Learning from safety events in healthcare: A sensemaking and mental model perspective

Organizational learning from safety relevant events is critical for improvement of healthcare practice. The identification of causes of safety events in hospitals and the design of improvements engage decision making processes that involve a high degree of interpretive activity by various professional groups (physicians, nurses, risk managers, pharmacists, etc.). From a sensemaking perspective (Weick, 1995, Weick, Sutcliffe, & Obstfeld, 2005), we conceptualize the event investigation and action planning processes as driven by cognitive structures that help individuals understand an event from their own perspective, based on their experience, anticipation of what could happen, professional education and situational perceptions. To better understand these processes, we propose an individual-level framework suggesting that the construction of causal scenarios and the design of improvements are influenced by habitual mental models that contain assumptions and knowledge about safety and accident causation as well as by the analysts’ perceived action repertoires in defining corrective actions. Various influences on the individual cognitive processes in event analysis are discussed, such as professional education, cognitive style, organizational tools, culture, and the use of safety theories. As the framework is intended to stimulate future research, potential research questions and methods are discussed

Root causes and preventability of unintentionally retained foreign objects after surgery: a national expert survey from Switzerland.

BACKGROUND Retained foreign objects (RFO) after surgery are rare, serious patient safety events. In international comparisons based on routine data, Switzerland had remarkably high RFO rates. The objectives of this study were to 1) explore national key stakeholders' views on RFO as a safety problem, its preventability and need for action in Switzerland; and 2) to assess their interpretation of Switzerland's RFO incidence compared to other countries. METHODS A semi-structured expert survey was conducted among national key representatives, including clinician experts, patient advocates, health administration representatives and other relevant stakeholders (n = 21). Data were coded and analyzed to generate themes related to the study questions following a deductive approach. RESULTS Experts in this study unequivocally emphasized the tragedy for individual patients affected by RFOs. Productivity pressure and the strong economization of operating rooms were perceived as detrimental to safety culture, which was seen as essential for RFO prevention, specifically by those working in the OR. RFOs were seen as "maximally minimizable" but not completely preventable. There was strong agreement that within country differences in RFO risk between Swiss hospitals existed. On the systems level and compared to other safety issues, RFO were having less urgency for most experts. The international comparison of RFO incidences raised serious skepticism across all groups of experts. The validity of the data was questioned and the dominant interpretation of Switzerland's high RFO incidence compared to other countries was a "reporting artifact" based on high coding quality in Swiss hospitals. While most experts thought that the published RFO incidence warrants in-depth analysis of the data, there was little agreement about who's role it was to initiate any further activities. CONCLUSIONS This investigation offers valuable insights into the perspectives of significant stakeholders concerning RFOs, their root causes, and preventability. The findings demonstrate how international comparative safety data are perceived, interpreted, and utilized by national experts to derive conclusive insights

Learning from safety events in healthcare: A sensemaking and mental model perspective

Organizational learning from safety relevant events is critical for improvement of healthcare practice. The identification of causes of safety events in hospitals and the design of improvements engage decision making processes that involve a high degree of interpretive activity by various professional groups (physicians, nurses, risk managers, pharmacists, etc.). From a sensemaking perspective (Weick, 1995, Weick, Sutcliffe, & Obstfeld, 2005), we conceptualize the event investigation and action planning processes as driven by cognitive structures that help individuals understand an event from their own perspective, based on their experience, anticipation of what could happen, professional education and situational perceptions. To better understand these processes, we propose an individual-level framework suggesting that the construction of causal scenarios and the design of improvements are influenced by habitual mental models that contain assumptions and knowledge about safety and accident causation as well as by the analysts’ perceived action repertoires in defining corrective actions. Various influences on the individual cognitive processes in event analysis are discussed, such as professional education, cognitive style, organizational tools, culture, and the use of safety theories. As the framework is intended to stimulate future research, potential research questions and methods are discussed

Registration and Management of "Never Events" in Swiss Hospitals-The Perspective of Clinical Risk Managers.

BACKGROUND In Switzerland, there is no mandatory reporting of "never events." Little is known about how hospitals in countries with no "never event" policies deal with these incidents in terms of registration and analyses. OBJECTIVE The aim of our study was to explore how hospitals outside mandatory "never event" regulations identify, register, and manage "never events" and whether practices are associated with hospital size. METHODS Cross-sectional survey data were collected from risk managers of Swiss acute care hospitals. RESULTS Clinical risk managers representing 95 hospitals completed the survey (55% response rate). Among responding risk and quality managers, only 45% would be formally notified through a designated reporting channel if a "never event" has happened in their hospital. Averaged over a list of 8 specified events, only half of hospitals could report a systematic count of the number of events. Hospital size was not associated with "never event" management. Respondents reported that their hospital pays "too little attention" to the recording (46%), the analysis (34%), and the prevention (40%) of "never events." All respondents rated the systematic registration and analysis of "never events" as very (81%) or rather important (19%) for the improvement of patient safety. CONCLUSIONS A substantial fraction of Swiss hospitals do not have valid data on the occurrence of "never events" available and do not have reliable processes installed for the registration and exam of these events. Surprisingly, larger hospitals do not seem to be better prepared for "never events" management

