Improving the Process of Shared Decision-Making by Integrating Online Structured Information and Self-Assessment Tools.

The integration of face-to-face communication and online processes to provide access to information and self-assessment tools may improve shared decision-making (SDM) processes. We aimed to assess the effectiveness of implementing an online SDM process with topics and content developed through a participatory design approach. We analyzed the triggered and completed SDM cases with responses from participants at a medical center in Taiwan. Data were retrieved from the Research Electronic Data Capture (REDCap) database of the hospital for analysis. Each team developed web-based patient decision aids (PDA) with empirical evidence in a multi-digitized manner, allowing patients to scan QR codes on a leaflet using their mobile phones and then read the PDA content online. From July 2019 to December 2020, 48 web-based SDM topics were implemented in the 24 clinical departments of this hospital. The results showed that using the REDCap system improved SDM efficiency and quality. Implementing an online SDM process integrated with face-to-face communication enhanced the practice and effectiveness of SDM, possibly through the flexibility of accessing information, self-assessment, and feedback evaluation.

Effect of implementing decision support to activate a rapid response system by automated screening of verified vital sign data: A retrospective database study.

AIM: Activating a rapid response system (RRS) at general wards requires memorizing trigger criteria, identifying deterioration, and timely notification of abnormalities. We aimed to assess the effect of decision support (DS)-linked RRS activation on management and outcomes. METHODS: We retrospectively analyzed general ward RRS activation cases from 2013 to 2017 and the incidence of cardiopulmonary resuscitations (CPR) from 2013 to 2020. A DS-alerting mechanism was added to the conventional RRS activation process in 2017, with an alert window appearing whenever the system automatically detected any verified abnormal vital sign entry, alerting the nurse to take further action. Logistic and linear regression analyses were used to compare outcomes. RESULTS: We analyzed 27,747 activations and 64,592 DS alerts. RRS activations increased from 3.5 to 30.3 per 1,000 patient-days (P < 0.001) after DS implementation. The first DS activations occurred earlier than conventional ones (-2.9 days, 95% confidence interval = -3.6 to -2.1 days). After adjustment with inverse probability of treatment weighting, main (conventional vs DS-linked activations after implementation) and sensitivity analyses showed that DS activation cases had a lower risk of CPR and in-hospital mortality. Cases with more DS alerts before RRS activation had a higher risk of CPR (P trend = 0.017) and in-hospital mortality (P trend < 0.001). The incidence of CPR at the general ward decreased. CONCLUSION: Implementing a DS mechanism with an automated screening of verified abnormal vital signs linked to RRS activations at general wards was associated with improved practice and timeliness of hospital-wide RRS activations and reduced in-hospital resuscitations and mortality.

In-Hospital Patient Safety Events, Healthcare Costs and Utilization: An Analysis from the Incident Reporting System in an Academic Medical Center.

The possible association of patient safety events (PSEs) with the costs and utilization remains a concern. In this retrospective analysis, we investigated adult hospitalizations at a medical center between 2010 and 2015 with or without reported PSEs. Administrative and claims data were analyzed to compare the costs and length of stay (LOS) between cases with and without PSEs of the three most common categories during the first 14 days of hospitalization. Two models, including linear regression and propensity score-matched comparison, were performed for each reference day group of hospitalizations. Of 14,181 PSEs from 424,635 hospitalizations, 69.8% were near miss or no-harm events. Costs and LOS were similar between fall cases and controls in all of the 14 reference days. In contrast, for cases of tube and line events and controls, there were consistent differences in costs and LOS in the majority of the reference days (86% and 57%, respectively). Consistent differences were less frequently seen for medication events and control events (36% and 43%, respectively). Our study approach of comparing cases with PSEs and those without any PSE showed significant differences in costs and LOS for tube and line events, and medication events. No difference in cost or LOS was found regarding fall events. Further studies exploring adjustments for event risks and harm-oriented analysis are warranted.

Nurses' Attitudes Toward Electronic Clinical Quality Measures: A Descriptive Study.

BACKGROUND: Electronic clinical quality measures (eCQMs) are a method that automatically extract data from electronic health records (EHRs) and compute and generate the results to report and track the quality of care and patient outcomes. PURPOSE: The purpose of this study was to explore nurses' attitudes toward eCQMs and the factors influencing this attitude. METHODS: A descriptive cross-sectional study was conducted using a closed-ended questions survey of 92 nurses in a teaching hospital. RESULTS: The average score for nurses' attitudes toward eCQMs was 3.47 out of 4. Participants with a master's degree had more positive attitudes than those with a baccalaureate degree. Head nurses had more positive attitudes than staff nurses. CONCLUSIONS: The nurses in the study hospital have a positive attitude toward eCQMs. Health care organizations should strengthen the attitudes of nurses toward eCQMs.

