Quality Indicators for Transition from Paediatric to Adult Care for Youth with Chronic Conditions: Protocol for an Online Modified Delphi Study.

BACKGROUND: The transition from paediatric to adult care poses a significant health system-level challenge impeding the delivery of quality health services for youth with chronic health conditions. In Canada and globally, the transition to adult care is regarded as a top priority in adolescent health in need of readily applicable, adaptable, and relevant national metrics to evaluate and benchmark transition success across disease populations and clinical care settings. Unfortunately, existing literature fails to account for the lack of engagement from youth and caregivers in developing indicators, and its applicability across chronic conditions, primary care involvement, and health equity considerations. OBJECTIVE: Our proposed study aims to establish a consensus-driven set of quality indicators for the transition to adult care that are universally applicable across physical, developmental, and/or mental health conditions, clinical care settings, and health jurisdictions. METHODS: Using an integrated knowledge translation (iKT) approach, a panel comprised of youth, caregivers, interdisciplinary healthcare providers, and health system leaders will be established to collaborate with our research team to ensure the study methodology, materials, and knowledge dissemination are suitable and reflect the perspectives of youth and their families. We will then conduct an iterative 3-round Online Modified Delphi (OMD) study (n= 160) to (1) compare and contrast the perspectives of youth, caregivers, health care providers, and health system leaders on quality indicators for transition, and (2) prioritize a key set of quality indicators for transition applicable across disease populations that are the most important, useful, and feasible in the Canadian context. Using the RAND/UCLA Appropriateness Method (RAM) multi-stage analytic approach, data from each panel and stakeholder group will be examined separately and compared to establish a key set of indicators endorsed by both panels. RESULTS: The study is funded by the Canadian Institutes of Health Research and Physicians Services Incorporated. CONCLUSIONS: This study will produce quality indicators to evaluate and inform action equitably to improve transition from paediatric to adult care for youth and their families in Canada.

Patient, caregiver and other knowledge user engagement in consensus-building healthcare initiatives: a scoping review protocol.

INTRODUCTION: Patient engagement and integrated knowledge translation (iKT) processes improve health outcomes and care experiences through meaningful partnerships in consensus-building initiatives and research. Consensus-building is essential for engaging a diverse group of experienced knowledge users in co-developing and supporting a solution where none readily exists or is less optimal. Patients and caregivers provide invaluable insights for building consensus in decision-making around healthcare, policy and research. However, despite emerging evidence, patient engagement remains sparse within consensus-building initiatives. Specifically, our research has identified a lack of opportunity for youth living with chronic health conditions and their caregivers to participate in developing consensus on indicators/benchmarks for transition into adult care. To bridge this gap and inform our consensus-building approach with youth/caregivers, this scoping review will synthesise the extent of the literature on patient and other knowledge user engagement in consensus-building healthcare initiatives. METHODS AND ANALYSIS: Following the scoping review methodology from Joanna Briggs Institute, published literature will be searched in MEDLINE, EMBASE, CINAHL and PsycINFO databases from inception to July 2023. Grey literature will be hand-searched. Two independent reviewers will determine the eligibility of articles in a two-stage process, with disagreements resolved by a third reviewer. Included studies must be consensus-building studies within the healthcare context that involve patient engagement strategies. Data from eligible studies will be extracted and charted on a standardised form. Abstracted data will be analysed quantitatively and descriptively, according to specific consensus methodologies, and patient engagement models and/or strategies. ETHICS AND DISSEMINATION: Ethics approval is not required for this scoping review protocol. The review process and findings will be shared with and informed by relevant knowledge users. Dissemination of findings will also include peer-reviewed publications and conference presentations. The results will offer new insights for supporting patient engagement in consensus-building healthcare initiatives. PROTOCOL REGISTRATION: https://osf.io/beqjr.

Using the Operating Room Black Box to Assess Surgical Team Member Adaptation Under Uncertainty: An Observational Study.

