Application of a trigger tool in near real time to inform quality improvement activities: a prospective study in a general medicine ward

Promoting a Patient-Centered Understanding of Safety in Acute Mental Health Wards: A User-Centered Design Approach to Develop a Real-Time Digital Monitoring Tool

BACKGROUND

Acute mental health services report high levels of safety incidents that involve both patients and staff. The potential for patients to be involved in interventions to improve safety within a mental health setting is acknowledged, and there is a need for interventions that proactively seek the patient perspective of safety. Digital technologies may offer opportunities to address this need.

OBJECTIVE

This research sought to design and develop a digital real-time monitoring tool (WardSonar) to collect and collate daily information from patients in acute mental health wards about their perceptions of safety. We present the design and development process and underpinning logic model and programme theory.

METHODS

The first stage involved a synthesis of the findings from a systematic review and evidence scan, interviews with patients (n=8) and health professionals (n=17), and stakeholder engagement. Cycles of design activities and discussion followed with patients, staff, and stakeholder groups, to design and develop the prototype tool.

RESULTS

We drew on patient safety theory and the concepts of contagion and milieu. The data synthesis, design, and development process resulted in three prototype components of the digital monitoring tool (WardSonar): (1) a patient recording interface that asks patients to input their perceptions into a tablet computer, to assess how the ward feels and whether the direction is changing, that is, "getting worse" or "getting better"; (2) a staff dashboard and functionality to interrogate the data at different levels; and (3) a public-facing ward interface. The technology is available as open-source code.

CONCLUSIONS

Recent patient safety policy and research priorities encourage innovative approaches to measuring and monitoring safety. We developed a digital real-time monitoring tool to collect information from patients in acute mental health wards about perceived safety, to support staff to respond and intervene to changes in the clinical environment more proactively.

Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic review

Many hospitals continue to use incident reporting systems (IRSs) as their primary patient safety data source. The information IRSs collect on the frequency of harm to patients [adverse events (AEs)] is generally of poor quality, and some incident types (e.g. diagnostic errors) are under-reported. Other methods of collecting patient safety information using medical record review, such as the Global Trigger Tool (GTT), have been developed. The aim of this study was to undertake a systematic review to empirically quantify the gap between the percentage of AEs detected using the GTT to those that are also detected via IRSs. The review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies published in English, which collected AE data using the GTT and IRSs, were included. In total, 14 studies met the inclusion criteria. All studies were undertaken in hospitals and were published between 2006 and 2022. The studies were conducted in six countries, mainly in the USA (nine studies). Studies reviewed 22 589 medical records using the GTT across 107 institutions finding 7166 AEs. The percentage of AEs detected using the GTT that were also detected in corresponding IRSs ranged from 0% to 37.4% with an average of 7.0% (SD 9.1; median 3.9 and IQR 5.2). Twelve of the fourteen studies found <10% of the AEs detected using the GTT were also found in corresponding IRSs. The >10-fold gap between the detection rates of the GTT and IRSs is strong evidence that the rate of AEs collected in IRSs in hospitals should not be used to measure or as a proxy for the level of safety of a hospital. IRSs should be recognized for their strengths which are to detect rare, serious, and new incident types and to enable analysis of contributing and contextual factors to develop preventive and corrective strategies. Health systems should use multiple patient safety data sources to prioritize interventions and promote a cycle of action and improvement based on data rather than merely just collecting and analysing information.

Electronic surveillance of patient safety events using natural language processing

Objective

We describe our approach to surveillance of reportable safety events captured in hospital data including free-text clinical notes. We hypothesize that a) some patient safety events are documented only in the clinical notes and not in any other accessible source; and b) large-scale abstraction of event data from clinical notes is feasible.

Materials and Methods

We use regular expressions to generate a training data set for a machine learning model and apply this model to the full set of clinical notes and conduct further review to identify safety events of interest. We demonstrate this approach on peripheral intravenous (PIV) infiltrations and extravasations (PIVIEs).

Results

During Phase 1, we collected 21,362 clinical notes, of which 2342 were reviewed. We identified 125 PIV events, of which 44 cases (35%) were not captured by other patient safety systems. During Phase 2, we collected 60,735 clinical notes and identified 440 infiltrate events. Our classifier demonstrated accuracy above 90%.

Conclusion

Our method to identify safety events from the free text of clinical documentation offers a feasible and scalable approach to enhance existing patient safety systems. Expert reviewers, using a machine learning model, can conduct routine surveillance of patient safety events.

