The impact of resident training on robotic operative times: is there a July Effect?

It is unknown whether the July Effect (a theory that medical errors and organizational inefficiencies increase during the influx of new surgical residents) exists in urologic robotic-assisted surgery. The aim of this study was to investigate the impact of urology resident training on robotic operative times at the beginning of the academic year. A retrospective chart review was conducted for urologic robotic surgeries performed at a single institution between 2008 and 2019. Univariate and multivariate mix model analyses were performed to determine the association between operative time and patient age, estimated blood loss, case complexity, robotic surgical system (Si or Xi), and time of the academic year. Differences in surgery time and non-surgery time were assessed with/without resident presence. Operative time intervals were included in the analysis. Resident presence correlated with increased surgery time (38.6 min (p < 0.001)) and decreased non-surgery time (4.6 min (p < 0.001)). Surgery time involving residents decreased by 8.7 min after 4 months into the academic year (July-October), and by an additional 5.1 min after the next 4 months (p = 0.027, < 0.001). When compared across case types stratified by complexity, surgery time for cases with residents significantly varied. Cases without residents did not demonstrate such variability. Resident presence was associated with prolonged surgery time, with the largest effect occurring in the first 4 months and shortening later in the year. However, resident presence was associated with significantly reduced non-surgery time. These results help to understand how new trainees impact operating room times.

What is the effectiveness of reporting systems in promoting learning in healthcare?

Patient safety in healthcare remains a top priority. Learning from safety events is vital to move towards safer systems. As a result, reporting systems are recognised as the cornerstone of safety, especially in high-risk industries. However, in healthcare, the benefits of reporting systems in promoting learning remain contentious. Though the strengths of these systems, such as promoting a safety culture and providing information from near misses are noted, there are problems that mean learning is missed. Understanding the factors that both enable and act as barriers to learning from reporting is also important to consider. This review, considers the effectiveness of reporting systems in contributing to learning in healthcare.

Medical Error Prevalence, Nursing Power, and Structural Empowerment: A Serial Mediation Analysis.

Aim: To investigate how structural empowerment and power may contribute to and predict the reduction of medical errors. Background: Medical errors threaten patient well-being, leading to adverse outcomes. Improving work conditions holds promise for reducing medical errors among nurses. Methods: A multisite correlational cross-sectional design was utilized. Data were completed by 375 nurses from four hospitals in Jordan. Data collection occurred between September and November 2023 using sociodemographic, structural empowerment, and medical error questionnaires. The study employed descriptive statistics, Pearson r correlation, and serial mediation analysis. Informed consent was obtained from each participant. Results: Pearson r correlation revealed significant negative correlations between medical error and structural empowerment, formal power, and informal power. The conceptual framework was significant and predicted 16% of the variance in medical errors. The mediation analysis confirmed that formal power and informal power mediate the relationship between structural empowerment and medical error. Conclusions and Implications. This study sheds light on the intricate connection of structural empowerment, formal and informal power, and their collective impact on reducing medical errors. Understanding and addressing these dynamics allows nurses and administrators to achieve a culture of patient safety. Reduction of medical errors is paramount to a safe healthcare environment that prioritizes patient outcomes. Strategies should be fostered to enhance structural empowerment, refine formal power structures, and leverage the positive aspects of informal networks.

A scoping review of the methodological approaches used in retrospective chart reviews to validate adverse event rates in administrative data.

