Patient Identification of Diagnostic Safety Blindspots and Participation in "Good Catches" Through Shared Visit Notes.

Policy Points Patients and families can identify clinically relevant errors, including "blindspots"-safety hazards that are difficult for clinicians or organizations to see. Health information transparency, including patient access to electronic visit notes, now federally mandated in the US and the subject of policy debate worldwide, creates a new opportunity to engage patients in diagnostic safety. However, not all patients access notes. Patient identification of blindspots in their notes underscores the need to systematically and equitably engage willing patients in safety, promote patient "good catches," and establish routine systems for patient feedback to help avoid preventable diagnostic errors and delays. CONTEXT: Policy shifts toward health information transparency provide a new opportunity for patients to contribute to diagnostic safety. We investigated whether sharing clinical notes with patients can support identification of "diagnostic safety blindspots"-potentially consequential breakdowns in the diagnostic process that may be difficult for clinical staff to observe. METHOD: We used mixed methods to analyze patient-reported ambulatory documentation errors among 22,889 patients at three US health care centers who read ≥ 1 visit note(s). We identified blindspots by tailoring a previously established taxonomy. We used multiple regression analysis to identify factors associated with blindspot identification. FINDINGS: 774 patients reported a total of 962 blindspots in 4 categories: (1) diagnostic misalignments (n = 421, 43.8%), including inaccurate symptoms or histories and failures or delay in diagnosis; (2) errors of omission (38.1%) including missed main concerns or next steps, and failure to listen to patients; (3) problems occurring outside visits (14.3%) such as tests, referrals, or appointment access; and (4) multiple low-level problems (3.7%) cascading into diagnostic breakdowns. Many patients acted on the blindspots they identified, resulting in "good catches" that may prevent potential negative consequences. Older, female, sicker, unemployed or disabled patients, or those who work in health care were more likely to identify a blindspot. Individuals reporting less formal education; those self-identifying as Black, Asian, other, or multiple races; and participants who deferred decision-making to providers were less likely to report a blindspot. CONCLUSION: Patients who read notes have unique insight about potential errors in their medical records that could impact diagnostic reasoning but may not be known to clinicians-underscoring a critical role for patients in diagnostic safety and organizational learning. From a policy standpoint, organizations should encourage patient review of visit notes, build systems to track patient-reported blindspots, and promote equity in note access and blindspot reporting.

Online patient feedback as a safety valve: An automated language analysis of unnoticed and unresolved safety incidents.

Safety reporting systems are widely used in healthcare to identify risks to patient safety. But, their effectiveness is undermined if staff do not notice or report incidents. Patients, however, might observe and report these overlooked incidents because they experience the consequences, are highly motivated, and independent of the organization. Online patient feedback may be especially valuable because it is a channel of reporting that allows patients to report without fear of consequence (e.g., anonymously). Harnessing this potential is challenging because online feedback is unstructured and lacks demonstrable validity and added value. Accordingly, we developed an automated language analysis method for measuring the likelihood of patient-reported safety incidents in online patient feedback. Feedback from patients and families (n = 146,685, words = 22,191,427, years = 2013-2019) about acute NHS trusts (hospital conglomerates; n = 134) in England were analyzed. The automated measure had good precision (0.69) and excellent recall (0.98) in identifying incidents; was independent of staff-reported incidents (r = -0.04 to 0.19); and was associated with hospital-level mortality rates (z = 3.87; p < 0.001). The identified safety incidents were often reported as unnoticed (89%) or unresolved (21%), suggesting that patients use online platforms to give visibility to safety concerns they believe have been missed or ignored. Online stakeholder feedback is akin to a safety valve; being independent and unconstrained it provides an outlet for reporting safety issues that may have been unnoticed or unresolved within formal channels.

Patient-Centered Insights: Using Health Care Complaints to Reveal Hot Spots and Blind Spots in Quality and Safety.

