Effects of auditing patient safety in hospital care: design of a mixed-method evaluation

Design and Validation of a Questionnaire to Measure Interprofessional Collaborative Practice for Auditing Integrated Hospital Care: Empirical Research

INTRODUCTION

Interprofessional teamwork is the key issue of delivering integrated hospital care; however, measuring interprofessional collaboration for auditing is fragmented. In this study, a questionnaire to measure InterProfessional collaborative Practice for Integrated Hospital care (IPPIH) has been developed and validated.

METHODS

A four-step iterative process was conducted: (1) literature search to find suitable questionnaires; (2) semistructured stakeholder interviews (individual and in focus groups) to discuss the topics and questions (face validity), (3) pretesting the prototype of the questionnaire in two different integrated care pathways for feasibility, usability, and internal consistency, and (4) testing (content and construct validity and responsiveness) of the revised questionnaire in eight integrated care pathways; the validation and responsiveness was tested by means of exploratory factor analysis, calculation of Cronbach alpha, item analysis, and linear mixed model analysis.

RESULTS

Based on six questionnaires and the opinion of direct stakeholders, the questionnaire IPPIH comprised 27 items. Five different domains could be distinguished: own skills, culture, coordination and collaboration, practical support, and appreciation with the Cronbach alpha varied from 0.91 to 0.48. The self-reported intensity of the collaboration within a specific care pathway significantly influenced the outcome (P = .000).

CONCLUSION

The product is a questionnaire, IPPIH, which can measure the degree of interprofessional collaborative practice in integrated hospital care pathways. The IPPIH was initially developed for quality assurance. However, the IPPIH also seems to be suitable as a self-assessment tool for directors to monitor and improve the interprofessional collaboration and the quality of their integrated care pathway.

Occurrence and types of medication error and its associated factors in a reference teaching hospital in northeastern Iran: a retrospective study of medical records

BACKGROUND

Medication errors are categorized among the most common medical errors that may lead to irreparable damages to patients and impose huge costs on the health system. A correct understanding of the prevalence of medication errors and the factors affecting their occurrence is indispensable to prevent such errors. The purpose of this study was to investigate the prevalence and types of medication errors among nurses in a hospital in northeastern Iran.

METHODS

The present descriptive-analytical research was conducted on 147 medical records of patients admitted to the Department of Internal Medicine at a hospital in northeastern Iran in 2019, selected by systematic sampling. The data were collected through a researcher-made checklist containing the demographic profiles of the nurses, the number of doctor's orders, the number of medication errors and the type of medication error, and were finally analyzed using STATA version 11 software at a significance level of 0.05.

RESULTS

Based on the findings of this study, the mean prevalence of medication error per each medical case was 2.42. Giving non-prescription medicine (47.8%) was the highest and using the wrong form of the drug (3.9%) was the lowest medication error. In addition, there was no statistically significant relationship between medication error and the age, gender and marital status of nurses (p > 0.05), while the prevalence of medication error in corporate nurses was 1.76 times higher than that of nurses with permanent employment status (IRR = 1.76, p = 0.009). The prevalence of medication error in the morning shift (IRR = 0.65, p = 0.001) and evening shift (IRR = 0.69, p = 0.011) was significantly lower than that in the night shift.

CONCLUSION

Estimating the prevalence and types of medication errors and identified risk factors allows for more targeted interventions. According to the findings of the study, training nurses, adopting an evidence-based care approach and creating interaction and coordination between nurses and pharmacists in the hospital can play an effective role in reducing the medication error of nurses. However, further research is needed to evaluate the effectiveness of interventions to reduce the prevalence of medication errors.

Changes in Safety and Teamwork Climate After Adding Structured Observations to Patient Safety WalkRounds

BACKGROUND

Patient safety is essential for the reliable delivery of health care. One way to positively influence patient safety is to improve the safety and teamwork climate of a clinical area. Research shows that patient safety WalkRounds (WRs) are an appropriate and common method to improve safety culture. The aim of this study was to combine WRs with observations of specific patient safety dimensions and to measure the safety and teamwork climate.

