Patient safety in surgical settings: A study on the challenges and improvement strategies in adverse event reporting from a nursing perspective

AIMS

To explore adverse event reporting in the surgical department through the nurses' experiences and perspectives.

DESIGN

An exploratory, descriptive qualitative study was conducted with a theoretical-methodological orientation of phenomenology.

METHODS

In-depth interviews were conducted with 15 nurses, followed by an inductive thematic analysis.

RESULTS

Themes include motives for reporting incidents, consequences, feelings and motivational factors. Key facilitators of adverse event reporting were effective communication, knowledge sharing, a non-punitive culture and superior feedback.

CONCLUSION

The study underscores the importance of supportive organisational culture for reporting, communication and feedback mechanisms, and highlights education and training in enhancing patient safety.

IMPLICATIONS

It suggests the need for strategies that foster incident reporting, enhance patient safety and cultivate a supportive organisational culture.

IMPACT

This study provides critical insights into adverse event reporting in surgical departments from nurses' lived experience, leading to two primary impacts: It offers specific solutions to improve adverse event reporting, which is crucial for surgical departments to develop more effective and tailored reporting strategies. The research underscores the importance of an open, supportive culture in healthcare, which is vital for transparent communication and effective reporting, ultimately advancing patient safety.

REPORTING METHOD

The study followed the Standards for Reporting Qualitative Research and the Consolidated Criteria for Reporting Qualitative Research guidelines.

PATIENTS OR PUBLIC CONTRIBUTION

No patients or public contribution.

Patient and family engagement interventions for hospitalized patient safety: A scoping review

AIM

To summarize existing studies that focused on improving hospitalized patient safety through patient and family engagement interventions to identify priorities and gaps.

DESIGN

A scoping review.

METHODS

Eight databases and citations of important reviews were searched on 30 September 2022. Two researchers independently screened the records. Then, two researchers extracted the data and cross-checked. The results were synthesized narratively, and a comparison was performed for studies from China and those from other countries.

RESULTS

Ninety-eight studies were included. The results indicated that patient and family engagement interventions were applied to decrease the incidence of patient safety incidents, and to improve the healthcare providers' and patients' knowledge, attitude or practice of patient safety. Most studies only engaged patients and families at the direct care level, and the engagement strategies at the organization and health system levels were insufficient. For stakeholders, many studies failed to consider patients' perspectives in intervention design and report taking staff training as a supportive strategy. Healthcare providers, especially nurses, were the main implementers of current interventions. Certain differences were observed between studies from China and those from other countries in the above aspects.

CONCLUSIONS

International interest in engaging patient and family for patient safety is growing. Future studies should enhance the patient and family engagement as a partner in various patient safety at the direct care level, and further explore the engagement at the organization and health system levels.

RELEVANCE TO CLINICAL PRACTICE

Nurses, as the main formal caregivers for patients, should promote patient and family engagement in patient safety, especially at direct care level. Nurse should also incorporate the perspectives of patients in the design and implementation of interventions.

REPORTING METHOD

PRISMA-ScR Checklist.

Guidelines in Practice: A Safe Environment of Care

Creating a safe environment for performing surgical procedures is essential to achieve successful patient outcomes and protect the perioperative personnel who are providing care. Numerous factors challenge the provision of a safe environment of care and create a complex setting for perioperative nurses to manage. The updated AORN "Guideline for a safe environment of care" provides perioperative nurses with recommendations for establishing a safe environment for both patients and personnel. This article provides an overview of the guideline and discusses recommendations for implementing fire safety protocols, using warming cabinets, and creating a latex-safe environment. It also includes a scenario describing the care of a patient with an unidentified latex allergy who is undergoing a laparoscopic sleeve gastrectomy and hiatal hernia repair. Perioperative nurses should review the guideline in its entirety and implement recommendations as applicable in operative and other procedural settings.

Systematic review on the frequency and quality of reporting patient and public involvement in patient safety research

BACKGROUND

In recent years, patient and public involvement (PPI) in research has significantly increased; however, the reporting of PPI remains poor. The Guidance for Reporting Involvement of Patients and the Public (GRIPP2) was developed to enhance the quality and consistency of PPI reporting. The objective of this systematic review is to identify the frequency and quality of PPI reporting in patient safety (PS) research using the GRIPP2 checklist.

METHODS

Searches were performed in Ovid MEDLINE, EMBASE, PsycINFO, and CINAHL from 2018 to December, 2023. Studies on PPI in PS research were included. We included empirical qualitative, quantitative, mixed methods, and case studies. Only articles published in peer-reviewed journals in English were included. The quality of PPI reporting was assessed using the short form of the (GRIPP2-SF) checklist.

RESULTS

A total of 8561 studies were retrieved from database searches, updates, and reference checks, of which 82 met the eligibility criteria and were included in this review. Major PS topics were related to medication safety, general PS, and fall prevention. Patient representatives, advocates, patient advisory groups, patients, service users, and health consumers were the most involved. The main involvement across the studies was in commenting on or developing research materials. Only 6.1% (n = 5) of the studies reported PPI as per the GRIPP2 checklist. Regarding the quality of reporting following the GRIPP2-SF criteria, our findings show sub-optimal reporting mainly due to failures in: critically reflecting on PPI in the study; reporting the aim of PPI in the study; and reporting the extent to which PPI influenced the study overall.

CONCLUSIONS

Our review shows a low frequency of PPI reporting in PS research using the GRIPP2 checklist. Furthermore, it reveals a sub-optimal quality in PPI reporting following GRIPP2-SF items. Researchers, funders, publishers, and journals need to promote consistent and transparent PPI reporting following internationally developed reporting guidelines such as the GRIPP2. Evidence-based guidelines for reporting PPI should be encouraged and supported as it helps future researchers to plan and report PPI more effectively.

TRIAL REGISTRATION

The review protocol is registered with PROSPERO (CRD42023450715).

TeamSTEPPS improves patient safety

BACKGROUND

Examine how Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) can be used to manage patient safety and improve the standard of care for patients.

METHODS

In order to improve key medical training in areas like surgical safety management, blood transfusion closed-loop management, drug safety management and identity recognition, we apply the TeamSTEPPS teaching methodology. We then examine the effects of this implementation on changes in pertinent indicators.

RESULTS

Our hospital's perioperative death rate dropped to 0.019%, unscheduled reoperations dropped to 0.11%, and defined daily doses fell to 24.85. Antibiotic usage among hospitalised patients declined to 40.59%, while the percentage of antibacterial medicine prescriptions for outpatient patients decreased to 13.26%. Identity recognition requirements were implemented at a rate of 94.5%, and the low-risk group's death rate dropped to 0.01%. Critical transfusion episodes were less common, with an incidence of 0.01%. The physician's TeamSTEPPS Teamwork Perceptions Questionnaire and Teamwork Attitudes Questionnaire scores dramatically improved following the TeamSTEPPS team instruction course.

