Safety and complexity

Developing a core outcome set for interventions to improve discharge from mental health inpatient services: a survey, Delphi and consensus meeting with key stakeholder groups

OBJECTIVE

To develop a core set of outcomes to be used in all future studies into discharge from acute mental health services to increase homogeneity of outcome reporting.

DESIGN

We used a cross-sectional online survey with qualitative responses to derive a comprehensive list of outcomes, followed by two online Delphi rounds and a face-to-face consensus meeting.

SETTING

The setting the core outcome set applies to is acute adult mental health.

PARTICIPANTS

Participants were recruited from five stakeholder groups: service users, families and carers, researchers, healthcare professionals and policymakers.

INTERVENTIONS

The core outcome set is intended for all interventions that aim to improve discharge from acute mental health services to the community.

RESULTS

Ninety-three participants in total completed the questionnaire, 69 in Delphi round 1 and 68 in round 2, with relatively even representation of groups. Eleven participants attended the consensus meeting. Service users, healthcare professionals, researchers, carers/families and end-users of research agreed on a four-item core outcome set: readmission, suicide completed, service user-reported psychological distress and quality of life.

CONCLUSION

Implementation of the core outcome set in future trials research will provide a framework to achieve standardisation, facilitate selection of outcome measures, allow between-study comparisons and ultimately enhance the relevance of trial or research findings to healthcare professionals, researchers, policymakers and service users.

Codesigning a Mental Health Discharge and Transitions of Care Intervention: A Modified Nominal Group Technique

BACKGROUND

Discharge from acute mental health services has long been associated with mortality, risk, and related adverse outcomes for patients. Many of the interventions that currently aim to reduce adverse outcomes focus on a single group of healthcare professionals within a single healthcare setting. A recent systematic review highlights very few robust interventions that specifically aim to improve communication across services. However the importance of promoting interagency working and improving information flow between services is continually highlighted as a key priority.

METHODS

Using a novel codesign and experience based approach we worked with a multistakeholder group to develop possible solutions to reduce the adverse outcomes commonly associated with discharge from acute mental health services. This utilized a modified Nominal Group Technique and creative problem solving method to follow a four-stage process: Problem Identification, Solution Generation, Decision-Making, Prioritization and Implementation. Thirty-two healthcare professionals and an expert by lived experienced engaged with the process that took place over two stakeholder events.

RESULTS

Stakeholders at the first event identified and agreed upon 24 potential ideas to improve discharge from acute mental health services. These were refined at the second event to four elements of an interagency intervention: a multiagency 'Discharge Team' (with designated discharge coordinator), inclusive technology enabled team meetings, universal documentation and a patient generated discharge plan.

CONCLUSION

This is the first study to codesign an interagency mental health discharge intervention based around a discharge team. We developed a model for working that places a greater focus on a patient generated discharge plan, interagency working, and information flow. A pilot of the proposed intervention is now needed to test the feasibility and effectiveness in reducing adverse outcomes.

Care trajectory management: A conceptual framework for formalizing emergent organisation in nursing practice

Aim

To offer a new conceptual framework for formalizing nurses’ work in managing emergent organisation in health and social care.

Background

Much health and social care requires continuous oversight and adjustments in response to contingencies. Nurses have an important role in managing these relationships.

Evaluation

A longstanding programme of research on the social organisation of health and social care work provided the foundations for the article.

Key issue

Nurses’ work in managing emergent organisation may be conceptualized as care trajectory management and factors contributing to trajectory complexity are explored.

Conclusions

Care trajectory management is essential for the quality and safety of health and social care but poorly served by existing management frameworks.

Implications for Nursing Management

Care trajectory management offers a conceptual framework for the development of new management structures to support an important but poorly supported element of nursing practice.

Analysing healthcare coordination using translational mobilization

Purpose

The purpose of this paper is to introduce translational mobilization theory (TMT) and explore its application for healthcare quality improvement purposes.

Design/methodology/approach

TMT is a generic sociological theory that explains how projects of collective action are progressed in complex organizational contexts. This paper introduces TMT, outlines its ontological assumptions and core components, and explores its potential value for quality improvement using rescue trajectories as an illustrative case.

Findings

TMT has value for understanding coordination and collaboration in healthcare. Inviting a radical reconceptualization of healthcare organization, its potential applications include: mapping healthcare processes, understanding the role of artifacts in healthcare work, analyzing the relationship between content, context and implementation, program theory development and providing a comparative framework for supporting cross-sector learning.