Policy Points: Health care complaints contain valuable data on quality and safety; however, there is no reliable method of analysis to unlock their potential. We demonstrate a method to analyze health care complaints that provides reliable insights on hot spots (where harm and near misses occur) and blind spots (before admissions, after discharge, systemic and low-level problems, and errors of omission). Systematic analysis of health care complaints can improve quality and safety by providing patient-centered insights that localize issues and shed light on difficult-to-monitor problems. CONTEXT: The use of health care complaints to improve quality and safety has been limited by a lack of reliable analysis tools and uncertainty about the insights that can be obtained. The Healthcare Complaints Analysis Tool, which we developed, was used to analyze a benchmark national data set, conceptualize a systematic analysis, and identify the added value of complaint data. METHODS: We analyzed 1,110 health care complaints from across England. "Hot spots" were identified by mapping reported harm and near misses onto stages of care and underlying problems. "Blind spots" concerning difficult-to-monitor aspects of care were analyzed by examining access and discharge problems, systemic problems, and errors of omission. FINDINGS: The tool showed moderate to excellent reliability. There were 1.87 problems per complaint (32% clinical, 32% relationships, and 34% management). Twenty-three percent of problems entailed major or catastrophic harm, with significant regional variation (17%-31%). Hot spots of serious harm were safety problems during examination, quality problems on the ward, and institutional problems during admission and discharge. Near misses occurred at all stages of care, with patients and family members often being involved in error detection and recovery. Complaints shed light on 3 blind spots: (1) problems arising when entering and exiting the health care system; (2) systemic failures pertaining to multiple distributed and often low-level problems; and (3) errors of omission, especially failure to acknowledge and listen to patients raising concerns. CONCLUSIONS: The analysis of health care complaints reveals valuable and uniquely patient-centered insights on quality and safety. Hot spots of harm and near misses provide an alternative data source on adverse events and critical incidents. Analysis of entry-exit, systemic, and omission problems provides insight on blind spots that may otherwise be difficult to monitor. Benchmark data and analysis scripts are downloadable as supplementary files.

Impossible decision? An investigation of risk trade-offs in the intensive care unit.

In the intensive care unit (ICU), clinicians must often make risk trade-offs on patient care. For example, on deciding whether to discharge a patient before they have fully recovered in order to create a bed for another, sicker, patient. When misjudged, these decisions can negatively influence patient outcomes: yet it can be difficult, if not impossible, for clinicians to evaluate with certainty the safest course of action. Using a vignette-based interview methodology, a naturalistic decision-making approach was utilised to study this phenomena. The decision preferences of ICU clinicians (n = 24) for two common risk trade-off scenarios were investigated. Qualitative analysis revealed the sample of clinicians to reach different, and sometimes oppositional, decision preferences. These practice variations emerged from differing analyses of risk, how decisions were 'framed' (e.g. philosophies on care), past experiences, and perceptions of group and organisational norms. Implications for patient safety and clinical decision-making are discussed. Practitioner Summary: Physicians managing ICUs have to make rapid decisions with incomplete information and suboptimal resources. A qualitative vignette-based interview study examined how such decisions are made. We found physicians used a heterogeneous mixture of risk assessments, factual knowledge and prior experience to make judgements, which leads to potential for inconsistent decision-making.

Human Factors in Financial Trading: An Analysis of Trading Incidents.

OBJECTIVE: This study tests the reliability of a system (FINANS) to collect and analyze incident reports in the financial trading domain and is guided by a human factors taxonomy used to describe error in the trading domain. BACKGROUND: Research indicates the utility of applying human factors theory to understand error in finance, yet empirical research is lacking. We report on the development of the first system for capturing and analyzing human factors-related issues in operational trading incidents. METHOD: In the first study, 20 incidents are analyzed by an expert user group against a referent standard to establish the reliability of FINANS. In the second study, 750 incidents are analyzed using distribution, mean, pathway, and associative analysis to describe the data. RESULTS: Kappa scores indicate that categories within FINANS can be reliably used to identify and extract data on human factors-related problems underlying trading incidents. Approximately 1% of trades (n = 750) lead to an incident. Slip/lapse (61%), situation awareness (51%), and teamwork (40%) were found to be the most common problems underlying incidents. For the most serious incidents, problems in situation awareness and teamwork were most common. CONCLUSION: We show that (a) experts in the trading domain can reliably and accurately code human factors in incidents, (b) 1% of trades incur error, and (c) poor teamwork skills and situation awareness underpin the most critical incidents. APPLICATION: This research provides data crucial for ameliorating risk within financial trading organizations, with implications for regulation and policy.

The relationship between national culture and safety culture: Implications for international safety culture assessments.