METHODS

In this observational study, WRs took place in eight work settings across a 770-bed university hospital in Switzerland. During rounds, health care workers (HCWs) were observed in relation to defined patient safety dimensions. In addition, HCWs were surveyed using safety and teamwork climate scales before the initial WRs and six to nine months later, and implementation of planned improvement actions following the WRs was evaluated.

RESULTS

During WRs, 810 activities of HCWs were observed, of which 85.4% met the requirements for safe care. Safety and teamwork climate did not change significantly after nine months. A total of 36 action plan items were planned to address safety deficits that surfaced during WRs, but only 40.7% of the action items had been implemented after nine months.

CONCLUSION

WRs with structured in-person observations identified safe care practices and deficits in patient safety. Improvement action plans to address safety deficits were not fully implemented nine months later, and there were no significant changes in the safety and teamwork climate at that time.

Hospital Staff's Adherence to Information Security Policy: A Quest for the Antecedents of Deterrence Variables

Information security has come to the forefront as an organizational priority since information systems are considered as some of the most important assets for achieving competitive advantages. Despite huge capital expenditures devoted to information security, the occurrence of security breaches is still very much on the rise. More studies are thus required to inform organizations with a better insight on how to adequately promote information security. To address this issue, this study investigates important factors influencing hospital staff’s adherence to Information Security Policy (ISP). Deterrence theory is adopted as the theoretical underpinning, in which punishment severity and punishment certainty are recognized as the most significant predictors of ISP adherence. Further, this study attempts to identify the antecedents of punishment severity and punishment certainty by drawing from upper echelon theory and well-acknowledged international standards of IS security practices. A survey approach was used to collect 299 valid responses from a large Taiwanese healthcare system, and hypotheses were tested by applying partial least squares-based structural equation modeling. Our empirical results show that Security Education, Training, and Awareness (SETA) programs, combined with internal auditing effectiveness are significant predictors of punishment severity and punishment certainty, while top management support is not. Further, punishment severity and punishment certainty are significant predictors of hospital staff’s ISP adherence intention. Our study highlights the importance of SETA programs and internal auditing for reinforcing hospital staff’s perceptions on punishment concerning ISP violation, hospitals can thus propose better internal strategies to improve their staff’s ISP compliance intention accordingly.

Feasibility of reusing routinely recorded data to monitor the safe preparation and administration of injectable medication: A multicenter cross-sectional study

BACKGROUND

Reusing routinely recorded data from electronic hospital records (EHR) may offer a less-time consuming, and more real time alternative for monitoring compliance by nurses with a protocol for the safe preparation and administration of injectable medication. However, at present it is unknown if the data necessary to calculate the quality indicators (QIs) are recorded in EHRs, or if these data are suitable for automated QI calculation. Therefore, the aim of this study was to determine the feasibility of monitoring compliance by nurses with a protocol for the safe injectable medication preparation and administration by reusing routinely recorded EHR data for the automated calculation of QIs.

METHODS

A cross-sectional study in 12 Dutch hospitals (October 2015-May 2016). The checks included in the currently prevailing national protocol for the safe preparation and administration of injectable medication were translated into 16 data elements required to calculate the QIs. At each hospital, one interview was conducted using a structured questionnaire to decide whether the data elements were available in EHRs. To present these results, descriptive statistics were used.

RESULTS

In total, 20 health-care professionals were interviewed and four different EHR systems were evaluated. The availability of data elements was comparable between the four evaluated EHR systems. Nine of the 16 required data elements were recorded in EHRs, eight in a structured format. The seven missing data elements were mainly related to checks such as 'gather all materials needed' or 'conduct hand hygiene'. Furthermore, changes were identified in the process for the preparation and administration of injectable medication. These changes are mostly related to the increased use of electronic medication administration registration and barcode medication administration systems.

