Risk Watch (February '21)
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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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.
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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.
QUALITY IMPROVEMENT/PRESSURE INJURIES
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.
QUALITY IMPROVEMENT/HAND HYGIENE
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.
ETHICAL DECISION MAKING/COVID-19
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.
HUMAN FACTORS/ COVID-19
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/ NURSING INTERVENTIONS
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.
QUALITY IMPROVEMENT/DIAGNOSTIC ERRORS
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
- Better housing is crucial for our health and the COVID-19 recovery (December 2020). The Health Foundation UK based study on the links between housing and health, exploring the inequalities in housing across different groups and types of tenures. The study considers the impact of COVID-19 on housing so far, future risks and possible ways forward.
- Changes in preterm birth phenotypes and stillbirth at 2 Philadelphia hospitals during the SARS-CoV-2 pandemic, March-June 2020 (December 2020). JAMA article indicating that an analysis of preterm or stillbirth rates from a racially diverse urban cohort of two Philadelphia hospitals did not detect significant changes in preterm or stillbirth rates during the March to June 2020 timeframe.
- Healthcare industry witnessed 45% spike in cyber attacks since Nov 20 (January 2021). The Hacker News reports that worldwide cyberattacks in the healthcare industry have increased by 45%, making it the most targeted industry by cybercriminals when compared to an overall 22% increase in cyberattacks across all industry sectors.
- ISMP provides recommendations for organizations preparing for COVID-19 vaccine administration (November 2020). Institute for Safe Medication Practices (ISMP) recommendations for preparing for flu and COVID-19 vaccination campaigns, including advance planning, safe storage, staff and training, safe dispensing, safe administration, patient education, and reporting adverse events.
- Nursing liability (December 2020). ECRI article on the liabilities faced by registered nurses, providing recommendations for developing policies and procedures, reviewing the work environment, developing competency assessments and ensuring a fair process for hiring and termination.
- Public perceptions of health and social care in light of COVID-19 (November 2020). The Health Foundation presents the findings of a survey commissioned by the Health Foundation and conducted by Ipsos MORI between 13 and 24 November 2020. This is a follow up survey to two previous rounds of polling: the first carried out in May 2020 and the second in July 2020.
- Stillbirths during the COVID-19 pandemic in England, April-June 2020 (December 2020). JAMA article on the analysis of National Health Service data on the number of stillbirths during the COVID-19 in England during a three month period. Results showed no evidence of any increase in stillbirths regionally or nationally during the COVID-19 pandemic in England when compared to the same months in the previous year.
- Update to the Provincial Council for Maternal and Child Health COVID-19 Guidelines (January 2021) includes information about COVID-19 vaccinations in pregnancy. Information Sheet - Pfizer-BioNTech and Moderna COVID-19 Vaccines; COVID-19 What you need to know before your COVID-19 vaccine appointment and pregnancy now considered as “other patient groups” and refers reader to a link to the Vaccination Recommendations for Special Populations guidance document.