Speaking up for patient safety by hospital-based health care professionals: a literature review

BACKGROUND: Speaking up is important for patient safety, but often, health care professionals hesitate to voice concerns. Understanding the influencing factors can help to improve speaking-up behaviour and team communication. This review focused on health care professionals’ speaking-up behaviour for patient safety and aimed at (1) assessing the effectiveness of speaking up, (2) evaluating the effectiveness of speaking-up training, (3) identifying the factors influencing speaking-up behaviour, and (4) developing a model for speaking-up behaviour. METHODS: Five databases (PubMed, MEDLINE, CINAHL, Web of Science, and the Cochrane Library) were searched for English articles describing health care professionals’ speaking-up behaviour as well as those evaluating the relationship between speaking up and patient safety. Influencing factors were identified and then integrated into a model of voicing behaviour. RESULTS: In total, 26 studies were identified in 27 articles. Some indicated that hesitancy to speak up can be an important contributing factor in communication errors and that training can improve speaking-up behaviour. Many influencing factors were found: (1) the motivation to speak up, such as the perceived risk for patients, and the ambiguity or clarity of the clinical situation; (2) contextual factors, such as hospital administrative support, interdisciplinary policy-making, team work and relationship between other team members, and attitude of leaders/superiors; (3) individual factors, such as job satisfaction, responsibility toward patients, responsibility as professionals, confidence based on experience, communication skills, and educational background; (4) the perceived efficacy of speaking up, such as lack of impact and personal control; (5) the perceived safety of speaking up, such as fear for the responses of others and conflict and concerns over appearing incompetent; and (6) tactics and targets, such as collecting facts, showing positive intent, and selecting the person who has spoken up. CONCLUSIONS: Hesitancy to speak up can be an important contributing factor to communication errors. Our model helps us to understand how health care professionals think about voicing their concerns. Further research is required to investigate the relative importance of different factors

Residents' intentions and actions after patient safety education

<p>Abstract</p> <p>Background</p> <p>Medical residents are key figures in delivering care and an important target group for patient safety education. The objective of this study was to assess residents' intentions and actions concerning patient safety improvement after patient safety education.</p> <p>Methods</p> <p>Four multi-specialty 2-day patient safety courses were organized, in which residents from five Dutch hospitals participated. At the end of these courses participants were asked to formulate an action point to improve patient safety. Three months later semi-structured interviews were conducted to reveal actions that were taken, factors that had influenced their behaviour and reactions concerning the education. An inductive theory approach was used to analyze transcriptions.</p> <p>Results</p> <p>Out of 71 participants, sixty-nine (97%) residents were interviewed. In total they had formulated 91 action points, which mainly focused on: 'Improving organization of own work/Follow policies' and 'Improving culture/Educating colleagues about patient safety'. Sixty-two (90%) residents declared to have taken action, and 50 (55%) action points were fully carried out. Most actions taken were at the level of the individual professional, rather than at the level of their social or organizational context. Results of actions included adjusting the structure of their own work, organizing patient safety education for colleagues, communicating more efficiently and in a more structured way with colleagues, and reporting incidents. Promoters for action included: 'Awareness of the importance of the action to be taken', 'Supportive attitude of colleagues' and 'Having received patient safety education'. Barriers included: 'Impeding attitude of colleagues', 'High work-pressure', 'Hierarchy' and 'Switching of work stations'.</p> <p>Conclusions</p> <p>After patient safety training, residents reported various intentions to contribute to patient safety improvement. Numerous actions were taken, but there still is a discrepancy between intentions and actual behaviour. To increase residents' participation in patient safety improvement, educational efforts should be supplemented with actions to remove experienced barriers, most of which are related to the residents' social and organizational context.</p