Comparison of complaints to the intensive care units and those to the general wards: an analysis using the Healthcare Complaint Analysis Tool in an academic medical center in Taiwan.

BACKGROUND: The management of complaints in the setting of intensive care may provide opportunities to understand patient and family experiences and needs. However, there are limited reports on the structured application of complaint analysis tools and comparisons between healthcare complaints in the critical care setting and other settings. METHODS: From the complaint management database of a university-affiliated medical center in Taiwan, we retrospectively identified the records of healthcare complaints to the intensive care units (ICUs) from 2008 to 2016. Complaints to the general wards in the same period were randomly selected from the database with twice the number of that of the ICU complaints. We coded, typed, and compared the complaints from the two settings according to the Healthcare Complaint Analysis Tool. RESULTS: We identified 343 complaints to the ICUs and randomly selected 686 complaints to the general wards during the 9-year study period. Most (94.7%) of the complaints to the ICUs came from the family members, whereas more complaints to the general wards came from the patients (44.2%). A total of 1529 problems (441 from ICU and 818 from general wards) were identified. Compared with the general ward complaints, in the ICU there were more complaints with multiple problems (25.1% vs. 16.9%, p = 0.002), complaints were referred more frequently to the nurses (28.1% vs. 17.5%, p < 0.001), and they focused more commonly on the care on the ICU/ward (60.5% vs. 54.2%, p = 0.029). The proportions of the three domains (clinical, management, and relationship) of complaints were similar between the ICU and general ward complaints (p = 0.121). However, in the management domain, the problems from ICU complaints focused more on the environment than on the institutional processes (90.9% vs. 74.5%, p < 0.001), whereas in the relationship domain, the problems focused more on communication (17.9% vs. 8.0%) and less on listening (34.6% vs. 46.5%) (p = 0.002) than the general ward complaints. CONCLUSIONS: A structured typing and systematic analysis of the healthcare complaints to the ICUs may provide valuable insights into the improvement of care quality, especially to the perceptions of the ICU environment and communications of the patients and their families.

Incidence of patient safety events and process-related human failures during intra-hospital transportation of patients: retrospective exploration from the institutional incident reporting system.

BACKGROUND: Intra-hospital transportation (IHT) might compromise patient safety because of different care settings and higher demand on the human operation. Reports regarding the incidence of IHT-related patient safety events and human failures remain limited. OBJECTIVE: To perform a retrospective analysis of IHT-related events, human failures and unsafe acts. SETTING: A hospital-wide process for the IHT and database from the incident reporting system in a medical centre in Taiwan. PARTICIPANTS: All eligible IHT-related patient safety events between January 2010 to December 2015 were included. MAIN OUTCOME MEASURES: Incidence rate of IHT-related patient safety events, human failure modes, and types of unsafe acts. RESULTS: There were 206 patient safety events in 2 009 013 IHT sessions (102.5 per 1 000 000 sessions). Most events (n=148, 71.8%) did not involve patient harm, and process events (n=146, 70.9%) were most common. Events at the location of arrival (n=101, 49.0%) were most frequent; this location accounted for 61.0% and 44.2% of events with patient harm and those without harm, respectively (p<0.001). Of the events with human failures (n=186), the most common related process step was the preparation of the transportation team (n=91, 48.9%). Contributing unsafe acts included perceptual errors (n=14, 7.5%), decision errors (n=56, 30.1%), skill-based errors (n=48, 25.8%), and non-compliance (n=68, 36.6%). Multivariate analysis showed that human failure found in the arrival and hand-off sub-process (OR 4.84, p<0.001) was associated with increased patient harm, whereas the presence of omission (OR 0.12, p<0.001) was associated with less patient harm. CONCLUSIONS: This study shows a need to reduce human failures to prevent patient harm during intra-hospital transportation. We suggest that the transportation team pay specific attention to the sub-process at the location of arrival and prevent errors other than omissions. Long-term monitoring of IHT-related events is also warranted.

Workplace interpersonal conflicts among the healthcare workers: Retrospective exploration from the institutional incident reporting system of a university-affiliated medical center.

