Medical error reporting software program development and its impact on pediatric units' reporting medical errors.

OBJECTIVE: The purpose of this quasi-experimental study was to developing web-based, anonymous reporting system to increase reporting of medication errors, blood transfusion errors and patient falls in pediatric units and to compare the computerized system with the written system already in use at the institution. METHODS: This study was conducted in all pediatric units of a research hospital. All physicians and nurses working in these units agreed to participate in the study. All units were visited to introduce the new reporting system. The number and quality of the reports sent on the new system in years 2014 and 2015 were compared to the reports sent the previous year using the written system. RESULTS: There was considerable increase in rates of reporting: 234% increase in medication error reporting rate, and 100% increase in the reports of blood transfusion errors. One of the most important results of this study that near-miss errors were not reported at all while the written system of the study institution was being used, whereas it was the most commonly reported type of errors in the electronic error reporting system. CONCLUSION: The web-based reporting system, which makes reporting easy, promoted the development of safety culture among doctors and nurses in common language.

Development and Feasibility Testing of a Device Briefing Tool and Training to Improve Patient Safety During Introduction of New Devices in Operating Rooms: Best Practices and Lessons Learned.

BACKGROUND: Introducing new surgical devices into the operating room (OR) can serve as a critical opportunity to address patient safety. The effectiveness of OR briefings to improve communication, teamwork, and safety has not been evaluated in this setting. METHODS: Ariadne Labs and Johnson and Johnson (J&J) collaborated to develop and assess an intervention including a Device Briefing Tool (DBT) and novel multidisciplinary team training for clinicians (surgeons and nurses) around the introduction of a new device in the OR. J&J sales representatives trained clinicians to use the DBT, a communication tool to improve patient safety when a new device is used for the first time. Surveys were administered to representatives (n = 10), surgeons (n = 15), and nurses (n = 30) at the baseline, after trainings, and after using the DBT in an operation at six different Thai hospitals. RESULTS: Familiarity with the Surgical Safety Checklist (SURGICAL SAFETY CHECKLIST) varied but increased post-training. Regarding trainings, 90% of representatives felt they very much or completely met all learning objectives but 50% felt only slightly prepared to train clinicians on using DBT. Post-training, clinician confidence in using a new device rose from 47 to 85%. Regarding the DBT, 90% of clinicians felt confident using it and reported they were very likely to use it in the future. Overall, over 90% of all clinicians and representatives felt safe having surgery in their hospitals. CONCLUSIONS: There is high acceptability and feasibility of the multidisciplinary trainings and the DBT among representatives and clinicians, albeit in a limited number of participants from a small number of institutions.

Nurses' perceptions of high-alert medication administration safety: A qualitative descriptive study.

AIMS: The aim of this study was to determine nurses' perceptions of supports and barriers to high-alert medication (HAM) administration safety. DESIGN: A qualitative descriptive design was used. METHODS: Eighteen acute care nurses were interviewed about HAM administration practices. Registered nurses (RNs) working with acutely ill adults in two hospitals participated in one-on-one interviews from July-September, 2017. Content analysis was conducted for data analysis. RESULTS: Three themes contributed to HAM administration safety: Organizational Culture of Safety, Collaboration, and RN Competence and Engagement. Error factors included distractions, workload and acuity. Work arounds bypassing bar code scanning and independent double check procedures were common. Findings highlighted the importance of intra- and interprofessional collaboration, nurse engagement and incorporating the patient in HAM safety. CONCLUSIONS: Current HAM safety strategies are not consistently used. An organizational culture that supports collaboration, education on safe HAM practices, pragmatic HAM policies and enhanced technology are recommended to prevent HAM errors. IMPACT: Hospitals incorporating these findings could reduce HAM errors. Research on nurse engagement, intra- and interprofessional collaboration and inclusion of patients in HAM safety strategies is needed.

Taking the Fall for Kids: A Journey to Reducing Pediatric Falls.

PURPOSE: To reduce harm related to pediatric falls, a quality improvement project was conducted at a children's hospital. DESIGN AND METHODS: An interprofessional team designed and implemented evidence-based interventions to align with the hospital's journey to reduce patient harm. These interventions included selection and implementation of a fall risk assessment tool, implementation of fall bundle elements, and implementation of fall prevention education to patients and families. Surveys, audits, and rate of falls were used to evaluate the project. RESULTS: Fall bundle compliance increased from 27% to 88% and there were zero patient falls in five out of the six months after implementation a comprehensive pediatric fall prevention program. CONCLUSIONS: Implementing pediatric-specific, evidence-based interventions can help to reduce patient falls. There was a substantial increase in fall bundle compliance and a decrease in falls and falls with injury. PRACTICE IMPLICATIONS: Engagement and empowerment of clinical nurses in the quality improvement process design and implementation can substantially improve patient outcomes and patient safety while reducing harm. Future research is needed to determine factors that promote enhanced reporting needed to determine the true incidence of patient falls in pediatric inpatient and outpatient settings.