Implementing a Robust Process Improvement Program in the Neonatal Intensive Care Unit to Reduce Harm

INTRODUCTION

Preventable harm continues to occur with critically ill neonates despite efforts by hospital neonatal intensive care units (NICUs) to improve processes and reduce harm. Attaining significant and sustainable improvements will require training including leadership support, mentoring, and patient family engagement to improve care processes. This paper describes the implementation of a robust process improvement (RPI) program in the NICU to reduce harm.

METHODS

Leaders, staff, and parents were trained in RPI concepts and tools. Multidisciplinary teams including parent members applied the training and received regular mentorship for their improvement initiatives.

RESULTS

Participants (N = 67) completed pretraining and post-training surveys. Training scores (0-10 scale) improved from an average of 4.45-7.60 (p < .001) for confidence in leading process improvement work, 2.36 to 7.49 (p < .001) for RPI knowledge, and 2.19 to 7.30 (p < .001) for confidence in using RPI tools; relative improvement of 71%, 217%, and 233% respectively. Participants applied their RPI training on improvement initiatives that resulted in improvements of central line blood stream infections, very low birth weight infant nutrition, and unplanned extubations.

CONCLUSIONS

Implementing an RPI program in the NICU to reduce harm resulted in significant and sustainable improvements on their improvement initiatives.

Defining the Epidemiology of Safety Risks in Neonatal Intensive Care Unit Patients Requiring Surgery

OBJECTIVE

The aim of the study was to determine the incidence, type, severity, preventability, and contributing factors of nonroutine events (NREs)-events perceived by care providers or skilled observers as a deviations from optimal care based on the clinical situation-in the perioperative (i.e., preoperative, operative, and postoperative) care of surgical neonates in the neonatal intensive care unit and operating room.

METHODS

A prospective observational study of noncardiac surgical neonates, who received preoperative and postoperative neonatal intensive care unit care, was conducted at an urban academic children's hospital between November 1, 2016, and March 31, 2018. One hundred twenty-nine surgical cases in 109 neonates were observed. The incidence and description of NREs were collected via structured researcher-administered survey tool of involved clinicians. Primary measurements included clinicians' ratings of NRE severity and contributory factors and trained research assistants' ratings of preventability.

RESULTS

One or more NREs were reported in 101 (78%) of 129 observed cases for 247 total NREs. Clinicians reported 2 (2) (median, interquartile range) NREs per NRE case with a maximum severity of 3 (1) (possible range = 1-5). Trained research assistants rated 47% of NREs as preventable and 11% as severe and preventable. The relative risks for National Surgical Quality Improvement Program - pediatric major morbidity and 30-day mortality were 1.17 (95% confidence interval = 0.92-1.48) and 1.04 (95% confidence interval = 1.00-1.08) in NRE cases versus non-NRE cases.

CONCLUSIONS

The incidence of NREs in neonatal perioperative care at an academic children's hospital was high and of variable severity with a myriad of contributory factors.

Identification and Adjudication of Adverse Events Following Rectal Cancer Surgery: Observational Case Series in a Region of Ontario, Canada

BACKGROUND

For patients undergoing rectal cancer surgery, we evaluated whether suboptimal preoperative surgeon evaluation of resection margins is a latent condition factor-a factor that is common, unrecognized, and may increase the risk of certain adverse events, including local tumour recurrence, positive surgical margin, nontherapeutic surgery, and in-hospital mortality.

METHODS

In this observational case series of patients who underwent rectal cancer surgery during 2016 in Local Health Integrated Network 4 region of Ontario (population 1.4 million), chart review and a trigger tool were used to identify patients who experienced the adverse events. An expert panel adjudicated whether each event was preventable or nonpreventable and identified potential contributing factors to adverse events.

RESULTS

Among 173 patients, 25 (14.5%) had an adverse event and 13 cases (7.5%) were adjudicated as preventable. Rate of surgeon awareness of preoperative margin status was low at 50% and similar among cases with and without an adverse event (p = 0.29). Suboptimal surgeon preoperative evaluation of surgical margins was adjudicated a contributing factor in all 11 preventable local recurrence, positive margin, and nontherapeutic surgery cases. Failure to rescue was judged a contributing factor in the two cases with preventable in-hospital mortality.

CONCLUSIONS

Suboptimal surgeon preoperative evaluation of surgical margins in rectal cancer is likely a latent condition factor. Optimizing margin evaluation may be an efficient quality improvement target.