CONCLUSION

An evidence-based team collaboration training programme called TeamSTEPPS combines clinical practice with team collaboration skills to enhance team performance in the healthcare industry and raise standards for medical quality, safety, and effectiveness.

A qualitative study of the reasons for low patient safety incident reporting among Indonesian nurses

OBJECTIVES

to investigate the reasons for low patient safety incident reporting among Indonesian nurses.

METHODS

this qualitative case study was conducted among 15 clinical nurses selected purposively from a public hospital in Lampung, Indonesia. Interview guidelines were used for data collection through face-to-face in-depth interviews in July 2022. The thematic approach was used to analyze the data.

RESULTS

in this present study, seven themes emerged (1) Understanding incident reporting; (2) The culture; (3) Consequences of reporting; (4) Socialization and training; (5) Facilities; (6) Feedback; and (7) Rewards and punishments.

FINAL CONSIDERATIONS

these findings should be considered challenges for the patient safety committee and hospital management to increase patient safety incident reporting, particularly among nurses in the hospital.

Sound psychometric properties of a short new screening tool for patient safety climate: applying a Rasch model analysis

BACKGROUND

WHO recommends repeated measurement of patient safety climate in health care and to support monitoring an 11 item questionnaire on sustainable safety engagement (HSE) has been developed by the Swedish Association of Local Authorities and Regions. This study aimed to validate the psychometric properties of the HSE.

METHODS

Survey responses (n = 761) from a specialist care provider organization in Sweden was used to evaluate psychometric properties of the HSE 11-item questionnaire. A Rasch model analysis was applied in a stepwise process to evaluate evidence of validity and precision/reliability in relation to rating scale functioning, internal structure, response processes, and precision in estimates.

RESULTS

Rating scales met the criteria for monotonical advancement and fit. Local independence was demonstrated for all HSE items. The first latent variable explained 52.2% of the variance. The first ten items demonstrated good fit to the Rasch model and were included in the further analysis and calculation of an index measure based on the raw scores. Less than 5% of the respondents demonstrated low person goodness-of-fit. Person separation index > 2. The flooring effect was negligible and the ceiling effect 5.7%. No differential item functioning was shown regarding gender, time of employment, role within organization or employee net promotor scores. The correlation coefficient between the HSE mean value index and the Rasch-generated unidimensional measures of the HSE 10-item scale was r = .95 (p < .01).

CONCLUSIONS

This study shows that an eleven-item questionnaire can be used to measure a common dimension of staff perceptions on patient safety. The responses can be used to calculate an index that enables benchmarking and identification of at least three different levels of patient safety climate. This study explores a single point in time, but further studies may support the use of the instrument to follow development of the patient safety climate over time by repeated measurement.

The Volume and Cost of Quality Metric Reporting

Importance

US hospitals report data on many health care quality metrics to government and independent health care rating organizations, but the annual cost to acute care hospitals of measuring and reporting quality metric data, independent of resources spent on quality interventions, is not well known.

Objective

To evaluate externally reported inpatient quality metrics for adult patients and estimate the cost of data collection and reporting, independent of quality-improvement efforts.

Design, Setting, and Participants

Retrospective time-driven activity-based costing study at the Johns Hopkins Hospital (Baltimore, Maryland) with hospital personnel involved in quality metric reporting processes interviewed between January 1, 2019, and June 30, 2019, about quality reporting activities in the 2018 calendar year.

Main Outcomes and Measures

Outcomes included the number of metrics, annual person-hours per metric type, and annual personnel cost per metric type.

Results

A total of 162 unique metrics were identified, of which 96 (59.3%) were claims-based, 107 (66.0%) were outcome metrics, and 101 (62.3%) were related to patient safety. Preparing and reporting data for these metrics required an estimated 108 478 person-hours, with an estimated personnel cost of $5 038 218.28 (2022 USD) plus an additional $602 730.66 in vendor fees. Claims-based (96 metrics; $37 553.58 per metric per year) and chart-abstracted (26 metrics; $33 871.30 per metric per year) metrics used the most resources per metric, while electronic metrics consumed far less (4 metrics; $1901.58 per metric per year).

Conclusions and Relevance

Significant resources are expended exclusively for quality reporting, and some methods of quality assessment are far more expensive than others. Claims-based metrics were unexpectedly found to be the most resource intensive of all metric types. Policy makers should consider reducing the number of metrics and shifting to electronic metrics, when possible, to optimize resources spent in the overall pursuit of higher quality.

The Safety of Inpatient Health Care

BACKGROUND

Adverse events during hospitalization are a major cause of patient harm, as documented in the 1991 Harvard Medical Practice Study. Patient safety has changed substantially in the decades since that study was conducted, and a more current assessment of harm during hospitalization is warranted.

METHODS

We conducted a retrospective cohort study to assess the frequency, preventability, and severity of patient harm in a random sample of admissions from 11 Massachusetts hospitals during the 2018 calendar year. The occurrence of adverse events was assessed with the use of a trigger method (identification of information in a medical record that was previously shown to be associated with adverse events) and from review of medical records. Trained nurses reviewed records and identified admissions with possible adverse events that were then adjudicated by physicians, who confirmed the presence and characteristics of the adverse events.

RESULTS

In a random sample of 2809 admissions, we identified at least one adverse event in 23.6%. Among 978 adverse events, 222 (22.7%) were judged to be preventable and 316 (32.3%) had a severity level of serious (i.e., caused harm that resulted in substantial intervention or prolonged recovery) or higher. A preventable adverse event occurred in 191 (6.8%) of all admissions, and a preventable adverse event with a severity level of serious or higher occurred in 29 (1.0%). There were seven deaths, one of which was deemed to be preventable. Adverse drug events were the most common adverse events (accounting for 39.0% of all events), followed by surgical or other procedural events (30.4%), patient-care events (which were defined as events associated with nursing care, including falls and pressure ulcers) (15.0%), and health care-associated infections (11.9%).

CONCLUSIONS

Adverse events were identified in nearly one in four admissions, and approximately one fourth of the events were preventable. These findings underscore the importance of patient safety and the need for continuing improvement. (Funded by the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions.).

Exploratory Clustering for Emergency Department Patients

Emergency department (ED) overcrowding is an increasing global problem raising safety concerns for the patients. Elaborating an effective triage system that properly separates patients requiring hospital admission remains difficult. The objective of this study was to compare a clustering-related technique assignment of emergency department patients with the admission output using the k-means algorithm. Incorporating such a model into triage practice could theoretically shorten waiting times and reduce ED overcrowding.

