Risk Watch (August '20)
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 firstname.lastname@example.org for assistance if required.
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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.
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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
- Coronavirus Disease 2019 (COVID-19) and diagnostic error (July 2020). Agency for Healthcare Research and Quality (US) patient safety primer applying well-established principles of diagnostic error and improving diagnostic accuracy to the topic of COVID-19.
- Culture as a cure: assessments of patient safety culture in OECD countries (June 2020). Organisation for Economic Co-operation and Development (FR) report highlighting findings from OECD countries on the state of the art for measurement practices related to patient safety culture.
- Multiple high-risk events involving workflow for wasting of medications used by anesthesia (July 2020). Agency for Healthcare Research and Quality (US) web M&M case discussing medication waste workflow, medication labeling, and controlled substance accountability in the safe disposal of medications.
- Protecting children from iatrogenic harm during COVID19 pandemic (June 2020). Journal of Paediatrics and Child Health (AU) viewpoint article highlighting the risks underlying a sudden change of clinical practice.
- Reimagining care for older adults: next steps in COVID-19 response in long-term care and retirement homes (July 2020). Canadian Foundation for Healthcare Improvement and Canadian Patient Safety Institute report focusing on promising practices in six key areas that have the potential to reduce the risk of future COVID-19 outbreaks or mitigate their effects.
- Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID‐19 disease (July 2020). Cochrane Database of Systematic Reviews (UK) review assessing the diagnostic accuracy of COVID-19 signs and symptoms.
- Spear phishing: top threats and trends volume 4 – Insights into attacker activity in compromised email accounts (July 2020). Barracuda Networks (US) report examining 159 compromised email accounts spanning 111 organizations (free with registration).
- The scientific literature on Coronaviruses, COVID-19 and its associated safety-related research dimensions: a scientometric analysis and scoping review (Sept 2020). Safety Science (NL) review article discussing the most common research on COVID-19 and safety issues to date.
- The Health Foundation COVID-19 Survey: a report of survey findings (June 2020). The Health Foundation (UK) report summarizing key insights of the general public in Great Britain to understand opinion on a range of issues.
- Virtual workplace investigations: the “next normal” – postponing the investigation vs. proceeding by virtual means (June 2020). Borden Ladner Gervais (CA) article presenting issues for employers to consider.
- What to say during telehealth visits with older adults (July 2020). Institute for Healthcare Improvement (US) blog article highlighting tips for telehealth visits using the Age-Friendly Health Systems 4Ms Framework.
- Will COVID-19 be a watershed moment for health inequalities? (May 2020). The Health Foundation (UK) article highlighting the uneven impact of COVID-19 on those already experiencing inequality.