Objectives: This systematic review sought to better understand the effect of standardized Morbidity and Mortality meetings (M&Ms) on learning, system improvement, clinician engagement, and patient safety culture.
Methods: Three electronic databases were searched using a range of text words, synonyms, and subject headings to identify the major concepts of M&M meetings. Articles published between October 2012 (the end date of an earlier review) and February 2021 were assessed against the inclusion criteria, and thematic synthesis was conducted on the included studies.
Results: After abstract and full-text review in Covidence, from 824 studies identified, 16 met the eligibility criteria. Studies were mostly surveys (n = 13) and evaluated effectiveness primarily from the perspectives of M&M chairs and participants, rather than assessment of objective improvement in patient outcomes. The most prevalent themes relating to the standardization of M&M processes were case selection (n = 15) and administration (n = 12). The objectives of quality improvement and education were equally prevalent (12 studies each), but several studies reported that these 2 objectives as conflicting rather than complementary. Clinician engagement, patient safety culture, and organizational governance and leadership were identified as facilitators of effective M&Ms.
Conclusions: There is insufficient evidence to guide best practice in M&Ms, but standardized structures and processes implemented with organizational leadership and administrative support are associated with M&Ms that address objectives related to learning and system improvement. Standardization of the structures and processes of M&Ms is perceived differently depending on participants' role and discipline, and clinician engagement is critical to support a culture of safety and quality improvement.
{"title":"Systematic Review of Morbidity and Mortality Meeting Standardization: Does It Lead to Improved Professional Development, System Improvements, Clinician Engagement, and Enhanced Patient Safety Culture?","authors":"Emily J Steel, Monika Janda, Shayaun Jamali, Michelle Winning, Bryan Dai, Kylie Sellwood","doi":"10.1097/PTS.0000000000001184","DOIUrl":"10.1097/PTS.0000000000001184","url":null,"abstract":"<p><strong>Objectives: </strong>This systematic review sought to better understand the effect of standardized Morbidity and Mortality meetings (M&Ms) on learning, system improvement, clinician engagement, and patient safety culture.</p><p><strong>Methods: </strong>Three electronic databases were searched using a range of text words, synonyms, and subject headings to identify the major concepts of M&M meetings. Articles published between October 2012 (the end date of an earlier review) and February 2021 were assessed against the inclusion criteria, and thematic synthesis was conducted on the included studies.</p><p><strong>Results: </strong>After abstract and full-text review in Covidence, from 824 studies identified, 16 met the eligibility criteria. Studies were mostly surveys (n = 13) and evaluated effectiveness primarily from the perspectives of M&M chairs and participants, rather than assessment of objective improvement in patient outcomes. The most prevalent themes relating to the standardization of M&M processes were case selection (n = 15) and administration (n = 12). The objectives of quality improvement and education were equally prevalent (12 studies each), but several studies reported that these 2 objectives as conflicting rather than complementary. Clinician engagement, patient safety culture, and organizational governance and leadership were identified as facilitators of effective M&Ms.</p><p><strong>Conclusions: </strong>There is insufficient evidence to guide best practice in M&Ms, but standardized structures and processes implemented with organizational leadership and administrative support are associated with M&Ms that address objectives related to learning and system improvement. Standardization of the structures and processes of M&Ms is perceived differently depending on participants' role and discipline, and clinician engagement is critical to support a culture of safety and quality improvement.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138463842","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Objectives: Before performing medical procedures, there is a patient safety initiative process (also referred to as "time-out"), part of this process is the use of a preprocedural safety checklist. This initiative was envisioned by the World Health Organization, supported by various accreditation bodies who include the process in their standards. Dentistry lags behind its medical colleagues in using it presurgical or invasive procedure. Our aim was to understand dentists' attitudes and knowledge about the process and their adherence to it.
Methods: A cross-sectional questionnaire was distributed between September and December 2021 and 102 dentists responded.
