Is culture associated with patient safety in the emergency department? A study of staff perspectives.

OBJECTIVE: To describe the patient safety culture of Dutch emergency departments (EDs), to examine associations between safety culture dimensions and patient safety grades as reported by ED staff and to compare these associations between nurses and physicians. DESIGN: Cross-sectional survey conducted in 2007. SETTING: Thirty-three non-academic EDs in the Netherlands. PARTICIPANTS: Four hundred and eighty nurses, 159 physicians and 91 other professionals. MAIN OUTCOME MEASURE: Self-reported level of patient safety. RESULTS: In unadjusted analyses, all dimensions of safety culture were positively associated with the reported level of patient safety and six of these associations with patient safety were statistically significant after adjustment ('teamwork across units', 'frequency of event reporting', communication openness', 'feedback about and learning from errors', 'hospital management support for patient safety'). Differences between nurses and physicians were found on two dimensions ('frequency of event reporting' and ' hospital management support for patient safety'). Physicians tended to grade patient safety higher than nurses whilst having equal judgements on these two dimensions. CONCLUSIONS: Staff identified several dimensions of safety culture that are associated with staff-reported safety in the ED. Physicians and nurses identified distinct dimensions of safety culture as associated with reported level of patient safety.

Barriers and facilitators for taking action after classroom-based crew resource management training at three ICUs.

BACKGROUND: Given growing awareness of the crucial role of nontechnical skills in providing safe patient care, crew resource management (CRM) training is being increasingly used to improve them. Implementing the plans of action that are formulated during CRM training may constitute an important first step in the successful uptake of skills. Accordingly, understanding the factors that determine why participants do or do not carry out those plans should help improve CRM training and enhance its impact. A study was conducted to examine the impact of pretraining readiness factors and posttraining barriers and facilitators on follow-up on plans of action. METHODS: Three ICUs, each at a different nonacademic teaching hospital in The Netherlands, received two-day classroom-based CRM training in 2010. During the training, new ideas for safety initiatives were documented as concrete plans of action. All plans were categorized as individual (for example, "Always ask a colleague to double-check your medication"), team, or organizational. Two months before and three months after the CRM training, all ICU employees were asked to fill out a set of questionnaires. RESULTS: Management support for patient safety before the training was a positive determinant of the number of perceived facilitators. A significant relationship was found between the perceived barriers and facilitators after CRM training and Taking Action. More barriers were negatively associated, while more facilitators were positively associated, with Taking Action. When assessed separately, none of the readiness factors were significantly associated with taking action, while when assessed together, the readiness factors were positive related to Taking Action. DISCUSSION: To overcome the barriers and profit from the facilitators, they should be considered during the training and in regular CRM meetings afterward.

Evaluation of aviation-based safety team training in a hospital in The Netherlands.

PURPOSE: The purpose of this paper is to evaluate the implementation of a broad-scale team resource management (TRM) program on safety culture in a Dutch eye hospital, detailing the program's content and procedures. Aviation-based TRM training is recognized as a useful approach to increase patient safety, but little is known about how it affects safety culture. DESIGN/METHODOLOGY/APPROACH: Pre- and post-assessments of the hospitals' safety culture was based on interviews with ophthalmologists, anesthesiologists, residents, nurses, and support staff. Interim observations were made at training sessions and in daily hospital practice. FINDINGS: The program consisted of safety audits of processes and (team) activities, interactive classroom training sessions by aviation experts, a flight simulator session, and video recording of team activities with subsequent feedback. Medical professionals considered aviation experts inspiring role models and respected their non-hierarchical external perspective and focus on medical-technical issues. The post-assessment showed that ophthalmologists and other hospital staff had become increasingly aware of safety issues. The multidisciplinary approach promoted social (team) orientation that replaced the former functionally-oriented culture. The number of reported near-incidents greatly increased; the number of wrong-side surgeries stabilized to a minimum after an initial substantial reduction. RESEARCH LIMITATIONS/IMPLICATIONS: The study was observational and the hospital's variety of efforts to improve safety culture prevented us from establishing a causal relation between improvement and any one specific intervention. ORIGINALITY/VALUE: Aviation-based TRM training can be a useful to stimulate safety culture in hospitals. Safety and quality improvements are not single treatment interventions but complex socio-technical interventions. A multidisciplinary system approach and focus on "team" instead of "profession" seems both necessary and difficult in hospital care.

Effectiveness of classroom based crew resource management training in the intensive care unit: study design of a controlled trial.

