Technology-Related Safety Event Analysis in Community Clinical Informatics: A Case Study.

This case study presents a process that was iteratively developed for clinical informaticians to identify, analyse, and respond to safety events related to health information technologies (HIT) in community care settings (This research was supported by the CIHR Health Systems Impact Fellowship Program. We would also like to thank Vancouver Coastal Health for their valuable contributions.). The goal was to build capacity within a clinical informatics team to integrate patient safety into their work and to help them recognize and respond to HIT-related safety events. The technology-related safety event analysis process that was ultimately developed included three key components: 1) an internal workflow to analyse voluntarily reported HIT-related safety events using a sociotechnical model, 2) safety huddles to amplify learnings from reviewed events, and 3) a cumulative analysis of all events over time to identify and respond to patterns. A systematic approach to quickly identify and understand HIT safety concerns enables informatics teams to proactively reduce risks and prevent harm.

Clinical Informatics Team Members' Perspectives on Health Information Technology Safety After Experiential Learning and Safety Process Development: Qualitative Descriptive Study.

BACKGROUND: Although intended to support improvement, the rapid adoption and evolution of technologies in health care can also bring about unintended consequences related to safety. In this project, an embedded researcher with expertise in patient safety and clinical education worked with a clinical informatics team to examine safety and harm related to health information technologies (HITs) in primary and community care settings. The clinical informatics team participated in learning activities around relevant topics (eg, human factors, high reliability organizations, and sociotechnical systems) and cocreated a process to address safety events related to technology (ie, safety huddles and sociotechnical analysis of safety events). OBJECTIVE: This study aimed to explore clinical informaticians' experiences of incorporating safety practices into their work. METHODS: We used a qualitative descriptive design and conducted web-based focus groups with clinical informaticians. Thematic analysis was used to analyze the data. RESULTS: A total of 10 informants participated. Barriers to addressing safety and harm in their context included limited prior knowledge of HIT safety, previous assumptions and perspectives, competing priorities and organizational barriers, difficulty with the reporting system and processes, and a limited number of reports for learning. Enablers to promoting safety and mitigating harm included participating in learning sessions, gaining experience analyzing reported events, participating in safety huddles, and role modeling and leadership from the embedded researcher. Individual outcomes included increased ownership and interest in HIT safety, the development of a sociotechnical systems perspective, thinking differently about safety, and increased consideration for user perspectives. Team outcomes included enhanced communication within the team, using safety events to inform future work and strategic planning, and an overall promotion of a culture of safety. CONCLUSIONS: As HITs are integrated into care delivery, it is important for clinical informaticians to recognize the risks related to safety. Experiential learning activities, including reviewing safety event reports and participating in safety huddles, were identified as particularly impactful. An HIT safety learning initiative is a feasible approach for clinical informaticians to become more knowledgeable and engaged in HIT safety issues in their work.

Characterization of Safety Events Involving Technology in Primary and Community Care.

BACKGROUND: The adoption of technology in health care settings is often touted as an opportunity to improve patient safety. While some adverse events can be reduced by health information technologies, technology has also been implicated in or attributed to safety events. To date, most studies on this topic have focused on acute care settings. OBJECTIVES: To describe voluntarily reported safety events that involved health information technology in community and primary care settings in a large Canadian health care organization. METHODS: Two years of safety events involving health information technology (2016-2018) were extracted from an online voluntary safety event reporting system. Events from primary and community care settings were categorized according to clinical setting, type of event, and level of harm. The Sittig and Singh sociotechnical system model was then used to identify the most prominent sociotechnical dimensions of each event. RESULTS: Of 104 reported events, most (n = 85, 82%) indicated the event resulted in no harm. Public health had the highest number of reports (n = 45, 43%), whereas home health had the fewest (n = 7, 7%). Of the 182 sociotechnical concepts identified, many events (n = 61, 59%) mapped to more than one dimension. Personnel (n = 48, 46%), Workflow and Communication (n = 37, 36%), and Content (n = 30, 29%) were the most common. Personnel and Content together was the most common combination of dimensions. CONCLUSION: Most reported events featured both technical and social dimensions, suggesting that the nature of these events is multifaceted. Leveraging existing safety event reporting systems to screen for safety events involving health information technology, and applying a sociotechnical analytic framework can aid health organizations in identifying, responding to, and learning from reported events.

Workplace continuing education for nurses caring for hospitalised older people.