In this article, we examine the relationship between safety culture and national culture, and the implications of this relationship for international safety culture assessments. Focussing on Hofstede's uncertainty avoidance (UA) index, a survey study of 13,616 Air Traffic Management employees in 21 European countries found a negative association between safety culture and national norm data for UA. This is theorized to reflect the influence of national tendencies for UA upon attitudes and practices for managing safety (e.g., anxiety on risk; reliance on protocols; concerns over reporting incidents; openness to different perspectives). The relationship between UA and safety culture is likely to have implications for international safety culture assessments. Specifically, benchmarking exercises will consistently indicate safety management within organizations in high UA countries to be poorer than low UA countries due to the influence of national culture upon safety practices, which may limit opportunities for identifying and sharing best practice. We propose the use of safety culture against international group norms (SIGN) scores to statistically adjust for the influence of UA upon safety culture data, and to support the identification of safety practices effective and particular to low or high UA cultures. PRACTITIONER POINTS: National cultural tendencies for uncertainty avoidance (UA) are negatively associated with safety culture.This indicates that employee safety-related attitudes and practices may be influenced by national culture, and thus factors outside the direct control of organizational management.International safety culture assessments should attempt to determine the influence of national culture upon safety culture in order that benchmarking exercises compare aspects of safety management and not national culture.Safety culture against international group norms (SIGN) scores provide a potential way to do this, and can facilitate the identification of best practice within countries operating in a low or high UA cultural cluster.

What can acute medicine learn from qualitative methods?

PURPOSE OF REVIEW: The contribution of qualitative methods to evidence-based medicine is growing, with qualitative studies increasingly used to examine patient experience and unsafe organizational cultures. The present review considers qualitative research recently conducted on teamwork and organizational culture in the ICU and also other acute domains. RECENT FINDINGS: Qualitative studies have highlighted the importance of interpersonal and social aspects of healthcare on managing and responding to patient care needs. Clear/consistent communication, compassion, and trust underpin successful patient-physician interactions, with improved patient experiences linked to patient safety and clinical effectiveness across a wide range of measures and outcomes. Across multidisciplinary teams, good communication facilitates shared understanding, decision-making and coordinated action, reducing patient risk in the process. SUMMARY: Qualitative methods highlight the complex nature of risk management in hospital wards, which is highly contextualized to the demands and resources available, and influenced by multilayered social contexts. In addition to augmenting quantitative research, qualitative investigations enable the investigation of questions on social behaviour that are beyond the scope of quantitative assessment alone. To develop improved patient-centred care, health professionals should therefore consider integrating qualitative procedures into their existing assessments of patient/staff satisfaction.

Safety sans Frontières: An International Safety Culture Model.

The management of safety culture in international and culturally diverse organizations is a concern for many high-risk industries. Yet, research has primarily developed models of safety culture within Western countries, and there is a need to extend investigations of safety culture to global environments. We examined (i) whether safety culture can be reliably measured within a single industry operating across different cultural environments, and (ii) if there is an association between safety culture and national culture. The psychometric properties of a safety culture model developed for the air traffic management (ATM) industry were examined in 17 European countries from four culturally distinct regions of Europe (North, East, South, West). Participants were ATM operational staff (n = 5,176) and management staff (n = 1,230). Through employing multigroup confirmatory factor analysis, good psychometric properties of the model were established. This demonstrates, for the first time, that when safety culture models are tailored to a specific industry, they can operate consistently across national boundaries and occupational groups. Additionally, safety culture scores at both regional and national levels were associated with country-level data on Hofstede's five national culture dimensions (collectivism, power distance, uncertainty avoidance, masculinity, and long-term orientation). MANOVAs indicated safety culture to be most positive in Northern Europe, less so in Western and Eastern Europe, and least positive in Southern Europe. This indicates that national cultural traits may influence the development of organizational safety culture, with significant implications for safety culture theory and practice.

Patient neglect in healthcare institutions: a systematic review and conceptual model.