CONCLUSIONS

Reusing EHR data to monitor compliance by nurses with the currently prevailing protocol for the safe preparation and administration of injectable medication is not entirely feasible. A decision should be made on which checks should be recorded in the EHRs and which checks should be audited in order to minimize the registration burden for nurses. Moreover, the currently prevailing protocol should be revised to bring it in line with work-as-done. Our results can be used as guidance for such a revision and also for designing new QIs that can be calculated by reusing routinely recorded EHR data.

Effects of patient safety auditing in hospital care: results of a mixed-method evaluation (part 1)

OBJECTIVE

To evaluate the effectiveness of internal auditing in hospital care focussed on improving patient safety.

DESIGN, SETTING AND PARTICIPANTS

A before-and-after mixed-method evaluation study was carried out in eight departments of a university medical center in the Netherlands.

INTERVENTION(S)

Internal auditing and feedback focussed on improving patient safety.

MAIN OUTCOME MEASURE(S)

The effect of internal auditing was assessed 15 months after the audit, using linear mixed models, on the patient, professional, team and departmental levels. The measurement methods were patient record review on adverse events (AEs), surveys regarding patient experiences, safety culture and team climate, analysis of administrative hospital data (standardized mortality rate, SMR) and safety walk rounds (SWRs) to observe frontline care processes on safety.

RESULTS

The AE rate decreased from 36.1% to 31.3% and the preventable AE rate from 5.5% to 3.6%; however, the differences before and after auditing were not statistically significant. The patient-reported experience measures regarding patient safety improved slightly over time (P < 0.001). The SMR, patient safety culture and team climate remained unchanged after the internal audit. The SWRs showed that medication safety and information security were improved (P < 0.05).

CONCLUSIONS

Internal auditing was associated with improved patient experiences and observed safety on wards. No effects were found on adverse outcomes, safety culture and team climate 15 months after the internal audit.

Process evaluation of the effects of patient safety auditing in hospital care (part 2)

Objective

To identify factors that explain the observed effects of internal auditing on improving patient safety.

Design setting and participants

A process evaluation study within eight departments of a university medical centre in the Netherlands.

Intervention(s)

Internal auditing and feedback for improving patient safety in hospital care.

Main outcome measure(s)

Experiences with patient safety auditing, percentage implemented improvement actions tailored to the audit results and perceived factors that hindered or facilitated the implementation of improvement actions.

Results

The respondents had positive audit experiences, with the exception of the amount of preparatory work by departments. Fifteen months after the audit visit, 21% of the intended improvement actions based on the audit results were completely implemented. Factors that hindered implementation were short implementation time: 9 months (range 5–11 months) instead of the 15 months’ planned implementation time; time-consuming and labour-intensive implementation of improvement actions; and limited organizational support for quality improvement (e.g. insufficient staff capacity and time, no available quality improvement data and information and communication technological (ICT) support).

Conclusions

A well-constructed analysis and feedback of patient safety problems is insufficient to reduce the occurrence of poor patient safety outcomes. Without focus and support in the implementation of audit-based improvement actions, quality improvement by patient safety auditing will remain limited.

Transparency about internal audit results to reduce the supervisory burden: A qualitative study on the preconditions of sharing audit results

Many working hours of healthcare professionals are spent on administrative tasks. Administrative burden is caused by political choices, legislation, the requirements of health insurers and supervisors. Coordination between the parties involved, is lacking. Therefore, we studied to what extent sharing internal audit results of hospitals with external supervisors is possible and the necessary preconditions. We interviewed 42 individuals from six hospitals and the Dutch Health and Youth Care Inspectorate. The interviewees expressed that there is no coordination in timing and content between internal audits and external supervision. They were in favour of sharing internal audit results with external supervisors to reduce the supervisory burden. They stated that internal audits give insight into quality problems and improvements, how hospital directors govern quality and safety, and the culture of improvement within healthcare provider teams. With this information, the inspectorate can judge to what extent hospitals are learning organisations. The interviewees mentioned the following preconditions for sharing audit results: reliable and risk-based information about quality and safety, collected by expert, trained auditors, and careful use of this information by the inspectorate in order to maintain openness among audited healthcare professionals. In conclusion, internal audit results can be shared conditionally with external supervisors. When internal audit results show that hospitals are open, learning and self-reflecting organisations, the healthcare inspectorate can reduce their supervisory burden.

