Leveraging Consistent Communication Tools and Organizational Values to Promote Accountability Among Health Care Providers.

Teamwork and effective communication between all health care staff members are essential to providing safe, high-quality patient care. High-reliability organizations align behavioral expectations with organizational values and prioritize safety over other performance metrics and pressures. Communication breakdowns, such as inadequate or incomplete information shared between caregivers, continues to be an issue that is linked to errors and staff member dissatisfaction. Initiatives to improve health care communication and improve patient outcomes are well documented, yet communication issues in the health care setting continue. An organization's credo defines its values and behavioral expectations. Educating team members on an organization's credo creates accountability among those teams to align their behavior with the organization's values, policies, and professional commitment. A Coworker Observation Reporting System offers a communication method for providing meaningful feedback on behaviors inconsistent with an organization's credo.

Barriers to Incident Reporting by Physicians: A Survey of Surgical Residents and Attending Physicians.

Objectives Incident reporting is vital to a culture of safety; however, physicians report at an alarmingly low rate. This study aimed to identify barriers to incident reporting among surgeons at a quaternary care center. Methods A survey was created utilizing components of the Agency for Healthcare Research and Quality (AHRQ) validated survey on patient safety culture. This tool was distributed to residents and attending physicians in general surgery and urology at a single academic medical center. Responses were de-identified and recorded for data analysis using REDCap (Research Electronic Data Capture) database tool (Vanderbilt University, Nashville, Tennessee, United States). Results We received 39 survey responses from 116 residents and attending physicians (34% response rate), including nine urologists and 30 general surgeons (24 attendings, 15 residents). Residents and attendings feel the person is being written up and not the issue (67%) and that there is a lack of feedback after changes are implemented (64%), though most believe adequate action is taken to address patient safety concerns (72%). Most do not report near-misses (64%), only significant adverse events (59%). Residents are likely to stay silent when patient safety events involve those in authority (60%). Faculty feel those in authority are open to patient safety concerns (67%), though residents feel neutral (47%) or disagree (33%). Conclusion Underreporting of incidents among physicians remains multifaceted and complex, from fear of retaliation to lack of feedback. Residents tend to feel less comfortable addressing authority figures when concerned about patient safety. While misunderstanding still exists about the applications and utility of incident reporting, a focus on quality over quantity could afford more meaningful progress toward high reliability in healthcare.

Oxygen-enriching triphase platform for reliable sensing of femtomolar Alzheimer's neurofilament lights.

Accurate quantification of neurofilament lights (NfLs), a prognostic blood biomarker, is highly required to predict neurodegeneration in the presymptomatic stages of Alzheimer's disease. Here, we report self-oxygen-enriching coral structures with triphase interfaces for the label-free photocathodic detection of NfLs in blood plasma with femtomolar sensitivities and high reliability. In conventional photocathodic immunoassays, the poor solubility and sluggish diffusion rate of the dissolved oxygen serving as electron acceptors have necessitated the incorporation of additional electron acceptors or aeration procedures. To address the challenge, we designed the coral-like copper bismuth oxides (CBO) with robust solid-liquid-air contact boundaries that enrich the interfacial oxygen levels without an external aeration source. By optimally assembling the perfluorododecyltrichlorosilane (FTCS) and platinum (Pt) co-catalysts into the silver-doped CBO (Ag:CBO), the stable solid-liquid-air contact boundaries were formed within the sensor interfaces, which allowed for the abundant supply of air phase oxygen through an air pocket connected to the atmosphere. The Pt/FTCS-Ag:CBO exhibited the stable background signals independent of the dissolved oxygen fluctuations and amplified photocurrent signals by 1.76-fold, which were attributed to the elevated interfacial oxygen levels and 11.15 times-lowered mass transport resistance. Under the illumination of white light-emitting diode, the oxygen-enriching photocathodic sensor composed of Pt/FTCS-Ag:CBO conjugated with NfLs-specific antibodies precisely quantified the NfLs in plasma with a low coefficient of variation (≤2.97%), a high degree of recovery (>97.0%), and a limit of detection of 40.38 fg/mL, which was 140 times lower than the typical photocathodic sensor with diphase interfaces.