Systematic psychometric review of self-reported instruments to assess patient safety culture in primary care.

AIMS: To give an overview of empirical studies using self-reported instruments to assess patient safety culture in primary care and to synthesize psychometric properties of these instruments. BACKGROUND: A key condition for improving patient safety is creating a supportive safety culture to identify weaknesses and to develop improvement strategies so recurrence of incidents can be minimized. However, most tools to measure and strengthen safety culture have been developed and tested in hospitals. Nevertheless, primary care is facing greater risks and a greater likelihood of causing unintentional harm to patients. DESIGN: A systematic literature review of research evidence and psychometric properties of self-reported instruments to assess patient safety culture in primary care. DATA SOURCES: Three databases until November 2016. REVIEW METHODS: The review was carried out according to the protocol for systematic reviews of measurement properties recommended by the COSMIN panel and the PRISMA reporting guidelines. RESULTS: In total, 1.229 records were retrieved from multiple database searches (Medline = 865, Web of Science = 362 and Embase = 2). Resulting from an in-depth literature search, 14 published studies were identified, mostly originated from Western high-income countries. As these studies come with great diversity in tools used and outcomes reported, comparability of the results is compromised. Based on the psychometric review, the SCOPE-Primary Care survey was chosen as the most appropriate instrument to measure patient safety culture in primary care as the instrument had excellent internal consistency with Cronbach's alphas ranging from 0.70-0.90 and item factor loadings ranging from 0.40-0.96, indicating a good structural validity. CONCLUSION: The findings of the present review suggest that the SCOPE-Primary Care survey is the most appropriate tool to assess patient safety culture in primary care. Further psychometric techniques are now essential to ensure that the instrument provides meaningful information regarding safety culture.

The Health and Safety of Nephrology Nurses and the Environments in Which They Work: Important for Nurses, Patients, and Organizations.

Nurse health and safety and the environments in which nurses work impact nurses, patient safety and quality of care, and organizational outcomes. In January 2018, we conducted a comprehensive national assessment of the overall health and safety of nephrology nurses and their work environments as a follow-up study to the 2014 study on Patient Safety Culture in Nephrology Nurse Settings conducted by American Nephrology Nurses Association. This article presents initial broad findings of this national study. Results identified a number of opportunities for improvement in nephrology nurse work environments, especially in the areas of staffing, optimizing the knowledge and skills of registered nurses, and mental and physical health.

Newborn screening: A complex system that requires a culture of safety.

As health care providers and organizations, we have a responsibility to examine our practices and systems for opportunities to improve quality and health outcomes. Today a critical opportunity exists in the newborn screening (NBS) system, which touches every one of the approximately 4 million babies born annually in the United States. This opportunity involves improving the quality of NBS by developing a culture of safety to prevent errors that in NBS represent missed babies and preventable morbidity and mortality. This commentary will explore the "culture of safety" for NBS, including the high reliability organization (HRO) paradigm and normal accident theory (NAT), which have been effective in reducing systems failures in other complex environments.

The Art of Speaking Up: Supporting a Culture of Safety in the OR.

Considering the high-risk, stressful, and fast-paced nature of the perioperative environment and vulnerability of surgical patients, the quest for maintaining a safety culture in the OR is ongoing. Speaking up-an interaction between perioperative team members to address a concern-requires team member empowerment to advocate for patient safety when needed. Hierarchical gradients, lack of psychological safety, incivility, and a nonsupportive organizational culture can impede speaking-up behaviors. Strategies to improve speaking up include using multimethod education initiatives, enhancing psychological safety, and managing conflict. Perioperative nurses can experience barriers to speaking up, such as lack of team familiarity, normalization of deviance, and differing perceptions among team members. The logistics of whole-team training initiatives can be challenging; however, such initiatives can help participants improve their understanding of the perspectives and communication goals of all involved personnel. Perioperative nurses and leaders should collaborate to promote speaking up for safety when warranted.

Factors in the Perioperative Nurses' Work Environment That Predict Work Engagement.