OBJECTIVE: Identify how surgical team members uniquely contribute to teamwork and adapt their teamwork skills during instances of uncertainty. BACKGROUND: The importance of surgical teamwork in preventing patient harm is well documented. Yet, little is known about how key roles (nurse, anesthesiologist, surgeon, and medical trainee) uniquely contribute to teamwork during instances of uncertainty, particularly when adapting to and rectifying an intraoperative adverse event (IAE). METHODS: Audiovisual data of 23 laparoscopic cases from a large community teaching hospital were prospectively captured using OR Black Box. Human factors researchers retrospectively coded videos for teamwork skills (backup behavior, coordination, psychological safety, situation assessment, team decision-making, and leadership) by team role under 2 conditions of uncertainty: associated with an IAE versus no IAE. Surgeons identified IAEs. RESULTS: In all, 1015 instances of teamwork skills were observed. Nurses adapted to IAEs by expressing more backup behavior skills (5.3× increase; 13.9 instances/hour during an IAE vs 2.2 instances/hour when no IAE) while surgeons and medical trainees expressed more psychological safety skills (surgeons: 3.6× increase; 30.0 instances/hour vs 6.6 instances/hour and trainees: 6.6× increase; 31.2 instances/hour vs 4.1 instances/hour). All roles expressed fewer situation assessment skills during an IAE versus no IAE. CONCLUSIONS: OR Black Box enabled the assessment of critically important details about how team members uniquely contribute during instances of uncertainty. Some teamwork skills were amplified, while others dampened when dealing with IAEs. The knowledge of how each role contributes to teamwork and adapts to IAEs should be used to inform the design of tailored interventions to strengthen interprofessional teamwork.

Grand rounds in methodology: key considerations for implementing machine learning solutions in quality improvement initiatives.

Machine learning (ML) solutions are increasingly entering healthcare. They are complex, sociotechnical systems that include data inputs, ML models, technical infrastructure and human interactions. They have promise for improving care across a wide range of clinical applications but if poorly implemented, they may disrupt clinical workflows, exacerbate inequities in care and harm patients. Many aspects of ML solutions are similar to other digital technologies, which have well-established approaches to implementation. However, ML applications present distinct implementation challenges, given that their predictions are often complex and difficult to understand, they can be influenced by biases in the data sets used to develop them, and their impacts on human behaviour are poorly understood. This manuscript summarises the current state of knowledge about implementing ML solutions in clinical care and offers practical guidance for implementation. We propose three overarching questions for potential users to consider when deploying ML solutions in clinical care: (1) Is a clinical or operational problem likely to be addressed by an ML solution? (2) How can an ML solution be evaluated to determine its readiness for deployment? (3) How can an ML solution be deployed and maintained optimally? The Quality Improvement community has an essential role to play in ensuring that ML solutions are translated into clinical practice safely, effectively, and ethically.

Applying an equity lens to hospital safety monitoring: a critical interpretive synthesis protocol.

INTRODUCTION: Hospital safety monitoring systems are foundational to how adverse events are identified and addressed. They are well positioned to bring equity-related safety issues to the forefront for action. However, there is uncertainty about how they have been, and can be, used to achieve this goal. We will undertake a critical interpretive synthesis (CIS) to examine how equity is integrated into hospital safety monitoring systems. METHODS AND ANALYSIS: This review will follow CIS principles. Our initial compass question is: How is equity integrated into safety monitoring systems? We will begin with a structured search strategy of hospital safety monitoring systems in CINAHL, EMBASE, MEDLINE and PsycINFO for up to May 2023 to identify papers on safety monitoring systems generally and those linked to equity (eg, racism, social determinants of health). We will also review reference lists of selected papers, contact experts and draw on team expertise. For subsequent literature searching stages, we will use team expertise and expert contacts to purposively search the social science, humanities and health services research literature to support the development of a theoretical understanding of our topic. Following data extraction, we will use interpretive processes to develop themes and a critique of the literature. The above processes of question formulation, article search and selection, data extraction, and critique and synthesis will be iterative and interactive with the goal to develop a theoretical understanding of equity in hospital monitoring systems that will have practice-based implications. ETHICS AND DISSEMINATION: This review does not require ethical approval because we are reviewing published literature. We aim to publish findings in a peer-reviewed journal and present at conferences.