Implementation of a critical care outreach team in a children's hospital.

Introduction: Proactive surveillance by a critical care outreach team (CCOT) can promote early recognition of deterioration in hospitalized patients but is uncommon in pediatric rapid response systems (RRSs). After our children's hospital introduced a CCOT in 2019, we aimed to characterize early implementation outcomes. We hypothesized that CCOT rounding would identify additional children at risk for deterioration. Methods: The CCOT, staffed by a dedicated critical care nurse (RN), respiratory therapist, and attending, conducts daily in-person rounds with charge RNs on medical-surgical units, to screen RRS-identified high-risk patients for deterioration. In this prospective study, observers tracked rounds discussion content, participation, and identification of new high-risk patients. We compared 'identified-patient-discussions' (IPD) about RRS-identified patients, and 'new-patient-discussions' (NPD) about new patients with Fisher's exact test. For new patients, we performed thematic analysis of clinical data to identify deterioration related themes. Results: During 348 unit-rounds over 20 days, we observed 383 discussions - 35 (9%) were NPD. Frequent topics were screening for clinical concerns (374/383, 98%), active clinical concerns (147/383, 39%), and watcher activation (66/383, 17%). Most discussions only included standard participants (353/383, 92%). Compared to IPD, NPD more often addressed active concerns (74.3% vs 34.8%, p < 0.01) and staffing resource concerns (5.7% vs 0.6%, p < 0.04), and more often incorporated extra participants (25.7% vs 6%, p < 0.01). In thematic analysis of 33 new patients, most (29/33, 88%) had features of deterioration. Conclusion: A successfully implemented CCOT enhanced identification of clinical deterioration not captured by existing RRS resources. Future work will investigate its impact on operational safety and patient-centered outcomes.

Developing a relational playbook for cardiology teams to cultivate supportive learning environments, enhance clinician well-being, and veteran care.

Introduction: Despite the Veterans Health Administration (VA) efforts to become a learning health system (LHS) and high-reliability organization (HRO), interventions to build supportive learning environments within teams are not reliably implemented, contributing to high levels of burnout, turnover, and variation in care. Supportive learning environments build capabilities for teaching and learning, empower teams to safely trial and adapt new things, and adopt highly reliable work practices (eg, debriefs). Innovative approaches to create supportive learning environments are needed to advance LHS and HRO theory and research into practice. Methods: To guide the identification of evidence-based interventions that cultivate supportive learning environments, the authors used a longitudinal, mixed-methods design and LHS and HRO frameworks. We partnered with the 81 VA cardiac catheterization laboratories and conducted surveys, interviews, and literature reviews that informed a Relational Playbook for Cardiology Teams. Results: The Relational Playbook resources and 50 evidence-based interventions are organized into five LHS and HRO-guided chapters: Create a positive culture, teamwork, leading teams, joy in work, communication, and high reliability. The interventions are designed for managers to integrate into existing meetings or trainings to cultivate supportive learning environments. Conclusions: LHS and HRO frameworks describe how organizations can continually learn and deliver nearly error-free services. The Playbook resources and interventions translate LHS and HRO frameworks for real-world implementation by healthcare managers. This work will cultivate supportive learning environments, employee well-being, and Veteran safety while providing insights into LHS and HRO theory, research, and practice.

Technical Tips: The Role of the Charge Neurodiagnostic Technologist.

The purpose of this strategic staffing study was to retrospectively evaluate the impact of the charge neurodiagnostic technologist (NDT) within a 24/7 pediatric NAEC Level IV, ABRET LAB-LTM accredited epilepsy monitoring unit (EMU) during a 4-month pilot. The association between a high-reliability organization (HRO), Lean thinking, and organizational strategic goals were utilized as guiding principles. This paper reviews the operational need to further develop frontline neurodiagnostic leadership roles within Ann & Robert H. Lurie Children's Hospital of Chicago along with the design and implementation, training, and competencies required.

