Lateral positioning for critically ill adult patients

We aim to assess the effect of the lateral position compared to other body positions on patient outcomes (mortality, morbidity and clinical adverse events during and following positioning) in critically ill adult patients. We will examine the single use of the lateral position (that is on the right or left side) and repeat use of the lateral position(s) in a positioning schedule (that is lateral positioning). We plan to undertake subgroup analysis for primary disease and condition, severity of illness, the presence of assisted ventilation and angle of lateral rotation.<br /

Implementation of an audit with feedback knowledge translation intervention to promote medication error reporting in health care: a protocol

Abstract Background Health professionals strive to deliver high-quality care in an inherently complex and error-prone environment. Underreporting of medical errors challenges attempts to understand causative factors and impedes efforts to implement preventive strategies. Audit with feedback is a knowledge translation strategy that has potential to modify health professionals’ medical error reporting behaviour. However, evidence regarding which aspects of this complex, multi-dimensional intervention work best is lacking. The aims of the Safe Medication Audit Reporting Translation (SMART) study are to: 1. Implement and refine a reporting mechanism to feed audit data on medication errors back to nurses 2. Test the feedback reporting mechanism to determine its utility and effect 3. Identify characteristics of organisational context associated with error reporting in response to feedback Methods/design A quasi-experimental design, incorporating two pairs of matched wards at an acute care hospital, is used. Randomisation occurs at the ward level; one ward from each pair is randomised to receive the intervention. A key stakeholder reference group informs the design and delivery of the feedback intervention. Nurses on the intervention wards receive the feedback intervention (feedback of analysed audit data) on a quarterly basis for 12 months. Data for the feedback intervention come from medication documentation point-prevalence audits and weekly reports on routinely collected medication error data. Weekly reports on these data are obtained for the control wards. A controlled interrupted time series analysis is used to evaluate the effect of the feedback intervention. Self-report data are also collected from nurses on all four wards at baseline and at completion of the intervention to elicit their perceptions of the work context. Additionally, following each feedback cycle, nurses on the intervention wards are invited to complete a survey to evaluate the feedback and to establish their intentions to change their reporting behaviour. To assess sustainability of the intervention, at 6 months following completion of the intervention a point-prevalence chart audit is undertaken and a report of routinely collected medication errors for the previous 6 months is obtained. This intervention will have wider application for delivery of feedback to promote behaviour change for other areas of preventable error and adverse events.http://deepblue.lib.umich.edu/bitstream/2027.42/111741/1/13012_2015_Article_260.pd

Patient perceptions of deterioration and patient and family activated escalation systems-a qualitative study

Aims and objectivesTo investigate the experiences of patients who received a medical emergency team review following a period of clinical deterioration and their views about the potential use of a patient and family activated escalation system.BackgroundDelay or failure by health professionals to respond to clinical deterioration remains a patient safety concern. Patients may sometimes identify subtle cues of early deterioration prior to changes in vital signs. In response to health professional and system failures, patient and family activated escalation systems have been mandated and implemented in Australia. However, little research has evaluated their effectiveness nor taken patients&rsquo; perspectives into account.DesignQualitative exploratory descriptive design was used.MethodsPurposive sampling was used. Semistructured interviews were undertaken in 2014 with 33 patients who required medical emergency team intervention. Data were collected from one private and one public hospital in Melbourne, Victoria, Australia. The framework method was used to analyse the data.ResultsAll patients stated that it was the clinician who detected and responded to deterioration. Private patient participants were unaware of the medical emergency team system, and felt escalating care was not their responsibility. These patients reported being too sick to communicate prior to and during medical emergency team review and did not favour a patient and family activated escalation system. Public patients were well informed about the medical emergency team system yet expressed concerns around overriding clinicians if activating a patient and family activated escalation system.ConclusionPatient participation during a period of deterioration is restricted by their clinical condition and limited medical knowledge. Patients felt comfortable to communicate concerns to clinicians but felt they would not activate the patient and family activated escalation system. This behoves clinicians to actively listen and respond to patient concerns.<br /

Use of an audit with feedback implementation strategy to promote medication error reporting by nurses

Aims and objectivesTo outline the development and effect of an audit with feedback implementation strategy that intended to increase the rate of voluntary medication error reporting by nurses.BackgroundMedication errors are a serious global health issue. Audit with feedback is a widely used implementation strategy that has potential to modify nurses’ reporting behaviour and improve medication error reporting rates.DesignQuasi‐experimental implementation study (fulfilling the TIDieR checklist) with two pairs of matched wards at a private hospital in Australia was conducted from March 2015–September 2016. One ward from each pair was randomised to either the intervention or control group.MethodNurses within intervention wards received audit with feedback on a quarterly basis over a 12‐month implementation period. Control wards underwent quarterly audits only (without feedback). Feedback consisted of a one‐page infographic poster, with content based on medication error data obtained from audits and the hospitals’ risk management system (RiskMan). The primary outcome—rate of medication errors reported per month—was determined in both groups at pre‐implementation, implementation and postimplementation phases. Differences between groups were compared using generalised linear mixed models with Poisson distribution and log link.ResultsA nonsignificant intervention effect was found for rate of medication errors reported per month. Interestingly, when combining data from both groups, a significant increasing time trend was observed for medication errors reported per month across pre‐implementation and implementation phases (80% increase).ConclusionsThe audit with feedback strategy developed in the present study did not effectively influence the voluntary reporting of medication errors by nurses.Relevance to clinical practiceDespite the lack of intervention effects, the use of a published checklist to optimise the reporting quality of this study will contribute to the field by furthering the understanding of how to enhance audit with feedback implementation strategies for nurses.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163422/2/jocn15447.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163422/1/jocn15447_am.pd

