Improving patient safety governance and systems through learning from successes and failures: qualitative surveys and interviews with international experts.

Patient harm is a leading cause of global disease burden with considerable morbidity, mortality, and economic impacts for individuals, families, and wider society. Large bodies of evidence exist for strategies to improve safety and reduce harm. However, it is not clear which patient safety issues are being addressed globally, and which factors are the most (or least) important contributors to patient safety improvements. We aimed to explore the perspectives of international patient safety experts to identify: (1) the nature and range of patient safety issues being addressed, and (2) aspects of patient safety governance and systems that are perceived to provide value (or not) in improving patient outcomes. English-speaking Fellows and Experts of the International Society for Quality in Healthcare participated in a web-based survey and in-depth semistructured interview, discussing their experience in implementing interventions to improve patient safety. Data collection focused on understanding the elements of patient safety governance that influence outcomes. Demographic survey data were analysed descriptively. Qualitative data were coded, analysed thematically (inductive approach), and mapped deductively to the System-Theoretic Accident Model and Processes framework. Findings are presented as themes and a patient safety governance model. The study was approved by the University of South Australia Human Research Ethics Committee. Twenty-seven experts (59% female) participated. Most hailed from Africa (n = 6, 22%), Australasia, and the Middle East (n = 5, 19% each). The majority were employed in hospital settings (n = 23, 85%), and reported blended experience across healthcare improvement (89%), accreditation (76%), organizational operations (64%), and policy (60%). The number and range of patient safety issues within our sample varied widely with 14 topics being addressed. Thematically, 532 textual segments were grouped into 90 codes (n = 44 barriers, n = 46 facilitators) and used to identify and arrange key patient safety governance actors and factors as a 'system' within the System-Theoretic Accident Model and Processes framework. Four themes for improved patient safety governance were identified: (1) 'safety culture' in healthcare organizations, (2) 'policies and procedures' to investigate, implement, and demonstrate impact from patient safety initiatives, (3) 'supporting staff' to upskill and share learnings, and (4) 'patient engagement, experiences, and expectations'. For sustainable patient safety governance, experts highlighted the importance of safety culture in healthcare organizations, national patient safety policies and regulatory standards, continuing education for staff, and meaningful patient engagement approaches. Our proposed 'patient safety governance model' provides policymakers and researchers with a framework to develop data-driven patient safety policy.

Potentially avoidable mortality after endoscopic retrograde cholangiopancreatography in Australia: an 8-year qualitative analysis.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure worldwide. The aim of this study was to examine cases of mortality after ERCP to identify clinical incidents that are potentially preventable, to improve patient safety. METHODS: The Australian and New Zealand Audit of Surgical Mortality provides an independent and externally peer-reviewed audit of surgical mortality pertaining to potentially avoidable issues. A retrospective review of prospectively collected data within this database was performed for the 8-year audit period from 1 January 2009 to 31 December 2016. Clinical incidents were identified by assessors through first- or second-line review, and thematically coded into periprocedural stages. These themes were then qualitatively analysed. RESULTS: There were 58 potentially avoidable deaths following ERCP, with 85 clinical incidents. Preprocedural incidents were most common (n = 37), followed by postprocedural (n = 32) and then intraprocedural (n = 8). Communication issues occurred across the periprocedural period (n = 8). Preprocedural incidents included delay to procedure, inadequate resuscitative management, decision to perform procedure and inadequate assessment. Intraprocedural incidents comprised technical factors and inadequate support. Postprocedural incidents involved inappropriate treatment, delay in definitive surgical treatment or in recognizing complications, inappropriate second-line intervention and inadequate assessment. Communication incidents comprised inadequate documentation, failure to escalate care and poor inter-clinician communication. CONCLUSION: Causes of mortality following ERCP are wide-ranging, and reviewing clinical incidents associated with potentially avoidable mortality can serve to inform and educate practitioners. In collating a subset of cases in which procedure-related mortality was deemed avoidable, a series of cautionary tales about ERCP is presented that may provide cues to practitioners on improving patient safety and inform future surgical practice.

Necrotising fasciitis deaths in Australia: patient characteristics and potential areas for improvement in clinical management.