A contribuição da Ergonomia para a segurança no trabalho / Ergonomics contribution to occupational safety

Resumo Introdução: processos de alto risco com elevadas taxas de acidentes desafiam a segurança. Por outro lado, sistemas ultrasseguros conquistaram ótimos indicadores. Em ambos, a prevenção parece ter chegado a um limite - em um deles, porque parece impotente para gerar prevenção; no outro, porque foi tão bem-sucedida que parece impossível avançar. Objetivo: evidenciar a contribuição da Ergonomia em prol da segurança, nas situações descritas, suas possibilidades ainda por explorar, entre elas a Ergonomia de concepção na integração homem-máquina (sistemas informatizados). Método: análise comparativa dos achados oriundos de estudos ergonômicos em sistemas de produção com altas taxas de acidentes e sistemas ultrasseguros. Discussão: a análise da atividade dos motofretistas mostrou que existem alternativas de ação ainda não exploradas entre as relações de trabalho desfavoráveis e a percepção de inevitabilidade dos acidentes. Nos sistemas ultrasseguros, o aparente limite pode ser superado com os avanços recentes na análise da ação e cognição situadas e na construção de espaços de debate que permitam o retorno da experiência de campo. Em sistemas informatizados, as práticas de projeto colaborativo, que se valem da experiência dos trabalhadores para alimentar as dinâmicas de aprendizagem e a confiabilidade técnica, são possibilidades ainda pouco praticadas na Engenharia de Segurança.

Abstract Introduction: while high-risk processes with high accident rates challenge safety, High Reliability Organization (HRO) achieve excellent indicators. In both cases, prevention seems to have reached a limit. In the former, because it seems powerless to generate prevention; in the latter, because it has been so successful that it seems impossible to reach greater levels. Objective: to highlight the contribution of Ergonomics to safety in these situations, pointing out unexplored possibilities such as design Ergonomics in man-machine integration (computerized systems). Method: comparative analysis of findings from ergonomic studies on production systems with high accident rates and HRO. Discussion: analysis of the motorcycle freight drivers' activity revealed alternatives yet to be explored between unfavorable work relations and the perceived inevitability of accidents. The apparent limit of HRO can be overcome with recent advances in the analysis of situated action and cognition and by building debate spaces based on field experience. Collaborative design practices, which draw on worker experience to feed learning dynamics and technical reliability, remains a poorly explored possibility in Safety Engineering when it comes to computerized systems.

Building Cultures of High Reliability: Lessons from the High Reliability Organization Paradigm.

Safety models from disciplines outside of health care have begun to diffuse into the health care safety arena. This article explores high reliability organizing (HRO) theory, which privileges culture as means to adaptively learn and reliably perform. A brief history of the HRO paradigm and factors that contribute to cultures of high reliability is provided, followed by review of existing research to discern which HRO ideas have diffused into research on anesthesiology and perioperative care. High reliability research is growing and concepts seem useful; but there is a long way to go before the benefits of HRO are fully realized.

Nontechnical Skills for Intraoperative Team Members.

Nontechnical skills, defined as the set of cognitive and social skills used by individuals and teams to reduce error and improve performance in complex systems, have become increasingly recognized as a key contributor to patient safety. Efforts to characterize, quantify, and teach nontechnical skills in the context of perioperative care continue to evolve. This review article summarizes the essential behaviors for safety, described in taxonomies for nontechnical skills assessments developed for intraoperative clinical team members (eg, surgeons, anesthesiologists, scrub practitioners, perfusionists). Furthermore, the authors describe emerging methods to advance understanding of the impact of nontechnical skills on perioperative outcomes.

Designing a Multilayered Oxygen Barrier Structure to Tackle Oxidation Challenges in Phase-Change Memory for Improved Reliability.

Phase-change memory (PCM) is considered one of the most promising candidates for universal memory. However, during the manufacturing process of PCM, phase-change materials (PCMs) encounter severe oxidation, which can cause degraded performance and reduced stability of PCM, hindering its industrialization process. In this work, a multilayered oxygen barrier (MOB) structure is proposed to tackle this challenge. Material characterization shows that the MOB structure can significantly reduce the extent of oxidation of PCMs from around 70% to as low as around 10%, achieving a remarkably low level of oxidation. Moreover, the material in the MOB structure exhibits notable enhancements in crystallization temperature and cycling capability. The improved stability is attributed to the oxygen barrier effect and the suppression of elemental segregation within the material, which are both conferred by the MOB structure. In summary, this work provides an effective solution to address the oxidation of PCMs, offering valuable guidance for realizing a high-reliability PCM in practical production.

