abstract: BACKGROUND: Positive attitude of nurses toward patient safety can play a major role in increasing the quality of nursing care and reducing missed nursing care. This study was conducted to determine the relationship between the Attitude of Nurses toward Patient Safety and missed nursing care.
METHODS: This study was conducted in 2021 at the hospitals of Tabriz University of Medical Sciences (Iran). In the present study, 351 nurses were included in the study by using a stratified random sampling method. Data collection tools were demographic questionnaire, missed nursing care questionnaire, and patient safety attitudes questionnaire. Missed Nursing Care Questionnaire includes 24 items, such as patient movement, rotation, evaluation, training, discharge planning, medication prescription, scored on a 4-point Likert scale ranging from score 1 (I miss rarely), score 2 (I miss occasionally), score 3 (I miss usually), and score 4 (I miss always). The highest score is 96 and the lowest score is 24 on this scale. A higher score indicates a higher possibility of missed care.
RESULTS: The mean total (standard deviation) of missed nursing care was 32.76 (7.13) (score range: 24-96) and the mean total score of nurses' patient safety attitudes was 53.19 (18.71) out of 100. Results of the present study showed that nurses' patient safety attitudes are at a moderate level and have a significant inverse relationship with the incidence of missed nursing care (P<0.001).
CONCLUSION: According to the results and given the relationship between patient safety attitudes and missed nursing care, it is essential to use individual and organizational interventions to increase patient safety attitudes in various dimensions in nurses and consequently to reduce missed nursing care and improve the quality of healthcare.
Source: Journal of Healthcare Quality Research, 2022 May-Jun; 37(3): 138-146
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Incidence and risk factors of adverse events in pediatric hemato-oncological patients: A cohort study

Abstract: BACKGROUND: Pediatric hemato-oncological (HO) patients are highly susceptible to the occurrence of adverse events (AE), nevertheless few research has been done in this field. Our aim was to describe the incidence, type, severity and preventability of AE in these patients, including bone marrow transplant (BMT) patients, and to identify patient's risk factors for having an AE.
METHODS: Retrospective cohort study. Children under 18yo hospitalized at the HO or BMT ward in 2016 were eligible for the study. Type of AE, severity and preventability were described as absolute and relative frequencies. Cumulative incidence of patients with at least one AE (CI_AE) and the rate of occurrence of all AE were calculated. Risk factors (sex, recovery probability, comorbidities and being a BMT patient) were analyzed using logistic regression.
RESULTS: 114 patients were included, 58% were male, average age was 8.7yo and 25 were BMT patients. 44 had at least one AE, with CI_AE of 38.6% (95%CI 29.7-47.5). Overall rate of occurrence of AE was 2.5 cases per 100 patients-day (95%CI 2.15-2.98). For BMT and non-BMT patients they were 2.8 (95%CI 2.2-3.6) and 2.5 (95%CI 1.98-3.1) respectively. Healthcare related infection was the most frequent AE. Most AE were moderate and with high preventability. Being a BMT patient was
the only independent factor associated with the occurrence of at least one AE (OR=11.5, p<0.001).
CONCLUSIONS: Our findings suggest that AE tend to be moderate and preventable in HO pediatric patients. BMT patients seem to be at greater risk of having an AE. Strategies focused on patient safety need to account for their specific characteristics.
Source: Journal of Healthcare Quality Research, 2022 Mar-Apr; 37(2): 110-116

How to WHO: lessons from aviation in checklists and debriefs
Abstract: INTRODUCTION: The World Health Organization (WHO) surgical safety checklist (SSC) has had an overall positive impact; however, it has not completely prevented adverse events and compliance with the checklist varies. The aviation industry is considered to have better engagement with their safety checklists, reporting not only safety improvements, but also a cultural shift in their checklist philosophy over recent years.
METHODS: We explored the personal attitudes of pilots working in the aviation industry to identify principles of an effective checklist philosophy that could be transposed to the healthcare setting to empower more effective, consistent and ultimately successful implementation of the WHO SSC. A questionnaire was developed by the authors. Three airline pilots were interviewed via telephone, and asked questions regarding the logistics of and attitudes to checklists in the aviation industry.
RESULTS: Several key factors for successful checklist implementation were identified. These include regular training and education on human factors and the checklist's purpose, and institution of an atmosphere that is receptive, engaged and welcoming. Much can be learned from the aviation industry, where not only has the incidence of adverse events decreased, but the attitudes of people working in the industry have also transformed.
CONCLUSION: The WHO SSC is an invaluable tool used in healthcare settings worldwide. However, it is not a standalone commodity. To be effective, it necessitates steadfast engagement from the team members involved in its implementation. Human and checklist must work in partnership, using each other's strengths and fallibilities, to optimise outcomes and prevent risks to patient safety.
Source: Annals of the Royal College of Surgeons of England, 2022 Jul; 104(7): 510-516

