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Price MA, Mulkern PJ, Condon M, Rakhilin M, Johansen K, Lyon AR, Saldana L, Pachankis J, Woodward SA, Roeder KM, Moran LR, Jerskey BA. Leveraging Community Engagement and Human-Centered Design to Develop Multilevel Implementation Strategies to Enhance Adoption of a Health Equity Intervention. RESEARCH SQUARE 2025:rs.3.rs-5702080. [PMID: 40195981 PMCID: PMC11974998 DOI: 10.21203/rs.3.rs-5702080/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2025]
Abstract
Background Health equity intervention implementation (which promotes positive health outcomes for populations experiencing disproportionately worse health) is often impeded by health-equity-specific barriers like provider bias; few studies demonstrate how to overcome these barriers through implementation strategies. An urgent health equity problem in the U.S. is the mental health of transgender youth. To address this, we developed Gender-Affirming Psychotherapy (GAP), a health equity intervention comprising best-practice mental health care for transgender youth. This paper details the identification of implementation determinants and the development of targeted strategies to promote provider adoption of GAP. Methods This study represents part of a larger study of mental health provider adoption of GAP. Here we describe the first 2 stages of the 3-stage community-engaged and human-centered design process - Discover, Design/Build, and Test - to identify implementation determinants of adoption and develop implementation strategies with transgender youth, their parents, and mental health providers. This process involved collecting data via focus groups, design meetings, usability testing, and champion meetings. Data were analyzed using rapid and conventional content analysis. Qualitative coding of implementation determinants was guided by the Health Equity Implementation Framework, and implementation strategy coding was facilitated by the ERIC Implementation Strategy Compilation. Results We identified 15 determinants of GAP adoption, and all were specific to the transgender population (e.g., inclusive record system, anti-transgender attitudes). Seventeen implementation strategies were recommended and 12 were developed, collectively addressing all identified determinants. Most strategies were packaged into an online self-paced mental health provider training (implementation intervention) with 6 training tools. Additional inner setting strategies were designed to support training uptake (e.g., mandate training) and GAP adoption (e.g., change record system). Conclusions Community-engaged and human-centered design methods can identify health equity intervention implementation determinants and develop targeted strategies. We highlight five generalizable takeaways for health equity implementation scientists: (1) implementer bias may be a key barrier, (2) experience with the health equity population may be an important facilitator, (3) stakeholder stories may be an effective training tool, (4) inner setting-level implementation strategies may be necessary, and (5) teaching implementers how to build implementation strategies can overcome resource-constraints. Trial registration: NCT05626231.
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Barros FDM, Dos Santos GRDS, da Silva CPG, Campos JF, da Silva RC. Implementation of Simulation-Based Technology to Promote Safety in the Nursing Handover in the Intensive Care Unit. J Clin Nurs 2025. [PMID: 40084816 DOI: 10.1111/jocn.17735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 03/04/2025] [Indexed: 03/16/2025]
Abstract
AIMS AND OBJECTIVES To evaluate the impact of implementing a prototype of simulation-based educational technology on raising awareness among ICU nurses, improving communication in nursing handover, and promoting patient safety. DESIGN Qualitative study based on the conceptual framework of patient safety. The COREQ tool guided the presentation of the research report. METHODS The research was conducted with 18 nurses from the ICU of a public hospital in Rio de Janeiro, Brazil, who worked directly in nursing handover. The technology implemented was developed based on communication failures identified in a previous stage of the macro research project. This evidence supported the development of a simulated scenario of a nursing handover of a critical patient, which was recorded in audio and video. The video addressed content (absence, incompleteness and lack of ordering of information) and behavioural errors (interruptions, distractions, noise and lack of clarity) during communication between intensive care nurses. The video was implemented with nurses through the use of telesimulation with debriefing. Finally, the nurses were subjected to a semi-structured interview to evaluate the potential of the technology, whose data underwent thematic analysis with an inductive model. RESULTS The nurses recognised the communication failures portrayed as part of their daily practice, reflected on their mistakes, and on actions to be adopted to change behaviour during the handover. CONCLUSIONS The simulation-based technology prototype has the potential to promote self-reflection and raise nurses' awareness of the need to change behaviours during the handover. RELEVANCE TO CLINICAL PRACTICE The simulation-based technology prototype can be applied as an educational strategy to improve communication safety in nursing handover. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution.
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Affiliation(s)
| | | | | | - Juliana Faria Campos
- Federal University of Rio de Janeiro, Anna Nery School of Nursing, Rio de Janeiro, Brazil
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3
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Germann JA, O'Sullivan TL, Greer AL, Spence KL. Biosecurity perceptions among Ontario horse owners during the COVID-19 pandemic. Equine Vet J 2025; 57:459-470. [PMID: 38934765 PMCID: PMC11807931 DOI: 10.1111/evj.14115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/16/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Disease outbreaks present a significant challenge to horse health and welfare and the economic stability of horse industries internationally. This is a particular concern in Ontario, Canada, where there have been frequent outbreaks of respiratory infectious diseases among horses. Despite these risks, there has been limited research on whether Ontario horse owners engage in biosecurity measures sufficient to mitigate risk of equine diseases, and whether current events such as the COVID-19 pandemic influence attitudes towards equine biosecurity practices. OBJECTIVE To explore Ontario horse owners' perceptions, attitudes and experiences relating to on-farm biosecurity during the COVID-19 pandemic. STUDY DESIGN Qualitative study using virtual semi-structured interviews. METHODS Participants (horse owners, frequent horse riders and part boarders) were recruited using social media snowball sampling where advertisements were shared by equine and veterinary organisations. Interviews were conducted virtually between June and September 2022 and were analysed using reflexive thematic analysis. RESULTS Three key themes relating to biosecurity perceptions among the 14 participants were identified. Participants relied on minimal preventative measures (such as vaccines) where perceived risk of disease was low, but implemented additional measures including quarantine and handwashing when perceived risk of disease was high. Participants' choice of biosecurity practices often mirrored those recommended by the barn manager. Moreover, participants felt that responsibility for biosecurity was not shared equally across horse owners, with more emphasis placed on those engaging in high-risk situations for disease spread. Despite experiencing biosecurity during the COVID-19 pandemic, horse owners were not consistently applying these practices to their horse care routines. MAIN LIMITATIONS The perspectives reported here are from a small sample of horse owners and may not be generalisable to all populations. CONCLUSIONS Our findings indicate that horse owners need improved access to and engagement with educational initiatives that emphasise the importance and purpose of all biosecurity measures.