OBJECTIVE: There have been concerns about the workplace interpersonal conflict (WIC) among healthcare workers. As healthcare organizations have applied the incident reporting system (IRS) widely for safety-related incidents, we proposed that this system might provide a channel to explore the WICs. METHODS: We retrospectively reviewed the reports to the IRS from July 2010 to June 2013 in a medical center. We identified the WICs and typed these conflicts according to the two foci (task content/process and interpersonal relationship) and the three properties (disagreement, interference, and negative emotion), and analyzed relevant data. RESULTS: Of the 147 incidents with WIC, the most common related processes were patient transfer (20%), laboratory tests (17%), surgery (16%) and medical imaging (16%). All of the 147 incidents with WIC focused on task content or task process, but 41 (27.9%) also focused on the interpersonal relationship. We found disagreement, interference, and negative emotion in 91.2%, 88.4%, and 55.8% of the cases, respectively. Nurses (57%) were most often the reporting workers, while the most common encounter was the nurse-doctor interaction (33%), and the majority (67%) of the conflicts were experienced concurrently with the incidents. There was a significant difference in the distribution of worker job types between cases focused on the interpersonal relationship and those without (p = 0.0064). The doctors were more frequently as the reporter when the conflicts focused on the interpersonal relationship (34.1%) than not on it (17.0%). The distributions of worker job types were similar between those with and without negative emotion (p = 0.125). CONCLUSIONS: The institutional IRS is a useful place to report the workplace interpersonal conflicts actively. The healthcare systems need to improve the channels to communicate, manage and resolve these conflicts.

Integrating team resource management program into staff training improves staff's perception and patient safety in organ procurement and transplantation: the experience in a university-affiliated medical center in Taiwan.

BACKGROUND: The process involved in organ procurement and transplantation is very complex that requires multidisciplinary coordination and teamwork. To prevent error during the processes, teamwork education and training might play an important role. We wished to evaluate the efficacy of implementing a Team Resource Management (TRM) program on patient safety and the behaviors of the team members involving in the process. METHODS: We implemented a TRM training program for the organ procurement and transplantation team members of the National Taiwan University Hospital (NTUH), a teaching medical center in Taiwan. This 15-month intervention included TRM education and training courses for the healthcare workers, focused group skill training for the procurement and transplantation team members, video demonstration and training, and case reviews with feedbacks. Teamwork culture was evaluated and all procurement and transplantation cases were reviewed to evaluate the application of TRM skills during the actual processes. RESULTS: During the intervention period, a total of 34 staff members participated the program, and 67 cases of transplantations were performed. Teamwork framework concept was the most prominent dimension that showed improvement from the participants for training. The team members showed a variety of teamwork behaviors during the process of procurement and transplantation during the intervention period. Of note, there were two potential donors with a positive HIV result, for which the procurement processed was timely and successfully terminated by the team. None of the recipients was transplanted with an infected organ. No error in communication or patient identification was noted during review of the case records. CONCLUSION: Implementation of a Team Resource Management program improves the teamwork culture as well as patient safety in organ procurement and transplantation.

[Patient safety as the first priority in healthcare].

Patient safety is an important issue in today's health care. This paper takes a human factor perspective to emphasize the importance of designing health care systems to account for caregiver personal characteristics and capabilities in order to compensate for individual caregiver limitations. This paper was designed to help nurses understand the impact of the human factor on patient safety. The authors hope that caregivers can use provided principles related to work systems, procedures, equipment and environments to improve patient safety and care systems.

Incidence and significance of clinically abnormal events in a tertiary referral medical center: implementation of the clinical alert system (CAS).

BACKGROUND: The prognosis of in-hospital cardiopulmonary arrest remains very poor. Reports have shown patients often have clinically abnormal events prior to arrest. To improve patient outcome and prevent arrest, detection of the abnormal events with early intervention has been advocated. However, the incidence of these events in Taiwan and their clinical significance remain unclear. METHODS: We conducted a prospective observational study with the implementation of the clinical alert system (CAS) in a university-affiliated tertiary referral medical center. Clinically abnormal events were detected using the CAS criteria for acute physiologic deterioration, and reported to experienced physicians for management. Patient and report data were retrieved, collected and analyzed. RESULTS: During the 14-month study period, a total of 2,050 events were detected in 1,640 patients. The estimated incidence of the events was 3.19 per 1,000 bed-days, which occurred in 2.14% of admissions. The most common event was abnormal heart rate (36.5%), followed by desaturation (26.7%), abnormal respiratory rate (24.5%), and abnormal blood pressure (23.1%). The majority of the events were reported in the day time, and nurses contributed most of the reports (66.4%). The 30-day and in-hospital mortality rates were 26.3% and 34%, respectively. Multivariate survival analysis showed that desaturation (relative risk [RR] = 1.715; p < 0.001), abnormal respiratory rate (RR = 1.652; p < 0.001), abnormal blood pressure (RR = 1.460; p = 0.001), coma (RR = 1.918; p < 0.001), and oliguria (RR = 1.424; p = 0.0024) were significantly associated with 30-day mortality. Mortality of patients in the last 2 months was significantly lower than that in the first 2 months (20.5% vs. 35.4%; p < 0.001), which suggests the effectiveness of the CAS. CONCLUSION: The development of clinically abnormal events is associated with poor outcome, which suggests that early detection and timely management of these events is necessary. Implementation of the CAS may improve the in-hospital outcome of these patients.