BACKGROUND: Necrotising fasciitis (NF) is a life-threatening bacterial infection with high mortality. This retrospective study aimed to investigate patient characteristics and potential areas for improvement in clinical management in NF cases in Australia. METHODS: Retrospective analysis of surgical death data from all public and private Australian hospitals in every state and territory, excluding New South Wales, collected through the Australian and New Zealand Audit of Surgical Mortality for the 9-year period, January 2009 to February 2018. RESULTS: A total of 290 NF cases were identified. Among these NF cases, obesity and diabetes mellitus were two of the most common comorbidities, with a prevalence of 26% and 41%, respectively. A total of 41 clinical management issues (CMIs) were identified among 36 NF cases. A larger proportion of NF cases had CMIs compared with non-NF surgical mortality cases. Delay in diagnosis was the leading CMI (n = 28, 68.3%), followed by delay to surgery (n = 7, 17.1%). The majority of delayed diagnoses were attributed to non-surgical clinicians in the hospital. CONCLUSION: CMIs were identified in a larger proportion of NF cases than in other non-NF surgical mortality cases, suggesting that there are areas for improvement in NF diagnosis and management in Australia. The leading potentially avoidable issue identified in NF deaths was delay in diagnosis. This highlights the importance of awareness among non-surgical clinicians that NF is a surgical emergency requiring urgent debridement.

Potentially avoidable issues in urology mortality cases in Australia: identification and improvements.

BACKGROUND: This study aimed to identify the most common potentially avoidable factors in urology deaths, focusing on the lessons that can be learnt. METHODS: This study analysed data from a well-established and comprehensive peer review audit of surgical deaths in Australian hospitals (excluding New South Wales) from 2009 to 2015, focusing on urology cases with identified areas for improvement in patient management. Of all audited deaths, 11% (79/719) had serious clinical management issues with a total of 109 individual clinical management issues identified. These were categorized based on perioperative stage (preoperative, intraoperative or post-operative), followed by thematic analysis within each stage. RESULTS: The study found preoperative issues to be the most common (n = 48), followed by post-operative issues (n = 32) with intraoperative issues less common (n = 13). Communication issues were seen at all three stages (n = 16). Overall, the most common theme was at the preoperative stage; inadequate preoperative assessment (n = 27). More specifically, the most common preoperative assessment issues involved a failure to order necessary preoperative investigations, or to administer necessary preoperative treatment (e.g. prophylactic antibiotics). The most common communication issue was between teams and at handover, often involving failure by junior medical staff to communicate issues to the responsible surgical consultant. CONCLUSION: Urological surgical cases with potentially avoidable mortality constitute a small, but important subset of deaths. The analysis of these cases can inform various stakeholders to improve the quality and safety of urological surgical care.

Mortality in Australian Cardiothoracic Surgery: Findings From a National Audit.

BACKGROUND: Independent peer review of mortality cases has potential to identify issues in cardiothoracic surgical patients. The Australian and New Zealand Audit of Surgical Mortality aims to improve surgical care through peer-reviewed assessment of all surgical mortality. The aim of this study was to describe common clinical management issues that contribute to patient mortality in a cohort of Australian cardiothoracic surgical patients. This approach may subsequently provide a basis for quality improvement. METHODS: Cardiothoracic mortality reports to the Australian and New Zealand Audit of Surgical Mortality from February 2009 through December 2015 were reviewed. The surgeon report and assessor comments were coded to identify clinical management issues. These were divided into perioperative stages (preoperative, intraoperative, and postoperative), and at each stage a thematic analysis was performed. RESULTS: Of the 908 cases analyzed, 1371 clinical management issues were identified. Postoperative issues were the most common (n = 552), followed by preoperative (n = 378) and intraoperative issues (n = 370). Communication issues were present at all 3 stages (n = 71). Overall the most common theme was intraoperative technical issues (n = 287). Many of these issues revolved around unintentional injury to anatomic structures during surgery and inadequate myocardial protection. Communication issues commonly related to surgical handover to the intensive care unit and lack of shared decision-making. Also common were consultant surgeons being unaware of patient deterioration or significant changes in management. CONCLUSIONS: The Australian and New Zealand Audit of Surgical Mortality provides valuable insights into issues affecting mortality in cardiothoracic patients. Potentially avoidable management issues play a large role in determining the outcome of these patients. Quality improvement initiatives targeting these areas may be valuable.