BACKGROUND: Crew resource management (CRM) has the potential to enhance patient safety in intensive care units (ICU) by improving the use of non-technical skills. However, CRM evaluation studies in health care are inconclusive with regard to the effect of this training on behaviour and organizational outcomes, due to weak study designs and the scarce use of direct observations. Therefore, the aim of this study is to determine the effectiveness and cost-effectiveness of CRM training on attitude, behaviour and organization after one year, using a multi-method approach and matched control units. The purpose of the present article is to describe the study protocol and the underlying choices of this evaluation study of CRM in the ICU in detail. METHODS/DESIGN: Six ICUs participated in a paired controlled trial, with one pre-test and two post test measurements (respectively three months and one year after the training). Three ICUs were trained and compared to matched control ICUs. The 2-day classroom-based training was delivered to multidisciplinary groups. Typical CRM topics on the individual, team and organizational level were discussed, such as situational awareness, leadership and communication. All levels of Kirkpatrick's evaluation framework (reaction, learning, behaviour and organisation) were assessed using questionnaires, direct observations, interviews and routine ICU administration data. DISCUSSION: It is expected that the CRM training acts as a generic intervention that stimulates specific interventions. Besides effectiveness and cost-effectiveness, the assessment of the barriers and facilitators will provide insight in the implementation process of CRM. TRIAL REGISTRATION: Netherlands Trial Register (NTR): NTR1976.

Proximal antecedents and correlates of adopted error approach: a self-regulatory perspective.

The current study aims to further investigate earlier established advantages of an error mastery approach over an error aversion approach. The two main purposes of the study relate to (1) self-regulatory traits (i.e., goal orientation and action-state orientation) that may predict which error approach (mastery or aversion) is adopted, and (2) proximal, psychological processes (i.e., self-focused attention and failure attribution) that relate to adopted error approach. In the current study participants' goal orientation and action-state orientation were assessed, after which they worked on an error-prone task. Results show that learning goal orientation related to error mastery, while state orientation related to error aversion. Under a mastery approach, error occurrence did not result in cognitive resources "wasted" on self-consciousness. Rather, attention went to internal-unstable, thus controllable, improvement oriented causes of error. Participants that had adopted an aversion approach, in contrast, experienced heightened self-consciousness and attributed failure to internal-stable or external causes. These results imply that when working on an error-prone task, people should be stimulated to take on a mastery rather than an aversion approach towards errors.

Implementation of Crew Resource Management: A Qualitative Study in 3 Intensive Care Units.

OBJECTIVES: Classroom-based crew resource management (CRM) training has been increasingly applied in health care to improve safe patient care. Crew resource management aims to increase participants' understanding of how certain threats can develop as well as provides tools and skills to respond to such threats. Existing literature shows promising but inconclusive results that might be explained by the quality of the implementation. The present research systematically describes the implementation from the perspective of 3 trained intensive care units (ICUs). METHODS: The design of the study was built around 3 stages of implementation: (1) the preparation, (2) the actions after the CRM training, and (3) the plans for the future. To assess all stages in 3 Dutch ICUs, 12 semistructured interviews with implementation leaders were conducted, the End-of-Course Critique questionnaire was administered, and objective measurements consisting of the number and types of plans of action were reported. RESULTS: The results categorize initiatives that all 3 ICUs successfully launched, including the development of checklists, each using a different implementation strategy. All ICUs have taken several steps to sustain their approach for the foreseeable future. Three similarities between the units were seen at the start of the implementation: (1) acknowledgment of a performance gap in communication, (2) structural time allocated for CRM, and (3) a clear vision on how to implement CRM. CONCLUSIONS: This study shows that CRM requires preparation and implementation, both of which require time and dedication. It is promising to note that all 3 ICUs have developed multiple quality improvement initiatives and aim to continue doing so.

Behind the wheel: What drives the effects of error handling?

Existing research comparing error management (a strategy focusing on increasing the positive and decreasing the negative consequences of errors) to error prevention (a strategy focusing on working faultlessly), has identified error management as beneficial for multiple outcomes. Yet, due to various methodological limitations, it is unclear whether the effects previously found are due to error prevention, error management, or both. We examine this in an experimental study with a 2 (error prevention: yes vs. no) × 2 (error management: yes vs. no) factorial design. Error prevention had negative effects on cognition and adaptive transfer performance. Error management alleviated worry and boosted one's perceived self-efficacy. Overall, the results show that error prevention and error management have unique outcomes on negative affect, self-efficacy, cognition, and performance.

Crew resource management training in the intensive care unit. A multisite controlled before-after study.