Results: Seventy three of the respondents (71.5%) claimed to be familiar with the time-out process, and 87 (85.3%) felt that it was an important or somewhat important process; however, only 62 (60.7%) were always performing the process before surgical or invasive outpatient procedures.
Conclusions: Patient safety must be given priority, as such it has been shown that preprocedural checklists help reduce medical errors. Recognizing the value of performing such a process, accreditation bodies have included the process in their standards and indeed in the Joint Commission focused patient safety goals.
{"title":"Dentists' Attitudes to the Preprocedural Safety Checklist \"Time-Out\" in Saudi Arabia.","authors":"Davide Rocchettta, Syed Sirajul Hassan, Jenny Gray","doi":"10.1097/PTS.0000000000001186","DOIUrl":"10.1097/PTS.0000000000001186","url":null,"abstract":"<p><strong>Objectives: </strong>Before performing medical procedures, there is a patient safety initiative process (also referred to as \"time-out\"), part of this process is the use of a preprocedural safety checklist. This initiative was envisioned by the World Health Organization, supported by various accreditation bodies who include the process in their standards. Dentistry lags behind its medical colleagues in using it presurgical or invasive procedure. Our aim was to understand dentists' attitudes and knowledge about the process and their adherence to it.</p><p><strong>Methods: </strong>A cross-sectional questionnaire was distributed between September and December 2021 and 102 dentists responded.</p><p><strong>Results: </strong>Seventy three of the respondents (71.5%) claimed to be familiar with the time-out process, and 87 (85.3%) felt that it was an important or somewhat important process; however, only 62 (60.7%) were always performing the process before surgical or invasive outpatient procedures.</p><p><strong>Conclusions: </strong>Patient safety must be given priority, as such it has been shown that preprocedural checklists help reduce medical errors. Recognizing the value of performing such a process, accreditation bodies have included the process in their standards and indeed in the Joint Commission focused patient safety goals.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138463840","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-03-01Epub Date: 2023-12-26DOI: 10.1097/PTS.0000000000001193
Carly E Milliren, Al Ozonoff, Kerri A Fournier, Jennifer Welcher, Assaf Landschaft, Amir A Kimia
Objective: This study assessed the feasibility of nursing handoff notes to identify underreported hospital-acquired pressure injury (HAPI) events.
Methods: We have established a natural language processing-assisted manual review process and workflow for data extraction from a corpus of nursing notes across all medical inpatient and intensive care units in a tertiary care pediatric center. This system is trained by 2 domain experts. Our workflow started with keywords around HAPI and treatments, then regular expressions, distributive semantics, and finally a document classifier. We generated 3 models: a tri-gram classifier, binary logistic regression model using the regular expressions as predictors, and a random forest model using both models together. Our final output presented to the event screener was generated using a random forest model validated using derivation and validation sets.
Results: Our initial corpus involved 70,981 notes during a 1-year period from 5484 unique admissions for 4220 patients. Our interrater human reviewer agreement on identifying HAPI was high ( κ = 0.67; 95% confidence interval [CI], 0.58-0.75). Our random forest model had 95% sensitivity (95% CI, 90.6%-99.3%), 71.2% specificity (95% CI, 65.1%-77.2%), and 78.7% accuracy (95% CI, 74.1%-83.2%). A total of 264 notes from 148 unique admissions (2.7% of all admissions) were identified describing likely HAPI. Sixty-one described new injuries, and 64 describe known yet possibly evolving injuries. Relative to the total patient population during our study period, HAPI incidence was 11.9 per 1000 discharges, and incidence rate was 1.2 per 1000 bed-days.
Conclusions: Natural language processing-based surveillance is proven to be feasible and high yield using nursing handoff notes.