Appendicectomy mortality: an Australian national audit.

BACKGROUND: Appendicectomy is a safe surgical procedure with minimal risks. Low mortality rates (0.04-0.24%) have been reported from a number of countries. Appendicectomy mortality rates have not been reported in Australia in recent years. The aim of the study was to conduct an appendicectomy mortality audit, to identify clinical management issues and to calculate the mortality rate of appendicectomy in Australia. METHODS: This study analysed data from a peer review of appendicectomy deaths in Australian hospitals of all states and territories, from 2006 to 2017. Additional procedural data were obtained from the Australian Institute of Health and Welfare for the calculation of mortality rates. RESULTS: The final analysis included 82 patients of whom 62 were elderly (age >65 years) with 47 males and 35 females. Two or more comorbidities were present in 68 patients. Open operation was performed in 62 patients, with complicated appendicitis found in 50 cases. The majority of management issues were non-surgical. Of the 16 surgical management issues identified, 11 issues occurred post-operatively in the elderly, which were potentially preventable. The overall mortality was 0.02% with 0.01% in the young (age <65 years) and 0.20% in the elderly. CONCLUSION: Australia's appendicectomy mortality rate was very low and comparable to international figures. Surgical management of appendicectomy was satisfactory in general. However, post-operative care in the elderly was found to be poor at times, with room for improvement. Further research is needed whether improvements in post-operative care could alter the clinical course to death in the elderly.

"Nobody told me": Communication Issues Affecting Australian Cardiothoracic Surgery Patients.

BACKGROUND: Failure of communication can have potentially severe results in cardiothoracic surgery. Previous literature regarding patient safety highlighted communication as a common area for improvement. This study utilized a qualitative approach to analyze a national mortality audit data set to identify and describe communication issues that could potentially contribute to patient mortality following cardiothoracic surgery. METHODS: We utilized a peer-reviewed audit of surgical deaths after cardiothoracic surgery in Australian hospitals from 2009 to 2015 via the Australian and New Zealand Audit of Surgical Mortality. Cases were identified with clinical management issues then individual analysis of cases highlighting communication issues was undertaken. A total of 91 reports from surgeons and assessors were analysed using a thematic analytic approach. RESULTS: A total of 908 cases of potentially avoidable mortality were identified as being associated with clinical management issues, and communication issues were identified in 91 (10%) of these cases, which served as the basis for this analysis. The study found that failure to achieve shared decision making was the most common theme (n = 38, 41.8%), followed by failure to notify patient deterioration (n = 22, 24.1%), misreporting of patient condition (n = 10, 11.0%) and issues related to informed consent (n = 9, 10.0%). The most frequent communication issues occurred between surgeons and the intensive care unit. CONCLUSIONS: Poor communication was identified in patients who died after cardiothoracic surgery. Communication is an important modifiable factor in patient mortality. Efforts to address teamwork and communication have the potential to improve safety and quality of care for patients undergoing cardiothoracic surgery.

Potentially avoidable issues in neurosurgical mortality cases in Australia: identification and improvements.

BACKGROUND: Mortality rates are commonly used to evaluate the quality of surgical care; however, a large proportion of surgical deaths are unavoidable. Examination of the potentially avoidable issues in surgical deaths can provide a strong basis for quality improvement. Using data from a well-established and comprehensive national surgical mortality audit, we sought to identify the most common avoidable factors in neurosurgical deaths, focusing on the lessons that can be learnt. METHODS: This study analysed data from a peer review audit of surgical deaths in Australian hospitals (excluding New South Wales) from 2009 to 2014, focusing on neurosurgery cases with identified areas for improvement in patient management. In the 6% of neurosurgical cases that had clinical incidents, there were 193 clinical events identified. These were first categorized based on the perioperative stage (pre-, intra- or postoperative) followed by thematic analysis within each stage. RESULTS: The study found preoperative issues to be the most common (n = 107) followed by postoperative issues (n = 31) and intraoperative issues (n = 29). The most common theme was inadequate assessment (n = 65) followed by poor communication (at any stage of treatment) (n = 26). CONCLUSION: Neurosurgical cases with potentially avoidable mortality constitute a small but important subset. Avoidable contributors to mortality occurred most frequently at the preoperative stage, most commonly relating to inadequate assessment and delays. These findings can inform various stakeholders to improve the quality and safety of surgical care.