Understanding safety differently: developing a model of resilience in the use of intravenous insulin infusions in hospital in-patients-a feasibility study protocol

BACKGROUND

Intravenous insulin infusions are considered the treatment of choice for critically ill patients and non-critically ill patients with persistent raised blood glucose who are unable to eat, to achieve optimal blood glucose levels. The benefits of using intravenous insulin infusions as well as the problems experienced are well described in the scientific literature. Traditional approaches for improving patient safety have focused on identifying errors, understanding their causes and designing solutions to prevent them. Such approaches do not take into account the complex nature of healthcare systems, which cannot be controlled solely by following standards. An emerging approach called Resilient Healthcare proposes that, to improve safety, it is necessary to focus on how work can be performed successfully as well as how work has failed.

METHODS AND ANALYSIS

The study will be conducted at Oxford University Hospitals NHS Foundation Trust and will involve three phases. Phase I: explore how work is imagined by analysing intravenous insulin infusion guidelines and conducting focus group discussions with guidelines developers, managers and healthcare practitioners. Phase II: explore the interplay between how work is imagined and how work is performed using mixed methods. Quantitative data will include blood glucose levels, insulin infusion rates, number of hypoglycaemic and hyperglycaemic events from patients' electronic records. Qualitative data will include video reflexive ethnography: video recording healthcare practitioners using intravenous insulin infusions and then conducting reflexive meetings with them to discuss selected video footage. Phase III: compare findings from phase I and phase II to develop a model for using intravenous insulin infusions.

ETHICS AND DISSEMINATION

Ethical approvals have been granted by the South Central-Oxford C Research Ethics Committee, Oxford University Hospitals NHS Foundation Trust and University of Reading. The results will be disseminated through presentations at appropriate conferences and meetings, and publications in peer-reviewed journals.

Important factors for effective patient safety governance auditing: a questionnaire survey

Background

Audits are increasingly used for patient safety governance purposes. However, there is little insight into the factors that hinder or stimulate effective governance based on auditing. The aim of this study is to quantify the factors that influence effective auditing for hospital boards and executives.

Methods

A questionnaire of 32 factors was developed using influencing factors found in a qualitative study on effective auditing. Factors were divided into four categories. The questionnaire was sent to the board of directors, chief of medical staff, nursing officer, medical department head and director of the quality and safety department of 89 acute care hospitals in the Netherlands.

Results

We approached 522 people, of whom 211 responded. Of the 32 factors in the questionnaire, 30 factors had an agreement percentage higher than 50%. Important factors per category were ‘audit as an improvement tool as well as a control tool’, ‘department is aware of audit purpose’, ‘quality of auditors’ and ‘learning culture at department’. We found 14 factors with a significant difference in agreement between stakeholders of at least 20%. Amongst these were ‘medical specialist on the audit team’, ‘soft signals in the audit report’, ‘patients as auditors’ and ‘post-audit support’.

Conclusion

We found 30 factors for effective auditing, which we synthesised into eight recommendations to optimise audits. Hospitals can use these recommendations as a framework for audits that enable boards to become more in control of patient safety in their hospital.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3577-9) contains supplementary material, which is available to authorized users.

Implementing paediatric early warning scores systems in the Netherlands: future implications

Background

Paediatric Early Warning Scores (PEWS) are increasingly being used for early identification and management of clinical deterioration in paediatric patients. A PEWS system includes scores, cut-off points and appropriate early intervention. In 2011, The Dutch Ministry of Health advised hospitals to implement a PEWS system in order to improve patient safety in paediatric wards. The objective of this study was to examine the results of implementation of PEWS systems and to gain insight into the attitudes of professionals towards using a PEWS system in Dutch non-university hospitals.