Comparison of active versus passive surveillance adverse event reporting in a paediatric ambulatory chiropractic care setting: a cluster randomised controlled trial

Objectives

This pragmatic, cluster, stratified randomised controlled trial (RCT) compared the quantity and quality of adverse event (AE) reports after chiropractic manual therapy in children less than 14 years of age, using active versus passive surveillance reporting systems.

Method

Data were collected between November 2014 and July 2017 from 60 consecutive paediatric patient visits to participating chiropractors. Those allocated to active surveillance collected AE information with three paper-based questionnaires (two from patients, one from chiropractors) to identify any new or worsening symptoms after treatment. Passive surveillance involved AE information reported by chiropractors on a web-based system. To assess quality of reporting, AE reports greater than mild were reviewed by content experts. The primary outcome was the cumulative incidence of AE reports in active versus passive surveillance.

Results

Ninety-six chiropractors agreed to participate and enrolled in the study: 34 chiropractors in active surveillance with 1894 patient visits from 1179 unique patients and 35 chiropractors in passive surveillance with 1992 patient visits from 1363 unique patients. In the active arm, AEs were reported in 8.8% (n=140, 95% CI 6.72% to 11.18%) of patients/caregivers, compared with 0.1% (n=2, 95% CI 0.02% to 0.53%) in the passive arm (p<0.001). The quality of AE reports was not evaluated because the five AE reports reviewed by the content experts were determined to be of mild severity.

Conclusion

We found that active surveillance resulted in significantly more AE reports than passive surveillance. Further prospective active surveillance research studies should be conducted with children receiving chiropractic manual therapy to understand mechanisms and risk factors for moderate and severe AEs, and to further explore how and when to solicit patient safety information.

A mixed methods study to effectively utilize trigger tools in the ICU

PURPOSE

This study aimed to create a trigger tool for our intensive care units (ICUs) to support our departmental quality improvement efforts.

METHODS

We compiled an initial list of triggers used in an ICU setting through literature review. We used a modified Delphi method to develop a unique set of triggers. An expert panel was selected for multidisciplinary and multi-site representation from four adult medical-surgical ICUs of a Canadian city. Respondents ranked triggers on a Likert scale based on its likelihood of being associated with adverse event (sensitivity to harm), and likelihood of being associated with suboptimal ICU processes (specificity for internal recommendations).

OUTCOMES

Our literature search yielded 10 articles and 59 triggers. Completion of the rating process resulted in 12 items that achieved consensus. Triggers included specific clinical, hospital-acquired infection, medication related, and procedural occurrences. One additional trigger (cardiopulmonary arrest) which consistently held high scores but did not achieve multidisciplinary consensus, was also included.

CONCLUSIONS

We used the modified Delphi process to derive consensus-selected triggers to identify ICU specific adverse events with opportunity for improvement in local care. This methodology can be adopted by other centers looking to introduce trigger tools in a manner selective to their practice needs.

The impact of hospital harm on length of stay, costs of care and length of person-centred episodes of care: a retrospective cohort study

BACKGROUND

There is a lack of data in Canada on the longitudinal effects of adverse events that occur in hospital, specifically in the period after discharge. Our objective was to quantify the impact of adverse events on hospital length of stay, length of person-centred episodes of care (PCEs) and costs of PCEs, as well as their impact on the total health system.

METHODS

We conducted a population-based, retrospective cohort study using linked health administrative databases. We included adults in Ontario who had an acute hospital admission between Apr. 1, 2015, and Mar. 31, 2016. We grouped hospital admissions into 1 of 9 episode types and used the Canadian Institute for Health Information methodology for hospital harm to measure adverse events. We specified generalized linear models to estimate the impact of hospital harm on the following: incremental length of index acute hospital admission, incremental length of the PCE, and incremental costs of the PCE.

RESULTS

Out of 610 979 hospital admissions, 36 004 (5.9%) involved an occurrence of harm. The impact of harm on the incremental length of hospital stay ranged from 0.4 to 24.2 days (p < 0.001); the incremental length of the PCE ranged from 0.3 to 30.2 days (p < 0.001); and the incremental costs of the PCE ranged from $800 to $51 067 (p < 0.001). Total hospital days attributable to hospital harm amounted to 407 696, and the total attributable cost to the Ontario health system amounted to $1 088 330 376.

INTERPRETATION

We found that experiencing harm in hospital significantly affects both in-hospital and post-discharge use of health services and costs of care, and constitutes an enormous expense to Ontario's publicly funded health system.

Study of a multisite prospective adverse event surveillance system

Background

We have designed a prospective adverse event (AE) surveillance method. We performed this study to evaluate this method’s performance in several hospitals simultaneously.