Safety and effectiveness of up to 3 years' bulevirtide monotherapy in patients with HDV-related cirrhosis

The entry inhibitor bulevirtide (BLV) received conditional approval from the EMA in July 2020 for the treatment of adult patients with compensated chronic hepatitis delta. However, the effectiveness and safety of BLV administered as monotherapy beyond 48 weeks in difficult-to-treat patients with HDV-related cirrhosis is presently unknown. Herein, we describe the first patients with HDV-related compensated cirrhosis who were treated with BLV (10 mg/day as a starting dose) for up to 3 years on a compassionate use program. Patients were also monitored for HBcrAg and HBV RNA levels, and HDV- and HBV-specific T-cell markers. In the patient who stopped BLV at week 48, after achieving a virological and biochemical response, the initial virological and biochemical rebound was followed by alanine aminotransferase normalization coupled with low HDV RNA and HBsAg levels. In the 2 patients treated continuously for 3 years, virological and biochemical responses were maintained throughout the treatment period even after dose reduction. In a patient with advanced compensated cirrhosis, liver function tests significantly improved, esophageal varices disappeared, and histological/laboratory features of autoimmune hepatitis resolved. Overall, no safety issues were recorded, as bile salt increase was asymptomatic. While serum HBV RNA levels remained undetectable in all patients, HBV core-related antigen levels showed a progressive, yet modest decline during long-term BLV treatment. No HDV-specific interferon-γ-producing T cells were detected, neither after HDV reactivation (after BLV withdrawn in Patient 1) nor during 3 years of BLV treatment. In conclusion, this report shows that continuous administration of BLV monotherapy for 3 years leads to excellent virological and clinical responses in patients with HDV-related cirrhosis who had contraindications to interferon-based therapies.

Safety of Gastrointestinal Endoscopy in Korea: A Nationwide Survey and Population-Based Study

BACKGROUND

Attention should be paid to endoscopy-related complications and safety-related accidents that may occur in the endoscopy unit. This study investigated the current status of complications associated with diagnostic and therapeutic endoscopy in Korea.

METHODS

A questionnaire survey on endoscopy-related complications was conducted in a total of 50 tertiary or general hospitals in Korea. The results were compared to the population-level claims data from the Health Insurance Review &amp; Assessment Service (HIRA), which analyzed endoscopy procedures conducted in 2017 in Korea.

RESULTS

The incidences of bleeding associated with diagnostic and therapeutic esophagogastroduodenoscopy (EGD) and with diagnostic and therapeutic colonoscopy were 0.224% and 3.155% and 0.198% and 0.356%, respectively, in the 2017 HIRA claims data, compared to 0.012% and 1.857%, and 0.024% and 0.717%, in the 50 hospitals surveyed. The incidences of perforation associated with diagnostic and therapeutic EGD and with diagnostic and therapeutic colonoscopy were 0.023% and 0.613%, and 0.007% and 0.013%, respectively, in the 2017 HIRA claims data compared to 0.001% and 0.325%, and 0.017% and 0.206%, in the 50 hospitals surveyed. In the HIRA claims data, the incidence of bleeding/perforation after diagnostic colonoscopy in clinics, community hospitals, general hospitals, and tertiary hospitals was 0.129%/0.000%, 0.088%/0.004%, 0.262%/0.009%, and 0.479%/0.030% respectively, and the corresponding incidence of bleeding/perforation after therapeutic colonoscopy was 0.258%/0.004%, 0.401%/0.007%, 0.408%/0.024%, and 0.731%/0.055%.

CONCLUSION

The incidences of complications associated with diagnostic and therapeutic EGD or colonoscopy tended to increase with the hospital volume in Korea.

TRIAL REGISTRATION

Clinical Research Information Service Identifier: KCT0001728.

Cardiovascular safety of celecoxib in rheumatoid arthritis and osteoarthritis patients: A systematic review and meta-analysis

Objective

To assess the cardiovascular safety of celecoxib compared to non-selective non-steroid anti-inflammatory drugs or placebo.

Methods

We included randomized controlled trials of oral celecoxib compared with a non-selective NSAID or placebo in rheumatoid arthritis and osteoarthritis patients. We conducted searches in EMBASE, Cochrane CENTRAL, MEDLINE, China National Knowledge Infrastructure, VIP, Wanfang, and Chinese Biomedical Literature Database. Study selection and data extraction were done by two authors independently. The risk of bias was assessed using Cochrane’s risk-of-bias Tool for Randomized Trials. The effect size was presented as a risk ratio with their 95% confidence interval.

Results

Until July 22^nd, 2021, our search identified 6279 records from which, after exclusions, 21 trials were included in the meta-analysis. The overall pooled risk ratio for Antiplatelet Trialists Collaboration cardiovascular events for celecoxib compared with any non-selective non-steroid anti-inflammatory drugs was 0.89 (95% confidence interval: 0.80–1.00). The pooled risk ratio for all-cause mortality for celecoxib compared with non-selective non-steroid anti-inflammatory drugs was 0.81 (95% confidence interval: 0.66–0.98). The cardiovascular mortality rate of celecoxib was lower than non-selective non-steroid anti-inflammatory drugs (risk ratio: 0.75, 95% confidence interval: 0.57–0.99). There was no significant difference between celecoxib and non-selective non-steroid anti-inflammatory drugs or placebo in the risk of other cardiovascular events.

Conclusion

Celecoxib is relatively safe in rheumatoid arthritis and osteoarthritis patients, independent of dose or duration. But it remains uncertain whether this would remain the same in patients treated with aspirin and patients with established cardiovascular diseases.

Nurses and physicians attitudes towards factors related to hospitalized patient safety

INTRODUCTION

The attitudes of healthcare staff towards patients' safety, including awareness of the risk for adverse events, are significant elements of an organization's safety culture.

AIM OF RESEARCH

To evaluate nurses and physicians' attitudes towards factors influencing hospitalized patient safety.

MATERIALS AND METHODS

The research included 606 nurses and 527 physicians employed in surgical and medical wards in 21 Polish hospitals around the country. The Polish adaptation of the Safety Attitudes Questionnaire (SAQ) was used to evaluate the factors influencing attitudes towards patient safety.

