Developing the TeamOBS-vacuum-assisted delivery checklist to assess clinical performance in a vacuum-assisted delivery: a Delphi study with initial validation.

Introduction: In Northern Europe, vacuum-assisted delivery (VAD) accounts for 6-15% of all deliveries; VAD is considered safe when conducted by adequately trained personnel. However, failed vacuum extraction can be harmful to both the mother and child. Therefore, the clinical performance in VAD must be assessed to guide learning, determine a performance benchmark, and evaluate the quality to achieve an overall high performance. We were unable to identify a pre-existing tool for evaluating the clinical performance in real-life vacuum-assisted births. Objective: We aimed to develop and validate a checklist for assessing the clinical performance in VAD. Methods: We conducted a Delphi process, described as an interactive process where experts answer questions until answers converge toward a "joint opinion" (consensus). We invited international experts as Delphi panelists and reached a consensus after four Delphi rounds, described as follows: (1) the panelists were asked to add, remove, or suggest corrections to the preliminary list of items essential for evaluating clinical performance in VAD; (2) the panelists applied weights of clinical importance on a Likert scale of 1-5 for each item; (3) each panelist revised their original scores after reviewing a summary of the other panelists' scores and arguments; and (4) the TeamOBS-VAD was tested using videos of real-life VADs, and the Delphi panel made final adjustments and approved the checklist. Results: Twelve Delphi panelists from the UK (n = 3), Norway (n = 2), Sweden (n = 3), Denmark (n = 3), and Iceland (n = 1) were included. After four Delphi rounds, the Delphi panel reached a consensus on the checklist items and scores. The TeamOBS-VAD checklist was tested using 60 videos of real-life vacuum extractions. The inter-rater agreement had an intraclass correlation coefficient (ICC) of 0.73; 95% confidence interval (95% CI) of [0.58, 0.83], and that for the average of two raters was ICC 0.84 95% CI [0.73, 0.91]. The TeamOBS-VAD score was not associated with difficulties in delivery, such as the number of contractions during vacuum extraction delivery, cephalic level, rotation, and position. Failed vacuum extraction occurred in 6% of the video deliveries, but none were associated with the teams with low clinical performance scores. Conclusion: The TeamOBS-VAD checklist provides a valid and reliable evaluation of the clinical performance of vaginal-assisted vacuum extraction.

Older Adults' Engagement and Mood During Robot-Assisted Group Activities in Nursing Homes: Development and Observational Pilot Study.

BACKGROUND: Promoting the well-being of older adults in an aging society requires new solutions. One resource might be the use of social robots for group activities that promote physical and cognitive stimulation. Engaging in a robot-assisted group activity may help in the slowdown of physical and cognitive decline in older adults. Currently, our knowledge is limited on whether older adults engage in group activities with humanlike social robots and whether they experience a positive affect while doing so. Both are necessary preconditions to achieve the intended effects of a group activity. OBJECTIVE: Our pilot study has 2 aims. First, we aimed to develop and pilot an observational coding scheme for robot-assisted group activities because self-report data on engagement and mood of nursing home residents are often difficult to obtain, and the existing observation instruments do have limitations. Second, we aimed to investigate older adults' engagement and mood during robot-assisted group activities in 4 different nursing care homes in the German-speaking part of Switzerland. METHODS: We developed an observation system, inspired by existing tools, for a structured observation of engagement and mood of older adults during a robot-assisted group activity. In this study, 85 older adult residents from 4 different care homes in Switzerland participated in 5 robot-assisted group activity sessions, and they were observed using our developed system. The data were collected in the form of video clips that were assessed by 2 raters regarding engagement (direction of gaze, posture as well as body expression, and activity) and mood (positive and negative affects). Both variables were rated on a 5-point rating scale. RESULTS: Our pilot study findings show that the engagement and mood of older adults can be assessed reliably by using the proposed observational coding scheme. Most participants actively engaged in robot-assisted group activities (mean 4.19, SD 0.47; median 4.0). The variables used to measure engagement were direction of gaze (mean 4.65, SD 0.49; median 5.0), posture and body expression (mean 4.03, SD 0.71; median 4.0), and activity (mean 3.90, SD 0.65; median 4.0). Further, we observed mainly positive affects in this group. Almost no negative affect was observed (mean 1.13, SD 0.20; median 1.0), while the positive affect (mean 3.22, SD 0.55; median 3.2) was high. CONCLUSIONS: The developed observational coding system can be used and further developed in future studies on robot-assisted group activities in the nursing home context and potentially in other settings. Additionally, our pilot study indicates that cognitive and physical stimulation of older adults can be promoted by social robots in a group setting. This finding encourages future technological development and improvement of social robots and points to the potential of observational research to systematically evaluate such developments.