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Affiliation(s)
- Juliet A. Germann
- Department of Population Medicine, Ontario Veterinary CollegeUniversity of GuelphGuelphOntarioCanada
| | - Terri L. O'Sullivan
- Department of Population Medicine, Ontario Veterinary CollegeUniversity of GuelphGuelphOntarioCanada
| | - Amy L. Greer
- Department of Population Medicine, Ontario Veterinary CollegeUniversity of GuelphGuelphOntarioCanada
| | - Kelsey L. Spence
- Department of Population Medicine, Ontario Veterinary CollegeUniversity of GuelphGuelphOntarioCanada
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Corrêa KC, Araújo LBD, Alves HMDS, Ferreira LMC, Miranda FJS, Junqueira MADB. Relations Between Suicide Risk and Patient Safety Attitudes Among the Nursing Team in a Brazilian Context. J Patient Saf 2025; 21:82-88. [PMID: 39705531 DOI: 10.1097/pts.0000000000001305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 11/12/2024] [Indexed: 12/22/2024]
Abstract
OBJECTIVES To analyze the aspects of suicide risks and their relation to patient safety attitudes among the nursing staff of a large public university hospital in Brazil. METHODS A cross-sectional and descriptive study with 226 nursing workers from a large public university hospital in Brazil. Socioprofessional information, health conditions, and family history related to suicide risk were collected through the Mini International Neuropsychiatric Interview Plus and the Safety Attitudes Questionnaire. A 95% CI was considered, and statistical tests such as the Student t test, χ 2 , analysis of variance, and multiple linear regression were used. RESULTS Most of the safety attitudes were below the average score considered positive (mean Safety Attitudes Questionnaire value >0.75), and 41 (18.1%) workers were considered to have any degree of suicide risk. Participants with parents or siblings who had attempted suicide were 3.44 times more likely to have moderate or high suicide risk. Negative safety attitudes were associated with health conditions and family history, considered suicide risk factors. Participants with moderate or high suicide risk were 2.83 times more likely to have worse patient safety attitudes concerning job satisfaction. CONCLUSIONS This study reveals significant associations between patient safety attitudes and the mental health of nursing workers, expanding the view of worker health management actions and, consequently, patient safety culture.
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Affiliation(s)
- Kariciele Cristina Corrêa
- Clinical Hospital of the Federal University of Uberlandia/Ebserh, Federal University of Uberlândia, Uberlãndia (MG)
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Chen C, Song H, Xu H, Chen M, Liang Z, Zhang M. Fall risk factors and mitigation strategies for hematological malignancy patients: insights from a qualitative study using the reason model. Support Care Cancer 2025; 33:118. [PMID: 39849285 DOI: 10.1007/s00520-025-09170-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Accepted: 01/11/2025] [Indexed: 01/25/2025]
Abstract
PURPOSE Our study aim was to understand the (human and organizational) factors influencing fall risk among people with hematological malignancies using the Reason model as a framework, providing insights that can inform the development of safe and effective fall management strategies. METHODS Purposive sampling was employed to conduct semi-structured interviews with 13 people with hematological malignancies and 12 nurses from the hematology department of a tertiary grade A hospital in Guangzhou from December 2023 to February 2024. The topic analysis method was utilized to analyze the interview data. RESULTS Factors influencing fall risk among people with hematological malignancies were categorized into four themes: (1) precondition of unsafe arts (lack of work experience in junior nurses, poor patient compliance, adverse drug reactions, inadequate ward facilities); (2) unsafe supervision (inadequate inspection management, inadequate accompanying capacity); (3) unsafe arts (variability in subjective assessment, lack of bidirectional education); and (4) organizational influences (limited nursing human resources, lack of organizational process management models). CONCLUSION The specific fall risk factors among people with hematological malignancies, as summarized based on the Reason model framework, provide a theoretical basis and direction for the construction of specialized fall risk assessment tools, aiming to improve the quality of fall management for inpatients and reduce the incidence of falls.