RESULTS

Both nurses and physicians scored highest in stress recognition (SR) (71.6 and 80.86), while they evaluated working conditions (WC) the lowest (45.82 and 52,09). Nurses achieved statistically significantly lower scores compared to physicians in every aspect of the safety attitudes evaluation (p<0.05). The staff working in surgical wards obtained higher scores within stress recognition (SR) compared to the staff working in medical wards (78.12 vs. 73.72; p = 0.001). Overall, positive working conditions and effective teamwork can contribute to improving employees' attitudes towards patient safety.

CONCLUSIONS

The results help identify unit level vulnerabilities associated with staff attitudes toward patient safety. They underscore the importance of management strategies that account for staff coping with occupational stressors to improve patient safety.

Using a resident-led patient safety quality council to educate future QI leaders

Resident-led councils represent an important initiative to involve trainees in patient safety, but little is known about how to create and sustain one of these councils. We evaluated the impact of a resident-led patient safety council in an internal medicine residency program. We assessed change in resident perception of safety issues over 3 years, scholarship activities, and behavioral choices to participate or lead patient safety activities after residency.The Stony Brook Internal Medicine Residency Program formed the Patient Safety and Quality Council (PSQC) in 2014, consisting of fifteen peer-nominated residents serving a three-year term. Surveys were distributed annually from 2014 to 2017 to measure resident council members' perception of patient safety. The number of safety-related abstract/publications were tracked during and one year after graduation. Additionally, graduates from the council were surveyed to assess the influence of the council on post residency involvement and leadership in safety activities.A total of 18 residents have participated in the council from 2014 to 2017. Overall, resident perception of safety culture improved. A total of 17/18 (94%) PSQC resident members demonstrated scholarship activities in safety during residency: 8/18 (44%) were engaged in an independent Quality Improvement (QI) project, 5/18 (27%) achieved a quality improvement leadership role post residency. A total of 15 of 18 (83%) recent graduates suggest that involvement with the safety council during residency fostered future involvement in patient safety.Implementation of a resident-led safety council can help to improve the safety culture, generate scholarly activities, and encourage continued participation in patient safety after graduation.

Comparing the dangers of a stay in English and German hospitals for high-need patients

OBJECTIVE

To estimate the risk of an avoidable adverse event for high-need patients in England and Germany and the causal impact that has on outcomes.

DATA SOURCES

We use administrative, secondary data for all hospital inpatients in 2018. Patient records for the English National Health Service are provided by the Hospital Episode Statistics database and for the German health care system accessed through the Research Data Center of the Federal Statistical Office.

STUDY DESIGN

We calculated rates of three hospital-acquired adverse events and their causal impact on mortality and length of stay through propensity score matching and estimation of average treatment effects.

DATA COLLECTION/EXTRACTION METHODS

Patients were identified based on diagnoses codes and translated Patient Safety Indicators developed by the Agency for Healthcare Research and Quality.

PRINCIPAL FINDINGS

For the average hospital stay, the risk of an adverse event was 5.37% in the English National Health Service and 3.26% in the German health care system. High-need patients are more likely to experience an adverse event, driven by hospital-acquired infections (2.06%-4.45%), adverse drug reactions (2.37%-2.49%), and pressure ulcers (2.25%-0.45%). Adverse event risk is particularly high for patients with advancing illnesses (10.50%-27.11%) and the frail elderly (17.75%-28.19%). Compared to the counterfactual, high-need patients with an adverse event are more likely to die during their hospital stay and experience a longer length of stay.

CONCLUSIONS

High-need patients are particularly vulnerable with an adverse event risking further deterioration of health status and adding resource use. Our results indicate the need to assess the costs and benefits of a hospital stay, particularly when care could be provided in settings considered less hazardous.

Hospital work environments affect the patient safety climate: A longitudinal follow-up using a logistic regression analysis model

Background

Occupational worker wellness and safety climate are key determinants of healthcare organizations’ ability to reduce medical harm to patients while supporting their employees. We designed a longitudinal study to evaluate the association between work environment characteristics and the patient safety climate in hospital units.

Methods

Primary data were collected from Norwegian hospital staff from 970 clinical units in all 21 hospitals of the South-Eastern Norway Health Region using the validated Norwegian Work Environment Survey and the Norwegian version of the Safety Attitudes Questionnaire. Responses from 91,225 surveys were collected over a three year period. We calculated the factor mean score and a binary outcome to measure study outcomes. The relationship between the hospital unit characteristics and the observed changes in the safety climate was analyzed by linear and logistic regression models.

Results

A work environment conducive to safe incident reporting, innovation, and teamwork was found to be significant for positive changes in the safety climate. In addition, a work environment supportive of patient needs and staff commitment to their workplace was significant for maintaining a mature safety climate over time.

Conclusions

A supportive work environment is essential for patient safety. The characteristics of the hospital units were significantly associated with the unit’s safety climate scores, hence improvements in working conditions are needed for enhancing patient safety.

Safety and Efficacy of Flexible-Dose Deutetrabenazine in Children and Adolescents With Tourette Syndrome: A Randomized Clinical Trial

IMPORTANCE

Tourette syndrome is a neurodevelopmental disorder characterized by childhood onset of motor and phonic tics; treatments for tics are associated with safety concerns. Deutetrabenazine is a selective vesicular monoamine transporter 2 inhibitor approved for the treatment of chorea associated with Huntington disease and tardive dyskinesia in adults.

OBJECTIVE

To examine whether deutetrabenazine is effective and safe for the treatment of Tourette syndrome in children and adolescents.

DESIGN, SETTING, AND PARTICIPANTS

This phase 2/3, randomized, double-masked, placebo-controlled, parallel-group, dose-titration study included children and adolescents (aged 6-16 years) with Tourette syndrome with active tics causing distress or impairment (ie, Yale Global Tic Severity Scale-Total Tic Score [YGTSS-TTS] ≥20). The trial was conducted over 12 weeks, with 1 week of follow-up from February 2018 to November 2019 at 36 centers in the United States, Canada, Denmark, Russia, Serbia, and Spain. Data analysis was conducted from January 31 to April 22, 2020.

INTERVENTION

Patients were randomized (1:1) to receive deutetrabenazine or placebo, titrated during 7 weeks to an optimal level, followed by a 5-week maintenance period. The maximum total daily deutetrabenazine dose was 48 mg/d.

MAIN OUTCOMES AND MEASURES

The primary efficacy end point was change from baseline to week 12 in YGTSS-TTS. Key secondary end points included changes in Tourette Syndrome-Clinical Global Impression, Tourette Syndrome-Patient Global Impression of Impact, and Child and Adolescent Gilles de la Tourette Syndrome-Quality of Life Activities of Daily Living subscale score. Safety was assessed based on treatment-emergent adverse events, vital signs, questionnaires, and laboratory parameters.

