Patients' and healthcare workers' perceptions of a patient safety advisory

Objective To assess patients' and healthcare workers' (hcw) attitudes and experiences with a patient safety advisory, to investigate predictors for patients' safety-related behaviors and determinants for staff support for the advisory. Design Cross-sectional surveys of patients (n= 1053) and hcw (n= 275). Setting Three Swiss hospitals. Participants Patients who received the safety advisory and hcw caring for these patients. Intervention Patient safety advisory disseminated to patients at the study hospitals. Main Outcome Measures Attitudes towards and experiences with the advisory. Hcw support for the intervention and patients' intentions to apply the recommendations were modelled using regression analyses. Results Patients (95%) and hcw (78%) agreed that hospitals should educate patients how to prevent errors. Hcw and patients' evaluations of the safety advisory were positive and followed a similar pattern. Patients' intentions to engage in safety were significantly predicted by behavioral control, subjective norms, attitudes, safety behaviors during hospitalization and experiences with taking action. Hcw support for the campaign was predicted by rating of the advisory (Odds ratio (OR) 3.4, confidence interval (CI) 1.8-6.1, P< 0.001), the belief that it prevents errors (OR 1.7, CI 1.2-2.5, P= 0.007), perceived increased vigilance of patients (OR 1.9, CI 1.1-3.3, P= 0.034) and experience of unpleasant situations (OR 0.6, CI 0.4-1.0, P= 0.035). Conclusions The safety advisory was well accepted by patients and hcw. To be successful, the advisory should be accompanied by measures that target norms and barriers in patients, and support staff in dealing with difficult situation

Safety climate and its association with office type and team involvement in primary care

Objective To assess differences in safety climate perceptions between occupational groups and types of office organization in primary care. Methods Primary care physicians and nurses working in outpatient offices were surveyed about safety climate. Explorative factor analysis was performed to determine the factorial structure. Differences in mean climate scores between staff groups and types of office were tested. Logistic regression analysis was conducted to determine predictors for a ‘favorable' safety climate. Results 630 individuals returned the survey (response rate, 50%). Differences between occupational groups were observed in the means of the ‘team-based error prevention'-scale (physician 4.0 vs. nurse 3.8, P < 0.001). Medical centers scored higher compared with single-handed offices and joint practices on the ‘team-based error prevention'-scale (4.3 vs. 3.8 vs. 3.9, P < 0.001) but less favorable on the ‘rules and risks'-scale (3.5 vs. 3.9 vs. 3.7, P < 0.001). Characteristics on the individual and office level predicted favorable ‘team-based error prevention'-scores. Physicians (OR = 0.4, P = 0.01) and less experienced staff (OR 0.52, P = 0.04) were less likely to provide favorable scores. Individuals working at medical centers were more likely to provide positive scores compared with single-handed offices (OR 3.33, P = 0.001). The largest positive effect was associated with at least monthly team meetings (OR 6.2, P < 0.001) and participation in quality circles (OR 4.49, P < 0.001). Conclusions Results indicate that frequent quality circle participation and team meetings involving all team members are effective ways to strengthen safety climate in terms of team-based strategies and activities in error preventio

Effect of a two-year national quality improvement program on surgical checklist implementation

Use of the surgical checklist in Switzerland is still incomplete and unsatisfactory. A national improvement program was developed and conducted in Switzerland to implement and improve the use of the surgical safety checklists. The aims of the implementation program were to implement comprehensive and correct checklist use in participating hospitals in every patient and in every surgical procedure; and to improve safety climate and teamwork as important cultural context variables. 10 hospitals were selected for participation in the implementation program. A questionnaire assessing use, knowledge, and attitudes towards the checklist and the Safety Climate Survey were conducted at two measurement occasions each in October/November 2013 and January/February 2015. Significant increases emerged for frequency of checklist use (F(1,1001)=340.9, p<0.001), satisfaction (F(1,1232)=25.6, p<0.001), and knowledge(F(1,1294)=184.5, p<0.001). While significant differences in norms (F(1,1284)=17.9, p<0.001) and intentions (F(1,1284)=7.8, p<0.01) were observed, this was not the case for attitudes (F(1,1283)=.8, n.s.) and acceptance (F(1,1284)=0.1, n.s.). Significant differences for safety climate and teamwork emerged in the present study (F(1,3555)=11.8, p<0.001 and F(1,3554)=24.6, p<0.001, respectively). However, although statistical significance was reached, effects are very small and practical relevance is thus questionable. The results of the present study suggest that the quality improvement program conducted by the Swiss Patient Safety Foundation in 10 hospitals led to successful checklist implementation. The strongest effects were seen in aspects concerning behaviour and knowledge specifically related to checklist use. Less impact was achieved on general cultural variables safety climate and teamwork. However, as a trend was observable, these variables may simply need more time in order to change substantially

