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Kushniruk A, Heidebrecht C, Zettler A, Pearce J, Cunha R, Quan S, Mansfield E, Tang T. The Perceived Ease of Use and Perceived Usefulness of a Web-Based Interprofessional Communication and Collaboration Platform in the Hospital Setting: Interview Study With Health Care Providers. JMIR Hum Factors 2023; 10:e39051. [PMID: 36689261 PMCID: PMC9947815 DOI: 10.2196/39051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 09/12/2022] [Accepted: 09/12/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Hospitalized patients with complex care needs require an interprofessional team of health professionals working together to support their care in hospitals and during discharge planning. However, interprofessional communication and collaboration in inpatient settings are often fragmented and inefficient, leading to poor patient outcomes and provider frustration. Health information technology can potentially help improve team communication and collaboration; however, to date, evidence of its effectiveness is lacking. There are also concerns that current implementations might further fragment communication and increase the clinician burden without proven benefits. OBJECTIVE In this study, we aimed to generate transferrable lessons for future designers of health information technology tools that facilitate team communication and collaboration. METHODS A secondary analysis of the qualitative component of the mixed methods evaluation was performed. The electronic communication and collaboration platform was implemented in 2 general internal medicine wards in a large community teaching hospital in Mississauga, Ontario, Canada. Fifteen inpatient clinicians in those wards, including nurses, physicians, and allied health care providers, were recruited to participate in semistructured interviews about their experience with a co-designed electronic communication and collaboration tool. Data were analyzed using the Technology Acceptance Model, and themes related to the constructs of perceived ease of use (PEOU) and perceived usefulness (PU) were identified. RESULTS A secondary analysis guided by the Technology Acceptance Model highlighted important points. Intuitive design precluded training as a barrier to use, but lack of training may hinder participants' PEOU if features designed for efficiency are not discovered by users. Organized information was found to be useful for creating a comprehensive clinical picture of each patient and facilitating improved handovers. However, information needs to be both comprehensive and succinct, and information overload may negatively impact PEOU. The mixed paper and electronic practice environment also negatively impacted PEOU owing to unavoidable double documentation and the need for printing. Participants perceived the tool to be useful as it improved efficiency in information retrieval and documentation, improved the handover process, afforded another mode of communication when face-to-face communication was impractical, and improved shared awareness. The PU of this tool depends on its optimal use by all team members. CONCLUSIONS Electronic tools can support communication and collaboration among interprofessional teams caring for patients with complex needs. There are transferable lessons learned that can improve the PU and PEOU of future systems.
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Affiliation(s)
| | | | - Andrea Zettler
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Jacklyn Pearce
- Bellwoods Centres for Community Living Inc, Toronto, ON, Canada
| | - Rafael Cunha
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | | | - Elizabeth Mansfield
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Terence Tang
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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2
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Law S, Antonacci R, Ormel I, Hidalgo M, Ma J, Dyachenko A, Laframboise D, Doucette E. Engaging patients, families and professionals at the bedside using whiteboards. J Interprof Care 2022; 37:400-409. [PMID: 35880772 DOI: 10.1080/13561820.2022.2074379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Health-care systems around the world are striving to be patient-centered, and there is growing evidence that engaging patients and families in their care, as well as in efforts to redesign services, contributes to improved outcomes and experiences for patients and providers. This patient-oriented care movement includes efforts to improve the quality of information and communication between health-care professionals and patients as well as families and caregivers. Whiteboards have emerged as a best practice in hospitals to promote engagement and improve information and communication, yet with limited empirical evidence regarding their value to patients, families, or interprofessional teams. We introduced whiteboards on an acute medical unit at a community hospital and conducted an evaluation using a pre-post design collecting both qualitative and quantitative data. Baseline and post-implementation data were collected via qualitative interviews with patients/family and providers and using the Canadian Patient Experience Survey; focus groups were held with staff and members of the care team. Qualitative results highlighted improvements in communication between the care team and patients as well as family members. Implications for practice include attention to patient/family empowerment and safety, adherence to guidance for good communication, and support for regular training and education in the use of communication tools for members of the interprofessional team.
