Individual Characteristics That Promote or Prevent Psychological Safety and Error Reporting in Healthcare: A Systematic Review

Development and implementation of paging and escalation guidelines to improve interprofessional communication on surgical units

INTRODUCTION

Suboptimal interprofessional communication in the surgical inpatient setting has important implications for patient safety. Our departmental quality committee identified numerous safety events resulting from discordant expectations between surgical floor nurses and surgical residents or advanced practice providers (APPs) who serve as responding clinicians (RCs), and from reluctance to escalate clinical concerns. Alphanumeric paging is frequently used to communicate, but there are opportunities to enhance its effectiveness. This initiative sought to improve perceptions of communication and responsiveness between nurses and RCs by providing a shared language and set of expectations about the urgency of pages, appropriate responses and the process of escalation to other team members if necessary.

METHODS

An interprofessional team of surgical faculty, nurses and residents solicited input from surgical floor nurses, operating room nurses, residents, APPs and attendings on their perceptions of communication barriers among team members via online surveys and focus groups. Guidelines were iteratively developed. They specify that every page should be classified as STAT, Urgent, Please Call or FYI. Each classification is associated with an expected response time and pathway for contacting alternative team members if no response is received. After 3 months of implementation on our hospital's two main general surgery units, follow-up online surveys with multiple-choice and free-response questions assessed perceived impacts on communication and clinical care. Differences in categorical variables were assessed with χ2 tests, and free text was analysed inductively.

RESULTS

After implementation, nurses reported favourable effects on communication, including significantly improved responsiveness during night shifts and timeliness from RCs during day shifts. Residents and attendings perceived the intervention to have overall neutral to mildly positive effects on communication.

CONCLUSIONS

Paging and Escalation Guidelines are a feasible approach to enhance the perceptions of communication between nurses and RCs by aligning expectations, streamlining responses and decreasing barriers to escalation.

Patient safety incident reporting systems and reporting practices in African healthcare organisations: a systematic review and meta-analysis

BACKGROUND

Patient safety incident reporting and learning systems are crucial for improving the safety and quality of healthcare. However, comprehensive evidence of their availability and use in African healthcare organisations is lacking. Therefore, this review aims to synthesise the existing literature on these systems and reporting practices within African healthcare organisations.

METHODS

A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Five electronic databases, including PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCOhost, Scopus, Web of Science and the Excerpta Medica Database (Embase), were searched to identify relevant records. Peer-reviewed articles and guidelines published in English were included in this review. Quality appraisal was performed using the Joanna Briggs Institute and Quality Assessment with Diverse Studies tool. A random effects model was used to compute the pooled prevalence using Stata V.17.0.

RESULTS

A systematic search retrieved 9279 records, of which 39 (36 articles and 3 guidelines) were included in this review. Eight patient safety incident reporting and learning systems were identified, with compliance rates ranging from low (16%) to high (87%) based on the WHO criteria. The pooled prevalence of patient safety incident reporting practices was 48% (95% CI 40% to 56%). However, the studies exhibited high heterogeneity (I²=98.75%, p<0.001).

CONCLUSION

In African healthcare organisations, it is imperative to establish robust patient safety incident reporting and learning systems, as none of the existing systems fully meet WHO criteria. In addition, optimising the existing systems and encouraging healthcare professionals to improve reporting practices will enhance patient safety and outcomes.

PROSPERO REGISTRATION NUMBER

CRD42023455168.

Mindfulness and Voice Behaviour: A Diary Study of Ego Depletion and Work-Related Self-Efficacy Among Nurses

AIM

This study examined how mindfulness affects voice behaviour by altering nurses' daily resource levels.

BACKGROUND

Mindfulness is an essential personal resource; it can enhance the accumulation of resources and empower individuals to engage in adaptive resource regulation. This study suggests that on days when nurses' mindfulness is higher than average, they may accumulate more resources that facilitate their voice behaviour.

DESIGN

We employed an intensive longitudinal design in the form of a daily diary. Participants were asked to complete both one-time and daily surveys.

METHODS

We collected data between March and September 2024, and 119 nurses were tracked over seven workdays. We tested the hypothesised relationships using a multilevel analysis.

