Risk Watch (May '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.

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

Lori Borovoy headshot
                        Lori Borovoy

In this month’s Risk Watch, we feature a number of articles focusing on safety and quality improvement (QI). Elliott et al. explore ways to address safety issues in homecare with a pan-Canadian study using InterRAI assessment data. Mendlowitz et al. explore the economic impact of quality improvement projects using administrative and primary data. Leistikow et Al. describe the concepts of Safety-II, learning about things that go right and improving resilience, whereas the more traditional Safety-I approach is about learning from things that go wrong and improving compliance; the article explores Safety-II concepts in regulatory compliance. 

If you have any comments about these articles or Risk Watch, please email me at lborovoy@hiroc.com. We look forward to hearing from you. 

Hot Off the Press


"We've got the home care data, what do we do with it?": understanding data use in decision making and quality improvement
Elliott J, Gordon A, Tong C, et.al. BMC Health Serv Res. 2020 (online, March):1-8.

Study in Canada in collaboration with the Canadian Patient Safety Institute to understand how the use of InterRAI home care assessment data was being used to address safety issues and implement quality improvement initiatives. Results provided examples of how interRAI data has been used to guide patient safety as well as limitations, including the newness of the data, volume, and limited resources to interpret and analyse the data.  


Usage of primary and administrative data to measure the economic impact of quality improvement projects
Mendlowitz A, Croxford R, MacLagan L, et al. BMJ Open Qual. 2020 (online, April):1-6.

Article in Canada to explore the economic impact of quality improvement (QI) projects using administrative and primary data. Three case studies are described, using the Improving and Driving Excellence Across Sectors (IDEAS) quality improvement programme for health professionals. Authors note the economic impact can be weighed against a QI project’s implementation and operating costs, with estimates of economic value, improved efficiency and quality of care. 


Incidence of wrong-site surgery list errors for a 2-year period in a single National Health Service board
Geraghty A, Ferguson L, Mcllhenny C, et al. J Patient Saf. 2020 (March) 16(1):79-83.

Study in a UK 860-bed hospital to explore the incidence of wrong-side, wrong-site or wrong-procedure surgical theater listing errors (errors in operation lists due to incorrect information received) by surgical specialty. Results showed 86 wrong-site/side list errors were identified in 29,480 cases (0.29%). Authors stated, “Overall, the list errors themselves need to be addressed by examining how lists are compiled, processed, and implemented from human factors-based systems and design perspective to develop and test interventions for further minimizing the risk of catastrophic wrong-site surgery” (p. 82). 


Adapting rapid assessment procedures for implementation research using a team-based approach to analysis: a case example of patient quality and safety interventions in the ICU
Holdsworth L, Safaeinili N, Winget M, et al. Implementation Sci. 2020 (online, February):1-12.

Article describing a rapid assessment procedures (RAP) approach incorporating implementation science frameworks and a time-sensitive team-based qualitative analysis process deployed in four ICU sites within academic health centres. Each site used three common features: 1) electronic medical records and communication portals for patients and families to engage in the ICU care process; 2) interactive IT tools for care teams to aggregate, display and respond to safety practices; 3) interventions to address culture, provider behaviour, or workflow. Effectiveness of RAP methodology was found to be particularly suitable for studies which focus on a participatory approach in which participants not only provide data but help to inform how that data might be interpreted into action and validate conclusions; rapid, multidisciplinary team-based approach to analysis; and reliance on qualitative methods within a specified context, allowing for high internal validity.


Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality
Leistikow I, Bal R. BMJ Qual Saf. 2020 (online, March):1-4.

Article describing a concept of resilience, or Safety-II, using examples from the Netherlands, and United Kingdom. Authors defined the core concepts informing Saftey-II and explore how modern regulation in healthcare interact and how they can be seen to support Saftey-II. Authors provided some ideas and political commentary on the synergies and challenges in adapting the Saftey-II concepts in regulatory compliance frameworks. 


It’s time to step it up. Why safety investigations in healthcare should look more to safety science
Wiig S, Braithwaite J, Clay-Williams R. Int J Qual Health Care. 2020 (online, March):1-4.

Article describing evidence from multiple high-risk industries, including healthcare, to explore established accident theories and how these can support safety investigations in healthcare. Authors posited that current thinking in healthcare investigations remain focused on root cause analysis and linear thinking, and would benefit from integrating ideas from novel safety science theories.


Errors during resuscitation: the impact of perceived authority on delivery of care
Delaloye N, Tobler K, O’Neill T, et al. J Patient Saf. 2020 (March);16(1):73-78.