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Affiliation(s)
- Susan Law
- Mary's Research Centre, Department of Family Medicine, McGill UniversitySt. , Montreal, QC, Canada.,Institute for Better Health, University of Toronto & Senior Scientist, Toronto, ON, Canada
| | - Rosetta Antonacci
- Teaching Unit, St. Mary's HospitalNurse Manager - Medical-Clinical, Montreal, QC, Canada.,Ingram School of Nursing & Clinical Associate, Department of Academic and University Affairs, CIUSSS ODIM, Ingram School of Nursing, McGill University, Montreal, QC, Canada
| | - Ilja Ormel
- St. Mary's Research Centre, Montreal, QC, Canada
| | - Marcela Hidalgo
- Patient Engagement, St. Mary's Research Centre, Montreal, QC, Canada
| | - Julia Ma
- Biostatistician - Institute for Better Health, Trillium Health Partners.,Data Scientist, Precision Analytics, Montreal, QC, Canada
| | | | | | - Elaine Doucette
- Ingram School of Nursing, McGill University, Montreal, QC, Canada
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3
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Stucky CH, De Jong MJ, Kabo FW, Kasper CE. A Network Analysis of Perioperative Communication Patterns. AORN J 2020; 111:627-641. [DOI: 10.1002/aorn.13044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Martin-Delgado J, Martínez-García A, Aranaz JM, Valencia-Martín JL, Mira JJ. How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review. Med Princ Pract 2020; 29:524-531. [PMID: 32417837 PMCID: PMC7768139 DOI: 10.1159/000508677] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 05/12/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The aim of this systematic review was to consolidate studies to determine whether root cause analysis (RCA) is an adequate method to decrease recurrence of avoidable adverse events (AAEs). METHODS A systematic search of databases from creation until December 2018 was performed using PubMed, Scopus and EMBASE. We included articles published in scientific journals describing the practical usefulness in and impact of RCA on the reduction of AAEs and whether professionals consider it feasible. The Mixed Methods Appraisal Tool was used to assess the quality of studies. RESULTS Twenty-one articles met the inclusion criteria. Samples included in these studies ranged from 20 to 1,707 analyses of RCAs, AAEs, recommendations, audits or interviews with professionals. The most common setting was hospitals (86%; n = 18), and the type of incident most analysed was AAEs, in 71% (n = 15) of the cases; 47% (n = 10) of the studies stated that the main weakness of RCA is its recommendations. The most common causes involved in the occurrence of AEs were communication problems among professionals, human error and faults in the organisation of the health care process. Despite the widespread implementation of RCA in the past decades, only 2 studies could to some extent establish an improvement in patient safety due to RCAs. CONCLUSIONS RCA is a useful tool for the identification of the remote and immediate causes of safety incidents, but not for implementing effective measures to prevent their recurrence.
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Affiliation(s)
- Jimmy Martin-Delgado
- Atenea Investigation Group, Fundación para el Fomento de la Investigación Sanitario y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain,
| | | | | | | | - José Joaquín Mira
- Atenea Investigation Group, Fundación para el Fomento de la Investigación Sanitario y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Department of Health Psychology, Universidad Miguel Hernández, Alicante, Spain
- Alicante-Sant Joan d'Alacant Health District, Alicante, Spain
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5
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Clapper TC, Ching K. Debunking the myth that the majority of medical errors are attributed to communication. MEDICAL EDUCATION 2020; 54:74-81. [PMID: 31509277 DOI: 10.1111/medu.13821] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 10/10/2018] [Accepted: 01/10/2019] [Indexed: 06/10/2023]
Abstract
CONTEXT Many articles, book chapters and presentations begin with a declaration that the majority of medical errors are attributed to communication. However, this statement may not be supported by the research reported in the literature. OBJECTIVES The purpose of this systematic review is to identify where errors are reported in the research literature. METHODS A systematised review was conducted of research articles over the last 20 years (1998-2018) indexed in PubMed/MEDLINE and the Cumulative Index to Nursing and Allied Health (CINAHL) using term combinations: medical errors, research and communication. Inclusion was based on reported generalised primary research of medical error and the reported causes. RESULTS This systematised review resulted in 2881 research articles, which produced 42 that met the inclusion criteria. Although there was some overlap, three categories of errors were dominant in this research: errors of commission (20 articles; 47.6%), errors of omission (six articles; 14.2%) and errors through communication (four articles; 9.5%). There were 12 (28.5%) articles in which all three categories together significantly contributed to error. Of these 12 articles, errors of commission or omission were dominant in nine articles (21.4%) and errors of communication were prevalent in only three articles (7%). CONCLUSIONS The assertion that the majority of medical errors can be attributed to miscommunication is not supported by this systematic review. Overwhelmingly, most reported errors are attributed to errors of omission or commission. Intentionally or unintentionally providing misinformation may mislead patient safety initiatives, and research and funding agency priorities.