BACKGROUND: Patient neglect is an issue of increasing public concern in Europe and North America, yet remains poorly understood. This is the first systematic review on the nature, frequency and causes of patient neglect as distinct from patient safety topics such as medical error. METHOD: The Pubmed, Science Direct, and Medline databases were searched in order to identify research studies investigating patient neglect. Ten articles and four government reports met the inclusion criteria of reporting primary data on the occurrence or causes of patient neglect. Qualitative and quantitative data extraction investigated (1) the definition of patient neglect, (2) the forms of behaviour associated with neglect, (3) the reported frequency of neglect, and (4) the causes of neglect. RESULTS: Patient neglect is found to have two aspects. First, procedure neglect, which refers to failures of healthcare staff to achieve objective standards of care. Second, caring neglect, which refers to behaviours that lead patients and observers to believe that staff have uncaring attitudes. The perceived frequency of neglectful behaviour varies by observer. Patients and their family members are more likely to report neglect than healthcare staff, and nurses are more likely to report on the neglectful behaviours of other nurses than on their own behaviour. The causes of patient neglect frequently relate to organisational factors (e.g. high workloads that constrain the behaviours of healthcare staff, burnout), and the relationship between carers and patients. CONCLUSION: A social psychology-based conceptual model is developed to explain the occurrence and nature of patient neglect. This model will facilitate investigations of i) differences between patients and healthcare staff in how they perceive neglect, ii) the association with patient neglect and health outcomes, iii) the relative importance of system and organisational factors in causing neglect, and iv) the design of interventions and health policy to reduce patient neglect.

Understanding decisions about antibiotic prescribing in ICU: an application of the Necessity Concerns Framework.

BACKGROUND: Antibiotics are extensively prescribed in intensive care units (ICUs), yet little is known about how antibiotic-related decisions are made in this setting. We explored how beliefs, perceptions and contextual factors influenced ICU clinicians' antibiotic prescribing. METHODS: We conducted 4 focus groups and 34 semistructured interviews with clinicians involved in antibiotic prescribing in four English ICUs. Focus groups explored factors influencing prescribing, whereas interviews examined decision-making processes using two clinical vignettes. Data were analysed using thematic analysis, applying the Necessity Concerns Framework. RESULTS: Clinicians' antibiotic decisions were influenced by their judgement of the necessity for prescribing/not prescribing, relative to their concerns about potential adverse consequences. Antibiotic necessity perceptions were strongly influenced by beliefs that antibiotics would protect patients from deterioration and themselves from the ethical and legal consequences of undertreatment. Clinicians also reported concerns about prescribing antibiotics. These generally centred on antimicrobial resistance; however, protecting the individual patient was prioritised over these societal concerns. Few participants identified antibiotic toxicity concerns as a key influencer. Clinical uncertainty often complicated balancing antibiotic necessity against concerns. Decisions to start or continue antibiotics often represented 'erring on the side of caution' as a protective response in uncertainty. This approach was reinforced by previous experiences of negative consequences ('being burnt') which motivated prescribing 'just in case' of an infection. Prescribing decisions were also context-dependent, exemplified by a lower perceived threshold to prescribe antibiotics out-of-hours, input from external team members and local prescribing norms. CONCLUSION: Efforts to improve antibiotic stewardship should consider clinicians' desire to protect with a prescription. Rapid molecular microbiology, with appropriate communication, may diminish clinicians' fears of not prescribing or of using narrower-spectrum antibiotics.

Team leadership in the intensive care unit: the perspective of specialists.

OBJECTIVES: To identify the behaviors senior physicians (e.g., specialists, staff attendings) report using to lead multidisciplinary teams in the intensive care unit. DESIGN: Semistructured interviews focusing on team leadership, crisis management, and development of an environment that enable effective team performance in the intensive care unit. SETTING: Seven general intensive care units based in National Health Service hospitals in the United Kingdom. PARTICIPANTS: Twenty-five senior intensive care medicine physicians. MEASUREMENTS AND MAIN RESULTS: Responses to a semistructured interview were transcribed and subjected to "content" analysis. The interview analysis focused on references to the "functional" behaviors used by leaders to manage team performance and the "team development behaviors" used to build the conditions that enable effective team performance. Seven of the interviews were coded by a second psychologist to measure inter-rater reliability. Inter-rater reliability (Cohen's κ) was acceptable for both scales (κ = 0.72 and κ = 0.75). In total, 702 functional leadership behaviors (behaviors for information gathering, planning and decision-making, managing team members) were coded as being used to manage the intensive care unit, along with 216 team development behaviors (for providing team direction and establishing team norms). These behaviors were grouped together in a theoretically driven framework of intensive care unit team leadership. CONCLUSIONS: Intensive care unit senior physicians report using a variety of leadership behaviors to ensure high levels of team performance. The data described in this study provide insight into the team leadership behaviors used by intensive care unit team leaders and have implications for the development of team leadership training and assessment tools.

Teamwork and team training in the ICU: where do the similarities with aviation end?