Relationships among psychological safety, the principles of high reliability, and safety reporting intentions in pediatric nursing.

PURPOSE: The purpose of this study was to explore relationships among psychological safety, the principles of high reliability, and safety reporting intentions in pediatric nursing. Patient safety events are underreported and costly. To promote reporting, many healthcare organizations have adopted the high reliability framework with strategies to foster team psychological safety. DESIGN: A web-based survey was distributed through the Society of Pediatric Nurses and the National Pediatric Nurse Scientist Collaborative. Data were collected from 244 pediatric nurses using a demographic form, Safety Organizing Scale, Team Psychological Safety Scale, and Intention to Report Safety Events Scale. Data were analyzed using logistic and linear regression. RESULTS: Psychological safety and perception of working in a high reliability organization (HRO) showed positive statistically significant relationships with reporting intentions (p = 0.034). Odds of nurses achieving highest reporting intention scores increased by a factor of 0.3 with each practice year. CONCLUSIONS: Psychological safety was found to be a predictor for intention to report safety events among pediatric nurses. Findings also demonstrated that nurses' perceptions of whether they worked in a high reliability setting also profoundly affect their attitude towards reporting. PRACTICE IMPLICATIONS: Focusing organizational efforts on cultivating psychological safety and embedding the high reliability framework into professional practice may significantly affect attitudes towards safety event reporting.

Informatics Tools in Deprescribing and Medication Optimization in Older Adults: Development and Dissemination of VIONE Methodology in a High Reliability Organization.

PURPOSE: Polypharmacy is common in older adults, with almost 20% of older adults taking ≥10 medications. They are at great risk for adverse events related to potentially inappropriate medications (PIMs). Although evidence-based methods for deprescribing have been successful at reducing polypharmacy and improving quality of medication use, there are several challenges to implementing these methods on a large scale. VIONE, a medication deprescribing methodology, was developed to reduce polypharmacy and PIMs across the Veterans Health Administration (VHA). (VIONE stands for Vital, Important, Optional, Not indicated, and Every medication has an indication.) This study describes the tools created for implementation of VIONE and the dashboards used to track VIONE implementation and subsequent deprescribing across the VHA; their use and sustainment are examined in a health system-wide adoption of this deprescribing practice in a high reliability organization (HRO). METHODS: VIONE was disseminated by the VHA via the Diffusion of Excellence Initiative. Dissemination included an implementation toolkit and four dashboards that collect and display data from the electronic medical record to monitor utilization of VIONE, track medication discontinuations, and prospectively identify veterans who may be candidates for deprescribing. FINDINGS: Between 2016 and the present, VIONE has been adopted at >130 medical centers and influenced almost 700,000 unique patients. In addition, a total of >1.6 million medication orders have been discontinued by >15,000 providers. IMPLICATIONS: The VIONE methodology and informatics tools were widely disseminated and successfully adopted and sustained nationally in a high reliability organization, leading to a reduction in PIM use by older adults and improved quality and patient safety. Future efforts should continue to consider ways to leverage electronic medical record data and other relevant informatics tools to provide customized clinical decision support to further medication optimization and deprescribing efforts.

Research on three-state reliability evaluation method of high reliability system based on multi-source prior information.