Women\u27s decision-making processes and the influences on their mode of birth following a previous caesarean section in Taiwan: a qualitative study

BACKGROUND: Vaginal birth after caesarean (VBAC) is an alternative option for women who have had a previous caesarean section (CS); however, uptake is limited because of concern about the risks of uterine rupture. The aim of this study was to explore women\u27s decision-making processes and the influences on their mode of birth following a previous CS. METHODS: A qualitative approach was used. The research comprised three stages. Stage I consisted of naturalistic observation at 33-34&nbsp;weeks\u27 gestation. Stage II involved interviews with pregnant women at 35-37&nbsp;weeks\u27 gestation. Stage III consisted of interviews with the same women who were interviewed postnatally, 1 month after birth. The research was conducted in a private medical centre in northern Taiwan. Using a purposive sampling, 21 women and 9 obstetricians were recruited. Data collection involved in-depth interviews, observation and field notes. Constant comparative analysis was employed for data analysis. RESULTS: Ensuring the safety of mother and baby was the focus of women\u27s decisions. Women\u27s decisions-making influences included previous birth experience, concern about the risks of vaginal birth, evaluation of mode of birth, current pregnancy situation, information resources and health insurance. In communicating with obstetricians, some women complied with obstetricians\u27 recommendations for repeat caesarean section (RCS) without being informed of alternatives. Others used four step decision-making processes that included searching for information, listening to obstetricians\u27 professional judgement, evaluating alternatives, and making a decision regarding mode of birth. After birth, women reflected on their decisions in three aspects: reflection on birth choices; reflection on factors influencing decisions; and reflection on outcomes of decisions. CONCLUSIONS: The health and wellbeing of mother and baby were the major concerns for women. In response to the decision-making influences, women\u27s interactions with obstetricians regarding birth choices varied from passive decision-making to shared decision-making. All women have the right to be informed of alternative birthing options. Routine provision of explanations by obstetricians regarding risks associated with alternative birth options, in addition to financial coverage for RCS from National Health Insurance, would assist women\u27s decision-making. Establishment of a website to provide women with reliable information about birthing options may also assist women\u27s decision-making

Realist synthesis : illustrating the method for implementation research

BackgroundRealist synthesis is an increasingly popular approach to the review and synthesis of evidence, which focuses on understanding the mechanisms by which an intervention works (or not). There are few published examples of realist synthesis. This paper therefore fills a gap by describing, in detail, the process used for a realist review and synthesis to answer the question \u27what interventions and strategies are effective in enabling evidence-informed healthcare?\u27 The strengths and challenges of conducting realist review are also considered. MethodsThe realist approach involves identifying underlying causal mechanisms and exploring how they work under what conditions. The stages of this review included: defining the scope of the review (concept mining and framework formulation); searching for and scrutinising the evidence; extracting and synthesising the evidence; and developing the narrative, including hypotheses. ResultsBased on key terms and concepts related to various interventions to promote evidenceinformed healthcare, we developed an outcome-focused theoretical framework. Questions were tailored for each of four theory/intervention areas within the theoretical framework and were used to guide development of a review and data extraction process. The search for literature within our first theory area, change agency, was executed and the screening procedure resulted in inclusion of 52 papers. Using the questions relevant to this theory area, data were extracted by one reviewer and validated by a second reviewer. Synthesis involved organisation of extracted data into evidence tables, theming and formulation of chains of inference, linking between the chains of inference, and hypothesis formulation. The narrative was developed around the hypotheses generated within the change agency theory area. ConclusionsRealist synthesis lends itself to the review of complex interventions because it accounts for context as well as outcomes in the process of systematically and transparently synthesising relevant literature. While realist synthesis demands flexible thinking and the ability to deal with complexity, the rewards include the potential for more pragmatic conclusions than alternative approaches to systematic reviewing. A separate publication will report the findings of the review. <br /

Medical error and decision making : learning from the past and present in intensive care

Background : Human error occurs in every occupation. Medical errors may result in a near miss or an actual injury to a patient that has nothing to do with the underlying medical condition. Intensive care has one of the highest incidences of medical error and patient injury in any specialty medical area; thought to be related to the rapidly changing patient status and complex diagnoses and treatments.Purpose : The aims of this paper are to: (1) outline the definition, classifications and aetiology of medical error; (2) summarise key findings from the literature with a specific focus on errors arising from intensive care areas; and (3) conclude with an outline of approaches for analysing clinical information to determine adverse events and inform practice change in intensive care.Data source : Database searches of articles and textbooks using keywords: medical error, patient safety, decision making and intensive care. Sociology and psychology literature cited therein.Findings : Critically ill patients require numerous medications, multiple infusions and procedures. Although medical errors are often detected by clinicians at the bedside, organisational processes and systems may contribute to the problem. A systems approach is thought to provide greater insight into the contributory factors and potential solutions to avoid preventable adverse events.Conclusion : It is recommended that a variety of clinical information and research techniques are used as a priority to prevent hospital acquired injuries and address patient safety concerns in intensive care.<br /