What do double-check routines actually detect? An observational assessment and qualitative analysis of identified inconsistencies.

OBJECTIVES Double checking is used in oncology to detect medication errors before administering chemotherapy. The objectives of the study were to determine the frequency of detected potential medication errors, i.e., mismatching information, and to better understand the nature of these inconsistencies. DESIGN In observing checking procedures, field noteswere taken of all inconsistencies that nurses identified during double checking the order against the prepared chemotherapy. SETTING Oncological wards and ambulatory infusion centres of three Swiss hospitals. PARTICIPANTS Nurses' double checking was observed. OUTCOME MEASURES In a qualitative analysis, (1) a category system for the inconsistencies was developed and (2) independently applied by two researchers. RESULTS In 22 (3.2%) of 690 observed double checks, 28 chemotherapy-related inconsistencies were detected. Half of them related to non-matching information between order and drug label, while the other half was identified because the nurses used their own knowledge. 75% of the inconsistencies could be traced back to inappropriate orders, and the inconsistencies led to 33 subsequent or corrective actions. CONCLUSIONS In double check situations, the plausibility of the medication is often reviewed. Additionally, they serve as a correction for errors and that are made much earlier in the medication process, during order. Both results open up new opportunities for improving the medication process

Preferences for disclosure: the case of bedside rationing

While rationing is present in many health care systems, little empirical research has been undertaken to investigate the public's preferences and information needs towards the rationing of their care. This paper reports the results of an interactive survey administered via an internet survey panel to investigate preferences for the provision of information about explicit rationing decisions. We presented a series of vignettes to respondents, describing hypothetical patients and explicit rationing decisions. In two different survey versions, patients were either characterized as matching or mismatching respondents' age and gender. We observed strong preferences for the disclosure of rationing information to patients. Seventy one percent of responders expressed a general attitude in favor of explicitly informing patients about the rationing of their care. In the presented scenarios, the fraction supporting disclosure to patients ranged from 63% to 89%. The clinical situation described in the vignettes, a positive, general attitude towards the disclosure of rationing decisions, age, and gender of respondents were main predictors for participants' votes. Preferences were relatively unaffected and insensitive to the matching of hypothetical patients and respondents' characteristics. This study suggests that if doctors are to play an active role in health care rationing, patients expect them to honestly discuss the decisions made, the economics behind these and finally, to deal with those patients that do not accept the final decision.Rationing Information needs Health-care Doctor-patient relationship Survey Vignette study

Patientensicherheitsgefährdungen durch die Nutzung von IT in onkologischen Ambulatorien: eine prospektive Analyse des Informationsmanagements.