Understanding the wider impact of patient safety incidents
Abstract: Context: Patient safety incidents can have significant and sometimes life-changing consequences for patients and families. However, the broader impact of safety incidents on staff and the healthcare system is less well understood. This study aimed to understand the effect of patient safety incidents on nurses’ well-being and professional intentions.
Methods: The study used a descriptive correlational design to examine the relationship between involvement in a patient safety incident and subsequent job moves, intention to leave the profession and suicidal behaviour in nurses. The researchers recruited nurses from New York and Oregon who had been working in a clinical setting within the past 5 years and who had been involved in a patient safety incident.
This study used the Suicidal Behaviours Questionnaire–Revised, a four-item questionnaire which assesses lifetime suicide ideation, frequency of suicidal ideation over the past 12 months, assessment of the threat of a suicide attempt and the self-reported likelihood of future suicidal behaviour. Information on the type of safety incident, alongside career intention data, was also obtained.
Findings: Over several iterations of recruitment, 11 000 recruitment emails were sent randomly to registered nurses. In total, 216 registered nurses met the inclusion criteria, completed the questionnaire and were included in the analysis, representing a response rate of less than 3%. The respondents were predominantly women (93.6%), with participants being registered as a nurse for an average of 16 years. Almost all the respondents (94.9%) had been involved in a patient safety incident during their career, and 19.4% reported that their actions, or inactions, had led to a patient safety incident in the previous 12 months.
Involvement in a patient safety incident which resulted in a patient death was associated with a significantly increased likelihood of changing jobs, intention to leave the profession and future suicidal behaviour, in comparison to no harm. Similarly, respondents were more likely to consider leaving nursing when the degree of harm caused by the incident was permeant.
Commentary: Despite the low response rate and the lack of detailed data on how respondents were identified, these findings highlight the importance of safety incidents in clinical practice. To improve the worrying outcomes described, future research must address two concepts: the prevention of patient safety incidents and the provision of appropriate support following an incident.
The prevention of patient safety incidents is complex and requires not only targeted interventions aimed at specific adverse events (eg, actions to reduce patient falls) but also changes in organisational safety culture which foster psychological safety. The link between an environment of openness and trust and increased reporting of adverse events illustrates the influence of culture on learning from and preventing patient harm.
Supporting nurses and the wider multidisciplinary team, following a patient safety incident, is also crucial. The harm to individual well-being, combined with the subsequent impact on the healthcare system, has been described previously. This system impact can include losing staff from professions such as nursing and medicine, alongside a negative impact on the quality of subsequent patient care delivered by the practitioner involved. However, there are limited data focusing on how best to manage this complex situation, especially in relation to the impact of interventions on families and the patients at the centre of the incident. For example, recent literature has highlighted that terminology such as ‘second victim’ was challenging for families and patients to adopt in the context of healthcare harm. Future research should engage advocacy organisations and patients to understand the optimal recovery infrastructure for patient safety incidents. We suggest that nurses should be at the forefront of this research to ensure that it strikes this necessary balance.
Source: Evidence-Based Nursing, 2022; 25(3): 96