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Affiliation(s)
- Cuishan Chen
- Department of Nursing, Nanfang Hosptial of Southern Medical University, Guangzhou, 510515, People's Republic of China
- School of Nursing, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Huijuan Song
- Department of Nursing, Nanfang Hosptial of Southern Medical University, Guangzhou, 510515, People's Republic of China.
| | - Huijuan Xu
- Department of Hematology, Nanfang Hosptial of Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Min Chen
- Department of Hematology, Nanfang Hosptial of Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Zilu Liang
- Department of Nursing, Nanfang Hosptial of Southern Medical University, Guangzhou, 510515, People's Republic of China
- School of Nursing, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Muchen Zhang
- Department of Nursing, Nanfang Hosptial of Southern Medical University, Guangzhou, 510515, People's Republic of China
- School of Nursing, Southern Medical University, Guangzhou, 510515, People's Republic of China
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Brickhouse M, Gassen J, Ryan BJ, Muehlenbein MP. Survey of COVID-19 isolation cases at a major university campus in the United States. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2024; 72:3210-3215. [PMID: 36595621 DOI: 10.1080/07448481.2022.2155062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 07/13/2022] [Accepted: 09/19/2022] [Indexed: 06/17/2023]
Abstract
Objective: Baylor University established a surveillance system to assess the needs of students and faculty in isolation from SARS-CoV-2 as well as any longer-term symptoms. Participants: Overall, there were 309 responses between March 20 and May 19, 2021. Methods: A survey covering experience in isolation, symptoms, vaccination, and demographic characteristics was emailed to individuals on Day 7 of isolation; a follow-up health survey was sent 30 days later. Results: Only 9.6% of respondents reported needing assistance while in isolation. Nearly 75% of respondents experienced COVID-19 symptoms in isolation, and 31.9% had remaining symptoms after isolation. Older age, being male, and more severe symptoms were associated with longer symptom duration. Those vaccinated had lower odds of developing symptoms and having symptoms remaining post-isolation. Conclusions: The present study adds to our understanding of long-COVID in young adult populations, while providing a framework for similar institutions to sustain operations during a global pandemic.
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Affiliation(s)
| | - Jeffrey Gassen
- Department of Anthropology, Baylor University, Waco, Texas, USA
| | - Benjamin J Ryan
- Department of Environmental Science, Baylor University, Waco, Texas, USA
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de Kassio Nunes G, Araújo BGR, Rentz LBPA, Camerini FG, da Costa Machado Duarte S, Campos JF, da Silva RC. Intravenous Line Labels For High-Alert Drugs Administered To Critically Ill Patients: A Simulated Experimental Assessment. J Adv Nurs 2024. [PMID: 39425685 DOI: 10.1111/jan.16529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 09/03/2024] [Accepted: 09/29/2024] [Indexed: 10/21/2024]
Abstract
AIMS AND OBJECTIVES Evaluate the effect of IV line labels on nurses' identification of high-alert medications in a simulated scenario of multiple infusions for critically ill patients. DESIGN Randomised crossover simulation experimental study. METHODS A study was conducted on 29 nurses working in intensive care for over 6 months. They were given two critical scenarios in a simulated environment, one with labels and the other without labels, involving multiple intravenous infusions. The nurses had to identify the medications infused into the critical patients' intravenous lines and disconnect a specific line. The data were collected and analysed to evaluate the errors made by the nurses in identifying and disconnecting the medications and the time they spent carrying out the tasks. The Wilcoxon test was used to analyse the variation in outcome before and after the intervention. RESULTS Approximately one-third of the study participants incorrectly identified the intravenous lines in both scenarios. There was no significant difference in the average number of errors between the scenarios with and without labels. However, the time taken to perform the tasks in the scenario with labels was 1 min less than in the scenario without labels, suggesting a potential efficiency gain. CONCLUSIONS The labels on the intravenous lines allowed for quick drug identification and disconnection. The professionals performed similarly in correctly recognising the high-alert medication intravenous lines, in the scenarios with or without labels. RELEVANCE TO CLINICAL PRACTICE The label can be used as a technology to prevent misidentification of high-alert medications administered to critically ill patients through intravenous lines, thereby enhancing medication safety in healthcare institutions. No Public Contribution.
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Affiliation(s)
| | | | | | | | | | - Juliana Faria Campos
- Federal University of Rio de Janeiro, Anna Nery School of Nursing, Rio de Janeiro, Brazil
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Pacenko CDL, Figueiredo KC, Nunes E, Cruchinho P, Lucas P. Mapping Strategies for Strengthening Safety Culture: A Scoping Review. Healthcare (Basel) 2024; 12:1194. [PMID: 38921308 PMCID: PMC11203948 DOI: 10.3390/healthcare12121194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 05/30/2024] [Accepted: 06/11/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Twenty years after the "To Err Is Human" report, one in ten patients still suffer harm in hospitals in high-income countries, highlighting the need to strengthen the culture of safety in healthcare. This scoping review aims to map patient safety culture strengthening strategies described in the literature. METHOD This scoping review follows the JBI methodology. It adhered to all scoping review checklist items (PRISMA-ScR) with searches in the Lilacs, MedLine, IBECS, and PubMed databases and on the official websites of Brazilian and North American patient safety organizations. The research took place during the year 2023. RESULTS In total, 58 studies comprising 52 articles and 6 documents from health organizations were included. Various strategies were identified and grouped into seven categories based on similarity, highlighting the need for a comprehensive organizational approach to improve patient care. The most described strategies were communication (69%), followed by teamwork (58.6%) and active leadership (56.9%). CONCLUSION The identified strategies can promote the development of a culture in which an organization can achieve patient safety, involving practices and attitudes that reduce risks and errors in healthcare. However, the identification of strategies is limited because it is restricted to certain databases and websites of international organizations and does not cover a broader spectrum of sources. Furthermore, the effectiveness of these strategies in improving patient safety culture has not yet been evaluated.