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Affiliation(s)
- Timothy C Clapper
- Weill Cornell Medicine New York-Presbyterian Simulation Program and Center, Department of Pediatrics, Weill Cornell Medical College, New York, New York
| | - Kevin Ching
- Weill Cornell Medicine New York-Presbyterian Simulation Program and Center, Department of Pediatrics, Weill Cornell Medical College, New York, New York
- Department of Emergency Medicine, Weill Cornell Medical College, New York, New York
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Cullen SW, Xie M, Vermeulen JM, Marcus SC. Comparing Rates of Adverse Events and Medical Errors on Inpatient Psychiatric Units at Veterans Health Administration and Community-based General Hospitals. Med Care 2019; 57:913-920. [PMID: 31609847 PMCID: PMC6813795 DOI: 10.1097/mlr.0000000000001215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE There is limited knowledge about how general hospitals and Veterans Health Administration (VHA) hospitals fare relative to each other on a broad range of inpatient psychiatry-specific patient safety outcomes.This research compares data from 2 large-scale epidemiological studies of adverse events (AEs) and medical errors (MEs) in inpatient psychiatric units, one in VHA hospitals and the other in community-based general hospitals. METHOD Retrospective medical record reviews assessed the prevalence of AEs and MEs in a sample of 4371 discharges from 14 community-based general hospitals (derived from 69,081 discharges at 85 hospitals) and a sample of 8005 discharges from 40 VHA hospitals (derived from 92,103 discharges at 105 medical centers). Rates of AEs and MEs across hospital systems were calculated, controlling for relevant patient and hospital characteristics. RESULTS The overall rate of AEs and MEs in inpatient psychiatric units of VHA hospitals was 7.11 and 1.49 per 100 patient discharges; at community-based acute care hospitals, these rates were 13.48 and 3.01 per 100 patient discharges. The adjusted odds ratio of a patient experiencing an AE and a ME at community-based hospitals as compared with VHA hospitals was 2.11 and 2.08, respectively. CONCLUSION Although chart reviews may not document the complete nature and outcomes of care, even after controlling for differences in patient and hospital characteristics, psychiatric inpatients at community-based hospitals were twice as likely to experience AEs or MEs as inpatients at VHA hospitals. While community-based hospitals may lag behind VHA hospitals, both hospital systems should continue to pursue evidence-based improvements in patient safety. Future research aimed at changing hospital practices should draw on established strategies for bridging the gap from research to practice in order to improve the quality of care for this vulnerable patient population.
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Affiliation(s)
| | - Ming Xie
- School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jentien M Vermeulen
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Hamilton MJ, McEniery JA, Osborne JM, Coulthard MG. Implementation and strength of root cause analysis recommendations following serious adverse events involving paediatric patients in the Queensland public health system between 2012 and 2014. J Paediatr Child Health 2019; 55:1070-1076. [PMID: 30582234 DOI: 10.1111/jpc.14344] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 10/31/2018] [Accepted: 11/18/2018] [Indexed: 11/28/2022]
Abstract
AIM This study evaluates the implementation rate and strength of the recommendations developed in all root cause analyses (RCAs) performed following serious clinical incidents involving children that have resulted in permanent harm or death in Queensland public hospitals over a 3-year period. METHODS Severity assessment classification 1 events were identified from a Queensland Paediatric Quality Council database of paediatric clinical incidents that occurred in Queensland between 1 January 2012 and 31 December 2014. There were 150 recommendations extracted from RCAs pertaining to the 42 serious adverse events involving paediatric patients. RESULTS Of the recommendations, 82% were implemented; 33% of recommendations were classified as stronger, 33% as intermediate and 34% weaker in terms of their potential to improve patient safety. CONCLUSIONS This study describes the implementation of recommendations and classifies them in terms of potential to prevent patient harm and save lives. Future research is needed to determine if the RCA process does indeed prevent harm.
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Affiliation(s)
- Monique J Hamilton
- Academic Discipline of Paediatrics and Child Health, University of Queensland, Brisbane, Queensland, Australia
| | - Julie A McEniery
- Queensland Paediatric Quality Council, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - Jodie M Osborne
- Queensland Paediatric Quality Council, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - Mark G Coulthard
- Academic Discipline of Paediatrics and Child Health, University of Queensland, Brisbane, Queensland, Australia.,Queensland Paediatric Quality Council, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
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8
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Abraham J, Jaros J, Ihianle I, Kochendorfer K, Kannampallil T. Impact of EHR-based rounding tools on interactive communication: A prospective observational study. Int J Med Inform 2019; 129:423-429. [PMID: 31445286 DOI: 10.1016/j.ijmedinf.2019.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/09/2019] [Accepted: 07/15/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Structured rounding tools have shown to improve the overall efficiency and perceived satisfaction with the rounding process. However, little is known about how EHR-integrated rounding tools impact the content, structure and interactivity of communication during rounds. METHOD We conducted a prospective pre-post evaluation with two rounding tools: a Microsoft Word-based fillable rounding tool (usual tool), and an EHR-integrated rounding report tool (RRT). 27 clinicians across two teams participated in rounds for 169 patients (nusual=84, nRRT=85). We audio-recorded and coded communication during rounds using conversational analysis methods. Using the coded communication interactions, we investigated differences between the two tools on: clinical content discussed, questions raised, and breakdowns in interactive communication. Additionally, we gathered clinician perspectives on the rounding tools through follow-up interviews. RESULTS We found that the use of RRT was associated with significantly more discussion of patient identifiers (e.g., name), and action items (e.g., to-do list) and significantly less discussion of imaging (e.g., X-rays) than the usual tool. RRT was also associated with fewer questions (t = 3.1, p = 0.03), and correspondingly, fewer responses (t = 3.2, p = 0.02). Communication breakdowns related to incorrect responses was fewer during the use of RRT (t = 0.5, p = 0.01). There were no statistically significant differences in the time spent for rounding between the two tools. CONCLUSIONS Our findings showed that RRT impacted rounding workflow: during pre-rounding, by saving time and effort in gathering information from multiple sources; during rounding, by streamlining content of the conversations using the structured RRT template; and during post-rounding, by supporting explicit discussion of patient tasks and action items for patient care planning and management.
