When patients experience unexpected events, some health professionals become "second victims". These care givers feel as though they have failed the patient, second guessing clinical skills, knowledge base and career choice. Although some information exists, a complete understanding of this phenomenon is essential to design and test supportive interventions that achieve a healthy recovery.
The purpose of this article is to report interview findings with 31 second victims. After institutional review board approval, second victim volunteers representing different professional groups were solicited for private, hour-long interviews. The semistructured interview covered demographics, participant recount of event, symptoms experienced and recommendations for improving institutional support. After interviews, transcripts were analyzed independently for themes, followed by group deliberation and reflective use with current victims.
Participants experienced various symptoms that did not differ by sex or professional group. Our analysis identified six stages that delineate the natural history of the second victim phenomenon. These are (1) chaos and accident response, (2) intrusive reflections, (3) restoring personal integrity, (4) enduring the inquisition, (5) obtaining emotional first aid and (6) moving on. We defined the characteristics and typical questions second victims are desperate to have answered during these stages. Several reported that involvement in improvement work or patient safety advocacy helped them to once again enjoy their work.
We now believe the post-event trajectory is largely predictable. Institutional programs could be developed to successfully screen at-risk professionals immediately after an event, and appropriate support could be deployed to expedite recovery and mitigate adverse career outcomes.
Maryland hospitals have been improving the safety of medication use practices since 2000. A retrospective analysis of 35 hospitals was conducted for 2005–2007 to determine the changes in medication use practices, communication methods within hospitals, patient education and changes in medical record management.
Thirty-five Maryland hospitals completed the Institute for Safe Medication Practices Medication Safety Self-Assessment for Hospitals, a voluntary initiative to improve the safety of medication use. A weighting structure is applied to calculate key element scores, core characteristic scores and overall self-assessment scores that were used in ANOVA and regression analyses.
The state-wide aggregate score significantly increased from 74.2% in 2005 to 81.2% in 2007 (p<0.05). The 35 hospitals scored highest in the following key areas in 2007: drug standardisation, storage and distribution (90.2%); drug labelling, packaging and nomenclature (88.1%); and environmental factors (84.3%). Results indicated that hospitals scored lowest in the key element area related to accessibility of patient information (72.5%) and in the core characteristics pertaining to redundancies and independent double checks (64.2%) in 2007. A substantial number of hospitals had positive and significant (p<0.05) changes in certain key elements and/or core characteristics. Few hospitals showed significant (p<0.05) decreases in their scores.
MEDSAFE has directly assisted Maryland hospitals in improving medication use safety. The strategies and tools of MEDSAFE have been used in Maryland since 2000 and Singapore and Austria since 2006.
Evidence suggests that working long hours or unconventional shifts (night, evening and rotating shifts) can induce fatigue and stress in healthcare employees that might jeopardise quality of care and patient safety.
This study is based on a retrospective analysis of 13 years of occupational data from the National Longitudinal Survey of Youth, covering nearly 11 000 American workers. During the study period, 545 injuries were reported by employees in healthcare professions. Cox proportional hazard analyses were used to calculate adjusted hazard ratios comparing the risk of a job-related injury among healthcare workers in various types of demanding schedules to employees working conventional schedules. The analyses were stratified to estimate risks within different occupational classifications and care settings.
The greatest injury risks to healthcare workers were in schedules involving overtime or at least 60 h per week. Interestingly, an elevated risk of injury was not observed for healthcare employees working 12 or more hours per day or for those in night, evening or rotating shifts. Among employees working overtime and long-hour (>60 h per week) schedules, those at medical provider offices had a significantly higher risk of injury (HR 2.86) than at hospitals, rehabilitation clinics or long-term care facilities. Support personnel, including aids, attendants, technicians, therapists and dieticians, faced a higher risk of injury than did physicians and nurses.
Healthcare managers responsible for quality improvement and patient safety programmes should be aware of the possibility for worker fatigue and injury in particular scheduling arrangements.
Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes.
A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement.
The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff’s high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems.