RESULTS

Mindfulness was positively related to nurses' voice behaviour; this relationship was mediated by work-related self-efficacy (WRSE). Moreover, ego depletion and WRSE played a chain-mediating role between mindfulness and nurses' voice behaviour.

CONCLUSION

Mindfulness enhances nurses' voice behaviour as well as an individual's resource level and enables him/her to obtain more resources through voice behaviour.

IMPACT

Given the positive impact of mindfulness, we advocate for expanding mindfulness training for nurses to boost their resource levels and consequently encourage voice behaviour. In addition, given the mediating role of ego depletion and WRSE, we emphasise the importance of identifying and mitigating factors that contribute to nurses' ego depletion. Furthermore, we call for training on professional skills to be provided to enhance nurses' confidence in their abilities.

PATIENT OR PUBLIC CONTRIBUTION

There are no patient or public contributions. This study did not involve patients or the public in the design and implementation process because it focused on investigating the work behaviour of nurses, where the involvement of patients and the public may not have been essential.

Large-scale observational study of AI-based patient and surgical material verification system in ophthalmology: real-world evaluation in 37 529 cases

BACKGROUND

Surgical errors in ophthalmology can have devastating consequences. We developed an artificial intelligence (AI)-based surgical safety system to prevent errors in patient identification, surgical laterality and intraocular lens (IOL) selection. This study aimed to evaluate its effectiveness in real-world ophthalmic surgical settings.

METHODS

In this retrospective observational before-and-after implementation study, we analysed 37 529 ophthalmic surgeries (18 767 pre-implementation, 18 762 post implementation) performed at Tsukazaki Hospital, Japan, between 1 March 2019 and 31 March 2024. The AI system, integrated with the WHO surgical safety checklist, was implemented for patient identification, surgical laterality verification and IOL authentication.

RESULTS

Post implementation, five medical errors (0.027%) occurred, with four in non-authenticated cases (where the AI system was not fully implemented or properly used), compared with one (0.0053%) pre-implementation (p=0.125). Of the four non-authenticated errors, two were laterality errors during the initial implementation period and two were IOL implantation errors involving unlearned IOLs (7.3% of cases) due to delayed AI updates. The AI system identified 30 near misses (0.16%) post implementation, vs 9 (0.048%) pre-implementation (p=0.00067), surgical laterality errors/near misses occurred at 0.039% (7/18 762) and IOL recognition at 0.29% (28/9713). The system achieved>99% implementation after 3 months. Authentication performance metrics showed high efficiency: facial recognition (1.13 attempts, 11.8 s), surgical laterality (1.05 attempts, 3.10 s) and IOL recognition (1.15 attempts, 8.57 s). Cost-benefit analysis revealed potential benefits ranging from US$181 946.94 to US$2 769 129.12 in conservative and intermediate scenarios, respectively.

CONCLUSIONS

The AI-based surgical safety system significantly increased near miss detection and showed potential economic benefits. However, errors in non-authenticated cases underscore the importance of consistent system use and integration with existing safety protocols. These findings emphasise that while AI can enhance surgical safety, its effectiveness depends on proper implementation and continuous refinement.

Validation of the Neuroception of Psychological Safety Scale (NPSS) Among Health and Social Care Workers in the UK

Psychological safety is essential for rest, recovery, and fostering social connections, particularly for health and social care workers (HSCWs) who frequently operate in high-pressure environments. These workers are prone to traumatic stress, which can elevate their sense of threat and undermine their psychological safety. This study aimed to validate the Neuroception of Psychological Safety Scale (NPSS) among HSCWs in the UK (n = 443). The NPSS is based on polyvagal theory and assesses the dimensions of compassion, social engagement and bodily sensations. Internal consistency, test-retest reliability, convergent, discriminant, and concurrent validity were examined, along with the scale's dimensionality. A three-factor structure was confirmed, with internal consistencies ranging from acceptable to excellent across subscales. Validity was supported by significant associations with measures of team psychological safety, well-being, post-traumatic stress, burnout, body perception, and personality. The NPSS also demonstrated strong test-retest reliability. These results validate the NPSS as a reliable and multidimensional tool for assessing psychological safety in health and social care settings. The study highlights the importance of psychological safety for HSCWs and provides a valuable measure to support interventions aimed at fostering safer and more supportive work environments.