Wissenschaftliche Politikberatung im Agrarbereich: zwischen Wende und Wandel

"Die Zielorientierung einer nachhaltigen Entwicklung stellt nicht nur die wissenschaftliche Erzeugung von Wissen vor neue Herausforderungen, sondern fragt im Kern auch nach Formen der Kommunikation zwischen Wissenschaft und Politik, die eine reflexive, folgensensible und kontextspezifische Einbettung dieses Wissens in Entscheidungsprozesse ermöglicht. Diese Einsicht hat in den letzten Jahren vielfach den Ruf nach neuen Formen der Politikberatung laut werden lassen, die den spezifischen Herausforderungen von sozial-ökologischen Transformationsprozessen bessergerecht werden können. Der Agrarbereich in Deutschland verfügt über sehr spezifische, ausdifferenzierte und über viele Jahre gewachsene institutionelle Strukturen der Politikberatung. Gleichzeitig ist er in den letzten Jahren sowohl durch medienwirksame Skandale unter politischen Druck geraten, als auch einem eher langsameren und versteckteren Wandel der Orientierung, Selbstverständnisse und Bezugsrahmen unterworfen. Dort lässt sich also beobachten, wie gewachsene Institutionen auf politischen und gesellschaftlichen Veränderungsdruck reagieren, diesen nach eigenen Maßgaben integrieren und welche neuen Herausforderungen dabei entstehen. Der Vortrag möchte anhand der empirischen Zwischenergebnisse des BMBF-geförderten Forschungsprojektes 'Wissen für Entscheidungsprozesse - Ansätze für eine dialogisch-reflexive Schnittstellenkommunikation zwischen Wissenschaft und Politik' am Beispiel des Agrarbereiches die Frage diskutieren, welches die besonderen Problemen einer an Nachhaltigkeitsfragen orientierten, wissenschaftlichen Politikberatung sind und welche Interface-Ansätze diese aufgreifen, um den Austausch von Gestaltungswissen zu optimieren. Dabei wird das Hauptaugenmerk auf die Vielfältigkeit der Formen, Modi und Prozesse von wissenschaftlicher Politikberatung mit ihren jeweils sehr spezifischen Funktionen, Möglichkeiten und Grenzen gelegt, an der der oft pauschal vorgebrachte Ruf nach Partizipation und Dialogisierung gelegentlich vorbeigeht. Gerade diese Heterogenität verdeutlicht, so wollen die Verfasser argumentieren, dass 'erfolgreicher Wandel' nicht nur als mehr oder weniger zielangepasste Reaktion betroffener Institutionen und Settings auf Steuerungsimpulse begriffen werden darf. Als Ergebnis eines inkrementellen Interaktionsprozesses von gesellschaftlichen Transformationsimpulsen mit gegebenen Funktionen, Identitäten und Machtkonstellationen innerhalb dieser Institutionen ist gerade die Transformation zu Nachhaltigkeit einvielgestaltiger Such- und Entwicklungsprozess mit überraschenden (Zwischen-)Ergebnissen, deren Funktionalität oft erst auf den zweiten Blick sichtbar wird. Diese Diagnose soll im Rückgriff auf ihre Befunde zur Problemwahrnehmung der Schnittstellenkommunikation von Wissenschaft und Politik im Agrarbereich erhärtet werden." (Autorenreferat

Exploring the black box of quality improvement collaboratives: modelling relations between conditions, applied changes and outcomes

<p>Abstract</p> <p>Introduction</p> <p>Despite the popularity of quality improvement collaboratives (QICs) in different healthcare settings, relatively little is known about the implementation process. The objective of the current study is to learn more about relations between relevant conditions for successful implementation of QICs, applied changes, perceived successes, and actual outcomes.</p> <p>Methods</p> <p>Twenty-four Dutch hospitals participated in a dissemination programme based on QICs. A questionnaire was sent to 237 leaders of teams who joined 18 different QICs to measure changes in working methods and activities, overall perceived success, team organisation, and supportive conditions. Actual outcomes were extracted from a database with team performance indicator data. Multi-level analyses were conducted to test a number of hypothesised relations within the cross-classified hierarchical structure in which teams are nested within QICs and hospitals.</p> <p>Results</p> <p>Organisational and external change agent support is related positively to the number of changed working methods and activities that, if increased, lead to higher perceived success and indicator outcomes scores. Direct and indirect positive relations between conditions and perceived success could be confirmed. Relations between conditions and actual outcomes are weak. Multi-level analyses reveal significant differences in organisational support between hospitals. The relation between perceived successes and actual outcomes is present at QIC level but not at team level.</p> <p>Discussion</p> <p>Several of the expected relations between conditions, applied changes and outcomes, and perceived successes could be verified. However, because QICs vary in topic, approach, complexity, and promised advantages, further research is required: first, to understand why some QIC innovations fit better within the context of the units where they are implemented; second, to assess the influence of perceived success and actual outcomes on the further dissemination of projects over new patient groups.</p