Reusable personal protective equipment in Canadian healthcare: Safe, secure, and sustainable.

Personal Protective Equipment (PPE) that was intentionally designed and manufactured as reusable, including gowns, goggles, face shields, and elastomeric respirators, took on a heightened role during the pandemic. Healthcare workers who had access to these products and infrastructure for cleaning and sterilizing them had a greater sense of confidence to undertake their jobs due to an increased sense of personal safety. Using multiple data sources, including a literature review, roundtables, interviews, surveys, and Internet-based research, the project team investigated the impact of disposable PPE and role of reusable PPE during the pandemic in Canada. This research supports the claim that adopting and supporting reusable PPE systems throughout the health sector can, if used appropriately on an ongoing basis, provide continuous access to reusable PPE while also contributing many co-benefits, including lower costs, domestic jobs, and improved environmental performance such as reduced waste and greenhouse gas emissions.

Analyzing interprofessional teamwork in the operating room: An exploratory observational study using conventional and alternative approaches.

Intraoperative teamwork is vital for patient safety. Conventional tools for studying intraoperative teamwork typically rely on behaviorally anchored rating scales applied at the individual or team level, while others capture narrative information across several units of analysis. This prospective observational study characterizes teamwork using two conventional tools (Operating Theatre Team Non-Technical Skills Assessment Tool [NOTECHS]; Team Emergency Assessment Measure [TEAM]), and one alternative approach (modified-Systems Engineering Initiative for Patient Safety [SEIPS] model). We aimed to explore the advantages and disadvantages of each for providing feedback to improve teamwork practice. Fifty consecutive surgical cases at a Canadian academic hospital were recorded with the OR Black Box®, analyzed by trained raters, and summarized descriptively. Teamwork performance was consistently high within and across cases rated with NOTECHS and TEAMS. For cases analyzed with the modified-SEIPS tool, both optimal and suboptimal teamwork behaviors were identified, and team resilience was frequently observed. NOTECHS and TEAM provided summative assessments and overall pattern descriptions, while SEIPS facilitated a deeper understanding of teamwork processes. As healthcare organizations continue to prioritize teamwork improvement, SEIPS may provide valuable insights regarding teamwork behavior and the broader context influencing performance. This may ultimately enhance the development and effectiveness of multi-level teamwork interventions.

Cognitive biases in surgery: systematic review.

BACKGROUND: Although numerous studies have established cognitive biases as contributors to surgical adverse events, their prevalence and impact in surgery are unknown. This review aimed to describe types of cognitive bias in surgery, their impact on surgical performance and patient outcomes, their source, and the mitigation strategies used to reduce their effect. METHODS: A literature search was conducted on 9 April and 6 December 2021 using MEDLINE, Embase, PsycINFO, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. Included studies investigated how cognitive biases affect surgery and the mitigation strategies used to combat their impact. The National Institutes of Health tools were used to assess study quality. Inductive thematic analysis was used to identify themes of cognitive bias impact on surgical performance. RESULTS: Thirty-nine studies were included, comprising 6514 surgeons and over 200 000 patients. Thirty-one types of cognitive bias were identified, with overconfidence, anchoring, and confirmation bias the most common. Cognitive biases differentially influenced six themes of surgical performance. For example, overconfidence bias associated with inaccurate perceptions of ability, whereas anchoring bias associated with inaccurate risk-benefit estimations and not considering alternative options. Anchoring and confirmation biases associated with actual patient harm, such as never events. No studies investigated cognitive bias source or mitigation strategies. CONCLUSION: Cognitive biases have a negative impact on surgical performance and patient outcomes across all points of surgical care. This review highlights the scarcity of research investigating the sources that give rise to cognitive biases in surgery and the mitigation strategies that target these factors.