Exploring objective measures for assessing team performance in healthcare: an interview study.

Introduction: Effective teamwork plays a critical role in achieving high-performance outcomes in healthcare. Consequently, conducting a comprehensive assessment of team performance is essential for providing meaningful feedback during team trainings and enabling comparisons in scientific studies. However, traditional methods like self-reports or behavior observations have limitations such as susceptibility to bias or being resource consuming. To overcome these limitations and gain a more comprehensive understanding of team processes and performance, the assessment of objective measures, such as physiological parameters, can be valuable. These objective measures can complement traditional methods and provide a more holistic view of team performance. The aim of this study was to explore the potential of the use of objective measures for evaluating team performance for research and training purposes. For this, experts in the field of research and medical simulation training were interviewed to gather their opinions, ideas, and concerns regarding this novel approach. Methods: A total of 34 medical and research experts participated in this exploratory qualitative study, engaging in semi-structured interviews. During the interview, experts were asked for (a) their opinion on measuring team performance with objective measures, (b) their ideas concerning potential objective measures suitable for measuring team performance of healthcare teams, and (c) their concerns regarding the use of objective measures for evaluating team performance. During data analysis responses were categorized per question. Results: The findings from the 34 interviews revealed a predominantly positive reception of the idea of utilizing objective measures for evaluating team performance. However, the experts reported limited experience in actively incorporating objective measures into their training and research. Nevertheless, they identified various potential objective measures, including acoustical, visual, physiological, and endocrinological measures and a time layer. Concerns were raised regarding feasibility, complexity, cost, and privacy issues associated with the use of objective measures. Discussion: The study highlights the opportunities and challenges associated with employing objective measures to assess healthcare team performance. It particularly emphasizes the concerns expressed by medical simulation experts and team researchers, providing valuable insights for developers, trainers, researchers, and healthcare professionals involved in the design, planning or utilization of objective measures in team training or research.

Behavioural observation tool for patient involvement and collaboration in emergency care teams (PIC-ET-tool).

BACKGROUND: Patient participation is advocated in various healthcare settings. Instruments for assessment and feedback have been developed to strengthen clinician-patient interaction. In an emergency department context, such instruments are still missing. The study aimed to develop and test an observation tool for emergency teams' behaviour regarding patient involvement and collaboration. METHODS: The development of the behavioural observation tool followed a systematic approach. The tool's content was based on various data sources, i.e., published literature, interview and observational data, and expert consensus. An international expert panel reviewed the content and the rating scale and rated its importance for patient involvement and collaboration in a Delphi process. The feasibility and reliability of the tool were tested by trained observers using video recordings of simulated emergencies. Intraclass correlation (ICC) and Kappa-statistics were performed to test the tool's inter-rater reliability. RESULTS: The PIC-ET tool, a 22-item observation instrument was developed in which patient involvement and collaboration behaviours are rated from 'no' to 'high' using behavioural anchors. Expert agreement was obtained after three Delphi rounds on the tool content, the behavioural anchors and its importance for patient involvement and collaboration. The content validity was assessed as high, and the tool was found feasible for research. Overall inter-rater reliability was fair (Kappa 0.52). CONCLUSIONS: A novel tool for assessing emergency teams' behaviour regarding patient involvement and collaboration is introduced. The tool's psychometric properties were fair to good. Further validation of the PIC-ET tool is recommended for more robust evidence. Future adaptation to different contexts and areas of use, as well as further validity testing may be of value.

Healthcare providers' perceptions and expectations of video-assisted debriefing of real-life obstetrical emergencies: a qualitative study from Denmark.