Oncology nurses' beliefs and attitudes towards the double-check of chemotherapy medications:a cross-sectional survey study

BACKGROUND: Double-checking medications is a widely used strategy to enhance safe medication administration in oncology, but there is little evidence to support its effectiveness. The proliferated use of double-checking may be explained by positive attitudes towards checking among nurses. This study investigated oncology nurses' beliefs towards double-checking medication, its relation to beliefs about safety and the influence of nurses' level of experience and proximity to clinical care. METHODS: This was a survey of all oncology nurses in three Swiss hospitals. The questionnaire contained 41 items on 6 domains. Responses were recorded using a 7-point Likert scale. Multiple regression analysis was used to identify factors linked to strong beliefs in the effectiveness of double-checking. RESULTS: Overall, 274 (70%) out of 389 nurses responded (91% female, mean age 37 (standard deviation = 10)). Nurses reported very strong beliefs in the effectiveness and utility of double-checking. They were also confident about their own performance in double-checking. Nurses widely believed that double checking produced safety (e.g., 86% believed errors of individuals could be intercepted with double-checks). In contrast, some limitations of double-checking were also recognized, e.g., 33% of nurses reported that double checking caused frequent interruptions and 28% reported that double-checking was done superficially in their unit. Regression analysis revealed that beliefs in effectiveness of double-checking were mainly associated with beliefs in safety production (p < 0.001). Nurses with experience in barcode scanning held less strong beliefs in effectiveness of double-checking (p = 0.006). In contrast to our expectations, there were no differences in beliefs between any professional sub-groups. CONCLUSION: The widespread and strong believe in the effectiveness of double-checking is linked to beliefs about safety production and co-exists with acknowledgement of the major disadvantages of double-checking by humans. These results are important factors to consider when any existing procedures are adapted or new checking procedures are implemented

Protonation of Pyruvic Acid - Synthesis of a plain Superelectrophile

The syntheses of [H3C(O)CC(OH)(2)][MF6] and [H3C(OH)CC-(OH)(2)][MF6](2) (M=As, Sb) by reacting pyruvic acid in the superacidic systems HF/AsF, and HF/SbF5 are reported. The salts were characterized by low-temperature vibrational spectroscopy and in the cases of [H3C(O)CC(OH)(2)][SbF6] and [H3C(OH)CC-(OH)(2)][SbF6](2)center dot HF by X-ray crystal structure analyses. The exper- imental results are discussed together with quantum chemical calculations. Remarkably, the bond distance and the twisting angle around the central C-C bond are unaffected by the protonations despite increasing coulombic repulsion. The crystal structure reveals short interionic interactions that have a considerable influence on the C-C bond

Addressing Patient Safety Hazards Using Critical Incident Reporting in Hospitals: A Systematic Review

Critical incident reporting systems (CIRS) are in use worldwide. They are designed to improve patient care by detecting and analyzing critical and adverse patient events and by taking corrective actions to prevent reoccurrence. Critical incident reporting systems have recently been criticized for their lack of effectiveness in achieving actual patient safety improvements. However, no overview yet exists of the reported incidents' characteristics, their communication within institutions, or actions taken either to correct them or to prevent their recurrence. Our main goals were to systematically describe the reported CIRS events and to assess the actions taken and their learning effects. In this systematic review of studies based on CIRS data, we analyzed the main types of critical incidents (CIs), the severity of their consequences, their contributing factors, and any reported corrective actions.; Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we queried MEDLINE, Embase, CINAHL, and Scopus for publications on hospital-based CIRS. We classified the consequences of the incidents according to the National Coordinating Council for Medication Error Reporting and Prevention index, the contributing factors according to the Yorkshire Contributory Factors Framework and the Human Factors Classification Framework, and all corrective actions taken according to an action hierarchy model on intervention strengths.; We reviewed 41 studies, which covered 479,483 CI reports from 212 hospitals in 17 countries. The most frequent type of incident was medication related (28.8%); the most frequent contributing factor was labeled "active failure" within health care provision (26.1%). Of all professions, nurses submitted the largest percentage (83.7%) of CI reports. Actions taken to prevent future CIs were described in 15 studies (36.6%). Overall, the analyzed studies varied considerably regarding methodology and focus.; This review of studies from hospital-based CIRS provides an overview of reported CIs' contributing factors, characteristics, and consequences, as well as of the actions taken to prevent their recurrence. Because only 1 in 3 studies reported on corrective actions within the healthcare facilities, more emphasis on such actions and learnings from CIRS is required. However, incomplete or fragmented reporting and communication cycles may additionally limit the potential value of CIRS. To make a CIRS a useful tool for improving patient safety, the focus must be put on its strength of providing new qualitative insights in unknown hazards and also on the development of tools to facilitate nomenclature and management CIRS events, including corrective actions in a more standardized manner

Are cross-sectional safety climate survey results in operating room staff associated with the surgical site infection rates in Swiss hospitals?