{"title":"Enhancing Pressure Injury Surveillance Using Natural Language Processing.","authors":"Carly E Milliren, Al Ozonoff, Kerri A Fournier, Jennifer Welcher, Assaf Landschaft, Amir A Kimia","doi":"10.1097/PTS.0000000000001193","DOIUrl":"10.1097/PTS.0000000000001193","url":null,"abstract":"<p><strong>Objective: </strong>This study assessed the feasibility of nursing handoff notes to identify underreported hospital-acquired pressure injury (HAPI) events.</p><p><strong>Methods: </strong>We have established a natural language processing-assisted manual review process and workflow for data extraction from a corpus of nursing notes across all medical inpatient and intensive care units in a tertiary care pediatric center. This system is trained by 2 domain experts. Our workflow started with keywords around HAPI and treatments, then regular expressions, distributive semantics, and finally a document classifier. We generated 3 models: a tri-gram classifier, binary logistic regression model using the regular expressions as predictors, and a random forest model using both models together. Our final output presented to the event screener was generated using a random forest model validated using derivation and validation sets.</p><p><strong>Results: </strong>Our initial corpus involved 70,981 notes during a 1-year period from 5484 unique admissions for 4220 patients. Our interrater human reviewer agreement on identifying HAPI was high ( κ = 0.67; 95% confidence interval [CI], 0.58-0.75). Our random forest model had 95% sensitivity (95% CI, 90.6%-99.3%), 71.2% specificity (95% CI, 65.1%-77.2%), and 78.7% accuracy (95% CI, 74.1%-83.2%). A total of 264 notes from 148 unique admissions (2.7% of all admissions) were identified describing likely HAPI. Sixty-one described new injuries, and 64 describe known yet possibly evolving injuries. Relative to the total patient population during our study period, HAPI incidence was 11.9 per 1000 discharges, and incidence rate was 1.2 per 1000 bed-days.</p><p><strong>Conclusions: </strong>Natural language processing-based surveillance is proven to be feasible and high yield using nursing handoff notes.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10922576/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139038143","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-03-01Epub Date: 2024-01-19DOI: 10.1097/PTS.0000000000001187
Moritz Sebastian Schönfeld, Martin Härter, Ann Sophie Schröder, Katrin Kokartis, Hans-Jürgen Bartz, Levente Kriston
Objective: The objective of this study was to give an overview of the published literature on the implementation of mortality reviews in hospital settings.
Methods: We searched MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, and Web of Science databases up to August 2022 for studies describing implementation or results of implementation of hospital mortality reviews published in English or German. Quality appraisal was conducted using the Mixed Methods Appraisal Tool. Two independent reviewers screened the title/abstract and the full text of potentially relevant records and extracted data using a standardized form. We synthesized and integrated quantitative and qualitative findings narratively following a convergent segregated mixed methods review approach.
Results: From the 884 studies screened, 18 publications met all inclusion criteria and were included in the review. Observed mortality rates reported in 10 publications ranged from 0.4% to 7.8%. In 10 publications, mortality reviews were implemented as a multistep process. In 7 publications, structured mortality review meetings were implemented. Key aspects of success in developing and implementing mortality reviews in hospitals were involvement of multiple stakeholders, providing enough resources for included staff, and constant monitoring and adaption of the processes.
Conclusions: Although awareness of hospital mortality reviews has increased over the last decades, published research in this area is still rare. Our results may inform hospitals considering development and implementation of mortality reviews by providing key aspects and lessons learned from existing implementation experiences.