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Affiliation(s)
- Cristiane de Lima Pacenko
- Postgraduate Program in Nursing, Department of Nursing, Federal University of Paraná, Avenue Prefeito Lothário Meissner 632, Curitiba 80210-170, Brazil;
- Nursing Research, Innovation, and Development Centre of Lisbon (CIDNUR), Escola Superior de Enfermagem de Lisboa, Avenida Professor Egas Moniz, 1600-190 Lisboa, Portugal; (E.N.); (P.C.); (P.L.)
| | - Karla Crozeta Figueiredo
- Postgraduate Program in Nursing, Department of Nursing, Federal University of Paraná, Avenue Prefeito Lothário Meissner 632, Curitiba 80210-170, Brazil;
- Nursing Research, Innovation, and Development Centre of Lisbon (CIDNUR), Escola Superior de Enfermagem de Lisboa, Avenida Professor Egas Moniz, 1600-190 Lisboa, Portugal; (E.N.); (P.C.); (P.L.)
| | - Elisabete Nunes
- Nursing Research, Innovation, and Development Centre of Lisbon (CIDNUR), Escola Superior de Enfermagem de Lisboa, Avenida Professor Egas Moniz, 1600-190 Lisboa, Portugal; (E.N.); (P.C.); (P.L.)
| | - Paulo Cruchinho
- Nursing Research, Innovation, and Development Centre of Lisbon (CIDNUR), Escola Superior de Enfermagem de Lisboa, Avenida Professor Egas Moniz, 1600-190 Lisboa, Portugal; (E.N.); (P.C.); (P.L.)
| | - Pedro Lucas
- Nursing Research, Innovation, and Development Centre of Lisbon (CIDNUR), Escola Superior de Enfermagem de Lisboa, Avenida Professor Egas Moniz, 1600-190 Lisboa, Portugal; (E.N.); (P.C.); (P.L.)
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Rodriguez-Arrastia M, Martinez-Ortigosa A, Ruiz-Gonzalez C, Ropero-Padilla C, Roman P, Sanchez-Labraca N. Experiences and perceptions of final-year nursing students of using a chatbot in a simulated emergency situation: A qualitative study. J Nurs Manag 2022; 30:3874-3884. [PMID: 35411629 PMCID: PMC10084062 DOI: 10.1111/jonm.13630] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/15/2022] [Accepted: 04/04/2022] [Indexed: 12/30/2022]
Abstract
AIM The aim of this study is to explore the experiences and perceptions of final-year nursing students on the acceptability and feasibility of using a chatbot for clinical decision-making and patient safety. BACKGROUND The effective and inclusive use of new technologies such as conversational agents or chatbots could support nurses in increasing evidence-based care and decreasing low-quality services. METHODS A descriptive qualitative study was used through focus group interviews. The data analysis was conducted using a thematic analysis. RESULTS This study included 114 participants. After our data analysis, two main themes emerged: (i) experiences in the use of a chatbot service for clinical decision-making and and (ii) integrating conversational agents into the organizational safety culture. CONCLUSIONS The findings of our study provide preliminary support for the acceptability and feasibility of adopting SafeBot, a chatbot for clinical decision-making and patient safety. Our results revealed substantial recommendations for refining navigation, layout and content, as well as useful insights to support its acceptance in real nursing practice. IMPLICATIONS FOR NURSING MANAGEMENT Leaders and managers may well see artificial intelligence-based conversational agents like SafeBot as a potential solution in modern nursing practice for effective problem-solving resolution, innovative staffing and nursing care delivery models at the bedside and criteria for measuring and ensure quality and patient safety.
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Affiliation(s)
| | | | - Cristofer Ruiz-Gonzalez
- Department of Nursing Science, Physiotherapy and Medicine, University of Almeria, Almeria, Spain
| | | | - Pablo Roman
- Department of Nursing Science, Physiotherapy and Medicine, University of Almeria, Almeria, Spain.,Research Group CTS-451 Health Sciences, University of Almeria, Almeria, Spain.,Health Research Centre, University of Almeria, Almeria, Spain
| | - Nuria Sanchez-Labraca
- Department of Nursing Science, Physiotherapy and Medicine, University of Almeria, Almeria, Spain
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Ryan BJ, Muehlenbein MP, Allen J, Been J, Boyd K, Brickhouse M, Brooks BW, Burchett M, Chambliss CK, Cook JD, Ecklund A, Fogleman L, Granick P, Hynes S, Hudson T, Huse M, Lamb M, Lowe T, Marsh J, Nixon N, Nolan D, Nuñez G, Matthews W“S, Stern S, Wheelis M, Brickhouse N. Sustaining University Operations During the COVID-19 Pandemic. Disaster Med Public Health Prep 2022; 16:1901-1909. [PMID: 33678211 PMCID: PMC8134892 DOI: 10.1017/dmp.2021.69] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/01/2021] [Indexed: 12/19/2022]
Abstract
Colleges and universities around the world engaged diverse strategies during the COVID-19 pandemic. Baylor University, a community of ˜22,700 individuals, was 1 of the institutions which resumed and sustained operations. The key strategy was establishment of multidisciplinary teams to develop mitigation strategies and priority areas for action. This population-based team approach along with implementation of a "Swiss Cheese" risk mitigation model allowed small clusters to be rapidly addressed through testing, surveillance, tracing, isolation, and quarantine. These efforts were supported by health protocols including face coverings, social distancing, and compliance monitoring. As a result, activities were sustained from August 1 to December 8, 2020. There were 62,970 COVID-19 tests conducted with 1435 people testing positive for a positivity rate of 2.28%. A total of 1670 COVID-19 cases were identified with 235 self-reports. The mean number of tests per week was 3500 with approximately 80 of these positive (11/d). More than 60 student tracers were trained with over 120 personnel available to contact trace, at a ratio of 1 per 400 university members. The successes and lessons learned provide a framework and pathway for similar institutions to mitigate the ongoing impacts of COVID-19 and sustain operations during a global pandemic.
