Patient safety culture assessment in the nursing home.

OBJECTIVE: To assess patient safety culture (PSC) in the nursing home setting, to determine whether nursing home professionals differ in their PSC ratings, and to compare PSC scores of nursing homes with those of hospitals. METHODS: The Hospital Survey on Patient Safety Culture was modified for use in nursing homes (PSC-NH) and distributed to 151 professionals in four non-profit nursing homes. Mean scores on each PSC-NH dimension were compared across professions (doctors, pharmacists, advanced practitioners and nurses) and with published benchmark scores from 21 hospitals. RESULTS: Response rates were 68.9% overall and 52-100% for different professions. Most respondents (76%) were women and had worked in nursing homes for an average of 9.8 years, and at their current facility for 5.4 years. Professions agreed on 11 of 12 dimensions of the survey and differed significantly (p<0.05) only in ratings for one PSC dimension (attitudes about staffing issues), where nurses and pharmacists believed that they had enough employees to handle the workload. Nursing homes scored significantly lower (ie, worse) than hospitals (p<0.05) in five PSC dimensions (non-punitive response to error, teamwork within units, communication openness, feedback and communication about error, and organisational learning). CONCLUSIONS: Professionals in nursing homes generally agree about safety characteristics of their facilities, and the PSC in nursing homes is significantly lower than that in hospitals. PSC assessment may be helpful in fostering comparisons across nursing home settings and professions, and identifying targets for interventions to improve patient safety.

The emerging science of very early detection of disease outbreaks.

A surge of development of new public health surveillance systems designed to provide more timely detection of outbreaks suggests that public health has a new requirement: extreme timeliness of detection. The authors review previous work relevant to measuring timeliness and to defining timeliness requirements. Using signal detection theory and decision theory, the authors identify strategies to improve timeliness of detection and position ongoing system development within that framework.

Error analysis using organizational simulation.

Organizational simulations have been used by project organizations in civil and aerospace industries to identify work processes and organizational structures that are likely to fail under certain conditions. Using a simulation system based on Galbraith's information-processing theory and Simon's notion of bounded-rationality, we retrospectively modeled a chemotherapy administration error that occurred in a hospital setting. Our simulation suggested that when there is a high rate of unexpected events, the oncology fellow was differentially backlogged with work when compared with other organizational members. Alternative scenarios suggested that providing more knowledge resources to the oncology fellow improved her performance more effectively than adding additional staff to the organization. Although it is not possible to know whether this might have prevented the error, organizational simulation may be an effective tool to prospectively evaluate organizational "weak links", and explore alternative scenarios to correct potential organizational problems before they generate errors.

Representing the work of medical protocols for organizational simulation.

Developing and implementing patient care protocols within a specific organizational setting requires knowledge of the protocol, the organization, and the way in which the organization does its work. Computer-based simulation tools have been used in many industries to provide managers with prospective insight into problems of work process and organization design mismatch. Many of these simulation tools are designed for well-understood routine work processes in which there are few contingent tasks. In this paper, we describe theoretic that make it possible to simulate medical protocols using an information-processing theory framework. These simulations will allow medical administrators to test different protocol and organizational designs before actually using them within a particular clinical setting.

Making generic guidelines site-specific.

Health care providers are more likely to follow a clinical guideline if the guideline's recommendations are consistent with the way in which their organization does its work. Unfortunately, developing guidelines that are specific to an organization is expensive, and limits the ability to share guidelines among different institutions. We describe a methodology that separates the site-independent information of guidelines from site-specific information, and that facilitates the development of site-specific guidelines from generic guidelines. We have used this methodology in a prototype system that assists developers in creating generic guidelines that are sharable across different sites. When combined with site information, generic guidelines can be used to generate site-specific guidelines that are responsive to organizational change and that can be implemented at a level of detail that makes site-specific computer-based workflow management and simulation possible.

A survey of patient access to electronic mail: attitudes, barriers, and opportunities.

The use of electronic mail (e-mail) is increasing among both physicians and patients, although there is limited information in the literature about how patients might use e-mail to communicate with their physician. In our university-based internal medicine clinic, we have studied attitudes toward and access to e-mail among patients. A survey of 444 patients in our clinic showed that 46% of patients in the clinic use e-mail, and 89% of those with e-mail use it at work. Fifty-one percent would use e-mail all or most of the time to communicate with the clinic if it were available, and many of the communications that currently take place by phone could be replaced by e-mail. Barriers to e-mail use include privacy concerns among patients who use e-mail in the workplace, choosing the appropriate tasks for e-mail, and methods for efficiently triaging electronic messages in the clinic.