Effects of Unit Census and Patient Acuity Levels on Discussions During Patient Rounds.

OBJECTIVES: PICU teams adapt the duration of patient rounding discussions to accommodate varying contextual factors, such as unit census and patient acuity. Although studies establish that shorter discussions can lead to the omission of critical patient information, little is known about how teams adapt their rounding discussions about essential patient topics (i.e., introduction/history, acute clinical status, care plans) in response to changing contexts. To fill this gap, we examined how census and patient acuity impact time spent discussing essential topics during individual patient encounters. DESIGN: Observational study. SETTING: PICU at a university-affiliated children's hospital, Toronto, ON, Canada. SUBJECTS: Interprofessional morning rounding teams. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We observed 165 individual patient encounters during morning rounds over 10 weeks. Regardless of census or patient acuity, the duration of patient introductions/history did not change. When census was high versus low, acute clinical status discussions significantly decreased for both low acuity patients (00 min:50 s high census; 01 min:39 s low census; -49.5% change) and high acuity patients (01 min:10 s high census; 02 min:02 s low census; -42.6% change). Durations of care plan discussions significantly reduced as a function of census (01 min:19 s high census; 02 min:52 s low census; -54.7% change) for low but not high acuity patients. CONCLUSIONS: Under high census and patient acuity levels, rounding teams disproportionately shorten time spent discussing essential patient topics. Of note, while teams preserved time to plan the care for acute patients, they cut care plan discussions of low acuity patients. This study provides needed detail regarding how rounding teams adapt their discussions of essential topics and establishes a foundation for consideration of varying contextual factors in the design of rounding guidelines. As ICUs are challenged with increasing census and patient acuity levels, it is critical that we turn our attention to these contextual aspects and understand how these adaptations impact clinical outcomes to address them.

Decision-centered design of a clinical decision support system for acute management of pediatric congenital heart disease.

Background and Objectives: Children with congenital heart disease (CHD), have fragile hemodynamics and can deteriorate due to common childhood illnesses and the natural progression of their disease. During these acute periods of deterioration, these children often present to their local emergency departments (ED) where expertise in CHD is limited, and appropriate intervention is crucial to their survival. Previous studies identified that determining the appropriate intervention for CHD patients can be difficult for ED physicians, particularly since key components of effective decision making are not being met. Although key components of effective decision making for ED physicians have been identified, they have yet to be transformed into actionable guidance. We used decision centered design (DCD) to translate key components of decision making into decision requirements and associated design concepts, that we subsequently incorporated into a prototype clinical decision support system (CDSS). Methods: Using framework analysis, transcripts from Critical Decision Method interviews of CHD experts and ED physicians were inductively coded to identify key decision requirements for ED physicians that are currently not well supported, and their associated design concepts. A design workshop was held to refine the identified key decision requirements and design concepts as well as to sketch information that would satisfy the identified requirements. These were iteratively incorporated into a prototype CDSS. Results: Three decision requirements: (1) distinguish the patient's unique physiology based on their unique cardiac anatomy, (2) explicitly consider CHD specific differential diagnoses to allow a more structured reflection of diagnosis, and (3) select CHD appropriate interventions for each patient, were identified. These requirements along with design concepts and information needs identified through the design workshop were incorporated into the CDSS prototype. Conclusion: We identified key decision requirements and associated design concepts, that informed the design of a CDSS to provide actionable guidance for ED physicians when managing CHD patients. Meeting ED physicians' decision components with a CDSS requires the translation of their key decision requirements in its design. If not, we risk creating designs that interfere with clinician performance.

Impact of technology-assisted versus manual sterile compounding on safety and efficiency in a Canadian community hospital.