研究目的本研究旨在概述已发表的有关在医院环境中实施死亡率审查的文献:我们检索了截至 2022 年 8 月的 MEDLINE、Cochrane Central Register of Controlled Trials (CENTRAL)、CINAHL 和 Web of Science 数据库中用英语或德语发表的描述医院死亡率评审实施情况或实施结果的研究。采用混合方法评估工具进行质量评估。两名独立审稿人筛选了可能相关的记录的标题/摘要和全文,并使用标准表格提取数据。我们采用聚合分离的混合方法综述方法,对定量和定性研究结果进行了综合和整合:从筛选出的 884 项研究中,有 18 篇出版物符合所有纳入标准并被纳入综述。10 篇出版物中报告的观察死亡率从 0.4% 到 7.8% 不等。在 10 篇出版物中,死亡率审查是作为一个多步骤过程实施的。在 7 篇出版物中,实施了结构化死亡率评审会议。在医院中成功制定和实施死亡率审查的关键因素是多方利益相关者的参与、为相关人员提供足够的资源以及对流程的持续监控和调整:尽管在过去几十年中,人们对医院死亡率审查的认识有所提高,但这方面的公开研究仍然很少。我们的研究结果可以为考虑制定和实施死亡评审的医院提供参考,提供关键方面以及从现有实施经验中吸取的教训。
{"title":"Implementation of Hospital Mortality Reviews: A Systematic Review.","authors":"Moritz Sebastian Schönfeld, Martin Härter, Ann Sophie Schröder, Katrin Kokartis, Hans-Jürgen Bartz, Levente Kriston","doi":"10.1097/PTS.0000000000001187","DOIUrl":"10.1097/PTS.0000000000001187","url":null,"abstract":"<p><strong>Objective: </strong>The objective of this study was to give an overview of the published literature on the implementation of mortality reviews in hospital settings.</p><p><strong>Methods: </strong>We searched MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, and Web of Science databases up to August 2022 for studies describing implementation or results of implementation of hospital mortality reviews published in English or German. Quality appraisal was conducted using the Mixed Methods Appraisal Tool. Two independent reviewers screened the title/abstract and the full text of potentially relevant records and extracted data using a standardized form. We synthesized and integrated quantitative and qualitative findings narratively following a convergent segregated mixed methods review approach.</p><p><strong>Results: </strong>From the 884 studies screened, 18 publications met all inclusion criteria and were included in the review. Observed mortality rates reported in 10 publications ranged from 0.4% to 7.8%. In 10 publications, mortality reviews were implemented as a multistep process. In 7 publications, structured mortality review meetings were implemented. Key aspects of success in developing and implementing mortality reviews in hospitals were involvement of multiple stakeholders, providing enough resources for included staff, and constant monitoring and adaption of the processes.</p><p><strong>Conclusions: </strong>Although awareness of hospital mortality reviews has increased over the last decades, published research in this area is still rare. Our results may inform hospitals considering development and implementation of mortality reviews by providing key aspects and lessons learned from existing implementation experiences.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139492612","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-03-01Epub Date: 2023-12-21DOI: 10.1097/PTS.0000000000001189
Deulle Min, Seungmi Park, Suhee Kim, Hye Ok Park
Objectives: The aims of the study were to identify the systemic factors affecting the characteristics and safety of older adults living in nursing homes and the resulting resident outcomes and to explore the relationship between them through an integrated literature review.
Methods: A literature search was conducted from April 22 to May 6, 2021, in the PubMed, Embase, Cochrane CENTRAL, CIHNAL, RISS, NDL, and KoreaMed databases. The following key words and MeSH terms were used for the search: "nursing home," "skilled nursing facility," "long-term care facility," and "patient safety" or "safety."
Results: Forty-seven qualifying articles were finally selected. Three domains were derived as personal factors, 12 as facility factors, and one as a policy factor. The interrelationships between them could result in positive or negative resident outcomes. The relationship between them was also reconstructed from an ecological perspective.
Conclusions: The results demonstrated that the safety and quality of life of older adults living in nursing homes were affected by both individual and institutional factors.