That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.
To examine whether staff feedback on quality, safety and workforce issues is reflected in patient-reported experience.
166 NHS acute trusts in England.
Respondents to the 2006 surveys of adult inpatients and staff in 166 NHS acute trusts in England.
Multiple linear regression was used to model the relationship between responses by "frontline" staff and inpatients at trust level. Staff survey items were the explanatory variables and inpatient responses the dependent variables. Adjustments were made for location (London and non-London) and trust type.
69 500 staff and 81 000 patients responded to the surveys. There were several significant associations between staff and patients’ responses, including that staff availability of hand-washing materials was positively associated with patient feedback on cleanliness and hand washing by doctors/nurses (p<0.00). It was a significant predictor of patient experience also in several other models. Other significant predictors of patient experience were managerial support, witnessing and reporting of errors (positively associated with patient experience), working extra hours and stress (negatively associated). London trusts performed worse on patient experience than trusts outside London and specialist trusts performed better than other acute trusts.
Staff feedback was associated with patient-reported experience. Positive staff feedback on availability of hand-washing materials was broadly reflective of positive patient experience. Negative staff experience was reflected in poorer patient experience and vice versa. Although we cannot demonstrate causality, the consistent direction of the findings is indicative of it. Management boards of trusts and clinicians and other staff should monitor and act on the results of their staff surveys. This has the potential for improving quality, safety and patient experience.
Colorectal cancer (CRC) is the third-leading cause of cancer death for both men and women in the USA. Despite consensus recommendations for screening, just over half of eligible adults nationally have undergone screening. We therefore implemented a programme to improve the rate of CRC screening.
This study was conducted in the Utah Health Research Network and the University of Utah Community Clinics, a 100 000 patient, seven-practice, university-owned system offering primary and secondary care and ancillary services including endoscopy. We focused on patients aged >=50 who were seen between 1 January 2003 and 31 October 2006, and who were not current for CRC screening at the time of the visit. The study included a three-phase intervention: electronic medical record (EMR) reminders, physician and medical assistant (MA) education about CRC screening guidelines, and redesign of patient visit workflow with an expanded role for MAs to review patients’ CRC screening status and recommend testing when appropriate. With patient agreement, the MA entered a preliminary order in the EMR, and the physician confirmed or rejected the order. The primary outcome measure was the rate of screening colonoscopy ordered for eligible patients.
The baseline colonoscopy referral rate was 6.0%. Provider education and electronic reminders had minimal immediate impact on screening rates. Addition of the expanded MA role was associated with a sustained increase in colonoscopy referral order rate to 13.4%, a relative improvement of 123%.
The MA can play a key role in improving CRC screening rates as part of a redesigned system of primary care.
To test whether an integrated delivery system could, through the application of process redesign methodology and reliability science, implement multiple evidence-based medical practices across the continuum of care for a specific surgical intervention and deliver these practices consistently.
The programme–ProvenCare—had three components: establishing best practices for elective coronary artery bypass graft (CABG) patients; assembling a multidisciplinary team to "hardwire" these best practices into everyday workflow; and implementing the programme with real-time data collection, feedback and focused redesign to reach high reliability. Surgeons reviewed all class I and IIa 2004 ACC/AHA guidelines for CABG surgery and translated them into 19 clinically applicable recommendations. A frontline multidisciplinary team "hardwired" these, resulting in 40 measurable process elements. Feedback of gaps in care was given and the process redesigned as needed. Clinical outcome data on consecutive elective CABG patients seen in the 12 months pre-intervention were then compared with a post-intervention group.
Initially, 59% of patients received all 40 elements. At 3 months, compliance reached 100%, fell transiently to 86% and then reached 100% again, and was sustained for the remainder of the study. The overall trend in reliability was significant (p = 0.001). 30-day clinical outcomes showed improved trends in 8/9 measured areas (eg, patient readmissions to ICU decreased from 2.9% to 0.9% and blood products usage decreased from 23.4% to 16.2%). Operative mortality decreased to zero, but only likelihood of discharge was significant (p = 0.033). Frequency and length of readmissions fell, as did mean hospital charges.