Originality/value

Poor coordination and collaboration are well-recognized weaknesses in modern healthcare systems and represent important risks to quality and safety. While the organization and delivery of healthcare has been widely studied, and there is an extensive literature on team and inter-professional working, we lack readily accessible theoretical frameworks for analyzing collaborative work practices. TMT addresses this gap in understanding.

The importance, challenges and prospects of taking work practices into account for healthcare quality improvement

Purpose - The purpose of this paper is to underline the importance of taking work practices into account for quality improvement (QI) purposes, highlight some of the challenges of doing so, and suggest strategies for future research and practice. Patient status at a glance, a Lean-inspired QI intervention designed to alleviate nurses of their knowledge mobilisation function, is deployed as an illustrative case. Design/methodology/approach - Ethnographic data and practice-based theories are utilised to describe nurses' knowledge mobilisation work. The assumptions about knowledge sharing embedded in patient status at a glance white boards (PSAGWBs) are analysed drawing on actor network theory. Findings - There is a disparity between nurses' knowledge mobilisation practices and the scripts that inform the design of PSAGWBs. PSAGWBs are designed to be intermediaries and to transport meaning without transformation. When nurses circulate knowledge for patient management purposes, they operate as mediators, translating diverse information sources and modifying meaning for different audiences. PSAGWBs are unlikely to relieve nurses of their knowledge mobilisation function and may actually add to the burdens of this work. Despite this nurses have readily embraced this QI intervention. Research limitations/implications - The study is limited by its focus on a single case and by the inferential (rather than the empirical) nature of its conclusions. Originality/value - This paper illustrates the importance of taking practice into account in healthcare QI, points to some of the challenges of doing so and highlights the potential of practice-based approaches in supporting progress in this field.

Understanding the occupational and organizational boundaries to safe hospital discharge

OBJECTIVE

Safe hospital discharge relies upon communication and coordination across multiple occupational and organizational boundaries. Our aim was to understand how these boundaries can exacerbate health system complexity and represent latent sociocultural threats to safe discharge.

METHODS

An ethnographic study was conducted in two local health and social care systems (health economies) in England, focusing on two clinical areas: stroke and hip fracture patients. Data collection involved 345 hours of observations and 220 semi-structured interviews with health and social care professionals, patients and their lay carers.

RESULTS

Hospital discharge involves a dynamic network of interactions between heterogeneous health and social care actors, each characterized by divergent ways of organizing discharge activities; cultures of collaboration and interaction and understanding of what discharge involves and how it contributes to patient recovery. These interrelated dimensions elaborate the occupational and organisational boundaries that can influence communication and coordination in hospital discharge.

CONCLUSIONS

Hospital discharge relies upon the coordination of multiple actors working across occupational and organizational boundaries. Attention to the sociocultural boundaries that influence communication and coordination can help inform interventions that might support enhanced discharge safety.

A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety

OBJECTIVES

Paramedics routinely make critical decisions about the most appropriate care to deliver in a complex system characterized by significant variation in patient case-mix, care pathways and linked service providers. There has been little research carried out in the ambulance service to identify areas of risk associated with decisions about patient care. The aim of this study was to explore systemic influences on decision making by paramedics relating to care transitions to identify potential risk factors.

METHODS

An exploratory multi-method qualitative study was conducted in three English National Health Service (NHS) Ambulance Service Trusts, focusing on decision making by paramedic and specialist paramedic staff. Researchers observed 57 staff across 34 shifts. Ten staff completed digital diaries and three focus groups were conducted with 21 staff.

RESULTS

Nine types of decision were identified, ranging from emergency department conveyance and specialist emergency pathways to non-conveyance. Seven overarching systemic influences and risk factors potentially influencing decision making were identified: demand; performance priorities; access to care options; risk tolerance; training and development; communication and feedback and resources.

CONCLUSIONS

Use of multiple methods provided a consistent picture of key systemic influences and potential risk factors. The study highlighted the increased complexity of paramedic decisions and multi-level system influences that may exacerbate risk. The findings have implications at the level of individual NHS Ambulance Service Trusts (e.g. ensuring an appropriately skilled workforce to manage diverse patient needs and reduce emergency department conveyance) and at the wider prehospital emergency care system level (e.g. ensuring access to appropriate patient care options as alternatives to the emergency department).