Methods

Quantitative data were gathered at start, midway and at the end of the implementation period through retrospective patient record review (n = 554). Semi-structured interviews with professionals (n = 8) were used to gain insight in the implementation process and experiences. The interviews were transcribed and analysed using an inductive approach.

Results

Looking at PEWS systems of the five participating hospitals, different parameters and policies were found. While all hospitals included heart rate and respiratory rate, other variables differed among hospitals. At baseline, none of the hospitals used a PEWS system. After 1 year, PEWS were recorded in 69.2% of the patient records and elevated PEWS resulted in appropriate action in 49.1%. Three themes emerged from the interviews: 1) while the importance of using a PEWS system was acknowledged, professionals voiced some doubts about the effectiveness and validity of their PEWS system 2) registering PEWS required little extra effort and was facilitated by PEWS being integrated into the electronic patient record 3) Without a national PEWS system or guidelines, hospitals found it difficult to identify a suitable PEWS system for their setting. Existing systems were not always considered applicable in a non-university setting.

Conclusions

After 1 year, hospitals showed improvements in the use of their PEWS system, although some were decidedly more successful than others. Doubts among staff about validity, effectiveness and communication with other hospitals during transfer to higher level care hospital might hinder sustainable implementation. For these purposes the development of a national PEWS system is recommended, consisting of a “core set” of PEWS, cut-off points and associated early intervention.

Benchmarked performance charts using principal components analysis to improve the effectiveness of feedback for audit data in HIV care

BACKGROUND

Feedback tools for clinical audit data that compare site-specific results to average performance over all sites can be useful for quality improvement. Proposed tools should be simple and clearly benchmark the site's performance, so that a relevant action plan can be directly implemented to improve patient care services. We aimed to develop such a tool in order to feedback data to UK HIV clinics participating in the 2015 British HIV Association (BHIVA) audit assessing compliance with the 2011 guidelines for routine investigation and monitoring of adult HIV-1- infected individuals.

METHODS

HIV clinic sites were asked to provide data on a random sample of 50-100 adult patients attending for HIV care during 2014 and/or 2015 by completing a self-audit spreadsheet. Outcomes audited included the proportion of patients with recorded resistance testing, viral load monitoring, adherence assessment, medications, hepatitis testing, vaccination management, risk assessments, and sexual health screening. For each outcome we benchmarked the proportion for a specific site against the average performance. We produced performance charts for each site using boxplots for the outcomes. We also used the mean and differences from the mean performance to produce a dashboard for each site. We used principal components analysis to group correlated outcomes and simplify the dashboard.

RESULTS

The 106 sites included in the study provided information on a total of 7768 patients. Outcomes capturing monitoring of treatment of HIV-infection showed high performance across the sites, whereas testing for hepatitis, and risk assessment for cardiovascular disease and smoking, management of flu vaccination, sexual health screening, and cervical cytology for women were very variable across sites. The principal components analysis reduced the original 12 outcomes to four factors that represented HIV care, hepatitis testing, other screening tests, and resistance testing. These provided simplified measures of adherence to guidelines which were presented as a 4 bar dashboard of performance.

CONCLUSION

Our dashboard performance charts provide easily digestible visual summaries of locally relevant audit data that are benchmarked against the overall mean and can be used to improve feedback to HIV services. Feedback from clinicians indicated that they found these charts acceptable and useful.

Evaluation of the organisation and effectiveness of internal audits to govern patient safety in hospitals: a mixed-methods study

OBJECTIVES

Hospital boards are legally responsible for safe healthcare. They need tools to assist them in their task of governing patient safety. Almost every Dutch hospital performs internal audits, but the effectiveness of these audits for hospital governance has never been evaluated. The aim of this study is to evaluate the organisation of internal audits and their effectiveness for hospitals boards to govern patient safety.