Frontline medical care providers, led by process design specialists, can successfully redesign episodic processes to consistently deliver evidence-based medicine, which may improve patient outcomes and reduce resource use.
Hospital treatment of heart failure (HF) frequently does not follow published guidelines, potentially contributing to HF high morbidity, mortality and economic cost. The Experimental Prospective Study on the Effectiveness and Efficiency of the Implementation of Clinical Pathways was undertaken to determine how clinical pathways (CP) for hospital treatment of HF affected care variability, guidelines adherence, in-hospital mortality and outcomes at discharge.
Two-arm, cluster-randomised trial. Fourteen community hospitals were randomised either to the experimental arm (CP: appropriate therapeutic guidelines use, new organisation and procedures, patient education) or to the control arm (usual care). The main outcome was in-hospital mortality; secondary outcomes were length and appropriateness of the stay, rate of unscheduled readmissions, customer satisfaction, usage of diagnostic and therapeutic procedures during hospital stay and quality indicators at discharge. All outcomes were measured using validated instruments available in literature.
In-hospital mortality was 5.6% in the experimental arm (n = 12); 15.4% in controls (n = 33, p = 0.001). In CP and usual care groups, the mean rates of unscheduled readmissions were 7.9% and 13.9%, respectively. Adjusting for age, smoking, New York Heart Association score, hypertension and source of referral, patients in the CP group, as compared to controls, had a significantly lower risk of in-hospital death (OR 0.18; 95% CI 0.07 to 0.46) and unscheduled readmissions (OR 0.42; 95% CI 0.20 to 0.87). No differences were found between CP and control with respect to the appropriateness of the stay, costs and patient’s satisfaction. Except for electrocardiography, all recommended diagnostic procedures were used more in the CP group. Similarly, pharmaceuticals use was significantly greater in CP, with the exception of diuretics and anti-platelets agents.
The introduction of a specifically tailored CP for the hospital treatment of HF was effective in reducing in-hospital mortality and unscheduled readmissions. This study adds to previous knowledge indicating that CP should be used to improve the quality of hospital treatment of HF.
NCT00519038
Adjustment of patient satisfaction scores for case-mix variables such as age and sex may lead to overadjustment. The patient’s tendency to rate healthcare positively or negatively may be the only variable that should be adjusted to improve the comparability of satisfaction scores between healthcare providers.
To develop a measure of "rating tendency", assess its stability over time, explore its distribution across subgroups of patients and its association with patient opinion scores.
A scale based on 10 hypothetical scenarios describing hospital care episodes was developed. It was administered both before and after hospitalisation to 203 patients programmed for elective orthopaedic surgery in a Swiss teaching hospital. A problem score regarding the actual hospitalisation was obtained at follow-up.
The rating tendency scale had good internal consistency (Cronbach 0.85), and factor analysis confirmed that it measured a single underlying concept. However, the correlation between prehospitalisation and posthospitalisation measures was moderate (intraclass correlation coefficient 0.55, p<0.001), as was the correlation with the hospitalisation problem score (Spearman r = –0.22, p = 0.002). The pattern of rating tendency across subgroups of respondents mirrored the pattern of problem scores. Adjusting for the rating tendency had little effect on comparisons of problem scores between subgroups of patients, all of whom were treated at the same hospital.
A patient’s "rating tendency" can be measured using a reliable 10-item scale. The utility of adjusting satisfaction scores for rating tendency when comparing hospitals remains to be tested.
Low-back disorders are related to biomechanical demands, and nurses are among the professionals with the highest rates. Quantification of risk factors is important for safety assessment and reduction of low-back disorders.
This study aimed to quantify physical demands of frequent nursing tasks and provide evidence-based recommendations to increase low-back safety.
