Republished error management: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals.

INTRODUCTION: Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety incidents. The objective of this study is to review RCA reports (RCAR) for characteristics of verbal communication errors between hospital staff in an organisational perspective. METHOD: Two independent raters analysed 84 RCARs, conducted in six Danish hospitals between 2004 and 2006, for descriptions and characteristics of verbal communication errors such as handover errors and error during teamwork. RESULTS: Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13 (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between units and consults from other specialties, were particularly vulnerable processes. CONCLUSION: With the risk of bias in mind, it is concluded that more than half of the RCARs described erroneous verbal communication between staff members as root causes of or contributing factors of severe patient safety incidents. The RCARs rich descriptions of the incidents revealed the organisational factors and needs related to these errors.

[Checklists have a potential in health care]. / Tjeklister har et potentiale i sundhedsvæsnet.

A checklist is a cognitive tool specifying the actions necessary to complete a given task. It serves to improve the quality of care, support the memory of the user and it may serve to indicate the necessary communicative steps within a team. Checklists are used increasingly in health care. Preliminary results indicate a potential for patient safety. However, no evidence indicates that a checklist in itself is sufficient to obtain clinical results: training and motivating staff, supporting implementation, and conducting follow-up and evaluation are as important as the checklist itself to achieve results.

Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals.

INTRODUCTION: Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety incidents. The objective of this study is to review RCA reports (RCAR) for characteristics of verbal communication errors between hospital staff in an organisational perspective. METHOD: Two independent raters analysed 84 RCARs, conducted in six Danish hospitals between 2004 and 2006, for descriptions and characteristics of verbal communication errors such as handover errors and error during teamwork. RESULTS: Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13 (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between units and consults from other specialties, were particularly vulnerable processes. CONCLUSION: With the risk of bias in mind, it is concluded that more than half of the RCARs described erroneous verbal communication between staff members as root causes of or contributing factors of severe patient safety incidents. The RCARs rich descriptions of the incidents revealed the organisational factors and needs related to these errors.

Outcomes of classroom-based team training interventions for multiprofessional hospital staff. A systematic review.

CONTEXT: Several studies show that communication errors in healthcare teams are frequent and can lead to adverse events. Team training has been suggested as a way to safer communication and has been implemented in healthcare as classroom-based or simulation-based team training or a combination of both. The objective of this paper is to systematically review studies evaluating the outcomes of classroom-based multiprofessional team training for hospital staff. METHOD: The authors searched PubMed, EMBASE, ERIC, PsycInfo, Cinahl and the Cochrane Reviews database and selected 18 studies for description and comparison of learners and setting, objective, design, intervention, evaluation methods (reaction, learning, behaviour and results), intervention time before evaluation, outcomes and risk of bias. RESULTS: Participant reactions were positive. Learning and behaviour were positive in all studies, but for some only partially. The effect on clinical processes was in most instances positive. Results at patient level were limited. Only one study reported results at all four evaluation levels. Fifteen studies were uncontrolled, and 17 studies had a moderate or high risk of bias. More than half of the studies ended evaluation within 6 months. No studies reported qualitative measures that could have provided an insight as to why the interventions had the effect they had. CONCLUSION: Classroom-based team training for multiprofessional hospital staff is recommended as a way to improve patient safety. This review shows mainly positive effects of the intervention on participant reaction, learning and behaviour. The results at clinical level are still very limited.

[Clinical decision support: Is the number of medication errors reduced?]. / Beslutningsstøtte til elektronisk patientmedicinering: reduceres forekomsten af medicineringsfejl?

22 papers on clinical decision support (CDS) for computer physician order entry (CPOE) and the ability to reduce medication errors were reviewed. Among the 22 original clinical trials, 21 demonstrated a reduced number of medication errors after the implementation of CDS. The effect was strongest for 2nd and 3rd generation of the CDS-systems. CPOE with CDS is time consuming and may generate new medication errors in itself. All the trials had poor designs. A Danish data source for CDS has not yet been established.

[Adverse events management. Methods and results of a development project]. / Håndtering af utilsigtede haendelser. Metode og resultater af et udviklingsprojekt.

INTRODUCTION: This article describes the methods and results of a project in the Copenhagen Hospital Corporation (H:S) on preventing adverse events. The aim of the project was to raise awareness about patients' safety, test a reporting system for adverse events, develop and test methods of analysis of events and propagate ideas about how to prevent adverse events. MATERIALS AND METHODS: H:S developed an action plan and a reporting system for adverse events, founded an organization and developed an educational program on theories and methods of learning from adverse events for both leaders and employees. RESULTS: During the three-year period from 1 January 2002 to 31 December 2004, the H:S staff reported 6011 adverse events. In the same period, the organization completed 92 root cause analyses. More than half of these dealt with events that had been optional to report, the other half events that had been mandatory to report. CONCLUSION: The number of reports and the front-line staff's attitude towards reporting shows that the H:S succeeded in founding a safety culture. Future work should be centred on developing and testing methods that will prevent adverse events from happening. The objective is to suggest and complete preventive initiatives which will help increase patient safety.

[Wrong-site surgery: incidence and prevention]. / Forvekslingsindgreb: forekomst og forebyggelse.

INTRODUCTION: This paper illustrates how reporting of adverse events can be used to introduce changes in an organization. Starting from reports of incidents on wrong-site surgery, a method to prevent them and its implementation in the Copenhagen Hospital Corporation (H:S) are described. MATERIALS AND METHODS: The H:S adverse event database, the Danish Patient Insurance Association and international sources were searched to estimate the extent of wrong-site surgery. A method to prevent wrong-site surgery developed by the U.S. Department of Veterans Affairs was adapted for Danish conditions. It was introduced as "The Five Steps" in H:S in May 2005, accompanied by an information campaign. RESULTS: Wrong-site surgery incidents are rare: reports in the H:S show an occurrence of 1:32,500 surgical procedures, consistent with international figures. Seven root cause analyses were performed and showed a need for a more structured identification and communication process among the members of the operating team. The Five Steps were designed to prevent such problems. None of the Five Steps is in itself new or revolutionary. The crucial parts are systematization of the identification process and increased communication among the members of the operating team. The procedure is not associated with substantial resource utilization and involves more a change in culture than an investment. The method can be widely implemented in hospitals in Denmark without major changes. CONCLUSION: Wrong-site surgery is a rare but serious adverse event. This paper describes the results of root cause analyses after reports of incidents in the H:S. The analyses showed a need for better and more structured communication and identification of patients before surgical intervention.