Implementing resilience engineering for healthcare quality improvement using the CARE model: a feasibility study protocol

BACKGROUND

Resilience engineering (RE) is an emerging perspective on safety in complex adaptive systems that emphasises how outcomes emerge from the complexity of the clinical environment. Complexity creates the need for flexible adaptation to achieve outcomes. RE focuses on understanding the nature of adaptations, learning from success and increasing adaptive capacity. Although the philosophy is clear, progress in applying the ideas to quality improvement has been slow. The aim of this study is to test the feasibility of translating RE concepts into practical methods to improve quality by designing, implementing and evaluating interventions based on RE theory. The CARE model operationalises the key concepts and their relationships to guide the empirical investigation.

METHODS

The settings are the Emergency Department and the Older Person's Unit in a large London teaching hospital. Phases 1 and 2 of our work, leading to the development of interventions to improve the quality of care, are described in this paper. Ethical approval has been granted for these phases. Phase 1 will use ethnographic methods, including observation of work practices and interviews with staff, to understand adaptations and outcomes. The findings will be used to collaboratively design, with clinical staff in interactive design workshops, interventions to improve the quality of care. The evaluation phase will be designed and submitted for ethical approval when the outcomes of phases 1 and 2 are known.

DISCUSSION

Study outcomes will be knowledge about the feasibility of applying RE to improve quality, the development of RE theory and a validated model of resilience in clinical work which can be used to guide other applications. Tools, methods and practical guidance for practitioners will also be produced, as well as specific knowledge of the potential effectiveness of the implemented interventions in emergency and older people's care. Further studies to test the application of RE at a larger scale will be required, including studies of other healthcare settings, organisational contexts and different interventions.

Associations between perceived crisis mode work climate and poor information exchange within hospitals

BACKGROUND

Because hospital units operating in crisis mode could create unsafe transitions of care due to miscommunication, our objective was to estimate associations between perceived crisis mode work climate and patient information exchange problems within hospitals.

METHODS

Self-reported data from 247,140 hospital staff members across 884 hospitals were obtained from the 2010 Hospital Survey on Patient Safety Culture. Presence of a crisis mode work climate was defined as respondents agreeing that the hospital unit in which they work tries to do too much too quickly. Presence of patient information exchange problems was defined as respondents agreeing that problems often occur in exchanging patient information across hospital units. Multivariable ordinal regressions estimated the likelihood of perceived problems in exchanging patient information across hospital units, controlling for perceived levels of crisis mode work climate, skill levels, work climate, and hospital infrastructure.

RESULTS

Compared to those disagreeing, hospital staff members agreeing that the hospital unit in which they work tries to do too much too quickly were 1.6 times more likely to perceive problems in exchanging patient information across hospital units (odds ratio: 1.6, 95% confidence interval: 1.58-1.65).

CONCLUSIONS

Hospital staff members perceiving crisis mode work climates within their hospital unit are more likely to perceive problems in exchanging patient information across units, underscoring the need to improve communication during transitions of care.

Improving practice in safeguarding at the interface between hospital services and children’s social care: a mixed-methods case study

Background

Hospital settings have an important impact on children harmed by parents and carers. Concern arises from the capacity of these settings to respond effectively to individual needs despite increased NHS policy awareness and actions on safeguarding. Patient safety initiatives have rarely modelled in detail the social and cultural dynamics of child health settings and children’s safeguarding. This study is focused on supporting and evaluating clinician-led service design in an acute trust. A suite of initiatives and artefacts has been designed, based on sociotechnical principles, on the premise that only a thorough understanding of human, social and organisational challenges will afford effective solutions.

Objectives

The study addresses the following primary question: ‘Can a safeguarding culture be designed within the hospital environment that will provide the conditions for the detection of children at risk of abuse and support protective actions before discharge, including collaboration with external agencies?’ Objectives include the development of a sociologically rich understanding of why diagnostic failures and communication breakdowns occur; the design of a suite of integrated interventions for promoting a positive safety culture, following a user-centred approach; and the evaluation of the effectiveness of this package, including its generalisability across sites.

Design

The study took place in two sites: the primary site where the initiatives were developed and a further site with the original intention of transferring developments. The investigation follows a broaddesign scienceapproach. The evaluation of a design intervention relies on a rigorous understanding of the realities of everyday practice, and the study thus draws on mixed methods to examine the impact of service redesign on cultures and practices.