Objectives

To compare AE rates obtained by prospective AE surveillance in different hospitals and to evaluate measurement factors explaining observed variation.

Methods

We conducted a multicentre prospective observational study. Prospective AE surveillance was implemented for 8 weeks on the general medicine wards of five hospitals. To determine if population factors may have influenced results, we performed mixed-effects logistic regression. To determine if surveillance factors may have influenced results, we reassigned observers to different hospitals midway through surveillance period and reallocated a random sample of events to different expert review teams.

Results

During 3560 patient days of observation of 1159 patient encounters, we identified 356 AEs (AE risk per encounter=22%). AE risk varied between hospitals ranging from 9.9% of encounters in Hospital D to 35.8% of encounters in Hospital A. AE types and severity were similar between hospitals—the most common types were related to clinical procedures (45%), hospital-acquired infections (21%) and medications (19%). Adjusting for age and comorbid status, we observed an association between hospital and AE risk. We observed variation in observer behaviour and moderate agreement between clinical reviewers, which could have influenced the observed rate difference.

Conclusion

This study demonstrated that it is possible to implement prospective surveillance in different settings. Such surveillance appears to be better suited to evaluating hospital safety concerns within rather than between hospitals as we could not definitively rule out whether the observed variation in AE risk was due to population or surveillance factors.

Concept and contents of a voluntary course for medical students' achievement of a basic qualification in patient safety during the practical year of medical studies

Objective: Regarding the urgent need of qualification in the field of patient safety, the respective education and training were completed by a voluntary course for 10-15 students in their practical year (PY) provided in cooperation of the private University Hospital of Marburg and the Medical Faculty of the Philipps-University of Marburg. At the same time, this course was intended to develop important knowledge for implementing improvements of the current PY teaching as well as revising the curriculum of Marburg in the medium term. Project description: The PY course on patient safety is offered every six months since 2016 and comprises about 80 lessons. It is based on the principles of shifting simple knowledge transfer to autonomous preparation by the students themselves, of revising already experienced situations of the professional routine, of working with real data of current patients of the PY students, of fostering teamwork, and of applying very deliberately a large combination of methods with numerous interactive types of teaching. The topics of those 13 course units include the majority of the most important problem categories of patient safety as reported in the literature such as communication, drug safety, diagnostic errors, and handovers as well as methods for systematic identification and analysis of errors. In the context of a project task, the students evaluate by means of the global trigger tool and 10 patient files of their current wards each if harm has occurred in the treatment of these patients. Afterwards, the students elaborate in teams of 2 a fishbone diagram for one case where an avoidable harm had emerged. In this graph, the deficient process, the factors contributing to its development, the safety measures that are already applied in the department as well as suggested improvements of the students are visualized. In the final lesson of the course, the students explain and describe their diagram to a member of the managing board of the university hospital. Successful participation is confirmed by an official certificate issued by the Medical Center for Quality in Medicine (Ärztliches Zentrum für Qualität in der Medizin) stating that the course meets the level II requirements ("Basic qualification") of the training concept on "patient safety" of the Germany medical staff. Results: After meanwhile 5 episodes of this course, the whole curriculum obtained a mean score of "very good" based on the standard questionnaire of the Medical Faculty of the University of Marburg. The students perceive an enormous increase in competence regarding the implementation of specific projects to improve patient safety. Furthermore, the intensive cooperation with the PY students led to conceiving and establishing further 7 PY courses for the benefit of patient safety and consolidation of entrustable professional activities. In combination with experiences gained elsewhere from courses on patient safety, the collected knowledge could be used for a first draft of teaching and education of patient safety during the entire clinical studies that takes into account the local conditions. Conclusion: In the process of anchoring the topic of patient safety in the Marburg curriculum of medical studies, the introduction of an extensive voluntary course in the second four months of the clinical internship (practical year) turned out to have a very positive effect. Supported by the management board of the hospital and the medical faculty, we consider it useful to permanently provide such an extensive course for a group of students who want to early and intensively deal with the topic of patient safety.