PURPOSE: Interventions to improve the safety and efficiency of manual sterile compounding are needed. This study evaluated the impact of a technology-assisted workflow system (TAWS) on sterile compounding safety (checks, traceability, and error detection), and efficiency (task time). METHODS: Observations were conducted in an oncology pharmacy transitioning from a manual to a TAWS process for sterile compounding. Process maps were generated to compare manual and TAWS checks and traceability. The numbers and types of errors detected were collected, and task times were observed directly or via TAWS data logs. RESULTS: Analysis of safety outcomes showed that, depending on preparation type, 3 to 4 product checks occurred in the manual process, compared to 6 to 10 checks with TAWS use. TAWS checks (barcoding and gravimetric verification) produced better traceability (documentation). The rate of incorrect-drug errors decreased with technology-assisted compounding (from 0.4% [5 of 1,350 preparations] with the manual process to 0% [0 of 1,565 preparations] with TAWS use; P < 0.02). The TAWS increased detection of (1) errors in the amount of drug withdrawn from vials (manual vs TAWS, 0.4% [5/1,350] vs 1.2% [18/1565]; P < 0.02), and (2) errors in the amount of drug injected into the final container (manual vs TAWS, 0% [0/1,236] vs 0.9% [11/1,272]; P < 0.002). With regard to efficiency outcomes, TAWS use increased the mean mixing time (manual vs TAWS, 275 seconds vs 355 seconds; P < 0.001), had no significant impact on average visual checking time (manual vs TAWS, 21.4 seconds vs 21.6 seconds), and decreased average physical checking time (manual vs TAWS, 58.6 seconds vs 50.9 seconds; P < 0.001). CONCLUSION: In comparison to manual sterile compounding, use of the TAWS improved safety through more frequent and rigorous checks, improved traceability (via superior documentation), and enhanced error detection. Results related to efficiency were mixed.

Effect of the surgical safety checklist on provider and patient outcomes: a systematic review.

BACKGROUND: Despite being implemented for over a decade, literature describing how the surgical safety checklist (SSC) is completed by operating room (OR) teams and how this relates to its effectiveness is scarce. This systematic review aimed to: (1) quantify how many studies reported SSC completion versus described how the SSC was completed; (2) evaluate the impact of the SSC on provider outcomes (Communication, case Understanding, Safety Culture, CUSC), patient outcomes (complications, mortality rates) and moderators of these relationships. METHODS: A systematic literature search was conducted using Medline, CINAHL, Embase, PsycINFO, PubMed, Scopus and Web of Science on 10 January 2020. We included providers who treat human patients and completed any type of SSC in any OR or simulation centre. Statistical directional findings were extracted for provider and patient outcomes and key factors (eg, attentiveness) were used to determine moderating effects. RESULTS: 300 studies were included in the analysis comprising over 7 302 674 operations and 2 480 748 providers and patients. Thirty-eight per cent of studies provided at least some description of how the SSC was completed. Of the studies that described SSC completion, a clearer positive relationship was observed concerning the SSC's influence on provider outcomes (CUSC) compared with patient outcomes (complications and mortality), as well as related moderators. CONCLUSION: There is a scarcity of research that examines how the SSC is completed and how this influences safety outcomes. Examining how a checklist is completed is critical for understanding why the checklist is successful in some instances and not others.

Understanding Clinician Macrocognition to Inform the Design of a Congenital Heart Disease Clinical Decision Support System.