RESULTS

A total of 119 participants were randomized to deutetrabenazine (59 participants; mean [SD] age, 11.5 [2.5] years; 53 [90%] boys; 49 [83%] White; 3 [5%] Black) and placebo (60 participants; mean [SD] age, 11.5 [2.6] years; 51 [85%] boys; 53 [88%] White; 3 [5%] Black). At week 12, the difference in YGTSS-TTS score was not significant between deutetrabenazine and placebo (least squares mean difference, -0.7; 95% CI, -4.1 to 2.8; P = .69; Cohen d, -0.07). There were no nominally significant differences between groups for key secondary end points. Treatment-emergent adverse events were reported for 38 patients (66%) and 33 patients (56%) receiving deutetrabenazine and placebo, respectively, and were generally mild or moderate.

CONCLUSIONS AND RELEVANCE

In this study of deutetrabenazine in children and adolescents with Tourette syndrome, the primary efficacy end point was not met. No new safety signals were identified. These results may be informative for future studies of treatments for tics in Tourette syndrome.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03452943.

Effect of electronic medication reconciliation at the time of hospital discharge on inappropriate medication use in the community: an interrupted time-series analysis

BACKGROUND

It is unclear if enhanced electronic medication reconciliation systems can reduce inappropriate medication use and improve patient care. We evaluated trends in potentially inappropriate medication use after hospital discharge before and after adoption of an electronic medication reconciliation system.

METHODS

We conducted an interrupted time-series analysis in 3 tertiary care hospitals in London, Ontario, using linked health care data (2011-2019). We included patients aged 66 years and older who were discharged from hospital. Starting between Apr. 13 and May 21, 2014, physicians were required to complete an electronic medication reconciliation module for each discharged patient. As a process outcome, we evaluated the proportion of patients who continued to receive a benzodiazepine, antipsychotic or gastric acid suppressant as an outpatient when these medications were first started during the hospital stay. The clinical outcome was a return to hospital within 90 days of discharge with a fall or fracture among patients who received a new benzodiazepine or antipsychotic during their hospital stay. We used segmented linear regression for the analysis.

RESULTS

We identified 15 932 patients with a total of 18 405 hospital discharge episodes. Before the implementation of the electronic medication reconciliation system, 16.3% of patients received a prescription for a benzodiazepine, antipsychotic or gastric acid suppressant after their hospital stay. After implementation, there was a significant and immediate 7.0% absolute decline in this proportion (95% confidence interval [CI] 4.5% to 9.5%). Before implementation, 4.1% of discharged patients who newly received a benzodiazepine or antipsychotic returned to hospital with a fracture or fall within 90 days. After implementation, there was a significant and immediate 2.3% absolute decline in this outcome (95% CI 0.3% to 4.3%).

INTERPRETATION

Implementation of an electronic medication reconciliation system in 3 tertiary care hospitals reduced potentially inappropriate medication use and associated adverse events when patients transitioned back to the community. Enhanced electronic medication reconciliation systems may allow other hospitals to improve patient safety.

Impact of the WHO Surgical Safety Checklist Relative to Its Design and Intended Use: A Systematic Review and Meta-Meta-Analysis

BACKGROUND

The aim of this study was to identify what parts of the World Health Organization Surgical Safety Checklist (WHO SSC) are working, what can be done to make it more effective, and to determine if it achieved its intended effect relative to its design and intended use.

STUDY DESIGN

We conducted a qualitative thematic analysis and meta-meta-analyses of findings in WHO SSC systematic reviews following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

RESULTS

Twenty systematic reviews were included for qualitative thematic analysis. Narrative information was coded in 4 primary areas with a focus on impact of the WHO SSC. Four themes-Clinical Outcomes, Process Measures, Team Dynamics and Communication, and Safety Culture-pertained directly to the aims or purposes behind the development of the SSC. The other 2 themes-Efficiency and Workload involved in using the checklist and Checklist Impact on Institutional Practices-are associated with SSC use, but were not focal areas considered during its development. Included in the 20 systematic reviews were 24 unique observational cohort studies that reported pre-post data on a total of 18 clinical outcomes. Mortality, morbidity, surgical site infection, pneumonia, unplanned return to the operating room, urinary tract infection, blood loss requiring transfusion, unplanned intubation, and sepsis favored the use of the WHO SSC. Deep vein thrombosis was the only postoperative outcome assessed that did not favor use of the WHO SSC.

CONCLUSIONS

The WHO SSC positively impacts the things it was explicitly designed to address and does not positively impact things it was not explicitly designed for.

Evaluation of efficacy and safety of propofol in the treatment of procedural sedation/anesthesia in neonates: A protocol for systematic review and meta-analysis

BACKGROUND

In newborns, propofol anesthesia is commonly utilized. Propofol is increasingly being shown to be effective and safe in treating procedural sedation and anesthesia in neonates. This research aims to evaluate the efficacy and safety of propofol in neonates using systematic review and meta-analysis methodologies.

METHODS

A thorough review and meta-analysis of studies on propofol anesthesia in neonates will be conducted. Conduct comprehensive searches in Web of Science, PubMed, Cochrane Library, EMBASE database, WanFang database, and Chinese biomedical literature database before May 25, 2021, to obtain published and qualified research. Two reviewers will assess the quality of the included papers and extract the data independently. Then, for meta-analysis, we will utilize RevMan 5.3 software.

RESULTS

This study will pool the data of separate trials to analyze the efficacy and safety of propofol in the treatment of procedural sedation/anesthesia in neonates.

CONCLUSION

Our findings will give strong data for determining whether propofol is an effective treatment for procedural anesthesia in neonates.

A Dynamic Risk Management Approach for Reducing Harm From Invasive Bedside Procedures Performed During Residency

Internal medicine (IM) residents frequently perform invasive bedside procedures during residency training. Bedside procedure training in IM programs may compromise patient safety. Current evidence suggests that IM training programs rely heavily on the number of procedures completed during training as a proxy for resident competence instead of using objective postprocedure patient outcomes. The authors posit that the results of procedural training effectiveness should be reframed with outcome metrics rather than process measures alone. This article introduces the as low as reasonably achievable (ALARA) approach, which originated in the nuclear industry to increase safety margins, to help assess and reduce bedside procedural risks. Training program directors are encouraged to use ALARA calculations to define the risk trade-offs inherent in current procedural training and assess how best to reliably improve patient outcomes. The authors describe 5 options to consider: training all residents in bedside procedures, training only select residents in bedside procedures, training no residents in bedside procedures, deploying 24-hour procedure teams supervised by IM faculty, and deploying 24-hour procedure teams supervised by non-IM faculty. The authors explore how quality improvement approaches using process maps, fishbone diagrams, failure mode effects and analyses, and risk matrices can be effectively implemented to assess training resources, choices, and aims. Future research should address the drivers behind developing optimal training programs that support independent practice, correlations with patient outcomes, and methods that enable faculty to justify their supervisory decisions while adhering to ALARA risk management standards.