{"title":"Patient Safety in Nursing Homes From an Ecological Perspective: An Integrated Review.","authors":"Deulle Min, Seungmi Park, Suhee Kim, Hye Ok Park","doi":"10.1097/PTS.0000000000001189","DOIUrl":"10.1097/PTS.0000000000001189","url":null,"abstract":"<p><strong>Objectives: </strong>The aims of the study were to identify the systemic factors affecting the characteristics and safety of older adults living in nursing homes and the resulting resident outcomes and to explore the relationship between them through an integrated literature review.</p><p><strong>Methods: </strong>A literature search was conducted from April 22 to May 6, 2021, in the PubMed, Embase, Cochrane CENTRAL, CIHNAL, RISS, NDL, and KoreaMed databases. The following key words and MeSH terms were used for the search: \"nursing home,\" \"skilled nursing facility,\" \"long-term care facility,\" and \"patient safety\" or \"safety.\"</p><p><strong>Results: </strong>Forty-seven qualifying articles were finally selected. Three domains were derived as personal factors, 12 as facility factors, and one as a policy factor. The interrelationships between them could result in positive or negative resident outcomes. The relationship between them was also reconstructed from an ecological perspective.</p><p><strong>Conclusions: </strong>The results demonstrated that the safety and quality of life of older adults living in nursing homes were affected by both individual and institutional factors.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138832533","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-01-01Epub Date: 2023-12-01DOI: 10.1097/PTS.0000000000001181
Dan Le, Charles H Lim, Rouhi Fazelzad, Lyndon Morley, Jean-Pierre Bissonnette, Melanie Powis, Monika K Krzyzanowska
Objectives: There is limited guidance on how to effectively promote safety culture in health care settings. We performed a systematic review to identify interventions to promote safety culture, specifically in oncology settings.
Methods: Medical Subject Headings and text words for "safety culture" and "cancer care" were combined to conduct structured searches of MEDLINE, EMBASE, CDSR, CINAHL, Cochrane CENTRAL, PsycINFO, Scopus, and Web of Science for peer-reviewed articles published from 1999 to 2021. To be included, articles had to evaluate a safety culture intervention in an oncology setting using a randomized or nonrandomized, pre-post (controlled or uncontrolled), interrupted time series, or repeated-measures study design. The review followed PRISMA guidelines; quality of included citations was assessed using the ROBINS-I risk of bias tool.
Results: Eighteen articles meeting the inclusion criteria were retained, reporting on interventions in radiation (14 of 18), medical (3 of 18), or general oncology (1 of 18) settings. Articles most commonly addressed incident learning systems (7 of 18), lean initiatives (4 of 18), or quality improvement programs (3 of 18). Although 72% of studies reported improvement in safety culture, there was substantial heterogeneity in the evaluation approach; rates of reporting of adverse events (9 of 18) or Agency for Healthcare Research and Quality Safety Culture survey results (9 of 18) were the most commonly used metrics. Most of the studies had moderate (28%) or severe (67%) risk of bias.
Conclusions: Despite a growing evidence base describing interventions to promote safety culture in cancer care, definitive recommendations were difficult to make because of heterogeneity in study designs and outcomes. Implementation of incident learning systems seems to hold most promise.
目的:关于如何在卫生保健环境中有效促进安全文化的指导有限。我们进行了系统回顾,以确定促进安全文化的干预措施,特别是在肿瘤学环境中。方法:结合医学主题标题和“安全文化”和“癌症护理”的文本词,在MEDLINE、EMBASE、CDSR、CINAHL、Cochrane CENTRAL、PsycINFO、Scopus和Web of Science中进行结构化检索,检索1999年至2021年发表的同行评议文章。纳入的文章必须采用随机或非随机、前后(对照或非对照)、中断时间序列或重复测量研究设计来评估肿瘤学环境中的安全培养干预。审查遵循PRISMA准则;使用ROBINS-I偏倚风险工具评估纳入引文的质量。结果:18篇符合纳入标准的文章被保留下来,报道了放疗(18篇中的14篇)、医学(18篇中的3篇)或普通肿瘤学(18篇中的1篇)方面的干预措施。文章最常见的是讨论事件学习系统(18篇中的7篇),精益计划(18篇中的4篇),或者质量改进计划(18篇中的3篇)。尽管72%的研究报告了安全培养的改善,但评估方法存在很大的异质性;不良事件报告率(18个中的9个)或卫生保健研究和质量安全文化机构调查结果(18个中的9个)是最常用的指标。大多数研究有中度(28%)或重度(67%)偏倚风险。结论:尽管越来越多的证据基础描述了在癌症治疗中促进安全文化的干预措施,但由于研究设计和结果的异质性,很难提出明确的建议。事件学习系统的实施似乎最有希望。