INTRODUCTION: There is a growing awareness today that adverse events in the intensive care unit (ICU) are more often caused by problems related to non-technical skills than by a lack of technical, or clinical, expertise. Team training, such as crew resource management (CRM), aims to improve these non-technical skills. The present study evaluated the effectiveness of CRM in the ICU. METHODS: Six ICUs participated in a paired controlled trial, with one pretest and two post-test measurements (after 3 and 12 months). Three ICUs received CRM training and were compared with a matched control unit. The 2-day classroom-based training was delivered to multidisciplinary groups (ie, ICU physicians, nurses, managers). All levels of Kirkpatrick's evaluation framework were assessed using a mixed method design, including questionnaires, observations and routinely administered patient outcome data. RESULTS: Level I-reaction: participants were very positive directly after the training. Level II-learning: attitudes towards behaviour aimed at optimising situational awareness were relatively high at baseline and remained stable. Level III-behaviour: self-reported behaviour aimed at optimising situational awareness improved in the intervention group. No changes were found in observed explicit professional oral communication. Level IV-organisation: patient outcomes were unaffected. Error management culture and job satisfaction improved in the intervention group. Patient safety culture improved in both control and intervention units. CONCLUSIONS: We can conclude that CRM, as delivered in the present study, does not change behaviour or patient outcomes by itself, yet changes how participants think about errors and risks. This indicates that CRM requires a combination with other initiatives in order to improve clinical outcomes.

Organizational error management culture and its impact on performance: a two-study replication.

The authors argue that a high-organizational error management culture, conceptualized to include norms and common practices in organizations (e.g., communicating about errors, detecting, analyzing, and correcting errors quickly), is pivotal to the reduction of negative and the promotion of positive error consequences. Organizational error management culture was positively related to firm performance across 2 studies conducted in 2 different European countries. On the basis of quantitative and qualitative cross-sectional data from 65 Dutch organizations, Study 1 revealed that organizational error management culture was significantly correlated with both organizational goal achievement and an objective indicator of economic performance. This finding was confirmed in Study 2, using change-of-profitability data from 47 German organizations. The results suggest that organizations may want to introduce organizational error management as a way to boost firm performance.

Responses to professional identity threat: Identity management strategies in incident narratives of health care professionals.

PURPOSE: The purpose of this paper is to explore sensemaking of incidents by health care professionals through an analysis of the role of professional identity in narratives of incidents. Using insights from social identity theory, the authors argue that incidents may create a threat of professional identity, and that professionals make use of identity management strategies in response to this identity threat. DESIGN/METHODOLOGY/APPROACH: The paper draws on a qualitative analysis of incident narratives in 14 semi-structured interviews with physicians, nurses, and residents at a Dutch specialist hospital. The authors used an existing framework of identity management strategies to categorize the narratives. FINDINGS: The analysis yielded two main results. First, nurses and residents employed multiple types of identity management strategies simultaneously, which points to the possible benefit of combining different strategies. Second, physicians used the strategy of patronization of other professional groups, a specific form of downward comparison. RESEARCH LIMITATIONS/IMPLICATIONS: The authors discuss the implications of the findings in terms of the impact of identity management strategies on the perpetuation of hierarchical differences in health care. PRACTICAL IMPLICATIONS: The authors argue that efforts to manage incident handling may profit from considering social identity processes in sensemaking of incidents. ORIGINALITY/VALUE: This is the first study that systematically explores how health care professionals use identity management strategies to maintain a positive professional identity in the face of incidents. This study contributes to research on interdisciplinary cooperation in health care.

More explicit communication after classroom-based crew resource management training: results of a pragmatic trial.

RATIONALE, AIMS AND OBJECTIVES: Aviation-based crew resource management trainings to optimize non-technical skills among professionals are often suggested for health care as a way to increase patient safety. Our aim was to evaluate the effect of a 2-day classroom-based crew resource management (CRM) training at emergency departments (EDs) on explicit professional oral communication (EPOC; non-technical skills). METHOD: A pragmatic controlled before-after trial was conducted. Four EDs of general teaching hospitals were recruited (two intervention and two control departments). ED nurses and ED doctors were observed on their non-technical skills by means of a validated observation tool (EPOC). Our main outcome measure was the amount of EPOC observed per interaction in 30 minutes direct observations. Three outcome measures from EPOC were analysed: human interaction, anticipation on environment and an overall EPOC score. Linear and logistic mixed model analyses were performed. Models were corrected for the outcome measurement at baseline, days between training and observation, patient safety culture and error management culture at baseline. RESULTS: A statistically significant increase after the training was found on human interaction (ß=0.27, 95% CI 0.08-0.49) and the overall EPOC score (ß=0.25, 95% CI 0.06-0.43), but not for anticipation on environment (OR=1.19, 95% CI .45-3.15). This means that approximately 25% more explicit communication was shown after CRM training. CONCLUSIONS: We found an increase in the use of CRM skills after classroom-based crew resource management training. This study adds to the body of evidence that CRM trainings have the potential to increase patient safety by reducing communication flaws, which play an important role in health care-related adverse events.