DESIGN AND SETTING

A mixed-methods study consisting of a questionnaire regarding the organisation of internal audits among all Dutch hospitals (n=89) and interviews with stakeholders regarding the audit process and experienced effectiveness of audits within six hospitals.

RESULTS

Response rate of the questionnaire was 76% and 43 interviews were held. In every responding hospital, the internal audits followed the plan-do-check-act cycle. Every hospital used interviews, document analysis and site visits as input for the internal audit. Boards stated that effective aspects of internal audits were their multidisciplinary scope, their structured and in-depth approach, the usability to monitor improvement activities and to change hospital policy and the fact that results were used in meetings with staff and boards of supervisors. The qualitative methods (interviews and site visits) used in internal audits enable the identification of soft signals such as unsafe culture or communication and collaboration problems. Reported disadvantages were the low frequency of internal audits and the absence of soft signals in the actual audit reports.

CONCLUSION

This study shows that internal audits are regarded as effective for patient safety governance, as they help boards to identify patient safety problems, proactively steer patient safety and inform boards of supervisors on the status of patient safety. The description of the Dutch internal audits makes these audits replicable to other healthcare organisations in different settings, enabling hospital boards to complement their systems to govern patient safety.

Discharge communication from inpatient care: an audit of written medical discharge summary procedure against the new National Health Service Standard for clinical handover

Objective To audit written medical discharge summary procedure and practice against Standard Six (clinical handover) of the Australian National Safety and Quality Health Service Standards at a major regional Victorian health service. Methods Department heads were invited to complete a questionnaire about departmental discharge summary practices. Results Twenty-seven (82%) department heads completed the questionnaire. Seven (26%) departments had a documented discharge summary procedure. Fourteen (52%) departments monitored discharge summary completion and 13 (48%) departments monitored the timeliness of completion. Seven (26%) departments informed the patient of the content of the discharge summary and six (22%) departments provided the patient with a copy. Seven (26%) departments provided training for staff members on how to complete discharge summaries. Completing discharge summaries was usually delegated to the medical intern. Conclusions The introduction of the National Service Standards prompted an organisation-wide audit of discharge summary practices against the external criterion. There was substantial variation in the organisation’s practices. The Standards and the current audit results highlight an opportunity for the organisation to enhance and standardise discharge summary practices and improve communication with general practice. What is known about the topic? The Australian National Safety and Quality Health Service Standards (Standard 6) require health service organisations to implement documented systems that support structured and effective clinical handover. Discharge summaries are an important and often the only form of communication during a patient’s transition from hospital to the community. Incomplete, inaccurate and unavailable discharge summaries are common and expose patients to greater health risks. Junior staff members find completing discharge summaries difficult and fail to receive appropriate education or support. There is little published evidence regarding the discharge summary practices of inpatient health services. What does this paper add? The paper demonstrates that there is substantial variation in practice regarding discharge summaries in a large regional health service. Departments have different processes and vary in the degree of attention and quality assurance provided to discharge summaries. Variable organisation procedures make completing discharge summaries more difficult for junior doctors, who regularly move between departments. Variable practice is likely to increase the risk of absent, untimely, incomplete or incorrect communication between acute and community services, thereby reducing the quality of patient care. It is likely that similar findings would be found in other hospitals. What are the implications for practitioners? To be accredited under the National Safety and Quality Health Service Standards, health organisations must ensure that adequate processes are in place for safe and effective clinical handover. Organisations should reduce the practice variability by standardising processes, monitoring compliance with processes, and training and supporting junior doctors.

Adverse events in affiliated hospitals of mazandaran university of medical sciences

Due to the complexity of the hospital environment, its structure faces with multiple hazards. The risks whether by providing the care and whether by hospital environment endanger patients, relatives and care providers. Therefore, a more accurate reporting and analysis of the report by focusing on access to preventative methods is essential. In this study, hospitals' adverse event that has sent by affiliated hospitals of Mazandaran University of Medical Sciences to deputy for treatment has studied.