{"title":"Interventions to Promote Safety Culture in Cancer Care: A Systematic Review.","authors":"Dan Le, Charles H Lim, Rouhi Fazelzad, Lyndon Morley, Jean-Pierre Bissonnette, Melanie Powis, Monika K Krzyzanowska","doi":"10.1097/PTS.0000000000001181","DOIUrl":"10.1097/PTS.0000000000001181","url":null,"abstract":"<p><strong>Objectives: </strong>There is limited guidance on how to effectively promote safety culture in health care settings. We performed a systematic review to identify interventions to promote safety culture, specifically in oncology settings.</p><p><strong>Methods: </strong>Medical Subject Headings and text words for \"safety culture\" and \"cancer care\" were combined to conduct structured searches of MEDLINE, EMBASE, CDSR, CINAHL, Cochrane CENTRAL, PsycINFO, Scopus, and Web of Science for peer-reviewed articles published from 1999 to 2021. To be included, articles had to evaluate a safety culture intervention in an oncology setting using a randomized or nonrandomized, pre-post (controlled or uncontrolled), interrupted time series, or repeated-measures study design. The review followed PRISMA guidelines; quality of included citations was assessed using the ROBINS-I risk of bias tool.</p><p><strong>Results: </strong>Eighteen articles meeting the inclusion criteria were retained, reporting on interventions in radiation (14 of 18), medical (3 of 18), or general oncology (1 of 18) settings. Articles most commonly addressed incident learning systems (7 of 18), lean initiatives (4 of 18), or quality improvement programs (3 of 18). Although 72% of studies reported improvement in safety culture, there was substantial heterogeneity in the evaluation approach; rates of reporting of adverse events (9 of 18) or Agency for Healthcare Research and Quality Safety Culture survey results (9 of 18) were the most commonly used metrics. Most of the studies had moderate (28%) or severe (67%) risk of bias.</p><p><strong>Conclusions: </strong>Despite a growing evidence base describing interventions to promote safety culture in cancer care, definitive recommendations were difficult to make because of heterogeneity in study designs and outcomes. Implementation of incident learning systems seems to hold most promise.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138463841","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-01-01Epub Date: 2023-11-03DOI: 10.1097/PTS.0000000000001174
Adam Sutherland, Denham L Phipps, Andrea Gill, Stephen Morris, Darren M Ashcroft
Objectives: Medication is a common cause of preventable medical harm in pediatric inpatients. This study aimed to examine the sociotechnical system surrounding pediatric medicines management, to identify potential gaps in this system and how these might contribute to adverse drug events (ADEs).
Methods: An exploratory prospective qualitative study in pediatric wards in three hospitals in the north of England was conducted between October 2020 and May 2022. Analysis included a documentary analysis of 72 policies and procedures and analysis of field notes from 60 hours of participant observation. The cognitive work analysis prompt framework was used to generate a work domain analysis (WDA) and identify potential contributory factors to ADEs.
Results: The WDA identified 2 functional purposes, 7 value/priority measures, 6 purpose-related functions, 11 object-related processes and 14 objects. Structured means-ends connections supported identification of 3 potential contributory factors-resource limitations, cognitive demands, and adaptation of processes. The lack of resources (equipment, materials, knowledge, and experience) created an environment where distractions and interruptions were unavoidable. Families helped provide practical support in medicines administration but were largely unacknowledged at an organizational level. There was a lack of teamwork with regards to medication with different professionals responsible for different parts of the system. Mandated safety checks on medicines were frequently omitted because of limited resources and perceived redundancy. Interventions to support adherence to safety policies were also often bypassed because they created more work.