OBJECTIVES: Video-assisted debriefing (VAD) of real-life obstetrical emergencies provides an opportunity to improve quality of care, but is rarely used in clinical practice. A barrier for implementation is the expected mental reservations among healthcare providers. The aim of this study was to explore healthcare providers' perceptions and expectations of VAD of real-life events. SETTING: Participants were recruited from two Labour and Delivery Units in Denmark. In both units, VAD of real-life obstetrical emergencies had never been conducted. PARTICIPANTS: 22 healthcare providers (10 physicians, 9 midwives and 3 nursing assistants). During the study period (August-October 2021), semi-structured, individual interviews were conducted. Interviews were analysed using thematic analysis. PRIMARY AND SECONDARY OUTCOME MEASURES: A qualitative description of healthcare providers' perceptions and expectations of VAD of real-life events. RESULTS: Three major themes were identified: (1) Video-assisted debriefing (VAD) as an opportunity for learning: All participants expected VAD to provide an opportunity for learning and improving patient care. All participants expected the video to provide a 'bigger picture', by showing 'what was actually done' instead of 'what we believed was done'. (2) Video-assisted debriefing (VAD) as a cause for concern: The primary concern for all participants was the risk of being exposed as less competent. Participants were concerned that being confronted with every minor detail of their clinical practice would enhance their self-criticalness. (3) Preconditions for video-assisted debriefing (VAD): Participants emphasised the importance of organisational support from management. In addition, creating a safe environment for VAD, for example, by using only expert debriefers was considered an essential precondition for successful implementation. CONCLUSIONS: The risk of being exposed as less competent was a barrier towards VAD of real-life events. However, the majority found the educational benefits to outweigh the risk of being exposed.

StOP? II trial: cluster randomized clinical trial to test the implementation of a toolbox for structured communication in the operating room-study protocol.

BACKGROUND: Surgical care, which is performed by intensely interacting multidisciplinary teams of surgeons, anesthetists, and nurses, remains associated with significant morbidity and mortality. Intraoperative communication has been shown to be associated with surgical outcomes, but tools ensuring efficient intraoperative communication are lacking. In a previous study, we developed the StOP?-protocol that fosters structured intraoperative communication. Before the critical phases of the operation, the responsible surgeon initiates and leads one or several StOP?s. During a StOP?, the surgeon informs about the progress of the operation (status), next steps and proximal goals (objectives), and possible problems (problems) and encourages all team members to voice their observations and ask questions (?). In a before-after study performed mainly in visceral surgery, we found effects of the StOP?-protocol on mortality, length of hospital stay, and reoperation. We intend to assess the impact of the StOP?-protocol in a cluster randomized trial, in a wider variety of surgical specialties (i.e., general, visceral, thoracic, vascular surgery, surgical urology, and gynecology). The primary hypothesis is that the consistent use of the StOP?-protocol by the main surgeon reduces patient mortality within 30 days after the operation. The secondary hypothesis is that the consistent use of the StOP?-protocol by the main surgeon reduces unplanned reoperations, length of hospital stay, and unplanned hospital readmissions. METHODS: This study is designed as a multicenter, cluster-randomized parallel-group trial. Board-certified surgeons of participating clinical departments will be randomized 1:1 to the StOP? intervention group or to the standard of care (control) group. The intervention group will undergo a training to use the StOP?-protocol and receive regular feedback on their compliance with the protocol. The surgeons in the control group will communicate as usual during their operations. The unit of observation will be operations performed by cluster surgeons. Consecutive patients will be enrolled over 4 months per cluster. A total of 400 surgeons will be recruited, and we expect to collect patient outcome data for 14,000 surgical procedures. DISCUSSION: The StOP?-protocol was designed as a tool to structure communication during surgical procedures. Testing its effects on patient outcomes will contribute to implementing evidenced-based interventions to reduce surgical complications. TRIAL REGISTRATION: ClinicalTrials.gov NCT05356962. Registered on May 2, 2022.

Using the Global Trigger Tool in surgical and neurosurgical patients: A feasibility study.

BACKGROUND: The Global Trigger Tool (GTT) has become a worldwide used method for estimating adverse events through a retrospective patient record review. However, little is known about the facilitators and the challenges in the GTT-implementation process. Thus, this study followed two aims: First, to apply a comprehensive set of feasibility criteria to qualitatively and systematically assess the GTT-implementation process in three departments of German university hospitals. Second, to identify the facilitators and the obstacles met in the GTT-implementation process and to derive recommendations for supporting other hospitals in implementing the GTT in clinical practice. METHODS: The study used a qualitative documentary method based on process documentation, with written and verbal feedback from the reviewer, as well as evaluating the study sites during the implementation process. The study was conducted in three departments, each in a different German university hospital. The authors applied a comprehensive set of 22 feasibility criteria assessing the level of challenge in GTT implementation. The results were synthesized and they focused on the facilitators and the challenges. RESULTS: Of these 22 feasibility criteria, nine were assessed as a low-level challenge, eleven regarded as a moderate-level challenge, and two with a problematic level of challenge. In particular, the lack of time and staff resources, the quality of the information in the patient records, organizational procedures, and local issues, posed major challenges in the implementation process. By contrast, the use of local coordinators and an external expert made important contributions to the GTT implementation. CONCLUSIONS: Considering the facilitators and the obstacles beforehand may help with the implementation of the GTT in routine practice. In particular, early and effective planning can reduce or prevent critical challenges in terms of time, staff resources, and organizational aspects.