BACKGROUND AND OBJECTIVES: Children with congenital heart disease (CHD) are at risk of deterioration in the face of common childhood illnesses, and their resuscitation and acute treatment requires guidance of CHD experts. Many children with CHD, however, present to their local emergency departments (ED) with gastrointestinal and respiratory symptoms that closely mimic symptoms of CHD related heart failure. This can lead to incorrect or delayed diagnosis and treatment where CHD expertise is limited. An understanding of the differences in cognitive decision-making processes between CHD experts and ED physicians can inform how best to support ED physicians when treating CHD patients. METHODS: Cardiac intensivists (CHD experts) and pediatric emergency department physicians (ED physicians) in a major academic cardiac center were interviewed using the critical decision method. Interview transcripts were coded deductively based on Schubert and Klein's macrocognitive frameworks and inductively to allow for new or modified characterization of dimensions. RESULTS: In total, 6 CHD experts and 7 ED physicians were interviewed for this study. Although both CHD experts and ED physicians spent a lot of time sensemaking, their approaches to sensemaking differed. CHD experts reported readily recognizing the physiology of complex congenital heart disease and focused primarily on ruling out cardiac causes for the presenting illness. ED physicians reported a delay in attributing the signs and symptoms of the presenting illness to congenital heart disease, because these clinical findings were often non-specific, and thus explored different diagnoses. CHD experts moved quickly to treatment and more time anticipating potential problems and making specific contingency plans, while ED physicians spent more time gathering a range of data prior to arriving at a diagnosis. These findings were then applied to develop a prototype web-based decision support application for patients with CHD. CONCLUSION: There are differences in the cognitive processes used by CHD experts and ED physicians when managing CHD patients. An understanding of differences in the cognitive processes used by CHD experts and ED physicians can inform the development of potential interventions, such as clinical decision support systems and training pathways, to support decision making pertaining to the acute treatment of pediatric CHD patients.

Vulnerabilities for Drug Diversion in the Handling, Data Entry, and Verification Tasks of 2 Inpatient Hospital Pharmacies: Clinical Observations and Healthcare Failure Mode and Effect Analysis.

OBJECTIVES: Inpatient hospital pharmacies have a central role in managing controlled substances (CS) throughout the hospital medication use process (MUP). Our objectives were to identify vulnerabilities for diversion in the MUPs of 2 inpatient pharmacies, explore differences between the sites, and characterize the types of vulnerabilities identified. METHODS: We conducted clinical observations in 2 pharmacies to map their MUPs and performed a healthcare failure mode and effect analysis to proactively identify (1) the critical failure modes (CFMs) that make them vulnerable to diversion and (2) the controls that prevent, mitigate, or enhance the detectability of CFMs. RESULTS: We conducted 99 hours of observations between May-June and September-October 2018. We observed 36 pharmacy technicians, 4 pharmacists, and 1 clerk as they conducted tasks involving 4 processes common to both sites: procuring CS, receiving CS deliveries to the pharmacy, unit-dose packaging CS oral solids, and distributing CS to hospital units. The tasks and subtasks we mapped in the process flow diagrams led to the identification of 220 failure modes. Of these, 34 were deemed CFMs and were categorized as related to handling CS, data entry, or verification tasks. Three of the CFMs were unique to one site, given that the other site had a control for the CFM. CONCLUSIONS: Multiple vulnerabilities for diversion exist in inpatient pharmacy processes. Our results provide some much needed detail about how specific vulnerabilities in MUP tasks and subtasks lead to an increased risk of diversion.

Human Factors Analysis of Latent Safety Threats in a Pediatric Critical Care Unit.