OBJECTIVES Thorough management of patient information is crucial in cancer care in order to avoid errors. Clinicians need complete, up-to-date information to be able to develop an adequate mental model of the patient's situation. The aim of the present study was to identify patient safety hazards coming with the use of health information technology (HIT): patient safety hazards in three outpatient oncology infusion centers were assessed and priority topics identified. Additionally, the number of information sources clinicians have to use in order to get an idea of the patient's situation was systematically assessed. Interviews and observations were conducted with one nurse and one doctor of each ambulatory infusion center. PRINCIPAL RESULTS Information management-related patient safety hazards were omnipresent in daily care: eleven topics were identified from 125 assessed patient safety hazards. Three of them were particularly relevant to the clinicians' development of an adequate mental model about the patient: patient-related information was not stored in one place but often fragmented in different HIT systems; despite the introduction of HIT, paper documentation remained in place for certain information, making access difficult and increasing the number of relevant sources; the lack of usability of the HIT systems made it difficult to retrieve patient information in a timely manner. Clinicians needed to use between 5 and 11 sources of information to get a more complete picture of a patient's situation. MAJOR CONCLUSIONS Overall, it has been shown that the design of the HIT systems is not sufficiently adapted to the work processes and does not support clinicians in being fully informed about a patient. The topics identified point to future system design and areas for improvement. In this process, it is very important to align the real work requirements with the design of the HIT and to evaluate and monitor the actual implementation and use of HIT.Ziele der Studie: Sorgfältiges Management von patientenbezogener Information ist in der Behandlung krebskranker Patienten wichtig, um Fehler zu vermeiden. Klinisch Tätige benötigen vollständige, aktuelle Information, um sich ein adäquates ,,mentales Abbild‘‘ der Situation des Patienten machen zu können. Das Ziel der vorliegenden Studie war, Patientensicherheitsgefährdungen, die bei der Nutzung von HIT (Health Information Technology) entstehen, zu identifizieren: zum einen wurden explorativ Patientensicherheitsgefährdungen in drei onkologischen Ambulatorien erfasst und übergeordnete Themen identifiziert. Zum anderen wurde systematisch die Anzahl an Informationsquellen erfasst, die die klinisch Tätigen nutzen müssen, um sich ein Bild vom Patienten zu machen. Dafür wurden Interviews und Beobachtungen mit je einer Pflegefachperson und einem Arzt durchgeführt. Ergebnisse: Informationsmanagement-bezogene Patientensicherheitsgefährdungen waren in der täglichen Versorgung allgegenwärtig: ausgehend von 125 erfassten Patientensicherheitsgefährdungen wurden elf Themenfelder identifiziert. Drei waren besonders relevant für die Entwicklung eines adäquaten mentalen Modells über den Patienten der klinisch Tätigen: patientenbezogene Informationen wurden nicht an einem Ort, sondern häufig fragmentiert in verschiedenen HIT-Systemen verteilt gespeichert; trotz der Einführung von HIT blieb für bestimmte Informationen die Papierdokumentation bestehen, was den Zugriff darauf erschwerte und die Anzahl an relevanten Quellen erhöhte; die mangelnde Benutzerfreundlichkeit der HIT-Systeme machte es schwierig, zeitgerecht Patienteninformation abzurufen. Klinisch Tätige mussten zwischen fünf und elf Informationsquellen nutzen, um sich ein Bild über den Patienten zu machen. Schlussfolgerungen: Gesamthaft zeigte sich, dass die Gestaltung der HIT-Systeme nur unzureichend an die Arbeitsprozesse angepasst ist und es nicht begünstigt, sich vollständig über einen Patienten zu informieren. Die identifizierten Themenfelder zeigen auf, wo zukünftige Systemgestaltung und -verbesserung ansetzen kann. Dabei ist es von großer Bedeutung, die eigentlichen Anforderungen der Arbeitsprozesse auf die Gestaltung der HIT abzustimmen und die tatsächliche Implementierung und Nutzung von HIT eng zu begleiten

Patient Safety Threats in Information Management Using Health Information Technology in Ambulatory Cancer Care: An Exploratory, Prospective Study.

BACKGROUND Cancer care is complex, involving highly toxic drugs, critically ill patients, and various different care providers. Because it is important for clinicians to have the latest and complete information about the patient available, this study focused on patient safety issues in information management developing from health information technology (HIT) use in oncology ambulatory infusion centers. OBJECTIVE The aim was to exploratively and prospectively assess patient safety risks from an expert perspective: instead of retrospectively analyzing safety events, we assessed the information management hazards inherent to the daily work processes; instead of asking healthcare workers at the front line, we used them as information sources to construct our patient safety expert view on the hazards. METHODS The work processes of clinicians in three ambulatory infusion centers were assessed and evaluated based on interviews and observations with a nurse and a physician of each unit. The 125 identified patient safety issues were described and sorted into thematic groups. RESULTS A broad range of patient safety issues was identified, such as data fragmentation, or information islands, meaning that patient data are stored across different cases or software and that different professional groups do not use the same set of information. CONCLUSIONS The current design and implementation of HIT systems do not support adequate information management: clinicians needed to play very close attention and improvise to avoid errors in using HIT and treat cancer patients safely. It is important to take the clinical front-end practice into account when evaluating or planning further HIT improvements