Does classroom-based Crew Resource Management training improve patient safety culture? A systematic review.

AIM: To evaluate the evidence of the effectiveness of classroom-based Crew Resource Management training on safety culture by a systematic review of literature. METHODS: Studies were identified in PubMed, Cochrane Library, PsycINFO, and Educational Resources Information Center up to 19 December 2012. The Methods Guide for Comparative Effectiveness Reviews was used to assess the risk of bias in the individual studies. RESULTS: In total, 22 manuscripts were included for review. Training settings, study designs, and evaluation methods varied widely. Most studies reporting only a selection of culture dimensions found mainly positive results, whereas studies reporting all safety culture dimensions of the particular survey found mixed results. On average, studies were at moderate risk of bias. CONCLUSION: Evidence of the effectiveness of Crew Resource Management training in health care on safety culture is scarce and the validity of most studies is limited. The results underline the necessity of more valid study designs, preferably using triangulation methods.

Walk the talk: leaders' enacted priority of safety, incident reporting, and error management.

PURPOSE: The main goal of the current research was to investigate whether and how leaders in health care organizations can stimulate incident reporting and error management by "walking the safety talk" (enacted priority of safety). DESIGN/METHODOLOGY/APPROACH: Open interviews (N = 26) and a cross-sectional questionnaire (N = 183) were conducted at the Rotterdam Eye Hospital (REH) in The Netherlands. FINDINGS: As hypothesized, leaders' enacted priority of safety was positively related to incident reporting and error management, and the relation between leaders' enacted priority of safety and error management was mediated by incident reporting. The interviews yielded rich data on (near) incidents, the leaders' role in (non)reporting, and error management, grounding quantitative findings in concrete case descriptions. RESEARCH IMPLICATIONS: We support previous theorizing by providing empirical evidence showing that (1) enacted priority of safety has a stronger relationship with incident reporting than espoused priority of safety and (2) the previously implied positive link between incident reporting and error management indeed exists. Moreover, our findings extend our understanding of behavioral integrity for safety and the mechanisms through which it operates in medical settings. PRACTICAL IMPLICATIONS: Our findings indicate that for the promotion of incident reporting and error management, active reinforcement of priority of safety by leaders is crucial. VALUE/ORIGINALITY: Social sciences researchers, health care researchers and health care practitioners can utilize the findings of the current paper in order to help leaders create health care systems characterized by higher incident reporting and more constructive error handling.

Development and reliability of the explicit professional oral communication observation tool to quantify the use of non-technical skills in healthcare.

BACKGROUND: A lack of non-technical skills is increasingly recognised as an important underlying cause of adverse events in healthcare. The nature and number of things professionals communicate to each other can be perceived as a product of their use of non-technical skills. This paper describes the development and reliability of an instrument to measure and quantify the use of non-technical skills by direct observations of explicit professional oral communication (EPOC) in the clinical situation. METHODS: In an iterative process we translated, tested and refined an existing checklist from the aviation industry, called self, human interaction, aircraft, procedures and environment, in the context of healthcare, notably emergency departments (ED) and intensive care units (ICU). The EPOC comprises six dimensions: assertiveness, working with others; task-oriented leadership; people-oriented leadership; situational awareness; planning and anticipation. Each dimension is specified into several concrete items reflecting verbal behaviours. The EPOC was evaluated in four ED and six ICU. RESULTS: In the ED and ICU, respectively, 378 and 1144 individual and 51 and 68 contemporaneous observations of individual staff members were conducted. All EPOC dimensions occur frequently, apart from assertiveness, which was hardly observed. Intraclass correlations for the overall EPOC score ranged between 0.85 and 0.91 and for underlying EPOC dimensions between 0.53 and 0.95. CONCLUSIONS: The EPOC is a new instrument for evaluating the use of non-technical skills in healthcare, which is reliable in two highly different settings. By quantifying professional behaviour the instrument facilitates measurement of behavioural change over time. The results suggest that EPOC can also be translated to other settings.