Teamwork and Adherence to Guideline on Newborn Resuscitation-Video Review of Neonatal Interdisciplinary Teams.

Background: Little is known about the importance of non-technical skills for the adherence to guidelines, when teams of midwives, obstetricians, anesthesiologists, and pediatricians resuscitate and support the transition of newborns. Non-technical skills are competences underpinning successful teamwork in healthcare. These are usually referred to as leadership, situational awareness, communication, teamwork, decision making, and coping with stress and fatigue. Objective: By review of videos of teams managing newborns with difficult transition, we aimed to investigate whether the level of the teams' non-technical skills was associated with the degree of adherence to guidelines for newborn resuscitation and transitional support at birth. Methods: Four expert raters independently assessed 43 real-life videos of teams managing newborns with transitional difficulties, two assessed the non-technical score and two assessed the clinical performance. Exposure was the non-technical score, obtained by the Global Assessment Of Team Performance checklist (GAOTP). GAOTP was rated on a Likert Scale 1-5 (1 = poor, 3 = average and 5 = excellent). The outcome was the clinical performance score of the team assessed according to adherence of the European Resuscitation Counsel (ERC) guideline for neonatal resuscitation and transitional support. The ERC guideline was adapted into the checklist TeamOBS-Newborn to facilitate a structured and simple performance assessment (low score 0-60, average 60-84, high 85-100). Interrater agreement was analyzed by intraclass correlation (ICC), Bland-Altman analysis, and Cohen's kappa weighted. The risk of high and low clinical performance was analyzed on the logit scale to meet the assumptions of normality and constant standard deviation. Results: Teams with an excellent non-technical score had a relative risk 5.5 [95% confidence interval (CI) 2.4-22.5] of high clinical performance score compared to teams with average non-technical score. In addition, we found a dose response like association. The specific non-technical skills associated with the highest degree of adherence to guidelines were leadership and teamwork, coping with stress and fatigue, and communication with parents. Inter-rater agreement was high; raters assessing non-technical skills had an interclass coefficient (ICC) 0.88 (95% CI 0.79-0.94); the neonatologists assessing clinical performance had an ICC of 0.81 (95% CI 0.66-0.89). Conclusion: Teams with an excellent non-technical score had five times the chance of high clinical performance compared to teams with average non-technical skills. High performance teams were characterized by good leadership and teamwork, coping with stress, and fatigue and communication with parents.

Simulation-based training improves process times in acute stroke care (STREAM).

BACKGROUND: The objective of the STREAM Trial was to evaluate the effect of simulation training on process times in acute stroke care. METHODS: The multicenter prospective interventional STREAM Trial was conducted between 10/2017 and 04/2019 at seven tertiary care neurocenters in Germany with a pre- and post-interventional observation phase. We recorded patient characteristics, acute stroke care process times, stroke team composition and simulation experience for consecutive direct-to-center patients receiving intravenous thrombolysis (IVT) and/or endovascular therapy (EVT). The intervention consisted of a composite intervention centered around stroke-specific in situ simulation training. Primary outcome measure was the 'door-to-needle' time (DTN) for IVT. Secondary outcome measures included process times of EVT and measures taken to streamline the pre-existing treatment algorithm. RESULTS: The effect of the STREAM intervention on the process times of all acute stroke operations was neutral. However, secondary analyses showed a DTN reduction of 5 min from 38 min pre-intervention (interquartile range [IQR] 25-43 min) to 33 min (IQR 23-39 min, p = 0.03) post-intervention achieved by simulation-experienced stroke teams. Concerning EVT, we found significantly shorter door-to-groin times in patients who were treated by teams with simulation experience as compared to simulation-naive teams in the post-interventional phase (-21 min, simulation-naive: 95 min, IQR 69-111 vs. simulation-experienced: 74 min, IQR 51-92, p = 0.04). CONCLUSION: An intervention combining workflow refinement and simulation-based stroke team training has the potential to improve process times in acute stroke care.

Structure and concept of ICU rounds: the VIS-ITS survey.