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Affiliation(s)
- Joanna Abraham
- Department of Anesthesiology & Institute for Informatics, School of Medicine, Washington University in St Louis, St. Louis, MO, United States.
| | - Joanna Jaros
- Department of Biomedical and Health Information Sciences, College of Applied Health Sciences, United States
| | - Imade Ihianle
- Department of Biomedical and Health Information Sciences, College of Applied Health Sciences, United States
| | - Karl Kochendorfer
- Department of Family Medicine, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Thomas Kannampallil
- Department of Anesthesiology & Institute for Informatics, School of Medicine, Washington University in St Louis, St. Louis, MO, United States
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9
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Creating a Defined Process to Improve the Timeliness of Serious Safety Event Determination and Root Cause Analysis. Pediatr Qual Saf 2019; 4:e200. [PMID: 31745504 PMCID: PMC6831051 DOI: 10.1097/pq9.0000000000000200] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/04/2019] [Indexed: 11/27/2022] Open
Abstract
Serious Safety Events (SSEs) are defined as events in which there is a deviation from clinically accepted performance standards, causation, and significant patient harm or death. Given the nature of SSEs, it is important that the processes for declaration of SSEs, the performance of a root cause analysis (RCA), and action plan formation occur quickly, such that the window for potential recurrence of similar events is as small as possible. This manuscript describes a process put in place to improve the timeliness of SSE determination and RCA conduction and evaluates the effect of the process change on these parameters. Methods A causal analysis was performed of the baseline process to determine factors contributing to long process times. A new process was created and implemented both for the SSE determination process and the RCA completion process. We calculated the mean time for the pre-implementation phase (April 2016-December 2017) and the post-implementation phase (March 2018-January 2019) for both SSE determination and RCA completion. We evaluated differences with a two-sided t test assuming unequal variances. Results Comparing pre- versus post- implementation phases, the mean time for SSE determination for events that met the SSE criteria decreased from 38.4 to 4.8 days (P < 0.0001), determination for events that did not meet the SSE criteria decreased from 38.4 to 3.8 days (P < 0.0001), and RCA completion time dropped from 118.0 to 26.2 days (P < 0.0001). Conclusions A targeted intervention can significantly reduce SSE determination and RCA conduction times.
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Liu JJ, Rotteau L, Bell CM, Shojania KG. Putting out fires: a qualitative study exploring the use of patient complaints to drive improvement at three academic hospitals. BMJ Qual Saf 2019; 28:894-900. [PMID: 31123172 DOI: 10.1136/bmjqs-2018-008801] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 04/09/2019] [Accepted: 05/04/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Recent years have seen increasing calls for more proactive use of patient complaints to develop effective system-wide changes, analogous to the intended functions of incident reporting and root cause analysis (RCA) to improve patient safety. Given recent questions regarding the impact of RCAs on patient safety, we sought to explore the degree to which current patient complaints processes generate solutions to recurring quality problems. DESIGN/SETTING Qualitative analysis of semistructured interviews with 21 patient relations personnel (PRP), nursing and physician leaders at three teaching hospitals (Toronto, Canada). RESULTS Challenges to using the patient complaints process to drive hospital-wide improvement included: (1) Complaints often reflect recalcitrant system-wide issues (eg, wait times) or well-known problems which require intensive efforts to address (eg, poor communication). (2) The use of weak change strategies (eg, one-off educational sessions). (3) The handling of complaints by unit managers so they never reach the patient relations office. PRP identified giving patients a voice as their primary goal. Yet their daily work, which they described as 'putting out fires', focused primarily on placating patients in order to resolve complaints as quickly as possible, which may in effect suppress the patient voice. CONCLUSIONS Using patient complaints to drive improvement faces many of the challenges affecting incident reporting and RCA. The emphasis on 'putting out fires' may further detract from efforts to improve care for future patients. Systemically incorporating patients' voices in clinical operations, as with co-design and other forms of authentic patient engagement, may hold greater promise for meaningful improvements in the patient experience than do RCA-like analyses of patient complaints.