Patient safety is a key quality issue for health systems. Healthcare acquired adverse events (AEs) compromise safety and quality; therefore, their reporting and monitoring is a patient safety priority. Although administrative datasets are potentially efficient tools for monitoring rates of AEs, concerns remain over the accuracy of their data. Chart review validation studies are required to explore the potential of administrative data to inform research and health policy. This review aims to present an overview of the methodological approaches and strategies used to validate rates of AEs in administrative data through chart review. This review was conducted in line with the Joanna Briggs Institute methodological framework for scoping reviews. Through database searches, 1054 sources were identified, imported into Covidence, and screened against the inclusion criteria. Articles that validated rates of AEs in administrative data through chart review were included. Data were extracted, exported to Microsoft Excel, arranged into a charting table, and presented in a tabular and descriptive format. Fifty-six studies were included. Most sources reported on surgical AEs; however, other medical specialties were also explored. Chart reviews were used in all studies; however, few agreed on terminology for the study design. Various methodological approaches and sampling strategies were used. Some studies used the Global Trigger Tool, a two-stage chart review method, whilst others used alternative single-, two-stage, or unclear approaches. The sources used samples of flagged charts (n = 24), flagged and random charts (n = 11), and random charts (n = 21). Most studies reported poor or moderate accuracy of AE rates. Some studies reported good accuracy of AE recording which highlights the potential of using administrative data for research purposes. This review highlights the potential for administrative data to provide information on AE rates and improve patient safety and healthcare quality. Nonetheless, further work is warranted to ensure that administrative data are accurate. The variation of methodological approaches taken, and sampling techniques used demonstrate a lack of consensus on best practice; therefore, further clarity and consensus are necessary to develop a more systematic approach to chart reviewing.

AAPM WGPE report 394: Simulated error training for the physics plan and chart review.

BACKGROUND: Simulated error training is a method to practice error detection in situations where the occurrence of error is low. Such is the case for the physics plan and chart review where a physicist may check several plans before encountering a significant problem. By simulating potentially hazardous errors, physicists can become familiar with how they manifest and learn from mistakes made during a simulated plan review. PURPOSE: The purpose of this project was to develop a series of training datasets that allows medical physicists and trainees to practice plan and chart reviews in a way that is familiar and accessible, and to provide exposure to the various failure modes (FMs) encountered in clinical scenarios. METHODS: A series of training datasets have been developed that include a variety of embedded errors based on the risk-assessment performed by American Association of Physicists in Medicine (AAPM) Task Group 275 for the physics plan and chart review. The training datasets comprise documentation, screen shots, and digital content derived from common treatment planning and radiation oncology information systems and are available via the Cloud-based platform ProKnow. RESULTS: Overall, 20 datasets have been created incorporating various software systems (Mosaiq, ARIA, Eclipse, RayStation, Pinnacle) and delivery techniques. A total of 110 errors representing 50 different FMs were embedded with the 20 datasets. The project was piloted at the 2021 AAPM Annual Meeting in a workshop where participants had the opportunity to review cases and answer survey questions related to errors they detected and their perception of the project's efficacy. In general, attendees detected higher-priority FMs at a higher rate, though no correlation was found between detection rate and the detectability of the FMs. Familiarity with a given system appeared to play a role in detecting errors, specifically when related to missing information at different locations within a given software system. Overall, 96% of respondents either agreed or strongly agreed that the ProKnow portal and training datasets were effective as a training tool, and 75% of respondents agreed or strongly agreed that they planned to use the tool at their local institution. CONCLUSIONS: The datasets and digital platform provide a standardized and accessible tool for training, performance assessment, and continuing education regarding the physics plan and chart review. Work is ongoing to expand the project to include more modalities, radiation oncology treatment planning and information systems, and FMs based on emerging techniques such as auto-contouring and auto-planning.

Management of adverse events in a Moroccan regional hospital: a state of art and perspectives.

Introduction: the risk management system is useful to identify, analyze, and reduce the risk occurrence of adverse events (AEs) in health services. This system suggests useful improvements to patients and to the whole institution and also contributes to the acquisition of a collective and organizational safety culture. This study presented a state of the art of the management of AEs identified in different services of a regional hospital in the north of Morocco. Methods: this is a retrospective cross-sectional exploratory study carried out from 2017 to 2019 using observations and semi-structured interviews, which were recorded, re-transcribed, and analyzed. Data was also collected from audit reports, results of investigations of the nosocomial infection control committee and the risk management commission, AEs declaration sheets, and meetings reports. Results: a number of 83 AEs were recorded, 10 of which were urgent. The reported events were related to care, infection risk, the drugs circuit, and medico-technical events. Two hundred cases of nosocomial infections were also recorded, of which 75 occurred in the intensive care unit and 35 in the maternity service. Surgical site infections were the most frequently reported complication. Adverse events were related to organizational failure, equipment problems, and errors related to professional practices. Conclusion: our findings may guide the improvement of the event management system in order to reduce the occurrence of future incidents. Thus, improving the risk management system requires setting up training strategies for staff on the importance of this system and its mode of operation.