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Affiliation(s)
- Benjamin J. Ryan
- Department of Environmental Science, Environmental Health Science Program, Baylor University, Waco, TX, USA
| | | | - Jon Allen
- Information Technology Services, Baylor University, Waco, TX, USA
| | - Joshua Been
- Data and Digital Scholarship, Baylor University, Waco, TX, USA
| | - Kenneth Boyd
- Student-Athlete Health and Wellness, Baylor University, Waco, TX, USA
| | - Mark Brickhouse
- Environmental Health and Safety, Baylor University, Waco, TX, USA
| | - Bryan W. Brooks
- Department of Environmental Science, Environmental Health Science Program, Baylor University, Waco, TX, USA
| | | | - C. Kevin Chambliss
- Department of Chemistry and Biochemistry, Baylor University, Waco, TX, USA
| | - Jason D. Cook
- Marketing and Communications, Baylor University, Waco, TX, USA
| | - Adam Ecklund
- Health Services, Baylor University, Waco, TX, USA
| | - Lori Fogleman
- Media and Public Relations, Baylor University, Waco, TX, USA
| | - Peter Granick
- Operations, Finance and Administration, Baylor University, Waco, TX, USA
| | - Sharra Hynes
- Campus Living and Learning, Baylor University, Waco, TX, USA
| | - Tonya Hudson
- Media and Public Relations, Baylor University, Waco, TX, USA
| | | | - Micah Lamb
- IT Projects and Governance, Baylor University, Waco, TX, USA
| | - Tiffany Lowe
- Campus Living and Learning, Baylor University, Waco, TX, USA
| | - Jim Marsh
- Department of Counseling Services, Baylor University, Waco, TX, USA
| | - Niesha Nixon
- Health Services, Baylor University, Waco, TX, USA
| | - Dennis Nolan
- Environmental Health and Safety, Baylor University, Waco, TX, USA
| | - George Nuñez
- Office of Emergency Management, Baylor University, Waco, TX, USA
| | | | - Sharon Stern
- Health Services, Baylor University, Waco, TX, USA
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Coen M, Sader J, Junod-Perron N, Audétat MC, Nendaz M. Clinical reasoning in dire times. Analysis of cognitive biases in clinical cases during the COVID-19 pandemic. Intern Emerg Med 2022; 17:979-988. [PMID: 34997906 PMCID: PMC8742156 DOI: 10.1007/s11739-021-02884-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022]
Abstract
Cognitive biases are systematic cognitive distortions, which can affect clinical reasoning. The aim of this study was to unravel the most common cognitive biases encountered in in the peculiar context of the COVID-19 pandemic. Case study research design. Primary care. Single centre (Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland). A short survey was sent to all primary care providers (N = 169) taking care of hospitalised adult patients with COVID-19. Participants were asked to describe cases in which they felt that their clinical reasoning was "disrupted" because of the pandemic context. Seven case were sufficiently complete to be analysed. A qualitative analysis of the clinical cases was performed and a bias grid encompassing 17 well-known biases created. The clinical cases were analyzed to assess for the likelihood (highly likely, plausible, not likely) of the different biases for each case. The most common biases were: "anchoring bias", "confirmation bias", "availability bias", and "cognitive dissonance". The pandemic context is a breeding ground for the emergence of cognitive biases, which can influence clinical reasoning and lead to errors. Awareness of these cognitive mechanisms could potentially reduce biases and improve clinical reasoning. Moreover, the analysis of cognitive biases can offer an insight on the functioning of the clinical reasoning process in the midst of the pandemic crisis.
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Affiliation(s)
- Matteo Coen
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- grid.150338.c0000 0001 0721 9812Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Julia Sader
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- grid.8591.50000 0001 2322 4988iEh2-Institute for Ethics, History, and the Humanities-Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Noëlle Junod-Perron
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marie-Claude Audétat
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- grid.8591.50000 0001 2322 4988Institute of Primary Care (IuMFE), Faculty of Medicine, University of Geneva, Geneva, Switzerland
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12
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Zhu LL, Zhou Q. Nurses should not always be blamed for medication administration errors in pediatric inpatient care. J Pediatr Nurs 2022; 64:176-177. [PMID: 35256210 DOI: 10.1016/j.pedn.2022.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Ling-Ling Zhu
- VIP Ward, Division of Nursing, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Quan Zhou
- Department of Pharmacy, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China.
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Wiegmann DA, Wood LJ, Cohen TN, Shappell SA. Understanding the "Swiss Cheese Model" and Its Application to Patient Safety. J Patient Saf 2022; 18:119-123. [PMID: 33852542 PMCID: PMC8514562 DOI: 10.1097/pts.0000000000000810] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT This article reviews several key aspects of the Theory of Active and Latent Failures, typically referred to as the Swiss cheese model of human error and accident causation. Although the Swiss cheese model has become well known in most safety circles, there are several aspects of its underlying theory that are often misunderstood. Some authors have dismissed the Swiss cheese model as an oversimplification of how accidents occur, whereas others have attempted to modify the model to make it better equipped to deal with the complexity of human error in health care. This narrative review aims to provide readers with a better understanding and greater appreciation of the Theory of Active and Latent Failures upon which the Swiss cheese model is based. The goal is to help patient safety professionals fully leverage the model and its associated tools when performing a root cause analysis as well as other patient safety activities.