The Nature, Causes, and Clinical Impact of Errors in the Clinical Laboratory Testing Process Leading to Diagnostic Error:A Voluntary Incident Report Analysis

OBJECTIVES: Diagnostic errors, that is, missed, delayed, or wrong diagnoses, are a common type of medical errors and preventable iatrogenic harm. Errors in the laboratory testing process can lead to diagnostic errors. This retrospective analysis of voluntary incident reports aimed to investigate the nature, causes, and clinical impact of errors, including diagnostic errors, in the clinical laboratory testing process. METHODS: We used a sample of 600 voluntary incident reports concerning diagnostic testing selected from all incident reports filed at the University Medical Center Utrecht in 2017-2018. From these incident reports, we included all reports concerning the clinical laboratory testing process. For these incidents, we determined the following: nature: in which phase of the testing process the error occurred; cause: human, technical, organizational; and clinical impact: the type and severity of the harm to the patient, including diagnostic error. RESULTS: Three hundred twenty-seven reports were included in the analysis. In 77.1%, the error occurred in the preanalytical phase, 13.5% in the analytical phase and 8.0% in the postanalytical phase (1.5% undetermined). Human factors were the most frequent cause (58.7%). Severe clinical impact occurred relatively more often in the analytical and postanalytical phase, 32% and 28%, respectively, compared with the preanalytical phase (40%). In 195 cases (60%), there was a potential diagnostic error as consequence, mainly a potential delay in the diagnostic process (50.5%). CONCLUSIONS: Errors in the laboratory testing process often lead to potential diagnostic errors. Although prone to incomplete information on causes and clinical impact, voluntary incident reports are a valuable source for research on diagnostic error related to errors in the clinical laboratory testing process.</p

The Nature, Causes, and Clinical Impact of Errors in the Clinical Laboratory Testing Process Leading to Diagnostic Error:A Voluntary Incident Report Analysis

OBJECTIVES: Diagnostic errors, that is, missed, delayed, or wrong diagnoses, are a common type of medical errors and preventable iatrogenic harm. Errors in the laboratory testing process can lead to diagnostic errors. This retrospective analysis of voluntary incident reports aimed to investigate the nature, causes, and clinical impact of errors, including diagnostic errors, in the clinical laboratory testing process. METHODS: We used a sample of 600 voluntary incident reports concerning diagnostic testing selected from all incident reports filed at the University Medical Center Utrecht in 2017-2018. From these incident reports, we included all reports concerning the clinical laboratory testing process. For these incidents, we determined the following: nature: in which phase of the testing process the error occurred; cause: human, technical, organizational; and clinical impact: the type and severity of the harm to the patient, including diagnostic error. RESULTS: Three hundred twenty-seven reports were included in the analysis. In 77.1%, the error occurred in the preanalytical phase, 13.5% in the analytical phase and 8.0% in the postanalytical phase (1.5% undetermined). Human factors were the most frequent cause (58.7%). Severe clinical impact occurred relatively more often in the analytical and postanalytical phase, 32% and 28%, respectively, compared with the preanalytical phase (40%). In 195 cases (60%), there was a potential diagnostic error as consequence, mainly a potential delay in the diagnostic process (50.5%). CONCLUSIONS: Errors in the laboratory testing process often lead to potential diagnostic errors. Although prone to incomplete information on causes and clinical impact, voluntary incident reports are a valuable source for research on diagnostic error related to errors in the clinical laboratory testing process.</p

Quality systems in Dutch health care institutions

The implementation of quality systems in Dutch health care was supervised by a national committee during 1990-1995. To monitor the progress of implementation a large survey was conducted in the beginning of 1995. The survey enclosed all subsectors in health care. A postal questionnaire-derived from the European Quality Award-was sent to 1594 health care institutions; the response was 74%. The results showed that in 13% of the institutions a coherent quality system had been implemented. These institutions reported, among other effects, an increase in staff effort and job satisfaction despite the increased workload; 59% of the institutions had implemented parts of a quality system. It appeared that management pay more attention to human resource management compared to documentation of the quality system. The medical staff pay relatively more attention to protocol development than to quality-assurance procedures. Patients were hardly involved in these quality activities. The research has shown that it is possible to monitor the progress of implementation of quality systems on a national level in all subsectors of health care. The results play an important role in the discussions and policy on quality assurance in health care. (aut.ref.