The aviation industry has made significant progress in identifying the skills and behaviors that result in effective teamwork. Its conceptualization of teamwork, development of training programs, and design of assessment tools are highly relevant to the intensive care unit (ICU). Team skills are important for maintaining safety in both domains, as multidisciplinary teams must work effectively under highly complex, stressful, and uncertain conditions. However, there are substantial differences in the nature of work and structure of teams in the ICU in comparison with those in aviation. While intensive care medicine may wish to use the advances made by the aviation industry for conceptualizing team skills and implementing team training programs, interventions must be tailored to the highly specific demands of the ICU.

Stakeholders in safety: Patient reports on unsafe clinical behaviors distinguish hospital mortality rates.

Patient safety research has adapted concepts and methods from the workplace safety literature (safety climate, incident reporting) to explain why patients experience unintentional harm during clinical treatment in hospital (adverse events). Consequently, patient safety has primarily been studied through data generated by health care staff. However, because adverse events relate to patient injuries, it is suggested that patients and their families may also have valuable insights for investigating patient safety in hospitals. We conceptualized this idea by proposing that patients are stakeholders in hospital safety who, through their experiences of treatments and independence from institutional culture, can provide valid and supplementary data on unsafe clinical care. In 59 United Kingdom hospitals we investigated whether patient evaluations of care (N = 23,287 surveys) and the safety information contained in health care complaints (N = 2,017, containing 2.5 million words) explained variance in excess patient deaths (hospital mortality) beyond staff evaluations of care (N = 49,302 surveys) and incident reports (N = 242,859). The severity of reports on unsafe clinical behaviors (error and neglect) communicated in patient' health care complaints explained additional variance in hospital-level mortality rates beyond that of staff-generated data. The results indicate that patients provide valid and supplementary data on unsafe care in hospitals. Generalized to other organizational domains, the findings suggest that nonemployee stakeholders should be included in assessments of safety performance if they experience or observe unsafe behaviors. Theoretically, it is necessary to further examine how concepts such as safety climate can incorporate the observations and outcomes of stakeholders in safety. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Identifying and encouraging high-quality healthcare: an analysis of the content and aims of patient letters of compliment.

BACKGROUND: Although healthcare institutions receive many unsolicited compliment letters, these are not systematically conceptualised or analysed. We conceptualise compliment letters as simultaneously identifying and encouraging high-quality healthcare. We sought to identify the practices being complimented and the aims of writing these letters, and we test whether the aims vary when addressing front-line staff compared with senior management. METHODS: A national sample of 1267 compliment letters was obtained from 54 English hospitals. Manual classification examined the practices reported as praiseworthy, the aims being pursued and who the letter was addressed to. RESULTS: The practices being complimented were in the relationship (77% of letters), clinical (50%) and management (30%) domains. Across these domains, 39% of compliments focused on voluntary non-routine extra-role behaviours (eg, extra-emotional support, staying late to run an extra test). The aims of expressing gratitude were to acknowledge (80%), reward (44%) and promote (59%) the desired behaviour. Front-line staff tended to receive compliments acknowledging behaviour, while senior management received compliments asking them to reward individual staff and promoting the importance of relationship behaviours. CONCLUSIONS: Compliment letters reveal that patients value extra-role behaviour in clinical, management and especially relationship domains. However, compliment letters do more than merely identify desirable healthcare practices. By acknowledging, rewarding and promoting these practices, compliment letters can potentially contribute to healthcare services through promoting desirable behaviours and giving staff social recognition.

Sounds of silence: Data for analysing muted safety voice in speech.

Transcribed text from simulated hazards contains important content relevant for preventing harm. By capturing and analysing the content of speech when people raise (safety voice) or withhold safety concerns (safety silence), communication patterns may be identified for when individuals perceive risk, and safety management may be improved through identifying potential antecedents. This dataset contains transcribed speech from 404 participants (nstudents = 377; nfemale = 277, Age M(sd) = 22.897(5.386)) engaged in a simulated hazardous scenario (walking across an unsafe plank), capturing 18,078 English words (M(sd) = 46.117(37.559)). The data was collected through the Walking the plank paradigm (Noort et al, 2019), which provides a validated laboratory experiment designed for the direct observation of communication in response to hazardous scenarios that elicit safety concerns. Three manipulations were included in the design: hazard salience (salient vs not salient), responsibilities (clear vs diffuse) and encouragements (encouraged vs discouraged). Speech between two set timepoints in the hazardous scenario was transcribed based on video recordings and coded in terms of the extent to which speech involved safety voice or safety silence. Files contain i) a .csv containing the raw data, ii) a .csv providing variable description, iii) a Jupyter notebook (v. 3.7) providing the statistical code for the accompanying research article, iv) a .html version of the Jupyter notebook, v) a .html file providing the graph for the .html Jupyter notebook, vi) speech dictionaries, and vii) a copy of the electronic questionnaire. The data and supplemental files enable future research through providing a dataset in which participants can be distinguished in terms of the extent to which they are concerned and raise or withhold this. It enables speech and conversation analyses and the Jupyter notebook may be adapted to enable the parsing and coding of text using provided, existing and custom dictionaries. This may lead to the identification of communication patterns and potential interventions for unmuting safety voice. This data-in-brief is published alongside the research article: M. C. Noort, T.W. Reader, A. Gillespie. (2021). The sounds of safety silence: Interventions and temporal patterns unmute unique safety voice content in speech. Safety Science.

