Risk Watch (August '20)

Service: Risk Management
Type: Risk Watch

Selected research, publications, and resources to promote evidence-informed risk management in Canadian healthcare organizations. Prepared by the Healthcare Risk Management staff at the Healthcare Insurance Reciprocal of Canada (HIROC). Some titles are open access while others may require a subscription or library access; the librarian at your organization may be able to assist you. Please contact riskmanagement@hiroc.com for assistance if required.

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Editor's Note

Sara Chow headshot
                       Sara Chow

Our August issue of Risk Watch includes two articles related to the aftermath of adverse events: Busch et al. review common coping strategies second victims adopt and how they may positively or negatively impact healthcare providers, patients, and the healthcare system and noted that support programs “should not only focus on second victims’ psychological and psychosomatic symptoms but also explicitly address the type of the used coping strategies and their effects on all involved stakeholders.” Wiig et al. propose suggestions for and discuss the challenges of inviting families to participate in investigations. They state families can provide investigators with “rich information, a more holistic picture of the fatal event and new perspectives about additional actors and stakeholders involved in the causality chain.” We also feature articles that share learnings from specific types of safety events.

If you have comments about any of the articles, please email me at schow@hiroc.com.

Hot Off the Press

Palliative Care / Medical Assistance in Dying

Provision of medical assistance in dying: a scoping review
Zworth, Saleh C, Ball I, et al. BMJ Open. 2020 (online, July):1-8.

Article from Canada mapping the characteristics of the existing literature describing the medications, settings, participants and outcomes of medical assistance in dying (MAID), in order to identify knowledge gaps and areas for future research. “Clinical problems with MAID care are common, including poor communication between healthcare providers and patients, inconsistent application of eligibility criteria, unequal access and technical problems with medication administration” (p. 2).

Adverse Events / Second Victim

Dealing with adverse events: a meta-analysis on second victims coping strategies 
Busch I, Moretti F, Purgato M, et.al. J Patient Saf. 2020 (online, June);16(2):e51-e60.

Systematic review to explore coping strategies applied by second victims after an adverse event. Through meta-analyses of the 14 studies included, 26 coping strategies adopted by second victims were identified along with their frequency rates. Authors noted that coping strategies can influence healthcare providers, patients, and the healthcare system in a positive or negative way. “Indeed, the ability of a healthcare organization to provide high reliability under varying conditions is a critical achievement only possible through actively fostering the adaptability and creativity of human performance—a Safety II approach. Accordingly, a coping strategy can also be seen as functional for the system if it strengthens professionals’ resilience” (p. e54).

Patient Family Engagement / Critical Incidents

The patient died: what about involvement in the investigation process? 
Wiig S, Hibbert PD, Braithwaite J. Int J Qual Health Care. 2020 (June);32(5):342-346.

Article reviewing methods of involving families in investigations of fatal adverse events and how their greater participation might improve the quality of investigations. “Family involvement essentially contributes to closing the gap between ‘work as imagined’ (WAI) and ‘work as done’ (WAD)” (p. 2).

Safety II / Compliment Letters

Identifying and encouraging high-quality healthcare: an analysis of the content and aims of patient letters of compliment
Gillespie A, Reader T. BMJ Qual Saf. 2020 (online, July):1-9. 

Study in the UK analyzing 1,267 compliment letters from 54 hospitals to identify practices being complimented and whether the aims vary when addressing front-line staff compared with senior management. Authors noted, “compliment letters may further the goal of understanding high quality healthcare by providing distinctive data on the everyday adaptations that, from a patient perspective, make care effective and thus underpin safety II” (p. 2). 

Safety / Pediatric Diagnostic Errors

Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE 
Dadlez N, Adelman J, Bundy D, et al. Pediatr Qual Saf. 2020 (online May);5(3):e299-e305.

Study from the US to explore three diagnostic errors in peadiatrics including missed adolescent depression, missed elevated blood pressure, and missed actionable laboratory values. The study used 184 mini root cause analyses (RCA) from 28 ambulatory practices to identify failure points and contributing factors. Results are provided for the three diagnostic errors and include recommendations from the RCA. 

Incidents / Home Care

Reporting incidents involving the use of advanced medical technologies by nurses in home care: a cross-sectional survey and an analysis of registration data
Haken I, Ben Allouch S, van Harten W. BMJ Qual Saf. 2020 (online, June):1-8.

Study in the Netherlands using data collected from over 2,100 nursing shifts to identify frequency of medical device incidents in home care involving infusion therapy, parenteral nutrition, and morphine pumps; effects on patient outcomes; and actions taken by nurses following incidents. Incidents involving one of these technologies occurred in 3.7% of shifts, and in approximately 90% of incidents, nurses took action to discuss the event, however, “there is a discrepancy in quality circles: there is an implicit professional safety culture in which learning takes place more at the team level than formally at the organisational level” (p. 7).

Safety / Medication Adverse Events

User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study
Jones M, McGrogan A, Raynor D, et al. BMJ Qual Saf. 2020 (online, June):1-10.

Study in the UK using simulation to compare the frequency of medication errors when administering a high-risk medication using the current National Health Service Injectable Medicines Guide with a version revised with user-testing, which found significantly more simulations were completed without any errors with the user-tested guidelines (48%) compared with current guidelines (20%). Authors suggested, “the results also have wider implications, suggesting all health systems should consider adopting user-testing for medicines guidelines, particularly those that address high-risk and complex decisions”.

Mental Health / Death by Suicide

How health care systems let our patients down: a systematic review into suicide deaths 
Wyder M, Ray M, Roennfeldt, et al. Int J Qual Health Care. 2020 (June);32(5):285-291.

Systematic review to synthesize the literature in relation to findings of system errors through reviews of suicide deaths in the public mental health system. Seven overarching themes were identified: inappropriate or incomplete risk assessment; lack of family involvement; inadequate transitions and communication between different teams; policies and procedures not always followed; treatment not in line with current guidelines; access to means and observation; potential service gaps. “For hospitals to provide a safe environment for those who are experiencing suicidal thoughts, routine surveys of potential ligatures and anchor points should be conducted. Furthermore, specialized protocols for suicidal patients, including continuous monitoring when possible will potentially impact on suicidal acts on the wards” (p. 289).

Patient Deterioration / Sepsis

2019 John M. Eisenberg Patient Safety and Quality Awards: SPOTting sepsis to save lives: a nationwide computer algorithm for early detection of sepsis
Perlin J, Jackson E, Hall C, et al. Jt Comm J Qual Patient Saf. 2020 (July);46(7):381-391.

Article from the US describing the development and implementation of a computer algorithm that interprets available electronic and laboratory data in near real time to provide system-wide surveillance and alerting of care teams at the moment when inpatients meet criteria for sepsis. Authors reported a median difference of 6.3 hours between the algorithm’s performance and sepsis screening according to legacy practices and an average year-over-year improvement in mortality rate of 13%.

Other Resources of Interest