Study using simulation at four pediatric teaching hospitals in Canada to determine the influence of perceived authority on resuscitation teams’ reponse to incorrect medication orders. Half of the teams administered medication incorrectly; of these, 79% administered both the incorrect dose and rate of delivery. Further, years of clinical experience had no impact on the rate of challenging the incorrect order. Authors stressed the importance of interventions that focus on empowering healthcare providers' ability to speak up when given an unfamiliar or incorrect order, such as the “two-challenge rule,” which allows a subordinate to seek further action if two challenges go unacknowledged and patient safety continues to be put at risk.


Impact of simulation-based closed-loop communication training on medical errors in a pediatric emergency department
Diaz M, Dawson K. Am J Med Qual. 2020 (online, March):1-5.

Study using simulation-based closed-loop communication (CLC) training at a pediatric emergency department in the US to determine its effects on staff perceptions of their ability to use CLC. Staff perception of their ability to close the loop in communication improved, especially with the call-out directed to a specific person and loop closure steps. Medication error rates also reduced significantly. Authors noted a simulated resuscitation with a blindfolded team leader was specifically chosen to emphasize that seamless CLC requires clear verbalization and active listening skills from all team members. “In these specific situations the team leader standing at the foot of the bed may not be able to fully see the actual patient given the patient’s size and number of staff needed around the patient to perform the resuscitation” (p. 4).


Enabling effective oversight: enterprise risk management and board governance in healthcare
Martin N. Healthc Manage Forum. 2020 (online, April):1-4.

Article with recommendations for leaders to enable effective governance oversight through enterprise risk management, including instituting targeted education and capacity building, developing robust processes, and garnering strong institutional support. “Importantly, members of senior management must be provided with education and training that fosters an understanding of why risk management is important, how it benefits the organization, and what role senior management plays in ensuring risk is effectively managed and reported to the Board” (p. 2).

Other Resources of Interest

3D printing during COVID-19 (April 2020). Borden Ladner Gervais LLP (CDN) article on considerations for COVID-19 related medical devices and Health Canada requirements.

Barriers and facilitators to healthcare workers’ adherence with infection prevention and control (IPC) guidelines for respiratory diseases: a rapid qualitative evidence synthesis (April 2020). Cochrane Library (UK) review outlining findings and implementation considerations for healthcare facilities. The evidence summary is available here.

COVID-19 in primary care (UK) (March 2020). British Medical Journal infographic providing on guidance from Public Health England and Health Protection Scotland to prepare primary care practices in the UK.

COVID-19: peer support and crisis communication strategies to promote institutional resilience (April 2020). Annals of Internal Medicine (US) editorial highlighting three strategic principles for healthcare organizations to consider in responding to the pandemic.

COVID-19 privacy considerations for Ontario's health care sector (April 2020). Borden Ladner Gervais LLP (CDN) article outlining the impact of COVID-19 on privacy and access requests in Ontario.

COVID-19: remote consultations (March 2020). British Medical Journal quick guide for primary care summarizing steps to assessing patients by video or voice call.

COVID-19 virtual health toolkit (April 2020). BC Provincial Health Services Authority toolkit describing virtual solutions for use during the pandemic, including best use, privacy and security, and risks and limitations.

Expedited Death Response process COVID-19 (April 2020). Bereavement Authority of Ontario resource describing the new process for Ontario funeral homes which went into effect on April 14, 2020.

ISMP Medication Safety Alert! Acute Care (April 2020). Institute for Safe Medication Practices (US) newsletter on experiences of keeping infusion pumps outside of patient rooms to conserve personal protective equipment.

Making healthcare safer III: a critical analysis of existing and emerging patient safety practices (March 2020). Agency for Healthcare Research and Quality (US) resource summarizing the evidence for selected patient safety practices and factors important to their successful implementation and adoption.

Responding to the Covid-19 crisis: Professor Don Berwick (April 2020). The King’s Fund (UK) interview with Don Berwick discussing how leaders can take care of themselves, and their teams during this crisis.

Spotlight on medical devices in the age of COVID-19 (April 2020). Borden Ladner Gervais LLP (CDN) article outlining interim measures Health Canada introduced to respond to medical device needs with COVID-19.

Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic (April 2020). JAMA article summarizing key considerations for supporting healthcare providers.

Virtual care toolkit (April 2020). Health Standards Organization and Accreditation Canada toolkit to assist organizations to provide safe and reliable virtual care encounters during the COVID-19 pandemic.

Virtual witnessing of wills and power of attorney (April 2020). Borden Ladner Gervais LLP (CDN) article outlining requirements for virtual witnessing of wills and power of attorney documents with COVID-19 emergency rules.

What good leadership looks like during this pandemic (April 2020). Harvard Business Review (US) article highlighting four lessons for leaders in a novel crisis.