OBJECTIVE: To gather data about structural and procedural characteristics of patient rounds in the intensive care unit (ICU) setting. DESIGN: A structured online survey was offered to members of two German intensive care medicine societies. MEASUREMENTS AND MAIN RESULTS: Intensivists representing 390 German ICUs participated in this study (university hospitals 25%, tertiary hospitals 23%, secondary hospitals 36%, primary hospitals 16%). In 90% of participating ICUs, rounds were reported to take place in the morning and cover an average of 12 intensive care beds and 6 intermediate care beds within 60 min. With an estimated bed occupancy of 80%, this averaged to 4.3 min spent per patient during rounds. In 96% of ICUs, rounds were stated to include a bedside visit. On weekdays, 86% of the respondents reported holding a second ICU round with the attendance of a qualified decision-maker (e.g. board-certified intensivist). On weekends, 79% of the ICUs performed at least one round with a decision-maker per day. In 18%, only one ICU round per weekend was reported, mostly on Sundays. The highest-qualified decision-maker present during rounds on most ICUs was an ICU attending (57%). Residents (96%) and intensive care nurses (87%) were stated to be always or usually present during rounds. In contrast, physiotherapists, respiratory therapists or medical specialists such as pharmacists or microbiologist were not regular members of the rounding team on most ICUs. In the majority of cases, the participants reported examining the medical chart directly before or during the bedside visit (84%). An electronic patient data management system (PDMS) was available on 31% of ICUs. Daily goals were always (55%) or usually (39%) set during rounds. CONCLUSION: This survey gives a broad overview of the structure and processes of ICU rounds in different sized hospitals in Germany. Compared to other mostly Anglo-American studies, German ICU rounds appear to be shorter and less interdisciplinary.

Measuring Patient Safety Climate in Acute Stroke Therapy.

Background: Treatment of acute stroke is highly time-dependent and performed by a multiprofessional, interdisciplinary team. Interface problems are expectable and issues relevant to patient safety are omnipresent. The Safety Attitudes Questionnaire (SAQ) is a validated and widely used instrument to measure patient safety climate. The objective of this study was to evaluate the SAQ for the first time in the context of acute stroke care. Methods: A survey was carried out during the STREAM trial (NCT00032282) at seven university hospitals in Germany from October 2017 to October 2018. The anonymous survey included 33 questions (5-point Likert scale, 1 = disagree to 5 = agree) and addressed the entire multiprofessional stroke team. Statistical analyses were used to examine psychometric properties as well as descriptive findings. Results: 164 questionnaires were completed yielding a response rate of 66.4%. 67.7% of respondents were physicians and 25.0% were nurses. Confirmatory Factor Analysis revealed that the original 6-factor structure fits the data adequately. The SAQ for acute stroke care showed strong internal consistency (α = 0.88). Exploratory analysis revealed differences in scores on the SAQ dimensions when comparing physicians to nurses and when comparing physicians according to their duration of professional experience. Conclusion: The SAQ is a helpful and well-applicable tool to measure patient safety in acute stroke care. In comparison to other high-risk fields in medicine, patient safety climate in acute stroke care seems to be on a similar level with the potential for further improvements. Trial registration: www.ClinicalTrials.gov Identifier: NCT032282.

Simulation-based training improves patient safety climate in acute stroke care (STREAM).

BACKGROUND: Treatment of acute stroke performed by a multiprofessional, interdisciplinary team is highly time dependent. Interface problems are preprogrammed and pitfalls relevant to patient safety are omnipresent. The Safety Attitudes Questionnaire (SAQ) is a validated and widely used instrument to measure patient safety. The objective of this study was to evaluate the influence of Simulation-based Training of the Rapid Evaluation and Management of Acute Stroke (STREAM) on patient safety measured by SAQ in the context of acute stroke care. METHODS: During the STREAM trial at seven university hospitals in Germany from October 2017 to October 2018, an anonymous survey was conducted before and after the STREAM intervention centering around interdisciplinary simulation training. The questionnaire, based on the SAQ, included 33 items (5-point Likert scale, 1 = disagree to 5 = agree) and was addressed at the whole multiprofessional stroke team. Statistical analyses were used to examine psychometric properties as well as descriptive findings. RESULTS: In total 167 questionnaires were completed representing an overall response rate of 55.2%, including especially physicians (65.2%) and nurses (26.3%). Safety climate was significantly improved (pre-interventional: 3.34 ± .63 vs. post-interventional: 3.56 ± .69, p = .028). The same applies for teamwork climate among stroke teams (pre-interventional: 3.76 ± .59 vs. post-interventional: 3.84 ± .57, p = .001). The perceived benefit was most relevant among nurses. CONCLUSIONS: The STREAM intervention centering around interdisciplinary simulation training increases perceived patient safety climate assessed by the SAQ in acute stroke therapy. These results have the potential to be a basis for future quality improvement programs.