Combined Proactive Risk Assessment: Unifying Proactive and Reactive Risk Assessment Techniques in Health Care
Abstract: BACKGROUND: Reactive risk assessments (RRAs) such as incident reporting and root cause analysis (RCA), as well as proactive risk assessments (PRAs) such as failure mode and effects analysis, are generally conducted independently in health care. Literature promotes combining risk assessment techniques. This concept builds on previous methodologies and presents an innovative, scalable, and generalizable risk assessment methodology.
METHODS: A Combined Proactive Risk Assessment (CPRA) technique entails combining incident reports (RRAs), combining proactive risk assessments (PRAs), and merging components of PRA and RRA. Using specific keywords, this technique aligns patient safety reporting data with process steps and failure modes to assess risk within any of the process steps. This technique was tested by using PRAs from several Veterans Health Administration (VHA) facilities and national patient safety data from the VHA National Center for Patient Safety's database. Reported events and RCAs related to the outpatient blood draw process were used for this illustration. Repeatability was determined by independently applying the technique to two years of data and auditing results.
RESULTS: Aggregating PRAs from multiple facilities identified 220% more failure modes; and integrating incident reports into PRA identified 310% more failure modes than the single facility average. Overlaying safety reports onto a comprehensive process flow diagram revealed that 85.8% of events occurred in three of seven process steps. Accuracy of this technique was generally above 85%.
CONCLUSION: This technique is promising for identifying vulnerable points in health care processes or to compliment a traditional PRA. Single PRAs are less likely to identify all potential failures or focus on the most hazardous process steps. This technique may aid in assessing key health care processes at an enterprise level.
Source: Joint Commission Journal on Quality & Patient Safety, 2022 Jun-Jul; 48(6-7): 326-334

Family Input for Quality and Safety (FIQS): Using mobile technology for in-hospital reporting from families and patients
Abstract: OBJECTIVE: Despite three decades of effort, ensuring inpatient safety remains elusive. Patients and family members are a potential source of safety observations, but systems gathering these are limited. Our goal was to test a system to gather safety observations from hospitalized patients and their family members via a real-time mobile health tool.
METHODS: We developed a mobile-responsive website for reporting safety observations. We piloted the tool during June 2017-April 2018 on the medical-surgical unit of a children's hospital. Participants were English-speaking family members and patients >=13 years. We sent a daily text with a website link. We assessed: (1) face validity by comparing observations to incident reporting (IR) criteria and to hospital IRs and (2) associations between the number of safety observations/100 patient-days and participant characteristics using Poisson regression.
RESULTS: We enrolled 235 patients (43.8% of 537 reviewed for eligibility), resulting in 8.15 safety reports/100 patient-days, most frequently regarding medications (29% of reports) and communication (20% of reports). Fifty-one (40% of 125) met IR criteria; only one (1.1%) had been reported via the IR system. Latinx participants submitted fewer observations than White participants (3.9 vs. 10.1, p = .002); participants with more prior hospitalizations submitted more observations (p < .001). In adjusted analyses, including measures of preference in decision making, and patient activation, the difference between Latinx and White participants diminished substantially (6.4 vs. 11.3, p = .16).
CONCLUSIONS: We demonstrated the feasibility of real-time patient and family-member technology-enabled safety observation reporting and elicited reports not otherwise identified. Variation in reporting may potentially exacerbate disparities in safety if not addressed.
Source: Journal of Hospital Medicine (Online), 2022 Jun; 17(6): 456-465

A Retrospective Review of Serious Surgical Incidents in 5 Large UK Teaching Hospitals: A System-Based Approach
Abstract: OBJECTIVES: Surgical incidents are the most common serious patient safety incidents worldwide. We conducted a review of serious surgical incidents recorded in 5 large teaching hospitals located in one London NHS trust to identify possible contributing factors and propose recommendations for safer healthcare systems.
METHODS: We searched the Datix system for all serious surgical incidents that occurred in any operating room, excluding critical care departments, and were recorded between October 2014 and December 2016. We used the London Protocol system analysis framework, which involved a 2-stage approach. A brief description of each incident was produced, and an expert panel analyzed these incidents to identify the most likely contributing factors and what changes should be recommended.
RESULTS: One thousand fifty-one surgical incidents were recorded, 14 of which were categorized as "serious" with contributing factors relating to task, equipment and resources, teamwork, work environmental, and organizational and management. Operating room protocols were found to be unavailable, outdated, or not followed correctly in 8 incidents studied. The World Health Organization surgical safety checklist was not adhered to in 8 incidents, with the surgical and anesthetic team not informed about faulty equipment or product shortages before surgery. The lack of effective communication within multidisciplinary teams and inadequate medical staffing levels were perceived to have contributed.
CONCLUSIONS: Multiple factors contributed to the occurrence of serious surgical incidents, many of which related to human failures and faulty equipment. The use of faulty equipment needs to be recognized as a major risk within departments and promptly addressed. 

Source: Journal of patient safety, 2022 06 01; 18(4): 358-364