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Affiliation(s)
- Douglas A Wiegmann
- From the Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Laura J Wood
- From the Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Tara N Cohen
- Department of Surgery, Cedars-Sinai, Los Angeles, California
| | - Scott A Shappell
- Department of Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, Florida
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Moeng MS, Luvhengo TE. Analysis of Surgical Mortalities Using the Fishbone Model for Quality Improvement in Surgical Disciplines. World J Surg 2022; 46:1006-1014. [PMID: 35119512 DOI: 10.1007/s00268-021-06414-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The healthcare industry is complex and prone to the occurrence of preventable patient safety incidents. Most serious patient safety events in surgery are preventable. AIM This study was conducted to determine the rate of occurrence of preventable mortalities and to use the fishbone model to establish the main contributing factors. METHODS We reviewed the records of patients who died following admission to the surgical wards. Data regarding their demography, diagnosis, acuity, comorbidities, categorization of death and contributing factors were extracted from the Research Electronic Data Capture (REDCap) database. Factors which contributed to preventable and potentially preventable mortalities were collated. The fishbone model was used for root cause analysis. The study received prior ethical clearance (M190122). RESULTS Records of 859 mortalities were found, of which 65.7% (564/859) were males. The median age of the patients who died was 49 years (IQR: 33-64 years). The median length of hospital stay before death was three days (IQR: 1-11 days). Twenty-four percent (24.1%) of the deaths were from gastrointestinal (GIT) emergencies, 18.4% followed head injury and 17.0% from GIT cancers. Overall, 5.4% of the mortalities were preventable, and 41.1% were considered potentially preventable. The error of judgment and training issues accounted for 46% of mortalities. CONCLUSION Most surgical mortalities involve males, and around 46% are either potentially preventable or preventable. The majority of the mortality were associated with GIT emergencies, head injury and advanced malignancies of the GIT. The leading contributing factors to preventable and potentially preventable mortalities were the error of judgment, inadequate training and shortage of resources.
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Affiliation(s)
- M S Moeng
- Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), University of the Witwatersrand, Box 7053, Cresta, Johannesburg, Republic of South Africa.
| | - T E Luvhengo
- Clinical Head Department of Surgery, CMJAH, University of the Witwatersrand, Johannesburg, Republic of South Africa
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Innab AM. Nurses’ perceptions of fall risk factors and fall prevention strategies in acute care settings in Saudi Arabia. Nurs Open 2022; 9:1362-1369. [PMID: 35099122 PMCID: PMC8859041 DOI: 10.1002/nop2.1182] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/20/2021] [Accepted: 01/09/2022] [Indexed: 11/30/2022] Open
Abstract
Aim This study aimed to explore nurses’ perceptions of the factors associated with falls and of fall prevention strategies in acute care settings in Saudi Arabia. Design This is a cross‐sectional, correlational, descriptive study. Methods Data were collected from 102 nurses using a survey on the risk factors and prevention strategies of injurious falls. Results We found that impaired balance and muscle strength, limited mobility, and an inability to follow safety instructions were reported as the top factors in falls. Multidisciplinary fall prevention strategies are effective in reducing the prevalence of falls. Nurses with higher levels of education had higher perceptions towards the risk factors of falls. Formal patient safety training, including fall prevention education programmes, were shown to reduce falls by making nurses more aware of fall risk factors and prevention strategies. The findings of this study can be used to inform managers about factors that may contribute to falls in acute care settings.
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Affiliation(s)
- Adnan M. Innab
- Nursing Administration and Education Department College of Nursing King Saud University Riyadh Kingdom of Saudi Arabia
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16
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Relationship Between Pharmaceutical Knowledge and Probability of Medication Errors Among Nurses: A Cross-sectional Study in the Northwest of Iran in 2020. HEALTH SCOPE 2022. [DOI: 10.5812/jhealthscope.112269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Patient safety is a major concern for health care professionals. Medication errors have been considered a major indicator of health care quality. The lack of pharmacological knowledge is a cause of medication error among nurses. Objectives: The purpose of this study was to investigate the relationship between pharmacological knowledge and the probability of medical errors in nurses working in Urmia hospitals in 2020. Methods: This cross-sectional study included 490 nurses randomly selected from among those working in hospitals of Urmia in 2020. The data collection tool was a multiple-choice questionnaire about knowledge and pharmacological skills consisting of 3 sections: demographic information, nurses’ drug knowledge, and the confidence level of response in nurses. To analyze questions and hypotheses via SPSS version 21, the t-test and analysis of variance (ANOVA) were employed. Results: The highest pharmaceutical knowledge scores of nurses were related to methods of administration (2.9 ± 1.01 [72.56%]), and the lowest score was related to drug management (1.05 ± 0.63 [52.84%]). The mean of error probability was very low in 28.81% of nurses, low in 37.66%, high in 11.34%, and very high in 22.85%. Pharmaceutical knowledge had a significant relationship with gender, wards, type of hospital, and number of children (P < 0.05 for all). Conclusions: Since the nurses’ level of pharmaceutical knowledge has an important role in the correct prescription of medicine, we suggest that nurse managers and educational supervisors in the field of nursing use in-service training programs and prepare training booklets and posters to promote nurses’ pharmaceutical knowledge in this field.