Conclusions: The WDA has provided insights into the complex system of medication safety for children in hospital and has facilitated the identification of potential contributory factors to ADEs. We therefore advocate (in priority order) for processes to involve parents in the care of their children in hospital, development of skill-mix interventions to ensure appropriate expertise is available where it is needed, and modified checking procedures to permit staff to use their skills and judgment effectively and efficiently.
{"title":"Medication Safety Gaps in English Pediatric Inpatient Units: An Exploration Using Work Domain Analysis.","authors":"Adam Sutherland, Denham L Phipps, Andrea Gill, Stephen Morris, Darren M Ashcroft","doi":"10.1097/PTS.0000000000001174","DOIUrl":"10.1097/PTS.0000000000001174","url":null,"abstract":"<p><strong>Objectives: </strong>Medication is a common cause of preventable medical harm in pediatric inpatients. This study aimed to examine the sociotechnical system surrounding pediatric medicines management, to identify potential gaps in this system and how these might contribute to adverse drug events (ADEs).</p><p><strong>Methods: </strong>An exploratory prospective qualitative study in pediatric wards in three hospitals in the north of England was conducted between October 2020 and May 2022. Analysis included a documentary analysis of 72 policies and procedures and analysis of field notes from 60 hours of participant observation. The cognitive work analysis prompt framework was used to generate a work domain analysis (WDA) and identify potential contributory factors to ADEs.</p><p><strong>Results: </strong>The WDA identified 2 functional purposes, 7 value/priority measures, 6 purpose-related functions, 11 object-related processes and 14 objects. Structured means-ends connections supported identification of 3 potential contributory factors-resource limitations, cognitive demands, and adaptation of processes. The lack of resources (equipment, materials, knowledge, and experience) created an environment where distractions and interruptions were unavoidable. Families helped provide practical support in medicines administration but were largely unacknowledged at an organizational level. There was a lack of teamwork with regards to medication with different professionals responsible for different parts of the system. Mandated safety checks on medicines were frequently omitted because of limited resources and perceived redundancy. Interventions to support adherence to safety policies were also often bypassed because they created more work.</p><p><strong>Conclusions: </strong>The WDA has provided insights into the complex system of medication safety for children in hospital and has facilitated the identification of potential contributory factors to ADEs. We therefore advocate (in priority order) for processes to involve parents in the care of their children in hospital, development of skill-mix interventions to ensure appropriate expertise is available where it is needed, and modified checking procedures to permit staff to use their skills and judgment effectively and efficiently.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71428174","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-01-01Epub Date: 2023-11-10DOI: 10.1097/PTS.0000000000001183
See Chai Carol Chan
{"title":"The Power of Positive Reinforcement in Health Care.","authors":"See Chai Carol Chan","doi":"10.1097/PTS.0000000000001183","DOIUrl":"10.1097/PTS.0000000000001183","url":null,"abstract":"","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72015804","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-01-01Epub Date: 2023-10-25DOI: 10.1097/PTS.0000000000001170
Craig S Webster, Ties Coomber, Sue Liu, Kaitlin Allen, Tanisha Jowsey
Objective: The aim of the study is to identify quantitative evidence for the efficacy of interprofessional learning (IPL) to improve patient outcomes.
Methods: We conducted a systematic review and meta-analysis of quantitative patient outcomes after IPL in multidisciplinary healthcare teams reported in the Medline, Scopus, PsycInfo, Embase, and CINAHL databases.
Results: In 2022, we screened 15,248 reports to include 20 and extracted rates of mortality and primary outcomes in conventional care groups and intervention groups (involving initiatives to promote IPL in multidisciplinary teams). The meta-analysis of the 13 studies reporting mortality outcomes demonstrated that the 7166 patients in the intervention group had a significant 28% (95% confidence interval [CI], 40%-14%; P < 0.0003) reduced risk of dying compared with the 6809 patients in the conventional care group. The meta-analysis of the 14 studies reporting other treatment-related adverse outcomes demonstrated that the 4789 patients in the intervention group had a significant 23% (95% CI, 33%-12%; P < 0.0001) reduced risk of experiencing an adverse outcome during care compared with the 4129 patients in the conventional care group. Sensitivity analysis, involving the exclusion of the 20% of individual studies with the widest 95% CIs, confirmed the precision and reliability of our findings.
