Handoffs, Safety Culture, and Practices: Evidence from the Hospital Survey on Patient Safety Culture

Background: The context of the study is the Agency for Healthcare Research and Quality’s Hospital Survey on Patient Safety Culture (HSOPSC). The purpose of the study is to analyze how different elements of patient safety culture are associated with clinical handoffs and perceptions of patient safety. Methods: The study was performed with hierarchical multiple linear regression on data from the 2010 Survey. We examine the statistical relationships between perceptions of handoffs and transitions practices, patient safety culture, and patient safety. We statistically controlled for the systematic effects of hospital size, type, ownership, and staffing levels on perceptions of patient safety. Results: The main findings were that the effective handoff of information, responsibility, and accountability were necessary to positive perceptions of patient safety. Feedback and communication about errors were positively related to the transfer of patient information; teamwork within units and the frequency of events reported were positively related to the transfer of personal responsibility during shift changes; and teamwork across units was positively related to the unit transfers of accountability for patients. Conclusions: In summary, staff views on the behavioral dimensions of handoffs influenced their perceptions of the hospital’s level of patient safety. Given the known psychological links between perception, attitude, and behavior, a potential implication is that better patient safety can be achieved by a tight focus on improving handoffs through training and monitoring

Systematic observation in healthcare: Utility and limitations of a threat and error management-based safety audit

Improving teamwork has become a major safety goal for healthcare organizations. Audit tools currently available are useful, but they remain inadequate because they are reactive and fail to provide context for “the interaction between people and the operational context (i.e., organizational, regulatory and environmental factors) within which people discharge their operational duties” (Maurino, 2005). Accurate and relevant information about real-world team behavior is theorized to confer the ability to address, through process design &/or training, significant issues which can then be re-assessed through repeat observations. In the mid-1990s, the Federal Aviation Administration (FAA) funded collaboration between the University of Texas and Continental Airlines to directly observe in-flight behaviors associated with safety and risk. This methodology, now known as the Line Operation Safety Audit (LOSA), was instrumental in developing the Threat and Error Management (TEM) model of cockpit work performance. In 2006, the FAA made TEM-based LOSA a “voluntary safety recommendation,” and all major US commercial air carriers engage in this on a regular basis as a component of their safety management systems (FAA, 2006). This thesis describes the adaptation of LOSA to a Threat and Error Management-based Clinical Operation Safety Audit (COSA), and reports a series of 30 observations of trauma team activations in the Emergency Department at an American College of Surgeons accredited level 1 trauma center in the United States of America. Results of these observations showed discrepancies between work as designed and as executed, as well as other behaviors, associated with increased risk to patients. Analysis of data revealed important areas for targeted improvement based on risk created by the healthcare system during normal clinical operations. Systematic observation following the COSA protocol can become a vital and essential new tool to assist in improving patient safety in healthcare. The bulk of this thesis considers the criticality of context in work analysis throughout the discussion section. Though concepts of threats and undesired states were easily adaptable to healthcare, error was found to be too narrow a concept. I therefore propose discarding error for a more open and inclusive interpretation of performance: Task Adaptation. We therefore propose to widen our scope and continue to develop Threat Management and Task Adaptation-based COSA throughout the hospital to enhance system performance and improve patient safety

Implementation of TeamSTEPPS

This scholarly project focused on implementing Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) in an emergency room (ER). The aim of TeamSTEPPS is to improve patient outcomes by educating healthcare professionals on communication and teamwork skills. TeamSTEPPS teaches healthcare professionals leadership skills, shared mental models, mutual trust, and closed loop communication. The purpose of the scholarly project was to improve teamwork and communication. The study method was descriptive analysis of 51 pre and posttest questionnaires, specifically looking for increased knowledge of TeamSTEPPS tools. The participants included: ER physicians, ER nurses, ER certified nursing assistants/health unit coordinators, a pharmacy technician, public safety officers, and patient revenue management organization (PRMO). Further research is needed to evaluate how to significantly increase staff knowledge on TeamSTEPPS tools in a class setting

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Committed to Safety: Ten Case Studies on Reducing Harm to Patients

Presents case studies of healthcare organizations, clinical teams, and learning collaborations to illustrate successful innovations for improving patient safety nationwide. Includes actions taken, results achieved, lessons learned, and recommendations

Teams and cardiac surgery

Motivation\ud Our study is designed to identify human factors that are a threat to the safety of children with heart disease.\ud \ud Research approach\ud After an initial observation period, we will apply a major safety intervention. We will then re-measure the occurrence and types of human factors in the operating room, and the incidence of adverse events, near misses and hospital death, to evaluate if there was a significant post-intervention reduction. \ud \ud Findings/design\ud We focus on challenges encountered during the training of the observers. Research Limitations\ud Because of the complexity of the OR, observations are necessarily subjective. \ud \ud Originality/Value\ud This work is original because of the systematic evaluation of a safety intevention and the training protocol for the observers.\ud \ud Take Away Message\ud Systematic and periodic assessment of observers is required when teamwork is observed in complex, dynamic settings

Information and communication technology solutions for outdoor navigation in dementia

INTRODUCTION: Information and communication technology (ICT) is potentially mature enough to empower outdoor and social activities in dementia. However, actual ICT-based devices have limited functionality and impact, mainly limited to safety. What is an ideal operational framework to enhance this field to support outdoor and social activities? METHODS: Review of literature and cross-disciplinary expert discussion. RESULTS: A situation-aware ICT requires a flexible fine-tuning by stakeholders of system usability and complexity of function, and of user safety and autonomy. It should operate by artificial intelligence/machine learning and should reflect harmonized stakeholder values, social context, and user residual cognitive functions. ICT services should be proposed at the prodromal stage of dementia and should be carefully validated within the life space of users in terms of quality of life, social activities, and costs. DISCUSSION: The operational framework has the potential to produce ICT and services with high clinical impact but requires substantial investment