AIMS AND OBJECTIVES: To develop, implement and evaluate a workplace continuing education programme about nursing care of hospitalised older people. BACKGROUND: The healthcare system cannot rely solely upon nurses' prelicensure education to prepare them to meet the evolving needs of hospitalised older patients. Over the past decade, there has been a dramatic rise in the proportion of older people in hospitals, yet many nurses do not have specialised knowledge about the unique care needs of this population. DESIGN: A multimethod pre-to post-design was employed. METHODS: Between September 2013 and April 2014, data were collected via surveys, focus groups and interviews. Thirty-two Registered Nurses initially enrolled in the programme of which 22 completed all data points. Three managers also participated in interviews. One-way repeated-measures ANOVAs were conducted to evaluate the effect of the programme and change over time. Qualitative data were analysed using thematic analysis. RESULTS: Survey results indicated improvements in perceptions about nursing care of older people but no changes in knowledge. Themes generated from the qualitative data focused on participants' experiences of taking part in the programme and included: (i) relevance of content and delivery mode, (ii) value of participating in the programme and (iii) continuing education in the context of acute care. CONCLUSIONS: This study illustrated the potential role of workplace continuing education in improving care for hospitalised older people, particularly the potential to change nurses' perceptions about this population. Nurses prefer learning opportunities that are varied in delivery of educational elder-focused content and accessible at work. Organisational leaders need to consider strategies that minimise potential barriers to workplace continuing education. IMPLICATIONS FOR PRACTICE: Workplace continuing education can play a key role in improving quality of care for hospitalized older adults and ought to be a priority for employers planning education for nurses.

The effect of medical therapy and islet cell transplantation on diabetic nephropathy: an interim report.

BACKGROUND: The effect of islet cell transplantation (ICT) on renal function in type 1 diabetes is uncertain and some recent studies report a significant decline in estimated glomerular filtration rate (GFR) and worsening of albuminuria. METHODS: We are conducting a prospective crossover study comparing medical treatment with islet transplantation on the progression of diabetic complications, including renal function. The primary endpoint is change in GFR measured by Tc-diethylenetriaminepentaacetate with secondary endpoints including estimated GFR and albumin excretion. RESULTS: We have followed 21 patients after islet transplantation a median of 29 months (range 13-45) and compared their results with medically treated patients followed a median 29.5 months (range 13-56). There is no difference in the rate of decline in measured GFR between medically treated patients (-0.35+/-0.89; 95% CI: -0.57 to -0.13 mL/min/month/1.73 m) and those after ICT (-0.31+/-1.18; 95% CI: -0.61 to -0.01) and neither is significantly different from that expected for the general population. The rate of decline in our estimated GFR results is lower than that reported in other studies and we did not find any worsening of albuminuria. CONCLUSIONS: We do not find evidence of worsening of renal function after islet transplantation compared with medically treated patients.

Improved human pancreatic islet isolation for a prospective cohort study of islet transplantation vs best medical therapy in type 1 diabetes mellitus.

HYPOTHESIS: A local multiorgan donor pancreas procurement program can provide a source for optimized isolation of purified viable islets for transplantation into patients with type 1 diabetes mellitus receiving best medical therapy. DESIGN: Prospective before-after cohort study. SETTING: Tertiary referral center. PATIENTS: Glycemic control was assessed in 10 patients with diabetes-induced renal dysfunction who were enrolled in a best medical therapy program and then crossed over to islet transplantation. INTERVENTIONS: Thirty human pancreata were retrieved from local multiorgan donors and consecutively processed with intraductal collagenase perfusion, continuous digestion, and density gradient purification (group 1, n = 9) or similarly processed but impure tissue fractions cultured in vitro and then repurified to retrieve additional islets (group 2, n = 21). Islets were implanted by percutaneous portal embolization, providing more than 10 000 islet equivalents (IE) per kilogram of body weight (infusions from 1-3 donors per patient) under cover of antithymocyte globulin, sirolimus, or mycophenolate mofetil and tacrolimus. MAIN OUTCOME MEASURES: Islet yields, purity, and cell viability (caspase 3, terminal deoxynucleotidyl transferase-mediated biotin-deoxyuridine 5-triphosphate nick-end labeling stain, and insulin secretion in vitro) were compared. In patients, monitored metabolic parameters were C-peptide secretion, insulin requirements, glycemic excursion, and hemoglobin A(1c) (HbA(1c)). RESULTS: For group 1 vs group 2, no differences were observed in pancreas age (43 vs 44 years), cold storage (5 vs 4 hours), or weight (73 vs 82 g). Group 2 yielded 453 690 IE vs 214 109 IE in group 1 (P = .002). Grafts contained 50% or more endocrine cells in both groups. No difference occurred in cell viability or insulin secretion. Islets from 90% of group 2 pancreata met release criteria for transplantation. C-peptide secretion was detected in all recipients and persisted with a median follow-up to 12 months (range, 6-21 months) after full islet transplantation. Daily insulin dependence was reversed in all patients for at least 3 months. Five patients resumed small insulin doses. Compared with the best care program, all patients had improved metabolic stability. The mean +/- SE HbA(1c) level at entry into the study was 7.8% +/- 0.5%, and this decreased to 6.9% +/- 0.2% after best care (P = .38) and further to 6.2% +/- 0.2% at 6 months after transplantation (P = .002 vs entry; P = .15 vs best care; analysis of variance). CONCLUSIONS: Local pancreas donor retrieval with islet isolation and culture conditioning enabled an offer of islets for transplantation for 90% of consecutively processed pancreata. Isolated islets secreted insulin during prolonged follow-up after implantation into patients, yielding metabolic control comparable with that achieved by best medical therapy.