Psychological impact and recovery after involvement in a patient safety incident: A repeated measures analysis

OBJECTIVE: To examine individual, situational and organisational aspects that influence psychological impact and recovery of a patient safety incident on physicians, nurses and midwives. DESIGN: Cross-sectional, retrospective surveys of physicians, midwives and nurses. SETTING: 33 Belgian hospitals. PARTICIPANTS: 913 clinicians (186 physicians, 682 nurses, 45 midwives) involved in a patient safety incident. MAIN OUTCOME MEASURES: The Impact of Event Scale was used to retrospectively measure psychological impact of the safety incident at the time of the event and compare it with psychological impact at the time of the survey. RESULTS: Individual, situational as well as organisational aspects influenced psychological impact and recovery of a patient safety incident. Psychological impact is higher when the degree of harm for the patient is more severe, when healthcare professionals feel responsible for the incident and among female healthcare professionals. Impact of degree of harm differed across clinicians. Psychological impact is lower among more optimistic professionals. Overall, impact decreased significantly over time. This effect was more pronounced for women and for those who feel responsible for the incident. The longer ago the incident took place, the stronger impact had decreased. Also, higher psychological impact is related with the use of a more active coping and planning coping strategy, and is unrelated to support seeking coping strategies. Rendered support and a support culture reduce psychological impact, whereas a blame culture increases psychological impact. No associations were found with job experience and resilience of the health professional, the presence of a second victim support team or guideline and working in a learning culture. CONCLUSIONS: Healthcare organisations should anticipate on providing their staff appropriate and timely support structures that are tailored to the healthcare professional involved in the incident and to the specific situation of the incident

Turning Antibodies into Ratiometric Bioluminescent Sensors for Competition-Based Homogeneous Immunoassays

Here we present LUCOS (Luminescent Competition Sensor), a modular and broadly applicable bioluminescent diagnostic platform enabling the detection of both small molecules and protein biomarkers. The construction of LUCOS sensors entails the covalent and site-specific coupling of a bioluminescent sensor component to an analyte-specific antibody via protein G-mediated photoconjugation. Target detection is accomplished through intramolecular competition with a tethered analyte competitor for antibody binding. We established two variants of LUCOS: an inherent ratiometric LUCOSR variant and an intensiometric LUCOSI version, which can be used for ratiometric detection upon the addition of a split calibrator luciferase. To demonstrate the versatility of the LUCOS platform, sensors were developed for the detection of the small molecule cortisol and the protein biomarker NT-proBNP. Sensors for both targets displayed analyte-dependent changes in the emission ratio and enabled detection in the micromolar concentration range (KD,app = 16-92 μM). Furthermore, we showed that the response range of the LUCOS sensor can be adjusted by attenuating the affinity of the tethered NT-proBNP competitor, which enabled detection in the nanomolar concentration range (KD,app = 317 ± 26 nM). Overall, the LUCOS platform offers a highly versatile and easy method to convert commercially available monoclonal antibodies into bioluminescent biosensors that provide a homogeneous alternative for the competitive immunoassay.</p

Forward Amortized Inference for Likelihood-Free Variational Marginalization

In this paper, we introduce a new form of amortized variational inference by using the forward KL divergence in a joint-contrastive variational loss. The resulting forward amortized variational inference is a likelihood-free method as its gradient can be sampled without bias and without requiring any evaluation of either the model joint distribution or its derivatives. We prove that our new variational loss is optimized by the exact posterior marginals in the fully factorized mean-field approximation, a property that is not shared with the more conventional reverse KL inference. Furthermore, we show that forward amortized inference can be easily marginalized over large families of latent variables in order to obtain a marginalized variational posterior. We consider two examples of variational marginalization. In our first example we train a Bayesian forecaster for predicting a simplified chaotic model of atmospheric convection. In the second example we train an amortized variational approximation of a Bayesian optimal classifier by marginalizing over the model space. The result is a powerful meta-classification network that can solve arbitrary classification problems without further training.Comment: 9 pages, 3 figure