Exploring medical and nursing students' perceptions about a patient safety course: a qualitative study.

BACKGROUND: Educating health professionals on patient safety can potentially reduce healthcare-associated harm. Patient safety courses have been incorporated into medical and nursing curricula in many high-income countries and their impact has been demonstrated in the literature through objective assessments. This study aimed to explore student perceptions about a patient safety course to assess its influence on aspiring health professionals at a personal level as well as to explore differences in areas of focus between medical and nursing students. METHODS: A dedicated patient safety course was introduced for year III medical and year II and IV nursing students at the Aga Khan University (2021-2022). As part of a post-course assessment, 577 participating students (184 medical and 393 nursing) wrote reflections on the course, detailing its influence on them. These free-text responses were thematically analyzed using NVivo. RESULTS: The findings revealed five major themes: acquired skills (clinical, interpersonal), understanding of medical errors (increased awareness, prevention and reduction, responding to errors), personal experiences with patient safety issues, impact of course (changed perceptions, professional integrity, need for similar sessions, importance of the topic) and course feedback (format, preparation for clinical years, suggestions). Students reported a lack of baseline awareness regarding the frequency and consequences of medical errors. After the course, medical students reported a perceptional shift in favor of systems thinking regarding error causality, and nursing students focused on human factors and error prevention. The interactive course format involving scenario-based learning was deemed beneficial in terms of increasing awareness, imparting relevant clinical and interpersonal skills, and changing perspectives on patient safety. CONCLUSIONS: Student perspectives illustrate the benefits of an early introduction of dedicated courses in imparting patient safety education to aspiring health professionals. Students reported a lack of baseline awareness of essential patient safety concepts, highlighting gaps in the existing curricula. This study can help provide an impetus for incorporating patient safety as a core component in medical and nursing curricula nationally and across the region. Additionally, patient safety courses can be tailored to emphasize areas identified as gaps among each professional group, and interprofessional education can be employed for shared learning. The authors further recommend conducting longitudinal studies to assess the long-term impact of such courses.

Molar root canal treatment performed by undergraduate dental students; an observational study of procedural errors and student perception.

BACKGROUND: Molar root canal treatment (RCT) is challenging and requires training and specific skills. Rotary instrumentation (RI) reduces the time needed for instrumentation but may increase the risk of certain procedural errors. The aims of this study were to evaluate the quality of molar RCTs provided by undergraduate students, to compare the prevalence of procedural errors following manual and RI, and to assess the students' self-perceived confidence to perform molar RCT without supervision and their preference for either manual or RI. METHODS: Molar RCTs performed by the final year students were evaluated radiographically according to predefined criteria (Appendix 1). The procedural errors, treatment details, and the students' self-perceived confidence to perform molar RCT and their preference for either manual or RI were recorded. Descriptive statistics were performed, and the Chi-squared test was used to detect any statistically significant differences. RESULTS: 60.4% of RCTs were insufficient. RI resulted in more sufficient treatments compared with MI (49% vs. 30.3% respectively. X2: 7.39, p = 0.007), required fewer visits to complete (2.9 vs. 4.6 respectively. X2: 67.23, p < 0.001) and was the preferred technique by 93.1% of students. The most common procedural errors were underextension of the root canal obturation (48.4%), insufficient obturation (45.5%), and improper coronal seal (35.2%) without a significant difference between the two techniques. 26.4% of the participating students reported that they did not feel confident to perform molar RCT without supervision. CONCLUSION: The quality of molar RCT provided by UG students was generally insufficient. RI partially improved the technical quality of RCT compared with MI. UG students need further endodontic training and experience before they can safely and confidently practise molar RCT.

[Handoffs in the intensive care unit]. / Übergaben auf der Intensivstation.

