Risk Watch (July '19)

Service: Risk Management
Type: Risk Watch

Selected research, publications, and resources to promote evidence-informed risk management in Canadian healthcare organizations. Prepared by 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.

Editor's Note

Sara Chow HeadshotIn this month’s Risk Watch we have a variety of articles, including ones on crowding in Canadian pediatric emergency departments, end of life care in hospitals, and the updated clinical practice guideline for assisted vaginal birth. Doan et al. found a previously undescribed association between emergency department crowding and increased odds of admission among high-acuity patients. In the study by Rawlings et al., over 3,200 healthcare professionals were asked how they could change to more appropriately provide end of life care following education, and authors related the conclusions to theory on intention-behaviour that indicates intentions have a strong association with behaviour. The Society of Obstetricians and Gynaecologists of Canada’s clinical practice guideline provides five changes in practice, including encouraging safe and effective assisted vaginal birth by experienced and skilled care providers, five key messages, and 11 recommendations.

We hope you find these articles and informative and helpful. We look forward to your feedback, which can be provided to me at schow@hiroc.com.

Hot Off the Press

Emergency Department / Patient Deterioration

The impact of pediatric emergency department crowding on patient and health care system outcomes: a multicenter cohort study

Doan Q Wong H, Meckler G, et al. CMAJ. 2019 (June);191(23):E627-E635.

Study reviewing 1,931,465 emergency departments (ED) visits in eight pediatric ED across four Canadian provinces to evaluate the association between crowding and adverse outcomes. Among the findings was that crowding was associated with increased hospital admission at the time of visit for high acuity children. Authors suggest delays in treatment due to crowding could lead to deterioration requiring admission. 

Quality Improvement / Ambulance

Improving the prehospital management of ST elevation myocardial infacrtion: a national quality improvement initiative

Howard I, Castle N, Shaikh L, et al. BMJ Open Quality. 2019 (online, June):1-5. 

Quality improvement project in Qatar to improve prehospital care of patients with ST elevation myocardial infarction (STEMI) to a minimum compliance of 75% on four process measures and one bundle measure consisting of the four process measures. Strategies centred around clinical practice, training, and equipment/medication. The aim was achieved and results were sustained at 12 months post-implementation. 

Decision Support / Order Sets

When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record

Li R, Wang J, Sharp C, et al. BMJ Qual Saf. 2019 (online, June):1-10.

Study in the US reviewing 11,762 order set items used in 77,421 patient encounters to assess alignment between order set design and workflow needs. Results showed a significant variability in workflow alignment. Notably, 39% of order sets were associated with additional ordering of items not included in order sets, and 45% were associated with ordering of items despite being in the order set.   

Dementia / Long-Term Care Homes

TIME to reduce agitation in persons with dementia in nursing homes. A process evaluation of a complex intervention 

Lichtwarck B, Myhre J, Selbaek G, et al. BMC Health Serv Res. 2019 (May);19(1):1-16. 

Study in Norway to replicate the effectiveness of the Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms (TIME) which had demonstrated in a previous study reduction in agitation in nursing home residents with dementia. Authors concluded a high degree of adoption by those that participated, implementation of the intervention, and continued use of the program contributed to the effectiveness of TIME at the resident level. 

End of Life Care

Improving quality in hospital end-of-life care: honest communication, compassion and empathy

Rawlings D, Devery K, Poole N. BMJ Open Qual. 2019 (online, May):1-10. 

Study in Australia to explore how healthcare professionals, using developed e-learning modules for training in end-of-life care, interpret the question at the end of each module, “Tomorrow, the one thing I can change to more appropriately provide end-of-life care is…”. Results from 3,201 clinicians identified five themes including: communication, emotional insight, professional mindset, person-centred care and professional practice.  

Adverse Events / Third Victims

Patient safety professionals as the third victims of adverse events

Holden J, Card A. J Patient Saf Risk Manag. 2019 (online, June):1-10. 

Article from the US describing how those with indirect exposure to an adverse event can become “third victims” and focuses on the example of patient safety professionals responsible for incident investigation and improvement activities. Potential sources of harm are outlined; actions to prevent or reduce harm to third victims include extending second victim support services to patient safety professionals, redesigning the patient safety role, providing board-level and senior management leadership, creating a culture of psychological safety, and tracking metrics related to third victims.


Harnessing instability as an opportunity for health system strengthening: a review of health system resilience

Chamberland-Rowe C, Chiocchio F, Bourgeault I. Healthc Manage Forum. 2019 (online, May);32(3):128-135.  

Study to determine how health systems can use instability to achieve resiliency in healthcare. Authors provide an operational model of resilience, consisting of inputs (e.g. health system prerequisites), mediators (e.g. systems’ adaptive and absorptive capacity), and outputs (e.g. resilience, sustainability) for leaders to follow to strengthen the healthcare system and create resilient organizations.

Patient Safety

Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety

Macrae C. J R Soc Med. 2019 (online, May):1-5.

Article outlining the implementation of a system-wide approach to assessing healthcare risks using national safety investigation bodies in England and Norway. The author provides five core strategies to guide the development of these new independent investigative bodies.

Obstetrics / Assisted Vaginal Deliveries

No. 381-Assisted vaginal birth

Hobson S, Cassell K, Windrim R, et al. J Obstet Gynaecol Can. 2019 (June);41(6):870-882. 

Clinical practice guideline on safe vaginal deliveries. Outlined are interventions, indications, contraindications and risk factors and maternal and neonatal consequences associated with assisted vaginal birth. Authors provide recommendations to complete safe assisted vaginal deliveries.

Other Resources of Interest

Cybersecurity around implantable medical devices (May 2019). ECRI Institute (US) podcast discussing the scope of risk and strategies healthcare providers can take.

Growing number of medical trainees named in complaints (June 2019). Canadian Medical Association Journal News article on the increase of regulatory complaints involving medical trainees in the past decade.

Medical-legal cases in spinal surgery: 3 essential lessons (June 2019). Canadian Medical Protective Association article on informed consent, managing injuries during surgery, and verifying the correct level and side. 

Privacy breach response—prevention of future breaches (June 2019). Borden Ladner Gervais LLP (CDN) article highlighting the need for organizations to learn from past breaches to prevent future ones.   

Texting safely about patient care: strategies to minimize the risks (June 2019). Canadian Medical Protective Association article with considerations for maintaining confidentiality, supporting clear communication, and preventing negative perceptions.