A high reliability system has the characteristics of complexity, modularization, high cost and small sample size. Throughout the entire lifecycle of system development, storage and use, the high reliability requirements and the risk analysis form a direct contradiction with the testing expenses. In order to ensure the system, module or component maintains good reliability status and effectively reduces the cost of sampling tests, it is necessary to make full use of multi-source prior information to evaluate its reliability. Therefore, in order to evaluate the reliability of highly reliable equipment under the condition of a small sample size correctly, the equipment reliability evaluation model should be built based on multi-source prior information and form scientific computing methods to meet the needs of condition evaluation and fund assurance of high reliability system. In engineering practice, high reliability system or module gradually develops from normal state to failure state, generally going through three working states of "safety-potential failure-functional failure". Firstly, the historical test data under the three states can be used for the data source for the reliability evaluation of the system at the current stage, which supplements the deficiency of the field data; secondly, due to the lack of accurate judgment on the working state of a high reliability system or modules and analysis of the health status, the unnecessary maintenance may aggravate the evolution speed from potential failure to functional failure; thirdly, when high reliability system or module operates under overload or harsh conditions, the potential failure will be worsened to a certain extent. Aiming at the difficulty of multi-state system reliability evaluation, a reliability evaluation method based on non-information prior distribution is proposed by fusing multi-source prior information, which provides ideas and methods for reliability evaluation and optimization analysis of high reliability system or module. The results show that the three-state reliability evaluation method proposed in this article is consistent with the actual engineering situation, providing a scientific theoretical basis for preventive maintenance of high reliability system. At the same time, the research method not only helps evaluate the reliability state of a high reliability system accurately, but also achieves the goal of effectively reducing test costs with good economic benefits and engineering application value.

Developing a highly-reliable learning health system.

Multiple independent frameworks to support continuous improvement have been proposed to guide healthcare organizations. Two of the most visible are High-reliability Health care, (Chassin et al., 2013) which is emphasized by The Joint Commission, and Learning Health Systems, (Institute of Medicine, 2011) highlighted by the National Academy of Medicine. We propose that organizations consider tightly linking these two models, creating a "Highly-reliable Learning Health System." We describe several efforts at our organization that has resulted from this combined model and have helped our organization weather the COVID-19 pandemic. The organizational changes created using this framework will enable our health system to support a culture of quality across our teams and better fulfill our tripartite mission of high-quality care, effective education of trainees, and dissemination of important innovations.

A "High-Reliability Organization" Approach to Improve Trauma Imaging Performance.

PURPOSE: CT is the gold standard for triaging critically ill patients, including in trauma, and its use has increased over time. CT turnaround times (TATs) are frequently targeted for improvement. As opposed to linear reductionist processes such as Lean and Six Sigma, a high-reliability organization (HRO) approach focuses on culture and teams to enable rapid problem solving. The authors evaluated the HRO model to rapidly generate, trial, select, and implement improvement interventions to improve trauma patient CT performance. METHODS: All trauma patients presenting to a single institution's emergency department during a 5-month period were included. Project periods included 2-month preintervention, 1-month wash-in, and 2-month postintervention. Each initial trauma CT encounter during the wash-in and postintervention periods created job briefs in which the radiologist ensured that all involved had the pertinent clinical information and agreed on the imaging needed, thereby creating a shared mental model as well as an opportunity to raise concerns and provide ideas for improvement. RESULTS: A total of 447 patients were included: 145 preintervention, 68 wash-in, and 234 postintervention. The seven selected interventions were trauma text alert; scripted CT technologist-radiologist communication; modification of CT acquisition, processing, sending, and interpretation; and trauma mobile phones. The seven selected interventions reduced trauma patient CT median TATs by 60% (78 vs 31 min, P < .001), demonstrating the effectiveness of an HRO approach to improvement. CONCLUSIONS: An HRO-based approach was rapid in generating, trialing, selecting, and implementing improvement interventions, and the interventions were effective at substantially decreasing trauma patient CT TATs.

How the Five Principles of High Reliability Organizations Align with the Five Truths of Special Operations.

Special Operations medicine must provide highly reliable healthcare under intense and sometimes dangerous circumstances. In turn, it is important to understand the principles inherent to building a High Reliability Organization (HRO). These principles include (1) sensitivity to operations; (2) preoccupation with failure; (3) reluctance to simplify; (4) resilience; and (5) deference to expertise. Understanding them is crucial to turning good ideas into sound practical benefit in operational medicine. A prime teaching opportunity involves an interesting coincidence that occurred during the emergence of HROs. Specifically, United States Special Operations Command (USSOCOM) adopted five Special Operations Forces (SOF) Truths that contribute to success in Special Operations, including (1) humans are more important than hardware; (2) quality is better than quantity; (3) SOF cannot be mass produced; (4) competent SOF cannot be created after emergencies occur; and (5) most Special Operations require non-SOF support. These five Truths have more in common with the five HRO principles than merely quantity. They describe the same underlying ideas with a key focus on human performance in high-risk activities. As such, when presented alongside the five HRO principles, there is an opportunity to improve the overall health and performance of SOF personnel by integrating these principles across the range of Special Operations medicine from point of injury care to garrison human performance initiatives. The following discussion describes in greater detail the five HRO principles, the five SOF Truths, and how these similar ideas emerged as more than just a useful coincidence in illustrating the key concepts to produce high performance.