Findings

The data suggest that safeguarding children can become mainstream patient safety business. Board support is vital. In our primary site, there has been a steady integration of learning from serious case reviews and other child protection-related processes with ‘patient safety’-related incidents, with growing recognition that similar systemic issues impact on both domains. Making use of a familiar vocabulary to redescribesafeguardingas asafetyissue, and thus as something fundamental to the functions of an acute hospital, has been part of the success. The data suggest that persistence, resilience and vigilance from the safeguarding leadership and executive teams are crucial. Current policy includes the development of the Child Protection Information Sharing project, which is intended to improve information flow between the NHS, particularly hospitals and children’s social care. The findings from this study suggest the importance of good design, piloting, incrementalism and a thorough empirical engagement with everyday practices during implementation of this and any future information systems based reform.

Conclusions

Safeguarding takes place in a complex system and even minor changes within any part of that system can impact on the rest in unpredictable ways. It is important that managers adopt a ‘design attitude’ and seek to mitigate unintended consequences through careful experimentation. The findings suggest the need for the design of systems to enhance communication and not simply to ‘share information’. Technological solutions impact on everyday decision-making and can have unintended consequences. Attention to forces of change and stasis in health settings, the factors affecting technology transfer and the impact of the configuration of local authority services are suggested as a key priorities for future research.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A qualitative study of decision-making and safety in ambulance service transitions

Background

Decisions made by front-line ambulance staff are often time critical and based on limited information, but wrong decisions in this context could have serious consequences for patients. There has been little research carried out in the ambulance service setting to identify areas of risk associated with decisions about patient care.

Aim

The aim of this study was to qualitatively examine potential system-wide influences on decision-making in the ambulance service setting and to identify useful areas for future research and intervention.

Methods

We used a multisite, multimethod qualitative approach across three ambulance service trusts. In phase 1 we carried out 16 interviews to contextualise the study and provide discussion points for phase 2. For phase 2, university and ambulance service researchers observed paramedics on 34 shifts and 10 paramedics completed ‘digital diaries’ that reported challenges to decision-making or to patient safety. Six focus groups were held, three with staff (n = 21) and three with service users (n = 23). From observation and diary data we developed a typology of decisions made at the scene. Data from these and other sources were also coded within a human factors framework and then thematically analysed to identify influences on those decisions. In phase 3, workshops were held at each site to allow participants and stakeholders (n = 45) to comment on the study findings. Participants were asked to rank influences on decisions using a ‘paired comparison’ method.

Results

Interviews provided the context for further qualitative exploration. Nine types of decision were identified from observations and digital diaries, ranging from emergency department conveyance and specialist emergency pathways to non-conveyance. A synthesis of findings from the observations, diaries and staff focus groups revealed seven overarching system influences on decision-making and potential risk factors: meeting increasing demand for emergency care; impacts of performance regime and priorities on service delivery; access to appropriate care options; disproportionate risk aversion; education, training and professional development for crews; communication and feedback to crews; and ambulance service resources. Safety culture issues were also identified. Data from the service user focus groups reflected similar issues to those identified from the staff focus groups. Service user concerns included call handling and communication, triage, patient involvement in decisions, balancing demand, resources, access to care, risk aversion, geographical location and vulnerable patients. Group discussions highlighted a lack of awareness by the public of how best to use emergency and urgent care services. Workshop attendees were satisfied that the findings reflected relevant issues. The two issues ranked highest for warranting attention were staff training and development and access to alternative care.

Conclusions

Multiple qualitative methods allowed a range of perspectives to be accessed and validation of issues across perspectives. Recommendations for future research include exploring effective ways of providing access to alternative care pathways to accident and emergency, assessing public awareness and expectations of ambulance and related services, exploring safe ways of improving telephone triage decisions and assessing the effects of different staff skill levels on patient safety.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

An ethnographic study of knowledge sharing across the boundaries between care processes, services and organisations: the contributions to ‘safe’ hospital discharge

Background

Hospital discharge is a vulnerable stage in the patient pathway. Research highlights communication failures and the problems of co-ordination as resulting in delayed, poorly timed and unsafe discharges. The complexity of hospital discharge exemplifies the threats to patient safety found ‘between’ care processes and organisations. In developing this perspective, safe discharge is seen as relying upon enhanced knowledge sharing and collaboration between stakeholders, which can mitigate system complexity and promote safety.