Cockpit voice recorder transcript data: Capturing safety voice and safety listening during historic aviation accidents.

Cockpit Voice Recorder (CVR) transcripts capture audio data within cockpit environments. This aids the investigation of causal factors contributing to aviation accidents by revealing communication and other sounds prior to aviation accidents. This dataset contains 172 unique CVR transcripts (with 21,626 lines of transcript: averaging: 106.001 conversational turns; SD = 51.727, range: 1-641), and capturing approximately 15% of historic aviation fatalities in commercial and corporate aviation between 1962 and 2018. CVR transcripts involved airlines registered across 42 countries, with accidents occurring across 50 countries. The dataset was compiled by extracting CVR transcripts from three primary data sources and excluding duplicate and non-English entries. The data contains variables describing the (i) raw data, (ii) content and characteristics of the CVR transcripts, and (iii) behaviours coded by research assistants in support of the associated research article. The data existed of conversational turns amongst flight crew (total = 19,393; within transcripts: m = 112.750; SD = 124.829) and other data (n = 2213; within transcripts: m = 12.866; SD = 14.452; e.g., background sounds, transcriber notes). Conversational turns were uttered by junior (39.00%) and senior (35.44%) flight crew, and others (25.56%). The dataset enables future research through providing the first integrated dataset on communication behaviours prior to historic aviation accidents. Moreover, the dataset may support safety management through enabling the identification of communication behaviours contributing to accidents and the design of novel interventions. This data-in-brief is a co-submission associated with the research article: M. C. Noort, T.W. Reader, A. Gillespie. (2021). Safety voice and safety listening during aviation accidents: Cockpit voice recordings reveal that speaking-up to power is not enough. Safety Science.

At the end: A vignette-based investigation of strategies for managing end-of-life decisions in the intensive care unit.

BACKGROUND: Decision-making on end-of-life is an inevitable, yet highly complex, aspect of intensive care decision-making. End-of-life decisions can be challenging both in terms of clinical judgement and social interaction with families, and these two processes often become intertwined. This is especially apparent at times when clinicians are required to seek the views of surrogate decision makers (i.e., family members) when considering palliative care. METHODS: Using a vignette-based interview methodology, we explored how interactions with family members influence end-of-life decisions by intensive care unit clinicians (n = 24), and identified strategies for reaching consensus with families during this highly emotional phase of care. RESULTS: We found that the enactment of end-of-life decisions were reported as being affected by a form of loss aversion, whereby concerns over the consequences of not reaching a consensus with families weighed heavily in the minds of clinicians. Fear of conflict with families tended to arise from anticipated unrealistic family expectations of care, family normalization of patient incapacity, and belief systems that prohibit end-of-life decision-making. CONCLUSIONS: To support decision makers in reaching consensus, various strategies for effective, coherent, and targeted communication (e.g., on patient deterioration and limits of clinical treatment) were suggested as ways to effectively consult with families on end-of-life decision-making.

Intensivists' beliefs about rapid multiplex molecular diagnostic testing and its potential role in improving prescribing decisions and antimicrobial stewardship: a qualitative study.