Highly Tough and Reliable Poly(Amic Acid) with Ballistic Impact-Resistance through Modulation of Hydrogen Bonding Interactions.

Poly(amic acid) (PAA) materials as the precursor of polyimide generally show remarkably poor mechanical properties, thus limiting their application as the engineering plastics. In this study, it is demonstrated that the mechanical properties of PAA materials can be improved significantly for tens of folds with breaking strength >50 MPa, Young's modulus >400 MPa, and elongation at break >300% by incorporation of 20% (mol%) poly(propylene glycol) (PPO) soft segments. The optimization for suitable hard-soft composition with 20% PPO and the existence of various hydrogen bonds with different binding energies can dissipate energies efficiently, which simultaneously improve the material strength and toughness. In addition, PAA82 films exhibit excellent tolerance toward cyclic stretch, and have the capability to resist various harsh conditions including solar radiation testing (1 sun), heat (85 °C), alkalinity (pH 10), and acidity (pH 4) over one month. Noted that PAA82 films can be laminated with Kapton films, which show excellent resistance to ultrahigh (200 °C) and ultralow temperature (-196 °C). The laminated film also exhibits bulletproof property with a thickness of 6 mm. The strategy via modulation of hard-soft compositions and hydrogen bonds in PAA materials shows great potentials to improve the mechanical properties of polymeric materials.

The Highly Reliable, Patient-Centered Sports Medicine Practice.

Patient-centered care is safe and eliminates preventable patient harm. Sports medicine teams that understand and apply the principles of high reliability, as demonstrated by high-performing communities in the US Navy, will provide safer, higher-quality care. Sustaining high-reliability performance is challenging. Leadership is essential to creating an accountable but psychologically safe environment fostering active engagement by all team members and resisting complacency. Leaders who invest the time and energy to create the appropriate culture and who model the required behaviors enjoy an exponential return on their investment in terms of professional satisfaction and the delivery of truly patient-centered, safe, high-quality care.

Normalization of Deviance Is Contrary to the Principles of High Reliability.

Normalization of deviance is a phenomenon in which individuals and teams depart from an acceptable performance standard until the adopted way of practice becomes the new norm. This phenomenon is concerning in high-risk areas of health care because it erodes a safety culture. Additionally, it is inimical to the principles of high reliability-specifically, to the first of the five principles: preoccupation with failure. Although all high-reliability principles hold relevance to safety, preoccupation with failure describes a consistent alertness to risk and is critical for preventing adverse events, particularly in high-risk environments such as the OR. This article describes how normalization of deviance and preoccupation with failure cannot coexist and presents ways to mitigate normalization of deviance and bolster high reliability, ultimately making ORs safer for surgical patients.

3D Graphene-Nanowire "Sandwich" Thermal Interface with Ultralow Resistance and Stiffness.

Despite the recent advancements of passive and active cooling solutions for electronics, interfaces between materials have generally become crucial barriers for thermal transport because of intrinsic material dissimilarity and surface roughness at interfaces. We demonstrate a 3D graphene-nanowire "sandwich" thermal interface that enables an ultralow thermal resistance of ∼0.24 mm2·K/W that is about 1 order of magnitude smaller than those of solders and several orders of magnitude lower than those of thermal greases, gels, and epoxies, as well as a low elastic and shear moduli of ∼1 MPa like polymers and foams. The flexible 3D "sandwich" exhibits excellent long-term reliability with >1000 cycles over a broad temperature range from -55 °C to 125 °C. This nanostructured thermal interface material can greatly benefit a variety of electronic systems and devices by allowing them to operate at lower temperatures or at the same temperature but with higher performance and higher power density.