OBJECTIVES: To identify unique latent safety threats spanning routine pediatric critical care activities and categorize them according to their underlying work system factors (i.e., "environment, organization, person, task, tools/technology") and associated clinician behavior (i.e., "legal": expected compliance with or "illegal-normal": deviation from and "illegal-illegal": disregard for standard policies and protocols). DESIGN: A prospective observational study with contextual inquiry of clinical activities over a 5-month period. SETTING: Two PICUs (i.e., medical-surgical ICU and cardiac ICU) in an urban free-standing quaternary children's hospital. SUBJECTS: Attending physicians and trainees, nurse practitioners, registered nurses, respiratory therapists, dieticians, pharmacists, and patient services assistants were observed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Conducted 188 hours of observations to prospectively identify unique latent safety threats. Qualitative observational notes were analyzed by human factors experts using a modified framework analysis methodology to summarize latent safety threats and categorize them based on associated clinical activity, predominant work system factor, and clinician behavior. Two hundred twenty-six unique latent safety threats were observed. The latent safety threats were categorized into 13 clinical activities and attributed to work system factors as follows: "organization" (n = 83; 37%), "task" (n = 52; 23%), "tools/technology" (n = 40; 18%), "person" (n = 32; 14%), and "environment" (n = 19; 8%). Twenty-three percent of latent safety threats were identified when staff complied with policies and protocols (i.e., "legal" behavior) and 77% when staff deviated from policies and protocols (i.e., "illegal-normal" behavior). There was no "illegal-illegal" behavior observed. CONCLUSIONS: Latent safety threats span various pediatric critical care activities and are attributable to many underlying work system factors. Latent safety threats are present both when staff comply with and deviate from policies and protocols, suggesting that simply reinforcing compliance with existing policies and protocols, the common default intervention imposed by healthcare organizations, will be insufficient to mitigate safety threats. Rather, interventions must be designed to address the underlying work system threats. This human factors informed framework analysis of observational data is a useful approach to identifying and understanding latent safety threats and can be used in other clinical work systems.

Effect of clinical decision support systems on emergency medicine physicians' decision-making: A pilot scenario-based simulation study.

Background and objectives: Children with congenital heart disease (CHD) are predisposed to rapid deterioration in the face of common childhood illnesses. When they present to their local emergency departments (ED) with acute illness, rapid and accurate diagnosis and treatment is crucial to recovery and survival. Previous studies have shown that ED physicians are uncomfortable caring for patients with CHD and there is a lack of actionable guidance to aid in their decision making. To support ED physicians' key decision components (sensemaking, anticipation, and managing complexity) when managing CHD patients, a Clinical Decision Support System (CDSS) was previously designed. This pilot study evaluates the effect of this CDSS on ED physicians' decision making compared to usual care without clinical decision support. Methods: In a pilot scenario-based simulation study with repeated measures, ED physicians managed mock CHD patients with and without the CDSS. We compared ED physicians' CHD-specific and general decision-making processes (e.g., recognizing sepsis, starting antibiotics, and managing symptoms) with and without the use of CDSS. The frequency of participants' utterances related to each key decision components of sensemaking, anticipation, and managing complexity were coded and statistically analyzed for significance. Results: Across all decision-making components, the CDSS significantly increased ED physicians' frequency of "CHD specific utterances" (Mean = 5.43, 95%CI: 3.7-7.2) compared to the without CDSS condition (Mean = 2.05, 95%CI: 0.3-3.8) whereas there was no significant difference in frequencies of "general utterances" when using CDSS (Mean = 4.62, 95%CI: 3.1-6.1) compared to without CDSS (Mean = 5.14 95%CI: 4.4-5.9). Conclusion: A CDSS that integrates key decision-making components (sensemaking, anticipation, and managing complexity) can trigger and enrich communication between clinicians and enhance the clinical management of CHD patients. For patients with complex and subspecialized diseases such as CHD, a well-designed CDSS can become part of a multifaceted solution that includes knowledge translation, broader communication around interpretation of information, and access to additional expertise to support CHD specific decision-making.

Developing the first pan-Canadian survey on patient engagement in patient safety.