BACKGROUND: Rapid molecular diagnostic tests to investigate the microbial aetiology of pneumonias may improve treatment and antimicrobial stewardship in intensive care units (ICUs). Clinicians' endorsement and uptake of these tests is crucial to maximise engagement; however, adoption may be impeded if users harbour unaddressed concerns or if device usage is incompatible with local practice. Accordingly, we strove to identify ICU clinicians' beliefs about molecular diagnostic tests for pneumonias before implementation at the point-of-care. METHODS: We conducted semi-structured interviews with 35 critical care doctors working in four ICUs in the United Kingdom. A clinical vignette depicting a fictitious patient with signs of pneumonia was used to explore clinicians' beliefs about the importance of molecular diagnostics and their concerns. Data were analysed thematically. RESULTS: Clinicians' beliefs about molecular tests could be grouped into two categories: perceived potential of molecular diagnostics to improve antibiotic prescribing (Molecular Diagnostic Necessity) and concerns about how the test results could be implemented into practice (Molecular Diagnostic Concerns). Molecular Diagnostic Necessity stemmed from beliefs that positive results would facilitate targeted antimicrobial therapy; that negative results would signal the absence of a pathogen, and consequently that having the molecular diagnostic results would bolster clinicians' prescribing confidence. Molecular Diagnostic Concerns included unfamiliarity with the device's capabilities, worry that it would detect non-pathogenic bacteria, uncertainty whether it would fail to detect pathogens, and discomfort with withholding antibiotics until receiving molecular test results. CONCLUSIONS: Clinicians believed rapid molecular diagnostics for pneumonias were potentially important and were open to using them; however, they harboured concerns about the tests' capabilities and integration into clinical practice. Implementation strategies should bolster users' necessity beliefs while reducing their concerns; this can be accomplished by publicising the tests' purpose and benefits, identifying and addressing clinicians' misconceptions, establishing a trial period for first-hand familiarisation, and emphasising that, with a swift (e.g., 60-90 min) test, antibiotics can be started and refined after molecular diagnostic results become available.

Learning from complaints in healthcare: a realist review of academic literature, policy evidence and front-line insights.

INTRODUCTION: A global rise in patient complaints has been accompanied by growing research to effectively analyse complaints for safer, more patient-centric care. Most patients and families complain to improve the quality of healthcare, yet progress has been complicated by a system primarily designed for case-by-case complaint handling. AIM: To understand how to effectively integrate patient-centric complaint handling with quality monitoring and improvement. METHOD: Literature screening and patient codesign shaped the review's aim in the first stage of this three-stage review. Ten sources were searched including academic databases and policy archives. In the second stage, 13 front-line experts were interviewed to develop initial practice-based programme theory. In the third stage, evidence identified in the first stage was appraised based on rigour and relevance, and selected to refine programme theory focusing on what works, why and under what circumstances. RESULTS: A total of 74 academic and 10 policy sources were included. The review identified 12 mechanisms to achieve: patient-centric complaint handling and system-wide quality improvement. The complaint handling pathway includes (1) access of information; (2) collaboration with support and advocacy services; (3) staff attitude and signposting; (4) bespoke responding; and (5) public accountability. The improvement pathway includes (6) a reliable coding taxonomy; (7) standardised training and guidelines; (8) a centralised informatics system; (9) appropriate data sampling; (10) mixed-methods spotlight analysis; (11) board priorities and leadership; and (12) just culture. DISCUSSION: If healthcare settings are better supported to report, analyse and use complaints data in a standardised manner, complaints could impact on care quality in important ways. This review has established a range of evidence-based, short-term recommendations to achieve this.

Developing a team performance framework for the intensive care unit.

OBJECTIVE: There is a growing literature on the relationship between teamwork and patient outcomes in intensive care, providing new insights into the skills required for effective team performance. The purpose of this review is to consolidate the most robust findings from this research into an intensive care unit (ICU) team performance framework. DATA SOURCES: Studies investigating teamwork within the ICU using PubMed, Science Direct, and Web of Knowledge databases. STUDY SELECTION: Studies investigating the relationship between aspects of teamwork and ICU outcomes, or studies testing factors that are found to influence team working in the ICU. DATA EXTRACTION: Teamwork behaviors associated with patient or staff-related outcomes in the ICU were identified. DATA SYNTHESIS: Teamwork behaviors were grouped according to the team process categories of "team communication," "team leadership," "team coordination," and "team decision making." A prototype framework explaining the team performance in the ICU was developed using these categories. The purpose of the framework is to consolidate the existing ICU teamwork literature and to guide the development and testing of interventions for improving teamwork. CONCLUSIONS: Effective teamwork is shown as crucial for providing optimal patient care in the ICU. In particular, team leadership seems vital for guiding the way in which ICU team members interact and coordinate with others.