Colchicine efficacy and safety for the treatment of cardiovascular diseases

The emerging role of colchicine in the treatment of cardiovascular diseases is a strong demand for a comprehensive understanding of its efficacy and safety. This meta-analysis and systematic review aimed to study the efficacy in the reduction of adverse cardiovascular outcomes (CO), and the risk of colchicine-related adverse events (CRAEs). Fourteen thousand and nine eighty three patients from 22 randomized controlled trials (RCTs) were included, 9 in patients with coronary artery disease-CAD, 9 in patients with pericarditis, 4 in patients with atrial fibrillation-AF or heart failure. Colchicine was efficacious in the reduction of adverse CO across different settings: pericardial diseases (reduced risk of recurrent pericarditis, 17.6% vs. 35%, RR 0.50, 95% CI 0.41-0.61), CAD (reduced risk of cardiac death, myocardial infarction, stroke,coronary revascularization or hospitalization, 6.1% vs. 8.5%, RR 0.73, 95% CI 0.64-0.83), AF (reduced risk of arrhythmia recurrence, 14.2% vs. 22.7%, RR 0.62, 95% CI 0.44-0.88). Colchicine was associated with increased risk of gastrointestinal CRAEs (11.2% vs. 8.8%, RR 1.87, 95% CI 1.41-2.47) and drug discontinuation (5.4% vs. 3.7%, RR 1.58, 95% CI 1.25-1.99). In both cases, the risk was proportional to the daily dose or duration of treatment, possibly due to early drug discontinuation or tolerance. Other CRAEs (muscle-related, liver,hematologic,cutaneous, infections) were not increased by colchicine, as long as all-cause death (2.2% vs. 1.9%, RR 1.11, 95% CI 0.79-1.54) or non-cardiovascular death (1.5% vs. 1%, RR 1.43, 95% CI 0.93-2.19). Colchicine is efficacious and safe for the treatment of cardiovascular diseases. The risk of gastrointestinal CRAEs and drug discontinuation is not significant if colchicine is used at lower doses (0.5 mg daily) or for longer periods of time (> 6 months).

Crisis Containment: Tools for Harm Mitigation in Surgery

BACKGROUND

Surgical crises represent unrecognized opportunities for improving patient safety and adding value in healthcare. The first step in a crisis response is to contain and mitigate harm. While the principles of damage control are well established in surgery, methods of containing harm on broader clinical and organizational levels are not clearly defined.

STUDY DESIGN

A multimethods qualitative study identified crisis containment strategies and tools in commercial aviation. These were translated and clinically adapted in 3 stages: semi-structured observational fieldwork with commercial airlines, interviews with senior pilots, and focus groups with both healthcare and aviation safety experts. Thematic analysis and expert consensus methods were used to derive a framework for crisis containment.

RESULTS

Fieldwork with 2 commercial airlines identified 2 crisis containment concepts: the detrimental impact of surprising or startling events on operator performance; and the use of prioritization tools to take basic but critical actions (Aviate, Navigate and Communicate model). Twenty-two experts in aviation and healthcare practice informed the topic of crisis containment in 17 interviews and 3 focus groups. Three strategies were identified and used to form a crisis containment algorithm: 1. Manage the operators' startle response to facilitate meaningful mitigating actions (STOP tool); 2. Take priority actions to secure core functions. These included managing patients' physiologic shock, optimizing environmental risks, and mobilizing resources (Perfuse, Move and Communicate tool); 3. Deploy well-rehearsed drills targeting case-specific harms or errors (Memory Actions). This model requires validation in clinical practice.

CONCLUSIONS

Crisis containment can be achieved by controlling operators' startle response, applying prioritization tools, and deploying drills against specific failures. The application of this model may extend to healthcare areas outside surgery.

The pace of hospital life: A mixed methods study

The pace-of-life hypothesis is a socio-psychological theory postulating that citizens of different cities transact the business of life at varying paces, and this pace is associated with a number of population level variables. Here we apply the pace-of-life hypothesis to a hospital context to empirically test the association between pace and patient and staff outcomes. As pressure on hospitals grow and pace increases to keep up with demand, is there empirical evidence of a trade-off between a rapid pace and poorer outcomes? We collected data from four large Australian hospitals, inviting all staff (clinical and non-clinical) to complete a survey, and conducted a series of observations of hospital staff's walking pace and transactional pace. From these data we constructed three measures of pace: staff perception of pace, transactional pace, and walking pace. Outcome measures included: hospital culture, perceived patient safety, and staff well-being outcomes of job satisfaction and burnout. Overall, participants reported experiencing a "fast-paced" "hurried" and "rapid" pace-of-life working in the Australian hospital sector. We found a significant difference in perceived pace across four hospital sites, similar to trends observed for transactional pace. This provides support that the pace-of-life hypothesis may apply to the hospital context. We tested associations between faster perceived pace, hospital culture, staff well-being and patient safety. Results revealed perceived faster pace significantly predicted negative perceptions of organizational culture, greater burnout and lower job satisfaction. However, perceived pace did not predict perceptions of patient safety. Different perceptions of hospital pace-of-life were found between different clinical settings and the type of care delivered; staff working in emergency departments reported significantly "faster-paced" work environments than staff working in palliative, aged care, or rehabilitation wards.

Implementation of Complex Interventions: Lessons Learned From the Patient-Centered Outcomes Research Institute Transitional Care Portfolio

BACKGROUND

Despite the well-documented risks to patient safety associated with transitions from one care setting to another, health care organizations struggle to identify which interventions to implement. Multiple strategies are often needed, and studying the effectiveness of these complex interventions is challenging.

OBJECTIVE

The objective of this study was to present lessons learned in implementing and evaluating complex transitional care interventions in routine clinical care.

RESEARCH DESIGN

Nine transitional care study teams share important common lessons in designing complex interventions with stakeholder engagement, implementation, and evaluation under pragmatic conditions (ie, using only existing resources), and disseminating findings in outlets that reach policy makers and the people who could ultimately benefit from the research.

RESULTS

Lessons learned serve as a guide for future studies in 3 areas: (1) Delineating the function (intended purpose) versus form (prespecified modes of delivery of the intervention); (2) Evaluating both the processes supporting implementation and the impact of adaptations; and (3) Engaging stakeholders in the design and delivery of the intervention and dissemination of study results.