Aim

To identify interventions and practices that support knowledge sharing and collaboration in the processes of discharge planning and care transition.

Setting

The study was undertaken between 2011 and 2013 in two English health-care systems, each comprising an acute health-care provider, community and primary care providers, local authority social services and social care agencies. The study sites were selected to reflect known variations in local population demographics as well as in the size and composition of the care systems. The study compared the experiences of stroke and hip fracture patients as exemplars of acute care with complex discharge pathways.

Design

The study involved in-depth ethnographic research in the two sites. This combined (a) over 180 hours of observations of discharge processes and knowledge-sharing activities in various care settings; (b) focused ‘patient tracking’ to trace and understand discharge activities across the entire patient journey; and (c) qualitative interviews with 169 individuals working in health, social and voluntary care sectors.

Findings

The study reinforces the view of hospital discharge as a complex system involving dynamic and multidirectional patterns of knowledge sharing between multiple groups. The study shows that discharge planning and care transitions develop through a series of linked ‘situations’ or opportunities for knowledge sharing. It also shows variations in these situations, in terms of the range of actors, forms of knowledge shared, and media and resources used, and the wider culture and organisation of discharge. The study also describes the threats to patient safety associated with hospital discharge, as perceived by participants and stakeholders. These related to falls, medicines, infection, clinical procedures, equipment, timing and scheduling of discharge, and communication. Each of these identified risks are analysed and explained with reference to the observed patterns of knowledge sharing to elaborate how variations in knowledge sharing can hinder or promote safe discharge.

Conclusions

The study supports the view of hospital discharge as a complex system involving tightly coupled and interdependent patterns of interaction between multiple health and social care agencies. Knowledge sharing can help to mitigate system complexity through supporting collaboration and co-ordination. The study suggests four areas of change that might enhance knowledge sharing, reduce system complexity and promote safety. First, knowledge brokers in the form of discharge co-ordinators can facilitate knowledge sharing and co-ordination; second, colocation and functional proximity of stakeholders can support knowledge sharing and mutual appreciation and alignment of divergent practices; third, local cultures should prioritise and value collaboration; and finally, organisational resources, procedures and leadership should be aligned to fostering knowledge sharing and collaborative working. These learning points provide insight for future interventions to enhance discharge planning and care transition. Future research might consider the implementation of interviews to mediate system complexity through fostering enhanced knowledge sharing across occupational and organisational boundaries. Research might also consider in more detail the underlying complexity of both health and social care systems and how opportunities for knowledge sharing might be engendered to promote patient safety in other areas.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

An audit of operating room time utilization in a teaching hospital: is there a place for improvement?

Aim. To perform a thorough and step-by-step assessment of operating room (OR) time utilization, with a view to assess the efficacy of our practice and to identify areas of further improvement. Materials and Methods. We retrospectively analyzed the most ordinary general surgery procedures, in terms of five intervals of OR time utilization: anaesthesia induction, surgery preparation, duration of operation, recovery from anaesthesia, and transfer to postanaesthesia care unit (PACU) or intensive care unit (ICU). According to their surgical impact, the procedures were defined as minor, moderate, and major. Results. A total of 548 operations were analyzed. The mean (SD) time in minutes for anaesthesia induction was 19 (9), for surgery preparation 13 (8), for surgery 115 (64), for recovery from anaesthesia 12 (8), and for transfer to PACU/ICU 12 (9). The time spent in each step presented an ascending escalation pattern proportional to the surgical impact (P = 0.000), which was less pronounced in the transfer to PACU/ICU (P = 0.006). Conclusions. Albeit, our study was conducted in a teaching hospital, the recorded time estimates ranged within acceptable limits. Efficient OR time usage and outliers elimination could be accomplished by a better organized transfer personnel service, greater availability of anaesthesia providers, and interdisciplinary collaboration.