Design of a study on suboptimal cognitive acts in the diagnostic process, the effect on patient outcomes and the influence of workload, fatigue and experience of physician

BACKGROUND: Diagnostic error is an important error type since diagnostic adverse events are regularly judged as being preventable and the consequences are considered to be severe. Existing research often focuses on either diagnostic adverse events or on the errors in diagnostic reasoning. Whether and when an incorrect diagnostic process results in adverse outcomes has not been studied extensively. The present paper describes the design of a study that aims to study the relationship between a suboptimal diagnostic process and patient outcomes. In addition, the role of personal and circumstantial factors on the quality of the diagnostic process will be examined. METHODS/DESIGN: The research questions were addressed using several data sources. First, the differential diagnosis was assessed concurrently to the diagnostic process. Second, the patient records of 248 patients suffering from shortness of breath were reviewed by expert internists in order to reveal suboptimal cognitive acts and (potential) consequences for the patient. The suboptimal cognitive acts were discussed with the treating physicians and classified with the taxonomy of unsafe acts. Third, workload, fatigue and work experience were measured during the physicians work. Workload and fatigue were measured during the physicians shift using the NASA tlx questionnaire on a handheld computer. Physicians participating in the study also answered questions about their work experience. DISCUSSION: The design used in this study provides insight into the relationship between suboptimal cognitive acts in the diagnostic process and possible consequences for the patient. Suboptimal cognitive acts in the diagnostic process and its causes can be revealed. Additional measurements of workload, fatigue and experience allow examining the influence of these factors on the diagnostic process. In conclusion, the present design provides a method with which insights in weaknesses of the diagnostic process and the effect on patient outcomes can be studied and opportunities for improvement can be obtaine

To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints, claims and incident reports?

<p>Abstract</p> <p>Background</p> <p>Patient record review is believed to be the most useful method for estimating the rate of adverse events among hospitalised patients. However, the method has some practical and financial disadvantages. Some of these disadvantages might be overcome by using existing reporting systems in which patient safety issues are already reported, such as incidents reported by healthcare professionals and complaints and medico-legal claims filled by patients or their relatives. The aim of the study is to examine to what extent the hospital reporting systems cover the adverse events identified by patient record review.</p> <p>Methods</p> <p>We conducted a retrospective study using a database from a record review study of 5375 patient records in 14 hospitals in the Netherlands. Trained nurses and physicians using a method based on the protocol of The Harvard Medical Practice Study previously reviewed the records. Four reporting systems were linked with the database of reviewed records: 1) informal and 2) formal complaints by patients/relatives, 3) medico-legal claims by patients/relatives and 4) incident reports by healthcare professionals. For each adverse event identified in patient records the equivalent was sought in these reporting systems by comparing dates and descriptions of the events. The study focussed on the number of adverse event matches, overlap of adverse events detected by different sources, preventability and severity of consequences of reported and non-reported events and sensitivity and specificity of reports.</p> <p>Results</p> <p>In the sample of 5375 patient records, 498 adverse events were identified. Only 18 of the 498 (3.6%) adverse events identified by record review were found in one or more of the four reporting systems. There was some overlap: one adverse event had an equivalent in both a complaint and incident report and in three cases a patient/relative used two or three systems to complain about an adverse event. Healthcare professionals reported relatively more preventable adverse events than patients.</p> <p>Reports are not sensitive for adverse events nor do reports have a positive predictive value.</p> <p>Conclusions</p> <p>In order to detect the same adverse events as identified by patient record review, one cannot rely on the existing reporting systems within hospitals.</p