Does interprofessional team-training affect nurses' and physicians' perceptions of safety culture and communication practices? Results of a pre-post survey study.

BACKGROUND: Many hospitals seek to increase patient safety through interprofessional team-trainings. Accordingly, these trainings aim to strengthen important key aspects such as safety culture and communication. This study was designed to investigate if an interprofessional team-training, administered to a relatively small group of nurses and physicians would promote a change in healthcare professionals' perceptions on safety culture and communication practices throughout the hospital. We further sought to understand which safety culture aspects foster the transfer of trained communication practices into clinical practice. METHODS: We conducted a pre-post survey study using six scales to measure participants' perceptions of safety culture and communication practices. Mean values were compared according to profession and participation in training. Using multiple regression models, the relationship between safety culture and communication practices was determined. RESULTS: Before and after the training, we found high mean values for all scales. A significant, positive effect was found for the communication practices of the physicians. Participation in the training sessions played a variably relevant role in the communication practices. In addition, the multiple regression analyses showed that specific safety culture aspects have a cross-professional influence on communication practices in the hospital. CONCLUSIONS: This study suggest that interprofessional team-trainings of a small group of professionals can successfully be transferred into clinical practice and indicates the importance of safety culture aspects for such transfer processes. Thus, we recommend the consideration of safety culture aspects before starting a training intervention.

Influence of Gender, Profession, and Managerial Function on Clinicians' Perceptions of Patient Safety Culture: A Cross-National Cross-Sectional Study.

OBJECTIVES: In recent years, several instruments for measuring patient safety culture (PSC) have been developed and implemented. Correct interpretation of survey findings is crucial for understanding PSC locally, for comparisons across settings or time, as well as for planning effective interventions. We aimed to evaluate the influence of gender, profession, and managerial function on perceptions of PSC and on the interplay between various dimensions and perceptions of PSC. METHODS: We used German and Swiss survey data of frontline physicians and nurses (n = 1786). Data analysis was performed for the two samples separately using multivariate analysis of variance, comparisons of adjusted means, and series of multiple regressions. RESULTS: Participants' profession and managerial function had significant direct effect on perceptions of PSC. Although there was no significant direct effect of gender for most of the PSC dimensions, it had an indirect effect on PSC dimensions through statistically significant direct effects on profession and managerial function. We identified similarities and differences across participant groups concerning the impact of various PSC dimensions on Overall Perception of Patient Safety. Staffing and Organizational Learning had positive influence in most groups without managerial function, whereas Teamwork Within Unit, Feedback & Communication About Error, and Communication Openness had no significant effect. For female participants without managerial functions, Management Support for Patient Safety had a significant positive effect. CONCLUSIONS: Participant characteristics have significant effects on perceptions of PSC and thus should be accounted for in reporting, interpreting, and comparing results from different samples.

Separate Medication Preparation Rooms Reduce Interruptions and Medication Errors in the Hospital Setting: A Prospective Observational Study.

BACKGROUND: Interruptions and errors during the medication process are common, but published literature shows no evidence supporting whether separate medication rooms are an effective single intervention in reducing interruptions and errors during medication preparation in hospitals. We tested the hypothesis that the rate of interruptions and reported medication errors would decrease as a result of the introduction of separate medication rooms. AIM: Our aim was to evaluate the effect of separate medication rooms on interruptions during medication preparation and on self-reported medication error rates. METHODS: We performed a preintervention and postintervention study using direct structured observation of nurses during medication preparation and daily structured medication error self-reporting of nurses by questionnaires in 2 wards at a major teaching hospital in Switzerland. RESULTS: A volunteer sample of 42 nurses was observed preparing 1498 medications for 366 patients over 17 hours preintervention and postintervention on both wards. During 122 days, nurses completed 694 reporting sheets containing 208 medication errors. After the introduction of the separate medication room, the mean interruption rate decreased significantly from 51.8 to 30 interruptions per hour (P < 0.01), and the interruption-free preparation time increased significantly from 1.4 to 2.5 minutes (P < 0.05). Overall, the mean medication error rate per day was also significantly reduced after implementation of the separate medication room from 1.3 to 0.9 errors per day (P < 0.05). CONCLUSIONS: The present study showed the positive effect of a hospital-based intervention; after the introduction of the separate medication room, the interruption and medication error rates decreased significantly.

Using Prospective Risk Analysis Tools to Improve Safety in Pharmacy Settings: A Systematic Review and Critical Appraisal.