Relative benefit of a stage of change approach for the prevention of musculoskeletal pain and discomfort: a cluster randomised trial.

OBJECTIVES: To examine the benefit of a psychological Stage of Change (SOC) approach, relative to standard ergonomics advice, for the prevention of work-related musculoskeletal pain and discomfort (MSPD). METHODS: A cluster randomised trial was conducted in South Australia across a broad range of workplaces. Repeated face-to-face interviews were conducted onsite to assess MSPD, safety climate, job satisfaction and other factors. Changes in MSPD across intervention groups and time were investigated using Generalised Estimating Equation (GEE) methods. RESULTS: 25 workgroups (involving 242 workers) were randomly allocated to either a standard intervention or an intervention tailored according to SOC. The prevalence of MSPD increased for both groups, but was only significant for the standard group, in respect of lower back MSPD. Workers receiving tailored interventions were 60% less likely to experience lower back MSPD. After adjusting for age, gender and job satisfaction, it was found that company safety climate and length of employment were significantly correlated to the time-intervention effect. There was no correlation with workload. CONCLUSIONS: Compared with standard ergonomics advice to management, there was evidence of a benefit of stage-matched intervention for MSPD prevention, particularly for low back pain. Organisational safety climate should be taken into account when planning prevention programmes.

Musculoskeletal pain and discomfort and associated worker and organizational factors: a cross-sectional study.

BACKGROUND: Musculoskeletal disorders are a leading cause of work-related ill health, and a major cost burden for the individual, industry and the community. Despite the broad range of risk factors that have been identified, most studies have focused only on specific occupations or categories of risk factors, meaning that there is limited understanding of the relative contributions of individual and organisational, physical and psychosocial factors. OBJECTIVE: This cross-sectional survey of workers in medium-to-large workplaces in South Australia sought to examine a broad range of factors within various workplaces and industries. PARTICIPANTS: 404 workers from 29 workgroups and 23 separate companies participated in the research. METHODS: Questionnaires were administered face-to-face, assessing demographic and job characteristics, safety climate, musculoskeletal pain and discomfort (MSPD) and job satisfaction. Potential predictors were grouped in terms of personal/job and organizational characteristics and associations with MSPD examined. RESULTS: A considerable proportion of workers (40%) had experienced MSPD in the last 7 days and 15% had experienced severe MSPD. In a multivariate model, four variables were found to be significantly associated with MSPD, namely being aged > or =40 years (adjusted odds ratio=1.73), overall job satisfaction (negatively associated) (AOR=0.37), medium (vs. large) company size (AOR=1.80) and workgroup safety climate score (negatively associated) (AOR=0.58). CONCLUSIONS: The results confirm a link between non-physical factors and work-related musculoskeletal disorders, suggesting that these factors should received increased attention as part of overall health and safety strategies. Organizations should give greater consideration to both the satisfaction of their employees and organizational factors that set the tone for safety climate.

Time trends and predictive factors for safety perceptions among incoming South Australian university students.

PROBLEM: Young workers are over-represented in injury statistics. In order to develop injury prevention strategies, this study investigated time trends and predictive factors relating to safety skills, confidence, and attitudes. METHOD: Annual surveys were conducted from 2006-2009 among incoming students at the University of Adelaide. The questions addressed safety training, injury experience, and health and safety perceptions. RESULTS: Time trends in training, perceived safety skills, confidence, and attitudes were not significant. In terms of skills and confidence, the most important correlate was safety training outside of high school (odds ratio=1.6), especially when repeated, assessed, or in face to face mode. Feeling strongly about safety issues was best predicted by injury experience (OR=1.7) and gender. DISCUSSION: These results emphasize the value of assessed training, but they are also consistent with published U.S. data, indicating no improvement over time. It is suggested that there be a more integrated approach in safety education, involving schools and workplaces. IMPACT ON INDUSTRY: By developing an understanding of student safety perceptions and experiences, this research aims to target strategies to reduce the excess injury rate for young workers. Workplaces should be more aware of the limitations of school-based safety education and a more integrated and evidence-based approach should be developed, involving schools and workplaces.