Spatiotemporal dynamics of cortical representations during and after stimulus presentation

Visual perception is a spatiotemporally complex process. In this study, we investigated cortical dynamics during and after stimulus presentation. We observed that visual category information related to the difference between faces and objects became apparent in the occipital lobe after 63 ms. Within the next 110 ms, activation spread out to include the temporal lobe before returning to residing mainly in the occipital lobe again. After stimulus offset, a peak in information was observed, comparable to the peak after stimulus onset. Moreover, similar processes, albeit not identical, seemed to underlie both peaks. Information about the categorical identity of the stimulus remained present until 677 ms after stimulus offset, during which period the stimulus had to be retained in working memory. Activation patterns initially resembled those observed during stimulus presentation. After about 200 ms, however, this representation changed and class-specific activity became more equally distributed over the four lobes. These results show that, although there are common processes underlying stimulus representation both during and after stimulus presentation, these representations change depending on the specific stage of perception and maintenance. </p

Zorgverleners als "second victims" van patiëntveiligheidsincidenten: impact op functioneren en welzijn

A PSI is “an event or circumstance that could have resulted or did result in unnecessary harm to a patient”. Despite all efforts made to improve patient safety, adverse events (PSIs that result in harm for the patient) still occur in one out of seven patients, of which 1,5% ends in death of the patient. When a patient safety incident occurs, there can be three types of victims: the first victim is the patient and the involved family, the second victim is the involved healthcare professional and the third victim is the involved health care organization. Second victims can suffer on both professional and personal level. Symptoms may include insomnia, nightmares, reliving the incident repeatedly, loss of trust by their colleagues, lack of self–confidence and fear of making another error. This may lead in turn to further adverse impact on other patients and members of the healthcare organization. It is estimated that at least half of all healthcare providers will experience the second victim phenomenon during their professional career. Students in health care can become second victims as well. Organizations therefore need to consider appropriate support strategies. The overall goal of this study was to provide more insights into the phenomenon of second victims among healthcare professionals, and to formulate concrete recommendations to all stakeholders in order to successfully address this issue. A mixed-methods approach was used to address four research questions: 1. What is the prevalence and impact of involvement in a patient safety incident on physicians, nurses and midwives working in different hospital settings? 2. What is the impact of involvement in a patient safety incident on bachelor students in nursing and midwifery? 3. What is the prevalence and content of organizational-level support systems for healthcare professionals involved in a patient safety incident? 4. What are the situational, individual and organizational aspects that determine the impact of and recovery from a patient safety incident? We applied a multi-method research design to investigate the first research question. First, a quantitative study was performed within 33 acute and psychiatric Belgian hospitals to survey physicians and nurses on their experiences with PSIs as well as the relation between involvement in a PSI and degree of harm with medication use, alcohol consumption, risk of burnout, work-home interference and turnover intentions. Nine percent of the total sample (531/5788) had been involved in a PSI within a timeframe of six months. Physicians and nurses involved in a PSI were 2.07 times more likely to develop a risk of burnout. Involvement in a PSI was related to a higher chance of problematic medication use, higher work-home interference and more turnover intentions. The degree of harm to the patient caused by the PSI is positively related to problematic medication use, risk of burnout and work-home interference. Second, a qualitative study was performed by conducting 31 in-depth interviews among nurses, physicians and midwives who had been involved in a PSI during their entire career. Symptoms described by the participants in the aftermath of a PSI can be categorized under personal and professional symptoms. Both problem focused and emotion focused coping strategies were used. Problem focused strategies such as performing a root cause analysis and the opportunity to learn from what happened are the most appreciated, but negative emotional responses such as repression and flight were common. Informal support from colleagues and supervisors was needed the most. A few individuals described social support as unwanted. Three determinants define the extent to which a healthcare professional becomes a second victim: personal characteristics of the involved healthcare professional, situational aspects and the organizational safety culture. The impact of involvement in a PSI for bachelor students in nursing and midwifery (research question 2) was examined with an exploratory cross-sectional study. 