BACKGROUND: Effective handoffs in the intensive care unit (ICU) are key to patient safety. PURPOSE: This article aims to raise awareness of the significance of structured and thorough handoffs and highlights possible challenges as well as means for improvement. MATERIALS AND METHODS: Based on the available literature, the evidence regarding handoffs in ICUs is summarized and suggestions for practical implementation are derived. RESULTS: The quality of handoffs has an impact on patient safety. At the same time, communication in the intensive care setting is particularly challenging due to the complexity of cases, a disruptive work environment, and a multitude of inter- and intraprofessional interactions. Hierarchical team structures, deficiencies in feedback and error-management culture, (technical) language barriers in communication, as well as substantial physical and psychological stress may negatively influence the effectiveness of handoffs. Sets of interventions such as the implementation of checklists, mnemonics, and communication workshops contribute to a more structured and thorough handoff process and have the potential to significantly improve patient safety. CONCLUSION: Effective handoffs are the cornerstone of high-quality and safe patient care but face particular challenges in ICUs. Interventional measures such as structuring handoff concepts and periodic communication trainings can help to improve handoffs and thus increase patient safety.

Be careful about what you wish for in NHS patient safety reform.

John Tingle and Amanda Cattini discuss some recent reports on potential changes to litigation procedures for patient harm cases and to the Never Events framework.

Application of Global Trigger Tools in University Hospital and Comparison to Volunteer Adverse Events Reporting System.

BACKGROUND: A voluntary reporting system (VRS) is still used to detect adverse events (AEs) in health-care services in many countries. We attempted to apply the Global Trigger Tool (GTT) for the first time in our country and searched for an answer to the question of whether there could be new triggers. METHODS: Two hundred and forty inpatient records were selected from total of 1,807 inpatient files in the university obstetrics and gynecology clinic between 2018 and 2020. Twenty files per month were reviewed retrospectively using GTT, an approach developed by the American Institute for Health Development. VRS records of the same period were examined. The data were evaluated according to the National Coordinating Council for Medication Error Reporting and Prevention scale and those in the E, F, G, H, I categories were included. RESULTS: The number of AEs per 1,000 patient days was 47.81, AEs per 1,000 patient hospitalizations was 95.83, and hospitalizations with AEs was 9.58%. In the VRS data, 10 of 85 reporting cases were listed in the E category (Damage is temporary and requires intervention), 6 of them were related to fall of the patient, and 4 of them were related to medical device and material safety. By applying GTT, 45 cases in category E and 35 cases in category F (Damage is temporary and requires hospitalization or prolonged hospitalization) AEs were detected in 23 patients (9.58%). The number of AEs reported was 8.3 times higher in the GTT than with VRS. Healthcare related infection, development of complications from any procedure, APTT>100 Seconds, INR>6, Organ Injury - Repair or Removal, All Kinds of Operative Complications were found to be the most sensitive triggers (PPV = 100). There was no difference between the patients with and without AEs in terms of age and number of hospitalization days (p: 0.707, p: 0.618). The sensitivity rate of vaginal dinoprostone use and CRP elevation (30% and 22%, respectively) was higher than the mean sensitivity rate of GTT triggers (15.6%). CONCLUSIONS: The GTT is more effective than VRS in detecting AEs. Using vaginal dinoprostone (propess) and high CRP levels could be used as a trigger. The GTT is a credible and fruitful instrument for determining AEs when adapted to the departmental practices.

A perioperative overview of a retained surgical swab in spinal surgery: Case report and prevention protocol.

INTRODUCTION: Retained wound swabs although classified as a 'never event' and well documented in many surgical specialties are uncommon in spinal surgery. The aim of this article is to highlight the perioperative circumstances of an incident of a retained surgical swab and present a prevention protocol, in an attempt to eliminate its incidence. CASE REPORT: The perioperative management of a 53-year-old male undergoing spinal surgery in whom a surgical swab was retained is reported. In addition to existing safety procedures such as the World Health Organization checklist, a Retained Surgical Swab-Prevention Protocol was implemented in our hospital and is presented to eliminate the occurrence of this 'never event' occurring again. CONCLUSION: Retained surgical swabs or instruments are rare in spinal surgery occurring mostly in the lumbar spine, during emergency and prolonged procedures in patients with high body mass index. Maintaining a high index of suspicion and utilising a prevention protocol will prevent further harm to the patient.