Barriers and Enablers of Successful Workplace Integration of Internationally Educated Nurses (IENs) in a Host Country: A Qualitative Evidence Synthesis

The aim of this qualitative evidence synthesis (QES) is to critically appraise the contemporary literature to gain a comprehensive understanding of the barriers and enablers of workplace integration needs of internationally educated nurses (IENs). An electronic search was conducted across multiple databases, and eligibility criteria were applied to identify papers published between January 2013 and July 2023. Out of the 830 studies initially retrieved, six met the inclusion criteria. Study quality was assessed using the Critical Appraisal Skills Programme (CASP) tool. Thematic analysis of the included studies revealed various barriers and enablers for workplace integration experienced by IENs. Barriers were: (a) IEN-related factors (cultural differences, language barriers, and disparities in the scope of nursing practice), (b) organizational factors (poor leadership), and (c) contextual factors (racism and discrimination). Enablers emerged were: (a) IEN-related factors (commitment to learn and adapt) and (b) organizational factors (structured multifaceted program, supportive workplace environment, and mentorship). Dynamic interaction exists among these factors, therefore interventions should address multiple barriers simultaneously. The QES has illuminated essential factors which impact the integration of IENs, and emphasizes the necessity of a comprehensive approach that considers the diverse challenges and opportunities that arise.

From identifying patient safety risks to reporting patient complaints: A grounded theory study on patients' hospital experiences

AIM

To explore how patients with hospital experience construct patient safety, from the identification of a patient safety risk to the decision to file a complaint.

BACKGROUND

Patients play an important role in the prevention of adverse events in hospitals, but the ability of patients to act and influence their own safety is still challenged by multiple factors. Understanding how patients perceive risk and act to prevent harm may shed light on how to enhance patients' opportunities to participate in patient safety.

DESIGN

The research design of this study is qualitative and exploratory.

METHODS

Twelve participants who had experienced Swedish hospital care were interviewed between June 2022 and July 2023. The method of analysis was constructivist grounded theory, focusing on social processes. The COREQ checklist for qualitative research was followed.

RESULTS

Four categories were constructed: (1) defining the boundary between one's own capacity and that of the hospital, (2) acting to minimize the impact on one's safety, (3) finding oneself in the hands of healthcare professionals and (4) exploring the boundaries between normality and abnormality of the situation. This process was captured in the core category of navigating the path of least suffering. This illustrated how the participants constructed meaning about patient safety risks and showed that they prevented multiple adverse events.

CONCLUSIONS

Provided that participants were able to act independently, they avoided a multitude of adverse events. When they were dependent on healthcare professionals, their safety became more vulnerable. Failure to respond to the participants' concerns could lead to long-term suffering.

RELEVANCE TO CLINICAL PRACTICE

By responding immediately to patients' concerns about their safety, healthcare professionals can help prevent avoidable suffering and exhaustive searching for someone in the healthcare system who will take their needs seriously.

PATIENT CONTRIBUTION

A member check was performed with the help of one of the participants who read the findings to confirm familiarity.

Cultivating Inclusivity and Bridging Gaps Through Reverse Mentoring: A Feasibility Study Within the Royal College of Radiologists

AIM

The Royal College of Radiologists (RCR) recognizes the importance of addressing differential attainment, bridging existing disparities, and fostering diversity and equity.

MATERIALS AND METHODS

A joint-faculty reverse mentoring (RM) pilot launched from July 2023 to January 2024. Participation was voluntary, mentors (trainees) from ethnic minority backgrounds and mentees (RCR officers) were recruited across the UK. Mentoring pairs engaged in regular meetings focused on sharing lived experiences and informal discussions. Data were collected through prepilot and postpilot surveys, virtual question polls at induction meeting, and written reports. Data were analyzed using descriptive statistics and thematic analysis for quantitative and qualitative data, respectively.