941 bachelor students in nursing and midwifery from nine university colleges participated in an online survey regarding involvement in PSIs within a timeframe of six months, the perceived impact, the effect on their work, the received support and how this support was appreciated. 17.9% was personally involved in a PSI within a timeframe of 6 months. 41.4% said it had an impact on their professional life, 3.7% on their personal life and 14.4% on both. 40.5% of students concluded that the incident had no impact at all. Involvement in a PSI can have both positive and negative effects on the work of the students. Support was most received and best appreciated from a staff nurse/midwife or fellow students. To examine research question 3 a survey was sent to 109 Belgian hospitals regarding two aspects: first, the availability of a protocol for supporting second victims; and second, the presence of a contact person in the organization to provide support. Thirty organizations (50%) have a systematic plan to support second victims. Twelve percent (12%) cannot identify a contact person. The chief nursing officer is seen as one of the main contact persons when something goes wrong. A content analysis based on an Institute for Healthcare Improvement’s white paper (1) and the Scott Model (2) was performed to evaluate the protocols. In terms of the quality of the protocols, only a minority follow part of the international recommendations. A cross-sectional study with retrospective surveys of physicians, nurses and midwives was conducted within 33 Flemish hospitals, to examine situational, individual and organizational aspects that influence the impact and recovery from a PSI (research question 4). 913 health professionals (168 physicians, 682 nurses, 45 midwives) involved in a PSI participated in the study. Psychological impact is higher when the degree of harm for the patient is more severe, when healthcare professionals feel responsible for the incident and among female healthcare professionals. Psychological impact is lower among more optimistic professionals. Overall, impact decreased significantly over time. This effect was more pronounced for women, among those with high self-efficacy traits and those who feel responsible for the incident. The longer ago the incident took place, the stronger impact had decreased. Also, reported higher psychological impact is related with more active coping and planning coping strategy, however unrelated with support seeking coping strategies. Rendered support and a support culture reduce psychological impact, whereas a blame culture increases psychological impact. No associations were found with job experience and resilience of the health professional, the presence of a second victim support team or guideline, and working in a learning culture. We conclude that health professionals and student in health care are involved in PSIs more often than we think. These incidents do not only affect the patient, but can have a various impact on the health professional as well, depending on situational, individual and organizational aspects. We must be aware that involvement in a PSI does not only have negative consequences, but can also trigger psychological growth. Support in the aftermath of an incident is not always desired, therefore it should be adjusted to the second victims personal needs. Healthcare organizations should encourage the affected healthcare professional to discuss the event and recommend system changes to prevent the event from happening again. As for today, this research showed that health professionals involved in PSI need an open climate to talk about what happened with colleagues more than they need formal organizational support systems in place.status: publishe

Management challenges in care pathways: conclusions of a qualitative study within 57 health care organizations

The objectives of this paper are to study the aim of care pathways, who has decisional power concerning pathways, the actual follow-up, challenges in cross-boundary development and the support provided by information and communication technology (ICT). The study design included a qualitative study using semi-structured interviews with 88 care pathway coordinators and members of the executive board in 57 health-care organizations enrolled in the Belgian– Dutch Clinical Pathway Network. The study revealed that the most important objectives for introducing care pathways are more standardization and quality of care. In 76% of the interviewed organizations, pathways are discussed in a committee. There is a lack of continuous follow-up when care pathways are implemented. Pathways can facilitate cross-boundary care, but are a challenge because of the fragmentation within primary care. There is a need for more ICT support for care pathways. In conclusion, the executive board members and pathway coordinators state that clearly formulated objectives, a special steering committee, a clear follow-up to keep pathways alive, cross-boundary collaboration and ICT support are among the main challenges for the management of an organization.status: publishe