Implementation of a multimodal patient safety improvement program "SafetyLEAP" in intensive care units

Purpose Patient safety remains a top priority in healthcare. Many organizations have developed systems to monitor and prevent harm, and have invested in different approaches to quality improvement. Despite these organizational efforts to better detect adverse events, efficient resolution of safety problems remains a significant challenge. The authors developed and implemented a comprehensive multimodal patient safety improvement program called SafetyLEAP. The term "LEAP" is an acronym that highlights the three facets of the program including: a Leadership and Engagement approach; Audit and feedback; and a Planned improvement intervention. The purpose of this paper is to evaluate the implementation of the SafetyLEAP program in the intensive care units (ICUs) of three large hospitals. Design/methodology/approach A comparative case study approach was used to compare and contrast the adherence to each component of the SafetyLEAP program. The study was conducted using a convenience sample of three ( n=3) ICUs from two provinces. Two reviewers independently evaluated major adherence metrics of the SafetyLEAP program for their completeness. Analysis was performed for each individual case, and across cases. Findings A total of 257 patients were included in the study. Overall, the proportion of the SafetyLEAP tasks completed was 64.47, 100, and 26.32 percent, respectively. ICU nos 1 and 2 were able to identify opportunities for improvement, follow a quality improvement process and demonstrate positive changes in patient safety. The main factors influencing adherence were the engagement of a local champion, competing priorities, and the identification of appropriate resources. Practical implications The SafetyLEAP program allowed for the identification of processes that could result in patient harm in the ICUs. However, the success in improving patient safety was dependent on the engagement of the care teams. Originality/value The authors developed an evidence-based approach to systematically and prospectively detect, improve, and evaluate actions related to patient safety.

Evaluation of accuracy of IHI Trigger Tool in identifying adverse drug events: a prospective observational study

AIMS

Adverse drug events (ADEs) can seriously compromise the safety and quality of care provided to hospitalized patients, requiring the adoption of accurate methods to monitor them. We sought to prospectively evaluate the accuracy of the triggers proposed by the Institute for Healthcare Improvement (IHI) for identifying ADEs.

METHODS

A prospective study was conducted in a public university hospital in 2015 with patients over the age of 18. Triggers proposed by IHI and clinical alterations suspected to be ADEs were searched daily. The number of days in which the patient was hospitalized was considered as unit of measure to evaluate the accuracy of each trigger.

RESULTS

A total of 300 patients were included in this study. Mean age was 56.3 years (standard deviation (SD) 16.0), and 154 (51.3%) were female. The frequency of patients with ADEs was 24.7% and with at least one trigger was 53.3%. From those patients who had at least one trigger, the most frequent triggers were antiemetics (57.5%) and 'abrupt medication stop' (31.8%). The sensitivity of triggers ranged from 0.3 to 11.8% and the positive predictive value ranged from 1.2 to 27.3%. Specificity and negative predictive value were greater than 86%. Most patients identified by the presence of triggers did not have ADEs (64.4%). No triggers were identified in 40 (38.5%) ADEs.

CONCLUSIONS

IHI Trigger Tool did not show good accuracy in detecting ADEs in this prospective study. The adoption of combined strategies could enhance effectiveness in identifying patient safety flaws. Further discussion might contribute to improve trigger usefulness in clinical practice.

Adverse Events in Hospitalized Pediatric Patients

: media-1vid110.1542/5789657761001PEDS-VA_2017-3360Video Abstract BACKGROUND: Patient safety concerns over the past 2 decades have prompted widespread efforts to reduce adverse events (AEs). It is unclear whether these efforts have resulted in reductions in hospital-wide AE rates. We used a validated safety surveillance tool, the Global Assessment of Pediatric Patient Safety, to measure temporal trends (2007-2012) in AE rates among hospitalized children.

METHODS

We conducted a retrospective surveillance study of randomly selected pediatric inpatient records from 16 teaching and nonteaching hospitals. We constructed Poisson regression models with hospital random intercepts, controlling for patient age, sex, insurance, and chronic conditions, to estimate changes in AE rates over time.

RESULTS

Examining 3790 records, reviewers identified 414 AEs (19.1 AEs per 1000 patient days; 95% confidence interval [CI] 17.2-20.9) and 210 preventable AEs (9.5 AEs per 1000 patient days; 95% CI 8.2-10.8). On average, teaching hospitals had higher AE rates than nonteaching hospitals (26.2 [95% CI 23.7-29.0] vs 5.1 [95% CI 3.7-7.1] AEs per 1000 patient days, P < .001). Chronically ill children had higher AE rates than patients without chronic conditions (33.9 [95% CI 24.5-47.0] vs 14.0 [95% CI 11.8-16.5] AEs per 1000 patient days, P < .001). Multivariate analyses revealed no significant changes in AE rates over time. When stratified by hospital type, neither teaching nor nonteaching hospitals experienced significant temporal AE rate variations.

CONCLUSIONS

AE rates in pediatric inpatients are high and did not improve from 2007 to 2012. Pediatric AE rates were substantially higher in teaching hospitals as well as in patients with more chronic conditions.