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Affiliation(s)
- Jessica J Liu
- Division of Internal Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Leahora Rotteau
- Centre for Quality Improvment and Patient Safety (C-QuIPS), University of Toronto, Toronto, Ontario, Canada
| | - Chaim M Bell
- Division of Internal Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada.,Centre for Quality Improvment and Patient Safety (C-QuIPS), University of Toronto, Toronto, Ontario, Canada
| | - Kaveh G Shojania
- Division of Internal Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada.,Centre for Quality Improvment and Patient Safety (C-QuIPS), University of Toronto, Toronto, Ontario, Canada
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11
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Tang T, Heidebrecht C, Coburn A, Mansfield E, Roberto E, Lucez E, Lim ME, Reid R, Quan SD. Using an electronic tool to improve teamwork and interprofessional communication to meet the needs of complex hospitalized patients: A mixed methods study. Int J Med Inform 2019; 127:35-42. [PMID: 31128830 DOI: 10.1016/j.ijmedinf.2019.04.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 01/29/2019] [Accepted: 04/12/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Teamwork and interprofessional communication are important in addressing the comprehensive care needs of complex hospitalized patients. The objective of this study is to evaluate the impact of an electronic interprofessional communication and collaboration platform on teamwork, communication, and adverse events in the hospital setting. MATERIALS AND METHODS In this mixed methods study, we used a quasi-experimental design in the quantitative component and deployed the electronic tool in a staged fashion to 2 hospital wards 3 months apart. We measured teamwork, communication, and adverse events with Relational Coordination survey, video recordings of team rounds, and retrospective chart review. We conducted qualitative semi-structured interviews with clinicians to understand the perceived impacts of the electronic tool and other contextual factors. RESULTS Teamwork sustainably improved (overall Relational Coordination score improved from 3.68 at baseline to 3.84 at three and six months after intervention, p = 0.03) on ward 1. A small change in face-to-face communication pattern during team rounds was observed (making plans increased from 22% to 24%, p = 0.004) at 3 months on ward 1 but was not sustained at 6 months. Teamwork and communication did not change after the intervention on ward 2. There was no meaningful change to adverse event rates on either ward. Clinicians reported generally positive views about the electronic tool's impact but described non-technology factors on each ward that affected teamwork and communication. CONCLUSION The impact of using an electronic tool to improve teamwork and communication in the hospital setting appears mixed, but can be positive in some settings. Improving teamwork and communication likely require both appropriate technology and addressing non-technology factors.
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Affiliation(s)
- Terence Tang
- Institute for Better Health and Program of Medicine, Trillium Health Partners, 100 Queensway West, Clinical Administrative Building, 6th floor, Mississauga, Ontario, L5B 1B8, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | | | - Andrea Coburn
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Elizabeth Mansfield
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada; Department of Occupational Science and Occupational Therapy, University of Toronto, Canada
| | - Ellen Roberto
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Emanuel Lucez
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Morgan E Lim
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada
| | - Robert Reid
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada
| | - Sherman D Quan
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
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12
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Aboumrad M, Fuld A, Soncrant C, Neily J, Paull D, Watts BV. Root Cause Analysis of Oncology Adverse Events in the Veterans Health Administration. J Oncol Pract 2018; 14:e579-e590. [PMID: 30110226 DOI: 10.1200/jop.18.00159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Oncology providers are leaders in patient safety. Despite their efforts, oncology-related medical errors still occur, sometimes resulting in patient injury or death. The Veterans Health Administration (VHA) National Center of Patient Safety used data obtained from root cause analysis (RCA) to determine how and why these adverse events occurred in the VHA, and how to prevent future reoccurrence. This study details the types of oncology adverse events reported in VHA hospitals and their root causes and suggests actions for prevention and improvement. METHODS We searched the National Center for Patient Safety adverse event reporting database for RCA related to oncology care from October 1, 2013, to September 8, 2017, to identify event types, root causes, severity of outcomes, care processes, and suggested actions. Two independent reviewers coded these variables, and inter-rater agreement was calculated by κ statistic. Variables were evaluated using descriptive statistics. RESULTS We identified 48 RCA reports that specifically involved an oncology provider. Event types included care delays (39.5% [n = 19]), issues with chemotherapy (25% [n = 12]) and radiation (12.5% [n = 6]), other (12.5% [n = 6]), and suicide (10.5% [n = 5]). Of the 48 events, 27.1% (n = 13) resulted in death, 4.2% (n = 2) in severe harm, 18.8% (n = 9) in temporary harm, 20.8% (n = 10) in minimal harm, and 2.1% (n = 1) in no harm. The majority of root causes identified a need to improve care processes and policies, interdisciplinary communication, and care coordination. CONCLUSION This analysis highlights an opportunity to implement system-wide changes to prevent similar events from reoccurring. These actions include comprehensive cancer clinics, usability testing of medical equipment, and standardization of processes and policies. Additional studies are necessary to assess oncologic adverse events across specialties.