Perioperative nurse engagement and certification are associated with a culture of safety, which is crucial in perioperative environments. Therefore, examining relationships between engagement, the practice environment, and certification is warranted. The purposes of this study were to examine the relationships between the perioperative practice environment and reported nurse engagement, determine differences in engagement based on certification, and identify facilitators and barriers to attaining and sustaining certification. In this multiphase mixed-methods study, we used a convenience sample of perioperative nurses (N = 379) to examine relationships between engagement, the practice environment, and certification. Qualitative interviews were conducted (n = 15) to supplement the quantitative findings. Leadership support (ß = 0.23, P = .001) and nursing foundations for quality care (ß = 0.21, P = .01) were significant predictors of engagement. Certified nurses did not have significantly higher mean engagement scores when compared with noncertified peers. Qualitative interviews corroborated the findings.

Vaught's Single Story and Health Care's Culture of Safety.

To Err is Human: Building a Safer Health System, the Institute of Medicine's consequential 2000 report, focused attention on medical errors, championing preventive strategies to improve patient safety in hospitals. In the c.

A pseudo-outbreak of Burkholderia cepacia complex in a Kentucky hospital.

A cluster of Burkholderia cepacia complex cases from January to October 2020 among outpatients undergoing urologic procedures within a Kentucky hospital's operating rooms was investigated. This investigation included a laboratory look-back, chart reviews, exposure tracing, staff interviews, and direct observation of infection prevention and control practices. A significant protocol breach in a laboratory procedure led to contamination of surgical specimens submitted for culture with nonsterile saline. Pseudo-outbreaks often highlight gaps in infection control processes. Healthcare facilities can make substantial improvements in patient care quality and safety as they respond to identified gaps and improve systems and protocols.

Nurse leadership: Sustaining a culture of safety.

Background: Nurse leaders are essential to manage nursing practices that affect patient safety; therefore, they must create and sustain a sound safety culture in a diverse cultural environment. Aim: To describe the specific actions required by nurse leadership to enhance the sustainability of a safety culture in hospitals and among a diverse nursing team, ultimately improving patient outcomes. Setting: Two hospitals in the United Arab Emirates (UAE) were selected purposively, based on the diversity of the nursing team. Methods: A quantitative design, using Reason's safety culture framework and Ekenedo's behavioural safety model, formed the theoretical background of this study to identify the safety culture and positive work environment that exist among culturally diverse nurses. Thirty-four nurse managers and 417 nurses were conveniently selected to participate. Various instruments were used to gather hospital outcomes and other data from respondents pertaining to their demographics, patient safety, positive work environments and safety culture. Results: Findings received from the nursing team describe the correlation between patient safety, a diverse nursing workforce and positive work environment affecting a safety culture and promoting positive patient outcomes. Conclusion: Nurse leaders' integration of specific actions to address the system, as well as diverse nursing teams' behavioural practices, create a patient care environment that adequately contributes to safety culture practices and enhances positive patient outcomes, which are essential for a culture of safety. Contribution: The study contributes by providing a structured integration of specific actions for nurse leaders to sustain practices ensuring positive patient outcomes.

Implementation of a pharmacy-focused morbidity, mortality, and improvement conference.

PURPOSE: Review lessons learned during the development and implementation of a pharmacy-focused Morbidity, Mortality, and Improvement conference at an academic medical center. SUMMARY: Since the early 1900s, Morbidity and Mortality conferences have provided a forum for clinicians to discuss medical errors and adverse outcomes. Many institutions have now added "improvement" to the conference title to emphasize the goal of approaching these conferences in a systems-oriented manner. To date, a gap remains in the literature evaluating the impact of a pharmacy-focused Morbidity, Mortality, and Improvement (MM&I) conference. The primary goal in establishing this pharmacy-focused conference was to foster and strengthen the culture of medication safety within our department. In establishing our program, we identified an opportunity to leverage pharmacy residents similar to a medical resident-facilitated conference. After gaining leadership buy-in, a core planning team was formed to identify events and create conference materials. Primary metrics to gauge the success of implementation included event reporting trends and medication-safety strategic initiative tracking. The first year of MM&I conferences provided forward momentum for our department's safety culture. Safety event reporting by pharmacy staff increased by 150% over the fiscal year, and more frontline staff expressed a personal interest in becoming involved in safety projects and initiatives outside of their normal shift responsibilities. CONCLUSION: We have learned several important lessons that may be helpful to others, the primary of which is that improving a culture of safety takes time.

Just Culture: The Foundation of Staff Safety in the Perioperative Environment.

In today's perioperative setting, staff members are potentially exposed to a variety of safety and environmental concerns. As health care organizations implement measures to provide safe environments for perioperative team members, organizational leaders must pivot away from antiquated mindsets and responses and other hierarchical models of leadership. Foundational to creating and fostering safe environments is providing an atmosphere in which staff members, regardless of their role, are empowered to speak up for safety. This article defines a just culture; explores the critical elements of a just culture, including psychological safety, leader and staff member responsibilities, and staff member empowerment; and provides tools and resources that may be beneficial for leaders who are creating a just culture for staff safety in the perioperative setting.