Thirty-six volunteer female nurses participated in a cross-sectional study of nine nursing tasks. Lumbar range of motion (ROM) and motion during nursing tasks were measured. Compression and shear forces at L5/S1, ligament strain and percentage of population without sufficient torso strength to perform 14 phases of nine nursing tasks were estimated.
Peak flexions during trolley-to-bed, bed-to-chair and chair-to-bed transfers reached the maximum flexion ROM of the nurses. Average lumbar flexion during trolley-to-bed transfers was >50% of flexion ROM, being higher than during all other tasks. Mean (SD) compression at L5/S1 (4754 N (437 N)) and population without sufficient torso strength (37% (9%)) were highest during the pushing phase of bed-to-trolley transfers. Shear force (487 N (40 N)) and ligament strain (14% (5%)) were highest during the pulling phase of trolley-to-bed transfers.
Nursing tasks impose high biomechanical demands on the lumbar spine. Excessive lumbar flexion and forces are critical aspects of manual transfers requiring most of the nurses’ capabilities. Evidence-based recommendations to improve low-back safety in common nursing tasks were provided. Fitness to work, job modifications and training programs can now be designed and assessed based on the results.
Evidence-based clinical guidelines aim to improve the quality of care. In The Netherlands, considerable time and effort have been invested in the development and implementation of evidence-based guidelines since the 1990s. Thus far, no reviews are available on their effectiveness. The primary aim of this article was to assess the evidence for the effectiveness of Dutch evidence-based clinical guidelines in improving the quality of care.
A systematic review of studies evaluating the effects of Dutch evidence-based guidelines on both the process and structure of care and patient outcomes was conducted. The electronic databases Medline and Embase (1990–2007) and relevant scientific journals were searched. Studies were only selected if they included a controlled trial, an interrupted time series design or a before and after design.
A total of 20 studies were included. In 17 of 19 studies that measured the effects on the process or structure of care, significant improvements were reported. Thirteen of these studies reported improvement with respect to some of the recommendations studied. In addition, the size of the observed effects varied largely across the recommendations within guidelines. Six of nine studies that measured patient health outcomes showed significant but small improvements as a result of the use of clinical guidelines.
This review demonstrates that Dutch evidence-based clinical guidelines can be effective in improving the process and structure of care. The effects of guidelines on patient health outcomes were studied far less and data are less convincing. The high level of variation in effects across recommendations suggests that implementation strategies tailored to individual recommendations within the guideline are needed to establish relevant improvements in healthcare. Moreover, the results highlight the need for well-designed studies focusing on the level of the recommendations to determine which factors influence guideline utilisation and improved patient outcomes.
Teamwork and communication have been identified as root causes of sentinel events involving infant death and injury during delivery. However, despite the emphasis on team training as a way to improve maternal and fetal safety outcomes, valid and reliable markers of obstetrical team performance are not available to assess curricular efficacy.
The objective of this study was to develop and assess the usability of two obstetrical behavioural marking systems for use with simulation entitled Assessment of Obstetrical Team Performance (AOTP) and Global Assessment of Obstetrical Team Performance (GAOTP).
In a previous study, obstetrical teams were videotaped managing simulated emergency obstetrical scenarios. In the current study, 13 reviewers reviewed these videotapes and generated a list of behaviours judged to negatively or positively affect the teams’ performances. Qualitative analysis using research team consensus and NVivo generated themes and subthemes. Research team members developed descriptors for poor and excellent team performance for each of the behaviours. Subsequently, the usability of the prototypes was assessed by an additional 14 reviewers.
In total, the reviewers identified 1294 items, which were sorted into 6 themes and 18 subthemes of obstetrical team performance. In terms of usability, the median amount of time that participants spent completing the AOTP was 7.5 min (range 1.5 to 50 min) and 75% thought the time requirement was moderate and manageable.
Feedback regarding usability suggests that the AOTP allows for an accurate reflection of raters’ assessments of the performance of the team, and as a whole, it is comprehensive, quick and easy to use. Studies are underway to establish the validity and reliability of the AOTP and GAOTP.