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Mulac A, Hagesaether E, Granas AG. Medication dose calculation errors and other numeracy mishaps in hospitals: Analysis of the nature and enablers of incident reports. J Adv Nurs 2022; 78:224-238. [PMID: 34632614 DOI: 10.1111/jan.15072] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/30/2021] [Accepted: 09/26/2021] [Indexed: 11/29/2022]
Abstract
AIMS To investigate medication dose calculation errors and other numeracy mishaps in hospitals and examine mechanisms and enablers which lead to such errors. DESIGN A retrospective study using descriptive statistics and thematic analysis of the nature and enablers of reported incidents. METHODS Medication dose calculation errors and other numeracy mishaps were identified from medication-related incidents reported to the Norwegian Incident Reporting System in 2016 and 2017. The main outcome measures were medications and medication classes involved, severity of harm, outcome, and error enablers. RESULTS In total, we identified 100 numeracy errors, of which most involved intravenous administration route (n = 70). Analgesics were the most commonly reported drug class and morphine was the most common individual medication. Overall, 78 incidents described patient harm. Frequent mechanisms were 10- or 100-fold errors, mixing up units, and incorrect strength/rate entered into infusion pumps. The most frequent error enablers were: double check omitted or deviated (n = 40), lack of safety barriers to intercept prescribing errors (n = 25), and emergency/stress (n = 21). CONCLUSION Numeracy errors due to lack of or improper safeguards occurred during all medication management stages. Dose miscalculation after dilution of intravenous solutions, infusion pump programming, and double-checking were identified as unsafe practices. We discuss measures to prevent future calculation and numeracy errors. IMPACT Our analysis of medication dose calculation errors and other numeracy mishaps demonstrates the need for improving safety steps and increase standardization for medication management procedures. We discuss organizational, technological, and educational measures to prevent harm from numeracy errors.
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Affiliation(s)
- Alma Mulac
- Department of Pharmacy, The Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Ellen Hagesaether
- Department of Life Sciences and Health, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Anne Gerd Granas
- Department of Pharmacy, The Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
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Gopal DP, Chetty U, O'Donnell P, Gajria C, Blackadder-Weinstein J. Implicit bias in healthcare: clinical practice, research and decision making. Future Healthc J 2021; 8:40-48. [PMID: 33791459 DOI: 10.7861/fhj.2020-0233] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Bias is the evaluation of something or someone that can be positive or negative, and implicit or unconscious bias is when the person is unaware of their evaluation. This is particularly relevant to policymaking during the coronavirus pandemic and racial inequality highlighted during the support for the Black Lives Matter movement. A literature review was performed to define bias, identify the impact of bias on clinical practice and research as well as clinical decision making (cognitive bias). Bias training could bridge the gap from the lack of awareness of bias to the ability to recognise bias in others and within ourselves. However, there are no effective debiasing strategies. Awareness of implicit bias must not deflect from wider socio-economic, political and structural barriers as well ignore explicit bias such as prejudice.
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Affiliation(s)
- Dipesh P Gopal
- Barts and The London School of Medicine and Dentistry, London, UK
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Manalayil J, Kouranloo K, Horne L. "Incident Teaching (IT)" Lecture Series - Incorporating Education Surrounding Clinical Incidents and Complaints into Foundation Year 1 (FY1) Doctors' Induction. J Eur CME 2021; 10:1874643. [PMID: 33552678 PMCID: PMC7850408 DOI: 10.1080/21614083.2021.1874643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 11/22/2022] Open
Abstract
Patient safety incidents are any unintended or unexpected incidents which potentially could, or did, lead to harm to patients. Incident reports are crucial to improve patients' care and to identify further actions needed to prevent harm. A common view among the FY1 doctors in our local NHS Trust involved a fearful opinion surrounding being involved in clinical incidents. Significant anxiety in those situations prompted the need for a focus on the topic of "clinical incidents" during their induction to the Trust in two consecutive years of 2018 and 2019. A near-peer lecture series was delivered to new FY1 with qualitative pre- and post-lecture series feedbacks. Results from lecture series from two consecutive years showed all FY1 doctors agreed or strongly agreed that they had a good understanding of incidents following the lecture. Compared with their pre-course feedback, there was an increase of 6-fold (2018) and 8-fold (2019) in those that strongly agreed. Post-course, more than 90% of doctors reported that they would feel comfortable sharing with colleagues their involvement in an incident. In a growing culture of blame and litigation, it is important to address the harm associated with a blame-based culture. The process of investigating an incident has the potential to expose the areas of deficiency relating to an individual. Reducing stigma associated with incidents could theoretically reduce the second victim phenomenon. An open culture to incident reporting is a fundamental part of medical education and quality improvement. Encouraging this attitude amongst medical professionals and creating a supporting environment surrounding sharing of experiences will help to form a generation of doctors that see incident reporting in a positive light. Our model of lecture series could be utilised in other UK Foundation Programmes with the aim of enriching the FY1s' induction period.
