Risk Watch (February '21)

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.

COVID-19 Updates on HIROC.com
For information and resources related to COVID-19, please visit HIROC.com to access our COVID-19 Updates page. For a Q&A of Subscriber questions, log in and select COVID-19: Your Questions Answered from the Member Portal Links dropdown. 

Editor's Note

Sara Chow headshot
                       Dan Altenberg

The February issue of Risk Watch features a Canadian study from Shaw et al. focussing on system issues involved in the common home care patient safety event: “Found on Floor”.  Other topics in this month’s article review highlights a return to exploring patient safety basics such as: pressure injuries in acute care (Padula et al.); hand hygiene compliance (Anderson et al.) and physician handover communication (Alali, et al.). COVID-focused articles continue to surface, and December presented three articles investigating patient centred themes such as patient experience trends among those presenting with long-term symptoms (Ladds et al.), ethical decision making related to family presence during the pandemic (Bardon et al.), and using human factors to impact patient safety (Alagha et al.).

Additional resources incorporate a wide range of topics around COVID, including:  ISMP recommendations for vaccinations; PCMCH pregnancy information for vaccines; JAMA articles on still- and pre-term births; trends in healthcare cyber-attacks; and The Health Foundations research on the impact of housing and a continuation of the Ipsos survey of public perceptions of health during COVID.

If you have feedback about this month’s articles or Risk Watch, please send them to me at daltenberg@hiroc.com.

Hot Off the Press


System Issues Leading to “Found-on-Floor” Incidents: A Multi-Incident Analysis
Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021 Jan;17(1):30-35.

Canadian multi-incident analysis of found-on-floor (FOF) incidents. FOF incidents are a key patient safety issue that is unique to the home care setting and highlights a number of opportunities for system-level improvements to drive enhanced patient safety. Recommendations included: investment in electronic health records that are functional across the continuum of care; further research and understanding of the training and skills of personal support workers; and enhanced incentives or more punitive approaches (depending on the circumstances) to ensure accountability. 


Investing in Skilled Specialists to Grow Hospital Infrastructure for Quality Improvement
Padula WV, Nagarajan M, Davidson PM, et al.  J Patient Saf. 2021 Jan;17(1):51-55.

US study evaluating pressure injury rates as an indicator of performance in a retrospective observational cohort of 55 U.S. academic hospitals. The study compared ratios of board-certified wound care nurses per 1000 hospital beds to hospital-acquired pressure injury rates in these hospitals using mixed-effects regression of hospital quarters. Researchers concluded that adding one board-certified wound care nurse per 1000 hospital beds, hospitals had associated decreases in pressure injury rates by 17.7% relative to previous quarters, controlling for other interruptions.


Persistent symptoms after Covid-19: Qualitative study of 114 "long Covid" patients and draft quality principles for services
Ladds E, Rushforth A, Wieringa S, et al. BMC Health Serv Res. 2020 Dec; 20(1):1144.

UK Study incorporating individual interviews and focus groups. Participants included 114 participants aged 27-73 years. Participants included physicians and other health professionals. Results indicated integrating quality principles for a long COVID service such as ensuring access to care, reducing burden of illness, taking clinical responsibility and providing continuity of care, multi-disciplinary rehabilitation, evidence-based investigation and management, and further development of the knowledge base and clinical services.


Improving physician handover documentation process for patient transfer from paediatric intensive care unit to general ward
Alali H, Antar M, AlShehri A, et al. BMJ Open Qual. 2020 Dec; 9(4):e001020.

Study from Saudi Arabia looking at a QI initiative in handover communication from PICU to general ward. Brainstorming techniques were used to develop improvement interventions, including a standardised handover form and conducting education sessions for the new proposed process. Results showed improved physician compliance to handover documentation, improved physician satisfaction with communicated information, and that PICU emergency readmission rate within 48 hours declined to zero for four consecutive months.


Establishing the Foundation to Support Health System Quality Improvement: Using a Hand Hygiene Initiative to Define the Process
Anderson R, Rosenberg A, Garg S, et al. J Patient Saf. 2021 Jan; 17(1):23-29.

Study from the US that used a multifaceted approach to improve hand hygiene compliance. The study team implemented the Joint Commission’s Targeted Solutions Tool for Hand Hygiene, which showed approximately 20% improvement with hand hygiene compliance. The study team concluded that leadership engagement, data transparency, data and observer management, and system-wide communication of best practices helped to build an effective foundation for future process improvement programs.


An ethical approach to considering family presence during COVID-19
Bardon, E. Healthc Manage Forum. 2020 Dec; 23:840470420980655.

Article from Canada highlighting how an Ontario hospital handles COVID-19 challenges by applying an ethical decision making framework. The principles facilitated a balance between the tensions of rapidly changing COVID-19 response and decisions for the presence of family.


Patient Harm During COVID-19 Pandemic: Using a Human Factors Lens to Promote Patient and Workforce Safety
Alagha MA, Jaulin F, Yeung W, et al. J Patient Saf. 2020 Dec 2.

This article describes how the Human Factors Analysis and Classification System (HFACS) was used to highlight international examples of the COVID-19 rapid mobilizations of healthcare resources. Examining the COVID-19 response with the three levels of human factors can support decision makers with solutions to improve organizational efforts.


Adverse Events in Intensive Care and Continuing Care Units During Bed-Bath Procedures: The Prospective Observational NURSIng during critical carE (NURSIE) Study
Decormeille G, Maurer-Maouchi V, Mercier G, et al. Crit Care Med. 2021 Jan; 49(1):e20-e30.

The article takes a critical look at the relationship between adverse events and standard nursing interventions in the ICU. Twenty four ICUs in France, Belgium and Luxembourg studied the 1529 nursing procedures. Serious events concerned approximately 20% of the nurses and was seen in half of the patients. Further studies and caution are recommended.  


Increasing Physician Reporting of Diagnostic Learning Opportunities
Marshall TL, Ipsaro AJ, Le M, et al. Pediatrics. 2021 Jan;147(1):e20192400.

This US study demonstrates the approach used to engage physicians in reporting “diagnostic learning opportunities”. A quality improvement methodology was used to promote a safe reporting culture and increase understanding of the factors involved in diagnostics errors. The learnings from this project increased the numbers of reports and provided learnings into future quality improvement work.

Other Resources of Interest