BACKGROUND: Patient safety is a worldwide problem, and the patient contribution to mitigate the risk of patient harm is now recognized as a cornerstone to its solution. In order to understand the nature of integrating patients into patient safety and healthcare organizations and to monitor their integration, a Canadian survey tool has been co-constructed by patients, researchers and the Canadian Patient Safety Institute (CPSI). This questionnaire has been adapted from the French version of the patient engagement (PE) in patient safety (PS) questionnaire created for the province of Quebec, Canada. METHODOLOGY: The pan-Canadian PE in PS survey tool was developed in a five-step process: (1) a literature review and revision of the initial tool developed in the province of Quebec; (2) translation of the French questionnaire into an English version tool; (3) creation of a Canadian expert advisory group; (4) adaptation of the English version tool based on feedback from the expert advisory group (assessment and development of the construct's dimensions, wording assessment and adaptation for pan-Canadian use, technical testing of the online platform for the survey); and (5) pilot testing and pre-validation of the tool before pan-Canadian use. RESULTS AND CONCLUSION: Eight pan-Canadian PE in PS surveys were completed from five Canadian provinces by the expert advisory group and six surveys were completed during the pilot project by participants from different provinces in Canada. This survey tool comprises 5 sections: (1) demographic identification of the participants (Q1 to Q5); (2) general questions (Q6 to Q17); (3) the patient engagement process (experience level of participants and organizational incentives for PE in general) (Q18 to Q33); (4) PE in PS processes, such as current activities, strategies, structures, resources and factors (Q34 to Q67); and (5) the context and impact of PE in PS initiatives in Canadian healthcare organizations (CHOs) (Q68 to Q75), including outcome identification, improvement mechanisms and strategies, evaluation mechanisms, and indicators.

Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review.

INTRODUCTION: Trauma resuscitation is a complex and time-sensitive endeavour with significant risk for error. These errors can manifest from sequential system, team and knowledge-based failures, defined as latent safety threats (LSTs). In situ simulation (ISS) provides a novel prospective approach to recreate clinical situations that may manifest LSTs. Using ISS coupled with a human factors-based video review and modified framework analysis, we sought to identify and quantify LSTs within trauma resuscitation scenarios. METHODS: At a level 1 trauma centre, we video recorded 12 monthly unannounced ISS to prospectively identify trauma-related LSTs. The on-call multidisciplinary trauma team participated in the study. Using a modified framework analysis, human factors experts transcribed and coded the videos. We identified LST events, categorised them into themes and subthemes and used a hazard matrix to prioritise subthemes requiring intervention. RESULTS: We identified 843 LST events during 12 simulations, categorised into seven themes and 38 subthemes, of which 23 are considered critical. The seven themes relate to physical workspace, mental model formation, equipment, unclear accountability, demands exceeding individuals' capacity, infection control and task-specific issues. The physical workspace theme accounted for the largest number of critical LST events (n=152). We observed differences in LST events across the four scenarios; complex scenarios had more LST events. CONCLUSIONS: We identified a diverse set of critical LSTs during trauma resuscitations using ISS coupled with video-based framework analysis. The hazard matrix scoring, in combination with detailed LST subthemes, supported identification of critical LSTs requiring intervention and enhanced efforts intended to improve patient safety. This approach may be useful to others who seek to understand the contributing factors to common LSTs and design interventions to mitigate them.

Impact of an Electronic Decision-Support System on Nursing Triage Process: A Usability and Workflow Analysis.

PURPOSE: To qualitatively contrast emergency department triage workflow using a paper-based triage system and an electronic decision-support tool (electronic Canadian Triage and Acuity Scale (eCTAS)). METHODS: Triage nurses from a single institution were invited to perform triage assessments of mock patients using a paper-based triage system and eCTAS. These assessments were completed using simulation scenarios, some of which involved facilitators probing triage nurses' thoughts on the design of the eCTAS system. Participants were asked to "think aloud," describing their thought patterns as they completed the triage process. Similar patient scenarios with the same Canadian Emergency Department Information System (CEDIS) presenting complaint and triage score were used for comparison between paper-based triage and electronic decision-support tool (eCTAS) conditions. RESULTS: Eight participants completed at least two simulation scenarios for each condition and at least one usability scenario with eCTAS. The simulated encounters showed eCTAS provided several advantages to paper-based triage assessment process by shortlisting possible CEDIS complaints and preselecting relevant modifiers. However, usability concerns were identified with eCTAS including challenges related to data entry and eCTAS score overrides. CONCLUSIONS: Our study highlights several positive features of eCTAS and usability issues that should be addressed to enhance the intended use of eCTAS and support user adoption.