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Affiliation(s)
- Jyothis Manalayil
- Blackpool Victoria Hospital, Blackpool and Fylde NHS Foundation Trust, UK
| | - K Kouranloo
- Blackpool Victoria Hospital, Blackpool and Fylde NHS Foundation Trust, UK
| | - L Horne
- Blackpool Victoria Hospital, Blackpool and Fylde NHS Foundation Trust, UK
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20
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Doarn CR. A Series of Related Events: Phases. Telemed J E Health 2020; 26:1309. [PMID: 33164717 DOI: 10.1089/tmj.2020.29046.crd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Kilner T, Butterfield E, Poonian J. Common cognitive pitfalls in emergency medicine. Emerg Med Australas 2020; 32:849-851. [DOI: 10.1111/1742-6723.13626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 08/21/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Thomas Kilner
- Department of Emergency Medicine The Royal Melbourne Hospital Melbourne Victoria Australia
| | - Emma Butterfield
- Department of Emergency Medicine Royal Darwin Hospital Darwin Northern Territory Australia
| | - Jasmine Poonian
- Department of Emergency Medicine The Royal Melbourne Hospital Melbourne Victoria Australia
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22
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Song W, Li J, Li H, Ming X. Human factors risk assessment: An integrated method for improving safety in clinical use of medical devices. Appl Soft Comput 2020. [DOI: 10.1016/j.asoc.2019.105918] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Salib S. The Delicate Dance of Teaching Rounds. MEDICAL SCIENCE EDUCATOR 2019; 29:871-874. [PMID: 34457553 PMCID: PMC8368817 DOI: 10.1007/s40670-019-00741-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Sherine Salib
- The Department of Internal Medicine, Dell Medical School at the University of Texas at Austin, Austin, TX USA
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Lockhart JJ, Satya-Murti S. Blinding or information control in diagnosis: could it reduce errors in clinical decision-making? ACTA ACUST UNITED AC 2018; 5:179-189. [PMID: 30231010 DOI: 10.1515/dx-2018-0030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 08/21/2018] [Indexed: 11/15/2022]
Abstract
Background Clinical medicine has long recognized the potential for cognitive bias in the development of new treatments, and in response developed a tradition of blinding both clinicians and patients to address this specific concern. Although cognitive biases have been shown to exist which impact the accuracy of clinical diagnosis, blinding the diagnostician to potentially misleading information has received little attention as a possible solution. Recently, within the forensic sciences, the control of contextual information (i.e. information apart from the objective test results) has been studied as a technique to reduce errors. We consider the applicability of this technique to clinical medicine. Content This article briefly describes the empirical research examining cognitive biases arising from context which impact clinical diagnosis. We then review the recent awakening of forensic sciences to the serious effects of misleading information. Comparing the approaches, we discuss whether blinding to contextual information might (and in what circumstances) reduce clinical errors. Summary and outlook Substantial research indicates contextual information plays a significant role in diagnostic error and conclusions across several medical specialties. The forensic sciences may provide a useful model for the control of potentially misleading information in diagnosis. A conceptual analog of the forensic blinding process (the "agnostic" first reading) may be applicable to diagnostic investigations such as imaging, microscopic tissue examinations and waveform recognition. An "agnostic" approach, where the first reading occurs with minimal clinical referral information, but is followed by incorporation of the clinical history and reinterpretation, has the potential to reduce errors.
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Affiliation(s)
- Joseph J Lockhart
- Consulting Psychologist, Forensic Services Division, Department of State Hospitals, State of California, Suite 410, Sacramento, CA 95814, USA
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Seshia SS, Bryan Young G, Makhinson M, Smith PA, Stobart K, Croskerry P. Gating the holes in the Swiss cheese (part I): Expanding professor Reason's model for patient safety. J Eval Clin Pract 2018; 24:187-197. [PMID: 29168290 PMCID: PMC5901035 DOI: 10.1111/jep.12847] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 09/28/2017] [Accepted: 10/02/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Although patient safety has improved steadily, harm remains a substantial global challenge. Additionally, safety needs to be ensured not only in hospitals but also across the continuum of care. Better understanding of the complex cognitive factors influencing health care-related decisions and organizational cultures could lead to more rational approaches, and thereby to further improvement. HYPOTHESIS A model integrating the concepts underlying Reason's Swiss cheese theory and the cognitive-affective biases plus cascade could advance the understanding of cognitive-affective processes that underlie decisions and organizational cultures across the continuum of care. METHODS Thematic analysis, qualitative information from several sources being used to support argumentation. DISCUSSION Complex covert cognitive phenomena underlie decisions influencing health care. In the integrated model, the Swiss cheese slices represent dynamic cognitive-affective (mental) gates: Reason's successive layers of defence. Like firewalls and antivirus programs, cognitive-affective gates normally allow the passage of rational decisions but block or counter unsounds ones. Gates can be breached (ie, holes created) at one or more levels of organizations, teams, and individuals, by (1) any element of cognitive-affective biases plus (conflicts of interest and cognitive biases being the best studied) and (2) other potential error-provoking factors. Conversely, flawed decisions can be blocked and consequences minimized; for example, by addressing cognitive biases plus and error-provoking factors, and being constantly mindful. Informed shared decision making is a neglected but critical layer of defence (cognitive-affective gate). The integrated model can be custom tailored to specific situations, and the underlying principles applied to all methods for improving safety. The model may also provide a framework for developing and evaluating strategies to optimize organizational cultures and decisions. LIMITATIONS The concept is abstract, the model is virtual, and the best supportive evidence is qualitative and indirect. CONCLUSIONS The proposed model may help enhance rational decision making across the continuum of care, thereby improving patient safety globally.
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Affiliation(s)
- Shashi S Seshia
- Department of Pediatrics, University of Saskatchewan, Saskatoon, Canada
| | - G Bryan Young
- Clinical Neurological Sciences and Medicine (Critical Care), Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada, Grey Bruce Health Services, Owen Sound, Canada
| | - Michael Makhinson
- Department of Psychiatry and Biobehavioral Science, David Geffen School of Medicine at the University of California, Los Angeles, USA.,Department of Psychiatry, Harbor-UCLA Medical Center, Torrance, USA
| | - Preston A Smith
- College of Medicine, University of Saskatchewan, Health Sciences Building, Saskatoon, Canada
| | - Kent Stobart
- College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Pat Croskerry
- Critical Thinking Program, Division of Medical Education, Dalhousie University Medical School, Halifax, Canada
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