Creating a comprehensive, unit-based approach to detecting and preventing harm in the neonatal intensive care unit

Background

Error detection and analysis alone cannot create or sustain a culture of safe, high-quality, compassionate care for patients. Some experts have endorsed a unit-based approach to improving quality, but there are few examples and those rarely focus on reducing all preventable harms and engaging frontline clinicians, patients, and families. Approach: We implemented a unit-based approach comprising seven building blocks for creating a comprehensive approach to detect and prevent harm at the unit level within a hospital: (1) unit quality council and stakeholder buy-in, (2) parent engagement and advisory council, (3) frontline clinician and parent quality improvement training, (4) measurement of organizational contextual factors, (5) electronic health record trigger development and synthesis of harm measures, (6) subcommittees to review harm, and (7) quality improvement teams. Challenges and Lessons Learned: Challenges include conceptualizing triggers for a unit unfamiliar with this methodology, establishing unit resources for collecting and analyzing data, and creating processes to integrate parents in unit quality efforts. The seven essential building blocks helped overcome these challenges and could be adopted by other healthcare organizations.

Conclusion

These building blocks create a generalizable foundation for establishing a unit-based approach to detecting and preventing harm.

Development of a 'ready-to-use' tool that includes preventability, for the assessment of adverse drug events in oncology

Background Adverse drug events (ADEs) occur frequently in oncology and justify continuous assessment and monitoring. There are several methods for detecting them, but the trigger tool method seems the most appropriate. Although a generic tool exists, its use for ADEs in oncology has not been convincing. The development of a focused version is therefore necessary. Objective To provide an oncology-focused trigger tool that evaluates the prevalence, harm, and preventability in a standardised method for pragmatic use in ADE surveillance. Setting Hospitals with cancer care in France. Method The tool has been constructed in two steps: (1) constitution of an oncology-centred list of ADEs; 30 pharmacists/practitioners in cancer care from nine hospitals selected a list of ADEs using a method of agreement adapted from the RAND/UCLA Appropriateness Method; and (2) construction of three standardised dimensions for the characterisation of each ADE (including causality, severity, and preventability). Main outcome measure The main outcome measure was validation of the tool, including preventability criteria. Results The tool is composed of a final list of 15 ADEs. For each ADE, a 'reviewer form' has been designed and validated by the panel. It comprises (1) the trigger(s), (2) flowcharts to guide the reviewer, (3) criteria for grading harm, and (4) a standardised assessment of preventability with 6-14 closed sentences for each ADE in terms of therapeutic management and/or prevention of side-effects. Conclusion A complete 'ready-to-use' tool for ADE monitoring in oncology has been developed that allows the assessment of three standardised dimensions.

Triggers and Their Influence on Health Behaviors

This article provides a conceptual definition of the concept trigger within the context of health behaviors and applies it to the highly significant health issue of obesity. Healthy behaviors are essential to life and happiness, but they do not just happen. They are triggered, and an inner drive keeps them alive. To help patients gain and retain optimal health, nurses must understand the triggers of healthy behaviors. Walker and Avant's (2011) method of concept analysis is used as the basis for defining the concept of trigger. The antecedents, defining attributes, and consequences of trigger are identified. Findings suggest that nurses can play a role in triggering health behavior change through simple motivational efforts.

Translating staff experience into organisational improvement: the HEADS-UP stepped wedge, cluster controlled, non-randomised trial

OBJECTIVES

Frontline insights into care delivery correlate with patients' clinical outcomes. These outcomes might be improved through near-real time identification and mitigation of staff concerns. We evaluated the effects of a prospective frontline surveillance system on patient and team outcomes.

DESIGN

Prospective, stepped wedge, non-randomised, cluster controlled trial; prespecified per protocol analysis for high-fidelity intervention delivery.

PARTICIPANTS

Seven interdisciplinary medical ward teams from two hospitals in the UK.

INTERVENTION

Prospective clinical team surveillance (PCTS): structured daily interdisciplinary briefings to capture staff concerns, with organisational facilitation and feedback.

MAIN MEASURES

The primary outcome was excess length of stay (eLOS): an admission more than 24 hours above the local average for comparable patients. Secondary outcomes included safety and teamwork climates, and incident reporting. Mixed-effects models adjusted for time effects, age, comorbidity, palliation status and ward admissions. Safety and teamwork climates were measured with the Safety Attitudes Questionnaire. High-fidelity PCTS delivery comprised high engagement and high briefing frequency.