Risky Business: How Professionals and Professional Fields (Must) Deal with Organizational Issues

As professionals belong to occupational systems but also increasingly work inside organizations, new linkages between occupational and organizational domains are required, but they are difficult to develop. Occupational principles and professional standards are usually considered to be at odds with managerial and organizational control principles. This generates academic and practical dualisms. Either a return to professionalism is advocated in order to protect occupational spaces and ‘rescue’ professional work, or there is a move beyond professionalism in order to restrict autonomies and discipline professional work. This article argues that both stances are unsatisfactory and that new forms of organized professionalism are called for. Changing circumstances force professional services to respond to external changes that call for organizational capacities, also inside professional domains: (a) professionals develop new work preferences and seek organized work conditions; (b) professionals face new cases, which are difficult to categorize and call for well-organized multi-professional acts; (c) due to critical attention for case treatment and incidents, professionals face new risks that have to be managed. The article shows how these realities are incorporated in professional practices – albeit slowly – and it draws normative conclusions. Professionals must take organizing and managing more seriously and will have to develop organizational capacities. In addition, connective organizational standards must be established in order to strengthen the viability and legitimacy of professional services in demanding times.

Patient safety: learning the lessons in primary care

KEY MESSAGES

GPs are the champions of patient safety for their patients and have future possibility for driving patient safety across the entire health services. To fulfil this challenge clinicians need to consider how the techniques and tools widely applied in hospital care might best be used within primary care. This includes developing robust systems to effectively identify and capture information about safety events, procedures and collaborative activities to investigate and analyse safety event, and incentives and penalties for implementing safety improvements.

WHY THIS MATTERS TO ME

Patient safety should be at the forefront of health-care. Primary care clinicians have the opportunity to drive this agenda in the future.

The impact of information technology and organizational focus on the visibility of patient care errors

INVESTIGATED: The implementation of information systems and the creation of an open culture, characterized by emphasis on patient safety and problem solving, are 2 means suggested to improve health care quality. This study examines the effects of use of information technology and focus on patient safety and problem solving on the visibility of patient care errors.

SUBJECTS AND METHODS

A survey of nurses in Saudi Arabia is analyzed by means of factor analysis and multiregression analysis to examine nurses' use of information technology and culture in controlling errors.

RESULTS AND CONCLUSIONS

Our research suggests that greater use of information technology to control patient care errors may reduce the prevalence of such errors while an increased focus on patient safety and problem solving facilitates an open environment where errors can be more openly discussed and addressed. The use of technology appears to have a role in decreasing errors. Yet, an organization that focuses on problem solving and patient safety can open lines of communication and create a culture in which errors can be discussed and resolved.

Examining communication and team performance during clinical handover in a complex environment: the private sector post-anaesthetic care unit

Threats to patient safety during clinical handover have been identified as an ongoing problem in health care delivery. In complex handover situations, organisational, cultural, behavioural and environmental factors associated with team performance can affect patient safety by undermining the stability of team functioning and the effectiveness of interprofessional communication. We present a practical framework for promoting systematic, comprehensive measurement of the factors involved in clinical handover. The framework can be used to develop viable solutions to the problems of clinical handover. The framework was devised and used in a recent project examining interprofessional communication and team performance during clinical handover in post-anaesthetic care units. The framework combines five key concepts: clinical governance, clinician engagement, ecological validity, safety culture and team climate, and sustainability. We believe that use of this framework will help overcome the limitations of previous research that has not taken into account the complex and multifaceted influences on clinical handover and interprofessional communication.

Integration of patient safety technologies into sclerotherapy for varicose veins

The American College of Surgeons, the Joint Commission, the Needlestick Safety and Prevention Act, and the Occupational Safety and Health Administration all direct surgical departments, including vascular surgeons who supply sclerotherapy services, to develop formal mechanisms to improve the safety of the patient and health care worker (HCW), including integration of new safety technologies. The purpose of the present study was to identify and evaluate new safety technologies for outpatient sclerotherapy for chronic venous disease. Using national resources for patient safety and literature review, the following safety technologies were identified: (1) a safety needle to reduce inadvertent needlesticks to workers, and (2) the reciprocating procedure device (RPD) to reduce iatrogenic injuries to patients. Both devices were evaluated in the clinic, and physician responses were determined. Although the safety sheath of the needle was somewhat bulky and could interfere with the ultrasound transducer, sclerotherapy could be performed with it. The RPD safety device required instruction to show how the RPD functioned ("push-push" to aspirate-inject with the RPD rather than the usual "push-pull" with the conventional syringe), but the RPD permitted better needle control and more precise injections. The RPD was well accepted by physicians who found it to be convenient, safer, and less painful. Subsequently, the involved services successfully integrated these safety technologies into their routine clinical practices. As recommended by the Joint Commission, safety technologies can be successfully evaluated and introduced into the clinic to improve patient and HCW safety during physician-performed syringe and needle procedures, including sclerotherapy.