OBJECTIVES: This study aimed to review and critically appraise the published literature on 2 selected prospective risk analysis tools, Failure Mode and Effects Analysis and Socio-Technical Probabilistic Risk Assessment, as applied to the dispensing of medicines in both inpatient and outpatient pharmacy settings. METHODS: A comprehensive search of electronic databases (PubMed and Scopus) was conducted (January 1990-March 2016), supplemented by hand search of reference lists. Eligible articles were assessed for data sources used for the risk analysis, uniformity of the risk quantification framework, and whether the analysis teams assembled were multidisciplinary. RESULTS: Of 1011 records identified, 11 articles met our inclusion criteria. These studies were mainly focused on dispensing of high-alert medications, and most were conducted in inpatient settings. The main risks identified were transcription, preparation, and selection errors, whereas the most common corrective actions included electronic transmission of prescriptions to the pharmacy, use of barcode, and medication safety training. Significant risk reduction was demonstrated by implementing corrective measures in both inpatient and outpatient pharmacy settings. The main Failure Mode and Effects Analysis limitations were its subjectivity and the lack of common risk quantification criteria. CONCLUSIONS: The prospective risk analysis methods included in this review revealed relevant safety issues and hold significant potential for risk reduction. They were deemed suitable for application in both inpatient and outpatient pharmacy settings and should form an integral part of any patient safety improvement strategy.

A Strategic Core Role Perspective on Team Coordination: Benefits of Centralized Leadership for Managing Task Complexity in the Operating Room.

OBJECTIVE: We examine whether surgical teams can handle changes in task requirements better when their formal leader and strategic core role holder-that is, the main surgeon-is central to team coordination. BACKGROUND: Evidence regarding the benefits of shared leadership for managing complex tasks is divided. We tested whether a strategic core role holder's centrality in team coordination helps teams to handle different types of task complexity. METHOD: We observed coordination as specific leadership behavior in 30 surgical teams during real-life operations. To assess the strategic core role holder's coordination centrality, we conducted social network analyses. Task complexity (i.e., surgical difficulty and unexpected events) and surgical goal attainment were rated in a questionnaire. RESULTS: In the critical operation phase, surgical difficulty impaired goal attainment when the strategic core role holder's coordination centrality was low, while this effect was nonsignificant when his/her coordination centrality was high. Unexpected events had a negative effect on surgical goal attainment. However, coordination centrality of the strategic core role holder could not help manage unexpected events. CONCLUSION: The results indicate that shared leadership is not beneficial when teams face surgical difficulty during the critical operation phase. In this situation, team coordination should rather be centralized around the strategic core role holder. Contrarily, when unexpected events occur, centralizing team coordination around a single leader does not seem to be beneficial for goal attainment. APPLICATION: Leaders and team members should be aware of the importance of distributing leadership differently when it comes to managing different types of task complexity.

Applying the Global Trigger Tool in German Hospitals: A Pilot in Surgery and Neurosurgery.

OBJECTIVE: The aim of the study was to assess the feasibility and potential of the Global Trigger Tool (GTT) for identifying adverse events (AEs) in different specialties in German hospitals. METHODS: A total of 120 patient records were randomly selected from two surgical and one neurosurgery departments of three university hospitals in Germany for a period of 2 months per department between January and July 2017. The records were reviewed using an adaptation of the German version of the Institute for Healthcare Improvement GTT. RESULTS: Thirty-nine records (32.5%) contained at least one AE. A total of 53 AEs were found in these 39 records. The incidences of AEs were 18.9% and 35.9% in the two surgical departments and 45.3% in neurosurgery. This corresponded to AE rates of 25.5 to 72.1 per 1000 patient-days and from 25.0 to 60.0 per 100 admissions across the three departments. A total of 71.7% of all identified AEs resulted in temporary harm (category E), 26.4% in temporary harm, requiring prolonged hospitalization (category F), and 1.9% in permanent patient harm. We also identified practical challenges, such as the necessary adaptation of the GTT relative to the respective department. CONCLUSIONS: The application of the GTT is feasible and represents an effective instrument for quality measurement when adapted to the departmental specifics. The trigger detection with the GTT is a valuable addition for proactive analyses of high-risk processes.

Resilience in Healthcare (RiH): a longitudinal research programme protocol.