RESULTS

Implementation fidelity was variable, both in briefing frequency (median 80% working days/month, IQR 65%-90%) and engagement (median 70 issues/ward/month, IQR 34-113). 1714/6518 (26.3%) intervention admissions had eLOS versus 1279/4927 (26.0%) control admissions, an absolute risk increase of 0.3%. PCTS increased eLOS in the adjusted intention-to-treat model (OR 1.32, 95% CI 1.10 to 1.58, p=0.003). Conversely, high-fidelity PCTS reduced eLOS (OR 0.79, 95% CI 0.67 to 0.94, p=0.006). High-fidelity PCTS also increased total, high-yield and non-nurse incident reports (incidence rate ratios 1.28-1.79, all p<0.002). Sustained PCTS significantly improved safety and teamwork climates over time.

CONCLUSIONS

This study highlighted the potential benefits and pitfalls of ward-level interdisciplinary interventions. While these interventions can improve care delivery in complex, fluid environments, the manner of their implementation is paramount. Suboptimal implementation may have an unexpectedly negative impact on performance.

TRIAL REGISTRATION NUMBER

ISRCTN 34806867 (http://www.isrctn.com/ISRCTN34806867).

Translating concerns into action: a detailed qualitative evaluation of an interdisciplinary intervention on medical wards

OBJECTIVES

To understand how frontline reports of day-to-day care failings might be better translated into improvement.

DESIGN

Qualitative evaluation of an interdisciplinary team intervention capitalising on the frontline experience of care delivery. Prospective clinical team surveillance (PCTS) involved structured interdisciplinary briefings to capture challenges in care delivery, facilitated organisational escalation of the issues they identified, and feedback. Eighteen months of ethnography and two focus groups were conducted with staff taking part in a trial of PCTS.

RESULTS

PCTS fostered psychological safety-a confidence that the team would not embarrass or punish those who speak up. This was complemented by a hard edge of accountability, whereby team members would regulate their own behaviour in anticipation of future briefings. Frontline concerns were triaged to managers, or resolved autonomously by ward teams, reversing what had been well-established normalisations of deviance. Junior clinicians found a degree of catharsis in airing their concerns, and their teams became more proactive in addressing improvement opportunities. PCTS generated tangible organisational changes, and enabled managers to make a convincing case for investment. However, briefings were constrained by the need to preserve professional credibility, and staff found some comfort in avoiding accountability . At higher organisational levels, frontline concerns were subject to competition with other priorities, and their resolution was limited by the scale of the challenges they described.

CONCLUSIONS

Prospective safety strategies relying on staff-volunteered data produce acceptable, negotiated accounts, subject to the many interdisciplinary tensions that characterise ward work. Nonetheless, these strategies give managers access to the realities of frontline cares, and support frontline staff to make incremental changes in their daily work. These are goals for learning healthcare organisations.

TRIAL REGISTRATION

ISRCTN 34806867.

Design and reliability of a specific instrument to evaluate patient safety for patients with acute myocardial infarction treated in a predefined care track: a retrospective patient record review study in a single tertiary hospital in the Netherlands

OBJECTIVE

Numerous studies have shown that a substantial number of patients suffer from adverse events (AEs) as a result of hospital care. However, specific data on AEs in acute cardiac care are scarce. The current manuscript describes the development and validation of a specific instrument to evaluate patient safety of a predefined care track for patients with acute myocardial infarction (AMI).

DESIGN

Retrospective patient record review study.

SETTING AND PARTICIPANTS

A total of 879 hospital admissions treated in a tertiary care centre for an AMI (age 64±12 years, 71% male).

MAIN OUTCOME MEASURE

In the first phase, the medical records of patients with AMI warranting coronary angiography or coronary intervention were analysed for process deviations. In the second phase, the medical records of these patients were checked for any harm that had occurred which was caused by the healthcare provider or the healthcare organisation (AE) and whether the harm that occurred was preventable.

RESULTS

Of all 879 patients included in the analysis, 40% (n=354) had 1 or more process deviation. Of these 354 patients, 116 (33%) had an AE. Patients with AE experienced more process deviations compared with patients without AE (2±1.7 vs 1.5±0.9 process deviations per patient, p=0.005). Inter-rater reliability in assessing a causal relation of healthcare with the origin of an AE showed a κ of 0.67 (95% CI 0.51 to 0.83).

CONCLUSIONS

This study shows that it is possible to develop a reliable method, which can objectively assess process deviations and the occurrence of AEs in a specified population. This method could be a starting point for developing an electronic tracking system for continuous monitoring in strictly predefined care tracks.