An Examination of Factors That Predict the Perioperative Culture of Safety.

The perioperative setting is an intricate, complicated work environment in which patients are vulnerable to adverse events. Using a convenience sample, we examined relationships between the length of perioperative nurse experience, perioperative nurse engagement, and an OR culture of safety. We explored differences in safety culture scores based on CNOR certification status. There was no significant relationship between the length of perioperative nurse experience and the level of OR culture of safety. However, perioperative nurse engagement had a significant relationship with an OR culture of safety (P < .001), and this factor was a significant predictor of an OR culture of safety (P < .001). Perioperative nurses who held CNOR certification had significantly higher culture of safety scores compared with those who did not (P = .004). Additional research on perioperative nurse engagement and factors relating to patient safety may help perioperative leaders develop and implement engagement strategies.

Safety Culture and Patient Safety Outcomes in East Asia: A Literature Review.

This review examined associations between safety culture aspects and patient safety outcomes in East Asian hospitals and identified relevant research priorities. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, 16 articles were identified for review. Patient safety nursing activity was the most commonly investigated outcome in relation to safety culture aspects. Among safety culture aspects, feedback and communication, frequency of event reporting, teamwork within units, and managers' support for patient safety were most significantly related to patient safety outcomes. Areas for further research include the use of theory or theoretical frameworks, consensus upon the scoring strategies for computation of safety culture scores, and selecting appropriate units of analysis and statistical analyses. Finally, researchers should examine relations between unit-specific and nation-specific safety culture and patient safety outcomes, given the influence of cultural attitudes and behaviors on patient safety.

Nursing Salons Take to Hospital Education Days.

Salon gatherings featuring conversations about current themes in a profession are evolving with time and practice to meet the needs of modern nurses and their clinical partners. Nursing clinical educators at a Midwestern pediatric hospital system offered a nursing salon experience as a new component of education days to provide an opportunity for clinical staff to engage in content and conversations about practice in a setting away from direct patient care. The objective of the nursing salons was to engage in professional reflection. Staff members of a professional development center and a department of quality and safety collaborated to provide this experience for over 500 nurses, clinical support associates, and leaders, to enhance clinical education days.

Drug Diversion: Best Practices and Support for a Staff Assessment Process.

The characteristics of opioid prescribing and administration in cancer centers include large quantities and less restrictive regulatory mandates governing cancer-related pain, which may increase the risk of drug diversion by staff members. The purpose of this article is to provide a framework for creating respectful investigative processes for staff suspected of drug diversion. Organizations, including cancer centers, need to engage in careful oversight of potential drug diversions while simultaneously promoting a psychologically safe work environment for individuals to successfully seek help.

A demonstration project on the impact of safety culture on infection control practices in hemodialysis.

BACKGROUND: Infections among hemodialysis patients continues to be major causes of morbidity and mortality despite advances in the science of infection prevention. Many infections are potentially preventable, yet research suggests that evidence-based interventions are not uniformly practiced in dialysis settings. The purpose of the project was to reduce the risk of infection among hemodialysis patients in an outpatient dialysis clinic in upstate New York through the development of an enhanced patient safety culture. METHODS: A survey was used to assess the safety culture of a large outpatient dialysis program. A Comprehensive Unit-based Safety Program was instituted to enhance infection prevention practices. Evidence-based checklists and audit tools were used to track staff adherence to protocols. RESULTS: Scores on the survey were strongly correlated with bloodstream infection rates. Adherence to infection control standards improved when the End Stage Renal Disease Safety Program was implemented, with audits improving from 27%-82% of procedures performed correctly. Bloodstream infection rates decreased from 2.33-1.07 events per 100 patient months, and the standardized infection ratios decreased from 1.960-0.985 in the 12-months after implementation. CONCLUSIONS: The Comprehensive Unit-based Safety Program model and implementation of the safety program may be effective in improving the culture of safety and adherence to evidence-based practices in hemodialysis. Enhanced patient safety culture is correlated with improved patient outcomes.

Communication at Transitions of Care.

Communication errors during transitions of care are a leading source of adverse events for hospitalized patients. This article provides an overview of the role of communication errors in adverse events, describes the complexities of communication for hospitalized patients, and provides evidence regarding the positive effects of applying high-reliability principles to transitions of care and culture of safety. Elements of effective handoffs and a detailed approach for successful implementation of a handoff program are provided. The role of handoff communication in medical education at all levels, as well as for the interprofessional team, is discussed.