Conclusions: We believe that our results are the first to demonstrate significant quantitative evidence for the efficacy of IPL to translate into changes in clinical practice and improved patient outcomes. Our results reinforce earlier qualitative work of the value of IPL, but further prospective quantitative and mixed-methods research is needed to better define such benefits.
{"title":"Interprofessional Learning in Multidisciplinary Healthcare Teams Is Associated With Reduced Patient Mortality: A Quantitative Systematic Review and Meta-analysis.","authors":"Craig S Webster, Ties Coomber, Sue Liu, Kaitlin Allen, Tanisha Jowsey","doi":"10.1097/PTS.0000000000001170","DOIUrl":"10.1097/PTS.0000000000001170","url":null,"abstract":"<p><strong>Objective: </strong>The aim of the study is to identify quantitative evidence for the efficacy of interprofessional learning (IPL) to improve patient outcomes.</p><p><strong>Methods: </strong>We conducted a systematic review and meta-analysis of quantitative patient outcomes after IPL in multidisciplinary healthcare teams reported in the Medline, Scopus, PsycInfo, Embase, and CINAHL databases.</p><p><strong>Results: </strong>In 2022, we screened 15,248 reports to include 20 and extracted rates of mortality and primary outcomes in conventional care groups and intervention groups (involving initiatives to promote IPL in multidisciplinary teams). The meta-analysis of the 13 studies reporting mortality outcomes demonstrated that the 7166 patients in the intervention group had a significant 28% (95% confidence interval [CI], 40%-14%; P < 0.0003) reduced risk of dying compared with the 6809 patients in the conventional care group. The meta-analysis of the 14 studies reporting other treatment-related adverse outcomes demonstrated that the 4789 patients in the intervention group had a significant 23% (95% CI, 33%-12%; P < 0.0001) reduced risk of experiencing an adverse outcome during care compared with the 4129 patients in the conventional care group. Sensitivity analysis, involving the exclusion of the 20% of individual studies with the widest 95% CIs, confirmed the precision and reliability of our findings.</p><p><strong>Conclusions: </strong>We believe that our results are the first to demonstrate significant quantitative evidence for the efficacy of IPL to translate into changes in clinical practice and improved patient outcomes. Our results reinforce earlier qualitative work of the value of IPL, but further prospective quantitative and mixed-methods research is needed to better define such benefits.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71428173","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-01-01Epub Date: 2023-11-06DOI: 10.1097/PTS.0000000000001177
Bhavana Thota, Anna Rabinowitz, Oren Guttman
Abstract: The rise of the #TheatreCapChallenge in 2017, which saw participants donning surgical caps labeled with their names and roles, promises to be a seemingly simple intervention aimed at improving operating theater communication and patient safety. This narrative review strives to expand upon the perceived and studied benefits of this intervention and address potential concerns that have arisen with the use of these name and role-labeled surgical caps.
{"title":"Taking Up the Challenge to Improve Name and Role Recognition in the Operating Room.","authors":"Bhavana Thota, Anna Rabinowitz, Oren Guttman","doi":"10.1097/PTS.0000000000001177","DOIUrl":"10.1097/PTS.0000000000001177","url":null,"abstract":"<p><strong>Abstract: </strong>The rise of the #TheatreCapChallenge in 2017, which saw participants donning surgical caps labeled with their names and roles, promises to be a seemingly simple intervention aimed at improving operating theater communication and patient safety. This narrative review strives to expand upon the perceived and studied benefits of this intervention and address potential concerns that have arisen with the use of these name and role-labeled surgical caps.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":null,"pages":null},"PeriodicalIF":2.2,"publicationDate":"2024-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71434815","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}