RESULTS

Eight matched pairs met predominantly online, on average 4 times over 6 months. Discussions covered a wide range of topics exploring systemic biases and professional development. Expectations expressed were to learn from others' experiences and achieve personal and professional growth. The prepilot survey revealed that 50% of respondents had experienced or witnessed racial discrimination, with only 28.5% feeling capable of supporting colleagues facing challenges. By mid-pilot, meaningful connections were established, allowing mentors to share experiences, and foster safe spaces. The postpilot survey results indicated that 90% of respondents felt better equipped to support colleagues facing challenges related to protected characteristics. Key lessons included understanding cultural differences, resilience, and empowering participants to drive change.

CONCLUSIONS

The exchange of perspectives and experiences between individuals from diverse backgrounds and levels of expertise enhanced mutual understanding and inclusivity. This dynamic process has the potential to catalyze positive change across diverse domains, underlining its significance in shaping a more equitable postgraduate training landscape.

Fostering Psychological Safety and Supporting Mental Health Among Cardiovascular Health Care Workers: A Science Advisory From the American Heart Association

The psychological safety of health care workers is an important but often overlooked aspect of the rising rates of burnout and workforce shortages. In addition, mental health conditions are prevalent among health care workers, but the associated stigma is a significant barrier to accessing adequate care. More efforts are therefore needed to foster health care work environments that are safe and supportive of self-care. The purpose of this brief document is to promote a culture of psychological safety in health care organizations. We review ways in which organizations can create a psychologically safe workplace, the benefits of a psychologically safe workplace, and strategies to promote mental health and reduce suicide risk.

The effectiveness of checklists and error reporting systems in enhancing patient safety and reducing medical errors in hospital settings: A narrative review

Objectives

This narrative review aimed to explore the impact of checklists and error reporting systems on hospital patient safety and medical errors.

Methods

A systematic search of academic databases from 2013 to 2023 was conducted, and peer-reviewed studies meeting inclusion criteria were assessed for methodological rigor. The review highlights evidence supporting the efficacy of checklists in reducing medication errors, surgical complications, and other adverse events. Error reporting systems foster transparency, encouraging professionals to report incidents and identify systemic vulnerabilities.

Results

Checklists and error reporting systems are interconnected. Interprofessional collaboration is emphasized in checklist implementation. In this review, limitations arise due to the different methodologies used in the articles and potential publication bias. In addition, language restrictions may exclude valuable non-English research. While positive impacts are evident, success depends on organizational culture and resources.

Conclusions

This review contributes to patient safety knowledge by examining the relevant literature, emphasizing the importance of interventions, and calling for further research into their effectiveness across diverse healthcare and cultural settings. Understanding these dynamics is crucial for healthcare providers to optimize patient safety outcomes.

The Social Ecology of Burnout: A framework for research on nurse practitioner burnout

BACKGROUND

The U.S. health system is burdened by rising costs, workforce shortages, and unremitting burnout. Well-being interventions have emerged in response, yet data suggest that the work environment is the problem. Nurse practitioner (NP) burnout is associated with structural and relational factors in the work environment, practice autonomy, and hierarchical leadership.

PURPOSE

We explore the unique social, cultural, and political environment in which NPs work through the lens of social ecology and present the Social Ecology of Burnout (SEB) framework.

METHODS

We review current burnout frameworks in the context of the NP practice environment and discuss the SEB, specifically exploring psychological safety and its influence on burnout.

FINDINGS

Psychological safety, work environment, and policy are presented within the SEB and solutions which empower NPs are considered.

DISCUSSION

Our framework can serve as a guide for future nursing research, practice, and policy.

A Cycle of Reinforcing Challenges and Ideas for Action in Experiential Settings

Evidence suggests that both pharmacy students and preceptors are struggling in the experiential setting. Underlying this phenomenon is a potential interconnected and cyclic set of behaviors being reinforced between students and preceptors. These behaviors can contribute to or are the result of higher levels of burnout and a decrease in the development of student clinical skills and subsequent performance on rotation. In this review, the authors investigate various challenges commonly encountered in the experiential environment. These challenges can range from an observed decrease in student engagement, motivation, and critical thinking skills to an increase in preceptor burnout and culture shifts in the clinical practice environments. These factors all ultimately impact patient care and overall student performance. For each challenge identified, strategies will be presented that can be implemented by students, preceptors, and pharmacy programs to break the cyclic pattern identified.