Development and Preliminary Testing of the Coordination Process Error Reporting Tool (CPERT), a Prospective Clinical Surveillance Mechanism for Teamwork Errors in the Pediatric Cardiac ICU

BACKGROUND

Patient safety reporting systems (PSRSs) may not detect teamwork or coordination process errors that affect all dimensions of quality defined by the Institute of Medicine. This study aimed to develop and observe the performance of a novel tool, the Coordination Process Error Reporting Tool (CPERT), as a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU.

METHODS

Providers and parents used the qualitative nominal group technique to identify coordination process error examples. Using categories developed from these discussions, the CPERT was designed and observed to assess agreement among providers and with the PSRS. For each patient at the end of each observed shift, the nurse, frontline clinician, and attending physician were invited to complete the CPERT online. Responses among providers were compared to assess interobserver agreement. Patients with errors identified by the CPERT were matched 1:1 with patients without CPERT errors within the same shift. The PSRS and medical record were reviewed to judge whether a coordination process error occurred and whether patients with CPERT errors differed from controls.

RESULTS

Eight categories of errors were identified and incorporated into the CPERT. During 10 shifts (218 patients), the CPERT completion rate was 74%. Fifty-one patient shifts had errors identified by the CPERT (23%); these patients did not differ significantly from those without CPERT- reported errors. Only 5 CPERT-reported errors (10%) were identified by two or more providers. Of the 51 CPERT- reported errors, 43 (84%) were not documented in the PSRS.

CONCLUSION

The CPERT detects coordination process errors not identified through PSRS, making it or similar tools potentially useful for improvement efforts.

Clinical Information Systems - From Yesterday to Tomorrow

OBJECTIVES

To review the history of clinical information systems over the past twenty-five years and project anticipated changes to those systems over the next twenty-five years.

METHODS

Over 250 Medline references about clinical information systems, quality of patient care, and patient safety were reviewed. Books, Web resources, and the author's personal experience with developing the HELP system were also used.

RESULTS

There have been dramatic improvements in the use and acceptance of clinical computing systems and Electronic Health Records (EHRs), especially in the United States. Although there are still challenges with the implementation of such systems, the rate of progress has been remarkable. Over the next twenty-five years, there will remain many important opportunities and challenges. These opportunities include understanding complex clinical computing issues that must be studied, understood and optimized. Dramatic improvements in quality of care and patient safety must be anticipated as a result of the use of clinical information systems. These improvements will result from a closer involvement of clinical informaticians in the optimization of patient care processes.

CONCLUSIONS

Clinical information systems and computerized clinical decision support have made contributions to medicine in the past. Therefore, by using better medical knowledge, optimized clinical information systems, and computerized clinical decision, we will enable dramatic improvements in both the quality and safety of patient care in the next twenty-five years.

The Well-Defined Pediatric ICU: Active Surveillance Using Nonmedical Personnel to Capture Less Serious Safety Events

BACKGROUND

Adverse events, diverse and often costly, commonly occur in pediatric intensive care units (PICUs). Serious safety events (SSEs) are captured through well-developed systems, typically by voluntary reporting. Less serious safety events (LSSEs), including close calls, however, occur at a higher frequency than those that result in immediate harm or death but are underestimated by standard reporting systems. LSSEs can reveal system defects and precede serious events resulting in patient or provider harm.

METHODS

A unique active surveillance program was created at Children's Hospitals and Clinics of Minnesota to quantify and categorize, and, ultimately reduce, LSSEs, in PICUs. Premedical college graduates without formal health care training daily canvassed the PICUs and facilitated reporting of LSSEs at the point of care. Events were recorded on a Web application and stored in a relational database management system. Events were enumerated and categorized according to distinctive characteristics (Theme Index) and real or potential harm (Harm Index).

RESULTS

Some 1,980 PICU patients, representing 10,766 PICU patient-days in a 15-month period (June 1, 2013- August 31, 2014) experienced 2,465 LSSEs-5.4 LSSEs/ day or 0.23 LSSEs/patient-day. Such events resulted in a patient intervention 38% of the time. Some 158 quality/safety improvement projects were initiated during the observation period, 74 of which have been completed. Quality/safety information was broadcasted to providers, local leadership, and hospital management.

CONCLUSIONS

LSSEs occur frequently in our PICUs. Non-health care providers can cost-effectively facilitate reporting by actively canvassing PICU providers on a daily basis and can contribute to quality/safety improvement projects and local safety culture. Reported events can serve as a focus for quality/safety improvement projects. A Web application and mobile tablet interfaces are efficient tools to record events.