How different countries respond to adverse events whilst patients' rights are protected.

Patient safety is high on the policy agenda internationally. Learning from safety incidents is a core component in achieving the important goal of increasing patient safety. This study explores the legal frameworks in the countries to promote reporting, disclosure, and supporting healthcare professionals (HCPs) involved in safety incidents. A cross-sectional online survey was conducted to ascertain an overview of the legal frameworks at national level, as well as relevant policies. ERNST (The European Researchers' Network Working on Second Victims) group peer-reviewed data collected from countries was performed to validate information. Information from 27 countries was collected and analyzed, giving a response rate of 60%. A reporting system for patient safety incidents was in place in 85.2% (N = 23) of countries surveyed, though few (37%, N = 10) were focused on systems-learning. In about half of the countries (48.1%, N = 13) open disclosure depends on the initiative of HCPs. The tort liability system was common in most countries. No-fault compensation schemes and alternative forms of redress were less common. Support for HCPs involved in patient safety incidents was extremely limited, with just 11.1% (N = 3) of participating countries reporting that supports were available in all healthcare institutions. Despite progress in the patient safety movement worldwide, the findings suggest that there are considerable differences in the approach to the reporting and disclosure of patient safety incidents. Additionally, models of compensation vary limiting patients' access to redress. Finally, the results highlight the need for comprehensive support for HCPs involved in safety incidents.

Patient safety incidents in endoscopy: a human factors analysis of nonprocedural significant harm incidents from the National Reporting and Learning System (NRLS).

BACKGROUND: Despite advances in understanding and reducing the risk of endoscopic procedures, there is little consideration of the safety of the wider endoscopy service. Patient safety incidents (PSIs) still occur. We sought to identify nonprocedural PSIs (nPSIs) and their causative factors from a human factors perspective and generate ideas for safety improvement. METHODS: Endoscopy-specific PSI reports were extracted from the National Reporting and Learning System (NRLS). A retrospective, cross-sectional human factors analysis of data was performed. Two independent researchers coded data using a hybrid thematic analysis approach. The Human Factors Analysis and Classification System (HFACS) was used to code contributory factors. Analysis informed creation of driver diagrams and key recommendations for safety improvement in endoscopy. RESULTS: From 2017 to 2019, 1181 endoscopy-specific PSIs of significant harm were reported across England and Wales, with 539 (45.6%) being nPSIs. Five categories accounted for over 80% of all incidents, with "follow-up and surveillance" being the largest (23.4% of all nPSIs). From the free-text incident reports, 487 human factors codes were identified. Decision-based errors were the most common act prior to PSI occurrence. Other frequent preconditions to incidents were focused on environmental factors, particularly overwhelmed resources, patient factors, and ineffective team communication. Lack of staffing, standard operating procedures, effective systems, and clinical pathways were also contributory. Seven key recommendations for improving safety have been made in response to our findings. CONCLUSIONS: This was the first national-level human factors analysis of endoscopy-specific PSIs. This work will inform safety improvement strategies and should empower individual services to review their approach to safety.

Surgical Safety Does Not Happen By Accident: Learning From Perioperative Near Miss Case Studies.

Adverse surgical events cause negative patient health outcomes and harm that can often overshadow the safe and effective patient care provided daily by nurses as members of interprofessional healthcare teams. Near misses occur far more frequently than adverse events and are less visible to nurse leaders because patient harm is avoided due to chance, prevention, or mitigation. However, near misses have comparable root causes to adverse events and exhibit the same underlying patterns of failure. Reviewing near misses provides nurses with learning opportunities to identify patient care weaknesses and build appropriate solutions to enhance care. As the operating room is one of the most complex work settings in healthcare, identifying potential weaknesses or sources for errors is vital to reduce healthcare-associated risks for patients and staff. The purpose of this manuscript is to educate, inform, and stimulate critical thinking by discussing perioperative near miss case studies and the underlying factors that lead to errors. Our authors discuss 15 near miss case studies occurring across the perioperative patient experience of care and discuss barriers to near miss reporting. Nurse leaders can use our case studies to stimulate discussion among perioperative and perianesthesia nurses in their hospitals to inform comprehensive risk reduction programs.