CONCLUSION

These lessons can help guide future pragmatic studies of care transitions.

A survey of surgical team members' awareness and perceptions toward the implementation of the surgical safety checklist in gynecological and obstetrical operations

The World Health Organization Surgical Safety Checklist was developed to improve communication in perioperative care, reduce mortality and complications of patients, and ensure the consistent use of procedures for safe surgery. Despite the increased awareness of the checklist, the implementation compliance is reported as low and the degree of completeness varies. This study aimed to explore the possible supportive factors for the effective implementation and to identify potential awareness and barriers to its implementation in gynecological and obstetrical operation.A survey using a cross-sectional design that included surgeons, anesthetists, and operating room nurses was performed. We used an online link to distribute the survey to all eligible surgical team members in our hospital. The survey contained various aspects of perceptions on the Surgical Safety Checklist and an open-ended question that allowed respondents to offer their opinions on the topic.The overall self-reported awareness of the checklist within each professional group was high. The awareness of surgeons was lower than that of operating room nurses, particularly in the Time-out section. Most participants believed that operating room nurses ranked the highest compliance to the protocols, while surgeons stayed the lowest. Active leadership with experienced operating room nurses, good training for surgical team members, and simplification of the checklist would be the positive factors for the effective implementation.Although there is a high acceptance and adequate self-reported awareness of the Surgical Safety Checklist, it is not always possible to implement it successfully. Our findings suggest that with experienced and effective leadership, barriers to implementation can be overcome. With positive perception and commitment, the Surgical Safety Checklist is easy to implement and it can make a profound improvement on the safety of surgical care. Moreover, a strategy of repetitive training and assessment on the part of the involved health care professionals may be necessary to further improve patients' safety during surgery.

Patient safety management systems and activities related to promoting voluntary in-hospital reporting and mandatory national-level reporting for patient safety issues: A cross-sectional study

Both voluntary in-hospital reporting and mandatory national-level reporting systems for patient safety issues need to work well to develop a patient safety learning system that is effective in preventing the recurrence of adverse events. Some of the hospital systems and activities may increase voluntary in-hospital reporting and mandatory national-level reporting. This study aimed to identify the hospital systems and activities that increase voluntary in-hospital reporting and mandatory national-level reporting for patient safety issues. An anonymous mail survey of hospitals in Japan was conducted in 2017. The hospitals were selected by stratified random sampling according to number of beds. The survey examined the annual number of reported events in the voluntary in-hospital reporting system for patient safety and experience of reporting unexpected patient deaths possibly due to medical interventions to the mandatory national-level reporting system in the last 2 years. The relationship of the answer to the questions with the patient safety management systems and activities at each hospital was analyzed. The response rate was 18.8% (603/3,215). The number of in-hospital reports per bed was positively related to identifying events by referring complaints or questions of patients or family members, using root cause analysis for analyzing reported events, and developing manuals or case studies based on reported events, and negatively related to the unification and standardization of medical devices and equipment. The experience with mandatory national-level reporting of serious adverse events was positively related to identifying problematic cases by a person in charge of patient safety management from the in-hospital reporting system of complications and accidental symptoms. Enhanced feedback for reporters may promote voluntary in-hospital reporting of minor cases with low litigation risks. Developing an in-hospital mechanism that examines all serious complications and accidental symptoms may promote mandatory national-level reporting of serious adverse events with high litigation risks.

COVID-19: Perspectives From Frontline Critical Care Nurses in New York

New York City quickly became the epicenter of coronavirus disease-2019 (COVID-19) in early March of 2020. While hospitals were aware of the potential of COVID-19, the volume of critically ill patients that flooded the hospitals in the New York City area was clearly not anticipated. Hospital staff worked quickly to create COVID-19-free areas, but were overcome with the volume of COVID-positive critically ill patients. Many newly admitted patients required respiratory support with mechanical ventilation. As Governor Cuomo issued executive orders to stay at home in mid-March, some patients were afraid to go into hospitals despite symptoms of respiratory distress. Once these patients came to the hospital, they were often critically ill. Emergency departments and intensive care units filled rapidly, overwhelming staff and equipment needs with such things as pumps, dialysis machines, medications, and personal protective equipment. Plans for the day were disrupted with frequent rapid response calls and the need for additional beds. Key issues that confronted the COVID-19 response in critical care units at NYU Langone Health included communication, patient and staff safety.

The RCA ReCAst: A Root Cause Analysis Simulation for the Interprofessional Clinical Learning Environment

PROBLEM

The Accreditation Council for Graduate Medical Education calls for resident participation in real or simulated interprofessional analysis of a patient safety event. There are far more residents who must participate in these investigations than available institutional root cause analyses (RCAs) to accommodate them. To correct this imbalance, the authors developed an institutionally sponsored, interprofessional RCA simulation program and implemented it across all graduate medical education (GME) residency programs at the Hospital of the University of Pennsylvania.

APPROACH

The authors developed RCA simulations based upon authentic adverse events experienced at their institution. To provide relevance to all GME programs, RCA simulation cases varied widely and included examples of errors involving high-risk medications, communication, invasive procedures, and specimen labeling. Each simulation included residents and other health care professionals such as nurses or pharmacists whose disciplines were involved in the actual event. Participants adopted the role of RCA investigation team, and in small groups systematically progressed through the RCA process.

OUTCOMES

A total of 289 individuals from 18 residency programs participated in an RCA simulation in 2019-2020. This included 84 interns (29%), 123 residents (43%), 20 attending physicians (7%), and 62 (21%) other health care professionals. There was an increase in ability of GME trainees to correctly identify factors required for an RCA investigation (62% pre vs 80% post, P = .02) and an increase in intent to "always report" for each adverse event category (3% pre vs 37% post, P < .001) following the simulation.

NEXT STEPS

The authors plan to expand the RCA simulation program to other GME clinical sites while striving to involve all GME learners in this educational experience at least once during training. Additionally, by collaborating with health system patient safety leaders, they will annually review all new RCAs to identify cases suitable for simulation adaptation.

A Computer Vision Platform to Automatically Locate Critical Events in Surgical Videos: Documenting Safety in Laparoscopic Cholecystectomy

OBJECTIVE

The aim of this study was to develop a computer vision platform to automatically locate critical events in surgical videos and provide short video clips documenting the critical view of safety (CVS) in laparoscopic cholecystectomy (LC).

BACKGROUND

Intraoperative events are typically documented through operator-dictated reports that do not always translate the operative reality. Surgical videos provide complete information on surgical procedures, but the burden associated with storing and manually analyzing full-length videos has so far limited their effective use.