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Affiliation(s)
- Maya Aboumrad
- National Center for Patient Safety; White River Junction VA Medical Center, White River Junction, VT; The National Center for Patient Safety, Ann Arbor, MI; and Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Alexander Fuld
- National Center for Patient Safety; White River Junction VA Medical Center, White River Junction, VT; The National Center for Patient Safety, Ann Arbor, MI; and Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Christina Soncrant
- National Center for Patient Safety; White River Junction VA Medical Center, White River Junction, VT; The National Center for Patient Safety, Ann Arbor, MI; and Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Julia Neily
- National Center for Patient Safety; White River Junction VA Medical Center, White River Junction, VT; The National Center for Patient Safety, Ann Arbor, MI; and Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Douglas Paull
- National Center for Patient Safety; White River Junction VA Medical Center, White River Junction, VT; The National Center for Patient Safety, Ann Arbor, MI; and Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Bradley V Watts
- National Center for Patient Safety; White River Junction VA Medical Center, White River Junction, VT; The National Center for Patient Safety, Ann Arbor, MI; and Geisel School of Medicine at Dartmouth, Hanover, NH
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13
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Mira JJ, Lorenzo S, Carrillo I, Ferrús L, Silvestre C, Astier P, Iglesias-Alonso F, Maderuelo JA, Pérez-Pérez P, Torijano ML, Zavala E, Scott SD. Lessons learned for reducing the negative impact of adverse events on patients, health professionals and healthcare organizations. Int J Qual Health Care 2018; 29:450-460. [PMID: 28934401 DOI: 10.1093/intqhc/mzx056] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 05/05/2017] [Indexed: 12/21/2022] Open
Abstract
Purpose To summarize the knowledge about the aftermath of adverse events (AEs) and develop a recommendation set to reduce their negative impact in patients, health professionals and organizations in contexts where there is no previous experiences and apology laws are not present. Data sources Review studies published between 2000 and 2015, institutional websites and experts' opinions on patient safety. Study selection Studies published and websites on open disclosure, and the second and third victims' phenomenon. Four Focus Groups participating 27 healthcare professionals. Data extraction Study characteristic and outcome data were abstracted by two authors and reviewed by the research team. Results of data synthesis Fourteen publications and 16 websites were reviewed. The recommendations were structured around eight areas: (i) safety and organizational policies, (ii) patient care, (iii) proactive approach to preventing reoccurrence, (iv) supporting the clinician and healthcare team, (v) activation of resources to provide an appropriate response, (vi) informing patients and/or family members, (vii) incidents' analysis and (viii) protecting the reputation of health professionals and the organization. Conclusion Recommendations preventing aftermath of AEs have been identified. These have been designed for the hospital and the primary care settings; to cope with patient's emotions and for tacking the impact of AE in the second victim's colleagues. Its systematic use should help for the establishment of organizational action plans after an AE.