INTRODUCTION: Over the past three decades, extensive research has been undertaken to understand the elements of what constitutes high quality in healthcare. Yet, much of this research has been conducted on individual elements and their specific challenges. Hence, goals other than understanding the complex of factors and elements that comprises quality in healthcare have been privileged. This lack of progress has led to the conclusion that existing approaches to research are not able to address the inherent complexity of healthcare systems as characterised by a significant degree of performance variability within and across system levels, and what makes them resilient. A shift is, therefore, necessary in such approaches. Resilience in Healthcare (RiH) adopts an approach comprising a comprehensive research programme that models the capacity of healthcare systems and stakeholders to adapt to changes, variations and/or disruptions: that is, resilience. As such, RiH offers a fresh approach capable of capturing and illuminating the complexity of healthcare and how high-quality care can be understood and advanced. METHODS AND ANALYSIS: Methodologically, to illuminate what constitutes quality in healthcare, it is necessary to go beyond single-site, case-based studies. Instead, there is a need to engage in multi-site, cross-national studies and engage in long-term multidisciplinary collaboration between national and international researchers interacting with multiple healthcare stakeholders. By adopting such processes, multiple partners and a multidisciplinary orientation, the 5-year RiH research programme aims to confront these challenges and accelerate current understandings about and approaches to researching healthcare quality.The RiH research programme adopts a longitudinal collaborative interactive design to capture and illuminate resilience as part of healthcare quality in different healthcare settings in Norway and in five other countries. It combines a meta-analysis of detailed empirical research in Norway with cross-country comparison from Australia, Japan, Netherlands, Switzerland and the UK. Through establishing an RiH framework, the programme will identify processes with outcomes that aim to capture how high-quality healthcare provisions are achieved. A collaborative learning framework centred on engagement aims to systematically translate research findings into practice through co-construction processes with partners and stakeholders. ETHICS AND DISSEMINATION: The RiH research programme is approved by the Norwegian Centre for Research Data (No. 864334). The empirical projects selected for inclusion in this longitudinal research programme have been approved by the Norwegian Centre for Research Data or the Regional Committees for Medical and Health Research Ethics. The RiH research programme has an embedded publication and dissemination strategy focusing on the progressive sharing of scientific knowledge, information and results, and on engaging with the public, including relevant patient and stakeholder representatives. The findings will be disseminated through scientific articles, PhD dissertations, presentations at national and international conferences, and through social media, newsletters and the popular media.

Comparing perceived psychosocial working conditions of nurses and physicians in two university hospitals in Germany with other German professionals - feasibility of scale conversion between two versions of the German Copenhagen Psychosocial Questionnaire (COPSOQ).

BACKGROUND: In 2015, the WorkSafeMed study assessed, amongst others, perceived psychosocial working conditions in nurses (n = 567) and physicians (n = 381) from two German university hospitals using scales from the German standard version of the COPSOQ (Copenhagen Psychosocial Questionnaire). This standard version is based on the international COPSOQ I and II. Since 2017, a further developed version of the German COPSOQ (G-COPSOQ III) has been available and data from this version are stored in the German COPSOQ database. The aim of the present study was to compare scales depicting perceived psychosocial workloads and strain in hospital staff from the WorkSafeMed study with reference data (hospital care nurses, general hospital physicians, reference values across all occupations) from the German COPSOQ database (2012-2017). As preliminary work, we explored whether a conversion of COPSOQ scales based on data from the WorkSafeMed study to the G-COPSOQ III scales was possible. METHODS: We applied a multistep approach for conversion. First, we compared 17 COPSOQ scales used in the WorkSafeMed study with the corresponding scales from the G-COPSOQ III according to content and then decided if a conversion was appropriate. If possible, we converted WorkSafeMed scales - the converted scales comprised the same content and number of items as in G-COPSOQ III. An explorative statistical analysis for each original and converted WorkSafeMed scale followed detecting possible statistical and relevant differences between the scales. We then compared converted WorkSafeMed scales with reference data from the German COPSOQ database. RESULTS: Based on the comparison undertaken according to content, a conversion was possible for 16 scales. Using the data from the WorkSafeMed study, the statistical analysis showed only differences between original and converted COPSOQ scales "control over working time" (mean 40.2 vs. 51.8, dCohen = 0.56) and "social relations" (mean 55.6 vs. 41.8, dCohen = - 0.55). Comparing converted WorkSafeMed scales with reference data revealed higher values for "quantitative demands", "work-privacy-conflict", and "job satisfaction" in the WorkSafeMed sample. CONCLUSIONS: The conversion of WorkSafeMed scales was appropriate, allowed a comparison with three reference values in the German COPSOQ database and revealed some implications for improving psychosocial working conditions of nurses and physicians in university hospitals in Germany.