METHODS

A computer vision platform named EndoDigest was developed and used to analyze LC videos. The mean absolute error (MAE) of the platform in automatically locating the manually annotated time of the cystic duct division in full-length videos was assessed. The relevance of the automatically extracted short video clips was evaluated by calculating the percentage of video clips in which the CVS was assessable by surgeons.

RESULTS

A total of 155 LC videos were analyzed: 55 of these videos were used to develop EndoDigest, whereas the remaining 100 were used to test it. The time of the cystic duct division was automatically located with a MAE of 62.8 ± 130.4 seconds (1.95% of full-length video duration). CVS was assessable in 91% of the 2.5 minutes long video clips automatically extracted from the considered test procedures.

CONCLUSIONS

Deep learning models for workflow analysis can be used to reliably locate critical events in surgical videos and document CVS in LC. Further studies are needed to assess the clinical impact of surgical data science solutions for safer laparoscopic cholecystectomy.

Perioperative patient safety management activities: A modified theory of planned behavior

Patient safety is an important healthcare issue worldwide, and patient accidents in the operating room can lead to serious problems. Accordingly, we investigated the explanatory ability of a modified theory of planned behavior to improve patient safety activities in the operating room. Questionnaires were distributed to perioperative nurses working in 12 large hospitals in Korea. The modified theory of planned behavior data from a total of 330 nurses were analyzed. The conceptual model was based on the theory of planned behavior data, with two additional organizational factors—job factors and safety management system. Individual factors included attitude, subjective norms, perceived behavioral control, behavioral intention, and patient safety management activities. Results indicated that job factors were negatively associated with perceived behavioral control. The patient safety management system was positively associated with attitude, subjective norm, and perceived behavioral control. Attitude, subjective norm, and perceived behavioral control were positively associated with behavioral intention. Behavioral intention was positively associated with patient safety management activities. The modified theory of planned behavior effectively explained patient safety management activities in the operating room. Both organizations and individuals are required to improve patient safety management activities.

Focusing on long-term complications of mid-urethral slings among women with stress urinary incontinence as a patient safety improvement measure: A protocol for systematic review and meta-analysis

BACKGROUND

There are 3 different types of mid-urethral sling, retropubic, transobturator and single incision performed for women with stress urinary incontinence. Prior studies comparing these three surgeries merely focused on the successful rate or efficacy. But nevertheless, what is more clinically important dwells upon investigating postoperative complications as a safety improvement measure.

METHODS

A systematic review via PubMed, Ovid, and the Cochrane Database of Systematic Review and studies were applied based on the contents with clearly identified complications. Selected articles were reviewed in scrutiny by 2 individuals to ascertain whether they fulfilled the inclusion criteria: complications measures were clearly defined; data were extracted on study design, perioperative complications, postoperative lower urinary tract symptoms, postoperative pain, dyspareunia, and other specified late complications.

RESULTS

A total of 55 studies were included in the systemic review. Perioperative complications encompassed bladder perforation, vaginal injury, hemorrhage, hematoma, urinary tract infection. There were postoperative lower urinary tract symptoms including urine retention and de novo urgency. Furthermore, postoperative pain, tape erosion/ extrusion, further stress urinary incontinence surgery, and rarely, deep vein thrombosis and injury of inferior epigastric vessels were also reported.

CONCLUSIONS

Complications of mid-urethral sling are higher than previously thought and it is important to follow up on their long-term outcomes; future research should not neglect to address this issue as a means to improve patient safety.

Efficacy and safety of acupuncture combined with analgesics on lung cancer pain: A protocol for systematic review and meta-analysis

BACKGROUND

Lung cancer (LC) is the malignant tumor with the highest incidence in the world, and treatment methods include surgery, radiotherapy, chemotherapy, and immunotherapy. Cancer pain is a common symptom in patients with LC, and the clinical treatment is to relieve it with analgesics. Acupuncture can relieve cancer pain. This study aims to systematically study the efficacy and safety of acupuncture combined with analgesics on cancer pain in patients with LC.

METHODS

From the beginning to April 2021, search Medline, Embase, Cochrane Central Controlled Trials Register (Central), China National Knowledge Infrastructure (CNKI), Wanfang Database, China Biomedical Literature Database (CBM), and Chinese Science Journal Database (VIP database). Search the international clinical trial registration platform and the Chinese clinical trial registration platform to find ongoing or unpublished trials. The main outcome indicator is the total effective rate of analgesia, and the secondary outcome indicator is pain intensity score and adverse reactions. The RevMan 5.4 software will be used for statistical analysis.

RESULTS

This study will provide the latest evidence for acupuncture combined with analgesics to relieve LC pain.

CONCLUSION

The conclusion of this study is to evaluate the effectiveness and safety of acupuncture combined with analgesics in alleviating LC pain.

INPLASY REGISTRATION NUMBER

INPLASY202150051.

Bronchoscopy Teaching Without a Gold Standard: Attending Pulmonologists' Assessment of Learners, Supervisory Styles, and Variation in Practice

BACKGROUND

Despite the growing role of simulation in procedural teaching, bronchoscopy training largely is experiential and occurs during patient care. The Accreditation Council for Graduate Medical Education sets a target of 100 bronchoscopies to be performed during pulmonary fellowship. Attending physicians must balance fellow autonomy with patient safety during these clinical teaching experiences. Few data on best practices for bronchoscopy teaching exist, and a better understanding of how bronchoscopy currently is supervised could allow for improvement in bronchoscopy teaching.

RESEARCH QUESTION

How do attending bronchoscopists supervise bronchoscopy, and in particular, how do attendings balance fellow autonomy with patient safety?

STUDY DESIGN AND METHODS

This was a focused ethnography conducted at a single center using audio recording of dialog between attendings and fellows during bronchoscopies, supplemented by observation of nonverbal teaching. Interviews with attending bronchoscopists and limited interviews of fellows also were recorded. Interviews were transcribed verbatim before analysis. We used constant comparative analysis to analyze data and qualitative research software to support data organization and thematic analysis. Education researchers from outside of pulmonary critical care joined the team to minimize bias.

RESULTS

We observed seven attending bronchoscopists supervising eight bronchoscopies. We noted distinct teaching behaviors, classified into themes, which then were grouped into four supervisory styles of modelling, coaching, scaffolding, and fading. Observation and interviews illuminated that assessing fellow skill was one tool used to choose a style, and attendings moved between styles. Attendings accepted some, but not all, variation in both performing and supervising bronchoscopy.

INTERPRETATION

Attending pulmonologists used a range of teaching microskills as they moved between different supervisory styles and selectively accepted variation in practice. These distinct approaches may create well-rounded bronchoscopists by the end of fellowship training and should be studied further.