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Affiliation(s)
- Jose Joaquin Mira
- Alicante-Sant Joan Health Department, Alicante, Spain.,Miguel Hernández University, Elche, Spain
| | | | | | - Lena Ferrús
- Integrated Health Organisation, L'Hospitalet de Llobregat, Spain
| | | | - Pilar Astier
- Family and Community Medicine, Tauste Health District, Aragon Health Service (SALUD), Zaragoza, Spain
| | | | - Jose Angel Maderuelo
- Salamanca Primary Care Management, Castilla y León Health Service (SACYL), Salamanca, Spain
| | - Pastora Pérez-Pérez
- Patient Safety Observatory, Andalusian Agency for Healthcare Quality, Seville, Spain
| | | | | | - Susan D Scott
- University of Missouri Health System, Columbia, MO, USA
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Sullivan JL, Rivard PE, Shin MH, Rosen AK. Applying the High Reliability Health Care Maturity Model to Assess Hospital Performance: A VA Case Study. Jt Comm J Qual Patient Saf 2017; 42:389-411. [PMID: 27535456 DOI: 10.1016/s1553-7250(16)42080-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The lack of a tool for categorizing and differentiating hospitals according to their high reliability organization (HRO)-related characteristics has hindered progress toward implementing and sustaining evidence-based HRO practices. Hospitals would benefit both from an understanding of the organizational characteristics that support HRO practices and from knowledge about the steps necessary to achieve HRO status to reduce the risk of harm and improve outcomes. The High Reliability Health Care Maturity (HRHCM) model, a model for health care organizations' achievement of high reliability with zero patient harm, incorporates three major domains critical for promoting HROs-Leadership, Safety Culture, and Robust Process Improvement ®. A study was conducted to examine the content validity of the HRHCM model and evaluate whether it can differentiate hospitals' maturity levels for each of the model's components. METHODS Staff perceptions of patient safety at six US Department of Veterans Affairs (VA) hospitals were examined to determine whether all 14 HRHCM components were present and to characterize each hospital's level of organizational maturity. RESULTS Twelve of the 14 components from the HRHCM model were detected; two additional characteristics emerged that are present in the HRO literature but not represented in the model-teamwork culture and system-focused tools for learning and improvement. Each hospital's level of organizational maturity could be characterized for 9 of the 14 components. DISCUSSION The findings suggest the HRHCM model has good content validity and that there is differentiation between hospitals on model components. Additional research is needed to understand how these components can be used to build the infrastructure necessary for reaching high reliability.
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Affiliation(s)
- Jennifer L Sullivan
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, USA
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15
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Corwin GS, Mills PD, Shanawani H, Hemphill RR. Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration. Jt Comm J Qual Patient Saf 2017; 43:580-590. [PMID: 29056178 DOI: 10.1016/j.jcjq.2017.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 04/13/2017] [Accepted: 04/14/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND ICUs' provision of complex care for critically ill patients results in an environment with a high potential for adverse events. A study was conducted to characterize adverse events in Veterans Health Administration (VHA) ICUs that underwent root cause analysis (RCA) and to identify the root causes and their recommended actions. METHODS This retrospective observational study of RCA reports concerned events that occurred in VHA ICUs or as a result of ICU processes from January 1, 2013, through December 31, 2014. The type of event, root causes, and recommended actions were measured. RESULTS Some 70 eligible RCAs were identified in 47 of the 120 facilities with an ICU in the VHA system. Delays in care (30.0%) and medication errors (28.6%) were the most common types of events. There were 152 root causes and 277 recommended actions. Root causes often involved rules, policies, and procedure processes (28.3%), equipment/supply issues (15.8%), and knowledge deficits/education (15.1%). Common actions recommended were policy, procedure, and process actions (34.4%) and training/education actions (31.4%). Of the actions implemented, 84.4% had a reported effectiveness of "much better" or "better." CONCLUSION ICU adverse events often had several root causes, with protocols and process-of-care issues as root causes regardless of event type. Actions often included standardization of processes and training/education. Several recommendations can be made that may improve patient safety in the ICU, such as standardization of care process, implementation of team training programs, and simulation-based training.
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16
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Carrillo I, Mira JJ, Vicente MA, Fernandez C, Guilabert M, Ferrús L, Zavala E, Silvestre C, Pérez-Pérez P. Design and Testing of BACRA, a Web-Based Tool for Middle Managers at Health Care Facilities to Lead the Search for Solutions to Patient Safety Incidents. J Med Internet Res 2016; 18:e257. [PMID: 27678308 PMCID: PMC5059483 DOI: 10.2196/jmir.5942] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 08/03/2016] [Accepted: 09/06/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Lack of time, lack of familiarity with root cause analysis, or suspicion that the reporting may result in negative consequences hinder involvement in the analysis of safety incidents and the search for preventive actions that can improve patient safety. OBJECTIVE The aim was develop a tool that enables hospitals and primary care professionals to immediately analyze the causes of incidents and to propose and implement measures intended to prevent their recurrence. METHODS The design of the Web-based tool (BACRA) considered research on the barriers for reporting, review of incident analysis tools, and the experience of eight managers from the field of patient safety. BACRA's design was improved in successive versions (BACRA v1.1 and BACRA v1.2) based on feedback from 86 middle managers. BACRA v1.1 was used by 13 frontline professionals to analyze incidents of safety; 59 professionals used BACRA v1.2 and assessed the respective usefulness and ease of use of both versions. RESULTS BACRA contains seven tabs that guide the user through the process of analyzing a safety incident and proposing preventive actions for similar future incidents. BACRA does not identify the person completing each analysis since the password introduced to hide said analysis only is linked to the information concerning the incident and not to any personal data. The tool was used by 72 professionals from hospitals and primary care centers. BACRA v1.2 was assessed more favorably than BACRA v1.1, both in terms of its usefulness (z=2.2, P=.03) and its ease of use (z=3.0, P=.003). CONCLUSIONS BACRA helps to analyze incidents of safety and to propose preventive actions. BACRA guarantees anonymity of the analysis and reduces the reluctance of professionals to carry out this task. BACRA is useful and easy to use.