Worldwide, there is increasing focus on measures to reduce ineffective healthcare practices. Upper airway surgeries for the treatment of adult obstructive sleep apnoea (OSA) represent a case-study in this area, given recent publications that draw into question their efficacy. Policy stakeholders were canvassed to assess their perspectives on this.
Senior health policy stakeholders from Australia were criterion and snowball sampled (to identify opinion leaders). Participants were presented with preparatory material and took part in individual semistructured interviews. These focused on eliciting responses to recently published evidence and a relevant Cochrane review. Questions were posed relating to clinical effectiveness and associated policy implications. Interviews were taped and transcribed for thematic analysis. Participant comments were de-identified.
Ten stakeholders were interviewed before saturation was reached. Thematic analysis highlighted participant concern with the diversity of procedures on offer, coupled with limited effectiveness (suggesting potential clinical uncertainty) and considerations therefore of resource allocation (potential opportunity cost). Stakeholders seem aware of the methodological complexities, the ethical issues raised and the role of patients in considerations regarding appropriateness. Finally, policy stakeholders acknowledge that these procedures appear appropriate only for a minority, with consensus that policy level restrictions to government funding for these procedures may be warranted.
This report highlights that this clinical controversy is of interest and relevance from a policy perspective with lessons and potential implications for clinical practice. It further highlights the need for clinical consensus on definitions of surgical "success" in treating this condition, as this forms an important pretext to policy considerations.
To enhance overall accuracy of medication lists by providing performance feedback and training to the healthcare team and increasing patient participation in the medication reconciliation process.
This prospective study involved patients seen in four academic, ambulatory primary care internal medicine clinics. Before the interventions, baseline data were analysed, assessing completeness, correctness and accuracy of medication documentation in the electronic medical record. Interventions to provide performance feedback and training to the healthcare team, increase patient awareness and participation in the medication reconciliation process were implemented. Immediately after each intervention, a data collection was undertaken to assess the effectiveness of the intervention on the accuracy of individual medications and medication lists.
Completeness of medication lists improved from 20.4% to 50.4% (p<0.001). The incomplete documentation of medication lists was mostly because of lack of frequency (15.4%) and route (8.9%) for individual medications within a medication list. Correctness of medication lists improved from 23.1% to 37.7% (p = 0.087). The incorrectness in a medication list was mostly because of incorrect medications dose. Patient participation in the medication reconciliation process increased from 13.9% to 33% (p<0.001). The medication list accuracy improved from 11.5% to 29% (p = 0.014).
In this setting, it was helpful to engage the active participation of all members of the healthcare team and most importantly the patient to improve the accuracy of medication lists.
Hospital-acquired venous thromboembolism (VTE) is a potentially fatal complication of hospitalisation, with meta-analyses and guidelines supporting the use of proven prophylactic measures (graduated compression stockings (GCS) and anticoagulants). Despite this, prophylaxis is underutilised and represents one of the largest gaps between evidence and current clinical practice.
All episodes of VTE complicating hospitalisation were ascertained prospectively as part of a quality improvement programme over 3.5 years with a view to designing interventions to improve the use of prophylaxis and reduce the rate of VTE. Interventions initially centred upon highlighting the burden of VTE, the extent of failure to apply guideline evidence into practice, and the development and application of a hospital-wide risk assessment tool. Later interventions sought to build the risk-assessment tool into routine clinical care and enhanced feedback on VTE to clinical teams.
The annual rate of VTE fell in all the years following the intervention (2001), from 2.57 per 1000 cost-weighted separations to a nadir of 1.87 in 2003, with the difference being statistically significant (RR 0.68, 0.47 to 0.99, p = 0.04). The proportion of patients receiving anticoagulant prophylaxis increased (48% to 74%, p = 0.01) but there was no change in the measured use of GCS. There was a marked increase in the use of risk assessment for VTE in the ward setting (7.7% to 100%, p<0.001) during the programme.
Affordable and accessible interventions can improve the application of VTE prophylaxis guidelines into daily hospital care and are associated with reductions in this potentially life-threatening complication.