OBJECTIVES The aim of this study was to investigate the association between surgical site infections (SSIs), a major source of patient harm, and safety and teamwork climate. Prior research has been unclear regarding this relationship. DESIGN Based on the Swiss national SSI surveillance and a survey study assessing (a) safety climate and (b) teamwork climate, associations were analysed for three kinds of surgical procedures. SETTING AND PARTICIPANTS SSI surveillance data from 20 434 surgeries for hip and knee arthroplasty from 41 hospitals, 8321 for colorectal procedures from 28 hospitals and 4346 caesarean sections from 11 hospitals and survey responses from Swiss operating room personnel (N=2769) in 54 acute care hospitals. PRIMARY AND SECONDARY OUTCOMES The primary endpoint of the study was the 30-day (all types) or 1-year (knee/hip with implants) National Healthcare Safety Network-adjusted SSI rate. Its association with climate level and strength was investigated in regression analyses, accounting for respondents' professional background, managerial role and hospital size as confounding factors. RESULTS Plotting climate levels against infection rates revealed a general trend with SSI rate decreasing as the safety climate increased, but none of the associations were significant (5% level). Linear models for hip and knee arthroplasties showed a negative association between SSI rate and climate perception (p=0.02). For climate strength, there were no consistent patterns, indicating that alignment of perceptions was not associated with lower infection rates. Being in a managerial role and being a physician (vs a nurse) had a positive effect on climate levels regarding SSI in hip and knee arthroplasties, whereas larger hospital size had a negative effect. CONCLUSIONS This study suggests a possible negative correlation between climate level and SSI rate, while for climate strength, no associations were found. Future research should study safety climate more specifically related to infection prevention measures to establish clearer links

Medication double-checking procedures in clinical practice: a cross-sectional survey of oncology nurses' experiences.

BACKGROUND Double-checking is widely recommended as an essential method to prevent medication errors. However, prior research has shown that the concept of double-checking is not clearly defined, and that little is known about actual practice in oncology, for example, what kind of checking procedures are applied. OBJECTIVE To study the practice of different double-checking procedures in chemotherapy administration and to explore nurses' experiences, for example, how often they actually find errors using a certain procedure. General evaluations regarding double-checking, for example, frequency of interruptions during and caused by a check, or what is regarded as its essential feature was assessed. METHODS In a cross-sectional survey, qualified nurses working in oncology departments of 3 hospitals were asked to rate 5 different scenarios of double-checking procedures regarding dimensions such as frequency of use in practice and appropriateness to prevent medication errors; they were also asked general questions about double-checking. RESULTS Overall, 274 nurses (70% response rate) participated in the survey. The procedure of jointly double-checking (read-read back) was most commonly used (69% of respondents) and rated as very appropriate to prevent medication errors. Jointly checking medication was seen as the essential characteristic of double-checking-more frequently than 'carrying out checks independently' (54% vs 24%). Most nurses (78%) found the frequency of double-checking in their department appropriate. Being interrupted in one's own current activity for supporting a double-check was reported to occur frequently. Regression analysis revealed a strong preference towards checks that are currently implemented at the responders' workplace. CONCLUSIONS Double-checking is well regarded by oncology nurses as a procedure to help prevent errors, with jointly checking being used most frequently. Our results show that the notion of independent checking needs to be transferred more actively into clinical practice. The high frequency of reported interruptions during and caused by double-checks is of concern

Synthesis and in vitro evaluation of cyclodextrin hyaluronic acid conjugates as a new candidate for intestinal drug carrier for steroid hormones

Steroid hormones became increasingly interesting as active pharmaceutical ingredients for the treatment of endocrine disorders. However, medical applications of many steroidal drugs are inhibited by their very low aqueous solubilities giving rise to low bioavailabilities. Therefore, the prioritized oral administration of steroidal drugs remains problematic. Cyclodextrins are promising candidates for the development of drug delivery systems for oral route applications, since they solubilize hydrophobic steroids and increase their rate of transport in aqueous environments. In this study, the synthesis and characterization of polymeric β-cyclodextrin derivates is described, which result from the attachment of a hydrophilic β-CD-thioether to hyaluronic acid. Host-guest complexes of the synthesized β-cyclodextrin hyaluronic acid conjugates were formed with two poorly soluble model steroids (β-estradiol, dexamethasone) and compared to monomeric β-cyclodextrin derivates regarding solubilization and complexation efficiency. The β-cyclodextrin-drug (host-guest) complexes were evaluated in vitro for their suitability (cytotoxicity and transport rate) as intestinal drug carriers for steroid hormones. In case of β-estradiol, higher solubilities could be achieved by complexation with both synthesized β-cyclodextrin derivates, leading to significantly higher intestinal transport rates in vitro. However, this success could not be shown for dexamethasone, which namely solubilized better, but could not enhance the transport rate significantly. Thus, this study demonstrates the biocompatibility of the synthesized and characterized β-cyclodextrin derivates and shows their potential as new candidate for intestinal drug carrier for steroid hormones like β-estradiol