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Affiliation(s)
- Irene Carrillo
- Health Psychology Department, Miguel Hernández University, Elche, Spain.
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17
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Car LT, Papachristou N, Bull A, Majeed A, Gallagher J, El-Khatib M, Aylin P, Rudan I, Atun R, Car J, Vincent C. Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study. BMC FAMILY PRACTICE 2016; 17:131. [PMID: 27613564 PMCID: PMC5017013 DOI: 10.1186/s12875-016-0530-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 09/01/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Delayed diagnosis in primary care is a common, harmful and costly patient safety incident. Its measurement and monitoring are underdeveloped and underutilised. We created and implemented a novel approach to identify problems leading to and solutions for delayed diagnosis in primary care. METHODS We developed a novel priority-setting method for patient safety problems and solutions called PRIORITIZE. We invited more than 500 NW London clinicians via an open-ended questionnaire to identify three main problems and solutions relating to delayed diagnosis in primary care. 113 clinicians submitted their suggestions which were thematically grouped and synthesized into a composite list of 33 distinct problems and 27 solutions. A random group of 75 clinicians from the initial cohort scored these and an overall ranking was derived. The agreement between the clinicians' scores was presented using the Average Expert Agreement. RESULTS The top ranked problems were poor communication between secondary and primary care and the inverse care law, i.e. a mismatch between patients' medical needs and healthcare supply. The highest ranked solutions included: a more rigorous system of communicating abnormal results of investigations to patients, direct hotlines to specialists for GPs to discuss patient problems and better training of primary care clinicians in relevant areas. A priority highlighted throughout the findings is a need to improve communication between clinicians as well as with patients. The highest ranked suggestions had the highest consensus between experts. CONCLUSIONS The novel method we have developed is highly feasible, informative and scalable, and merits wider exploration with a view of becoming part of a routine pro-active and preventative system for patient safety assessment. Clinicians proposed a range of concrete suggestions with an emphasis on improving communication among clinicians and with patients and better GP training. In their view, delayed diagnosis can be largely prevented with interventions requiring relatively minor investment. Rankings of identified problems and solutions can serve as an aid to policy makers and commissioners of care in prioritization of scarce healthcare resources.
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Affiliation(s)
- Lorainne Tudor Car
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Nikolaos Papachristou
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Adrian Bull
- Imperial College Health Partners, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Joseph Gallagher
- gHealth Research Group, UCD Conway Institute, University College Dublin School of Medicine, Dublin, Ireland
| | - Mona El-Khatib
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Paul Aylin
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Igor Rudan
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh Medical School, Edinburgh, UK
| | - Rifat Atun
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, USA
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, USA
| | - Josip Car
- Health Services and Outcomes Research Programme, LKCMedicine, Nanyang Technological University, Singapore, Singapore
| | - Charles Vincent
- Department of Experimental Psychology, Medical Sciences Division, University of Oxford, Oxford, UK
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Chuang S, Howley PP, Lin SH. Implementing systems thinking for infection prevention: The cessation of repeated scabies outbreaks in a respiratory care ward. Am J Infect Control 2015; 43:499-505. [PMID: 25798774 DOI: 10.1016/j.ajic.2015.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 01/30/2015] [Accepted: 02/02/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Root cause analysis (RCA) is often adopted to complement epidemiologic investigation for outbreaks and infection-related adverse events in hospitals; however, RCA has been argued to have limited effectiveness in preventing such events. We describe how an innovative systems analysis approach halted repeated scabies outbreaks, and highlight the importance of systems thinking for outbreaks analysis and sustaining effective infection prevention and control. METHODS Following RCA for a third successive outbreak of scabies over a 17-month period in a 60-bed respiratory care ward of a Taiwan hospital, a systems-oriented event analysis (SOEA) model was used to reanalyze the outbreak. Both approaches and the recommendations were compared. RESULTS No nosocomial scabies have been reported for more than 1975 days since implementation of the SOEA. Previous intervals between seeming eradication and repeat outbreaks following RCA were 270 days and 180 days. Achieving a sustainable positive resolution relied on applying systems thinking and the holistic analysis of the system, not merely looking for root causes of events. CONCLUSION To improve the effectiveness of outbreaks analysis and infection control, an emphasis on systems thinking is critical, along with a practical approach to ensure its effective implementation. The SOEA model provides the necessary framework and is a viable complementary approach, or alternative, to RCA.
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