The anatomy of safe surgical teams: an interview-based qualitative study among members of surgical teams at tertiary referral hospitals in Norway

BACKGROUND

In spite of the global implementation of surgical safety checklists to improve patient safety, patients undergoing surgical procedures remain vulnerable to a high risk of potentially preventable complications and adverse outcomes. The present study was designed to explore the surgical teams' perceptions of patient safety culture, capture their perceptions of the risk for adverse events, and identify themes of interest for quality improvement within the surgical department.

METHODS

This qualitative study had an explorative design with an abductive approach. Individual semi-structured in-depth interviews were conducted between 10/01/23 and 11/05/23. The participants were members of surgical teams (n = 17), general and orthopedic surgeons (n = 5), anesthesiologists (n = 4), nurse anesthetists (n = 4) and operating room nurses (n = 4). Middle managers recruited purposively from general and orthopedic surgical teams in two tertiary hospitals in Norway, aiming for a maximum variation due to gender, age, and years within the specialty. The data material was analyzed following Braun and Clarke's method for reflexive thematic analysis to generate patterns of meaning and develop themes and subthemes.

RESULTS

The analysis process resulted in three themes describing the participants' perceptions of patient safety culture in the surgical context: (1) individual accountability as a safety net, (2) psychological safety as a catalyst for well-being and safe performance in the operating room, and (3) the importance of proactive structures and participation in organizational learning.

CONCLUSIONS

This study provided an empirical insight into the culture of patient safety in the surgical context. The study highlighted the importance of supporting the individuals' competence, building psychological safety in the surgical team, and creating structures and culture promoting a learning organization. Quality improvement projects, including interventions based on these results, may increase patient safety culture and reduce the frequency of adverse events in the surgical context.

Identifying self-presentation components among nursing students with unsafe clinical practice: a qualitative study

BACKGROUND

Maintaining patient safety is a practical standard that is a priority in nursing education. One of the main roles of clinical instructors is to evaluate students and identify if students exhibit unsafe clinical practice early to support their remediation. This study was conducted to identify self-presentation components among nursing students with unsafe clinical practice.

METHODS

This qualitative study was conducted with 18 faculty members, nursing students, and supervisors of medical centers. Data collection was done through purposive sampling and semi-structured interviews. Data analysis was done using conventional qualitative content analysis using MAXQDA10 software.

RESULTS

One main category labelled self-presentation emerged from the data along with three subcategories of defensive/protective behaviors, assertive behaviors, and aggressive behaviors.

CONCLUSION

In various clinical situations, students use defensive, assertive, and aggressive tactics to maintain their professional identity and present a positive image of themselves when they make a mistake or predict that they will be evaluated on their performance. Therefore, it seems that the first vital step to preventing unsafe behaviors and reporting medical errors is to create appropriate structures for identification, learning, guidance, and evaluation based on progress and fostering a growth mindset among students and clinical educators.

Perspectives on developing moral courage in pre-licensure education: A qualitative study

BACKGROUND

Error reporting and speaking up are mechanisms to reduce the incidence of healthcare errors. However, organizational policies don't always align with individuals' perceptions and beliefs to promote these mechanisms. When this misalignment produces fear, moral courage, which is taking action regardless of personal consequences, becomes necessary. Teaching moral courage in pre-licensure education may set a foundation for individuals to speak up in post-licensure careers.

AIM

To explore health professionals' perceptions of healthcare reporting and organizational culture to inform pre-licensure education on how to promote moral courage.

METHODS

Thematic analysis of four semi-structured focus groups with fourteen health professions educators followed by in-depth, semi-structured individual interviews.

FINDINGS

Organizational factors, characteristics that an individual must possess to enact moral courage and priority methods to guide moral courage were identified.

CONCLUSIONS

This study outlines the need for leadership education in moral courage and offers educational interventions to promote reporting and aid in developing moral courage academic guidelines to improve healthcare error reporting and speaking up behaviors.