Risk Watch (October '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

Jodi Potter headshot
                        Jodi Potter

We feature a number of articles in this month’s Risk Watch on the role of teamwork and effective communication in quality improvement projects and developing a patientcentred safety culture in healthcare. Smeulers et al. report on the effects of gathering patient information prior to outpatient visits in order to improve the effectiveness and patient experience of the visit. Woodcock et al. address challenges clinical teams encounter when measuring improvement in safety efforts and highlight the importance of specific training in measuring outcomes for clinicians. Zeltzer et al. derive theory from the aviation industry and review the applicability of Crew Resource Management (CRM) in healthcare to improve communication and decision making amoung clinical teams. McKenzie et al. explores a safety culture program and the influence of health care leaders. Finally, Spazzapan et al. provides insights into the value of bedside boards for nonmedical information to help healthcare professionals in a peadiatric intensive care unit better understand their patients’ needs and tailor treatment.

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

Hot Off the Press

Adverse Events/Patient Harm

The impact of hospital harm on length of stay, costs of care and length of person-centred episodes of care: a
retrospective cohort study

Tessier L, Guilcher S, Bai Y. CMAJ. 2019 (online, August);191(32):E879-E885.
Study in Canada to assess the impact of experiencing an adverse event during an admission to an acute care facility on length of stay (LOS) as well as duration and costs of person-centred episodes of care (PCEs) following discharge. Results showed an increase in both LOS and duration and costs of PCEs for patients who experienced harm during hospital admission.

Measurement/Quality Improvement

A mixed-methods study of challenges experienced by clinical teams in measuring improvement
Woodcock T, Liberati E, Dixon-Woods M. BMJ Qual Saf. 2019 (online, August);0:1-10.
Study to assess the challenges experienced by clinical teams in measuring improvement resulting from quality improvement initiatives in patient safety. Results show that many teams fail to effectively measure improvement outcomes. Authors suggest teams require extensive training to gain the technical skills and expertise necessary to conduct measurement.


Approaching the evidence basis for aviation-derived teamwork training in medicine
Zeltser M, Nash D. Am J Med Qual. 2019 (online, September);34(5):455-464.
Study to assess the implementation and effectiveness of crew resource management (CRM) or teamwork training in the healthcare setting. Authors suggest increasing the use of CRM to implement more structured training in teamwork, communication, and decision making for healthcare professionals can positively impact patient safety.

Records Completion/Ambulatory

Well-prepared outpatient visits satisfy patient and physician
Smeulers M, Dikmans M, van Vugt M. BMJ Open Qual. 2019 (online, August):1-3.
Report from The Netherlands on a project to increase the completeness of outpatient charts before patients’ first visit. Interventions involved gathering available data from referral forms and having interns call patients two weeks ahead of their first visit to obtain additional information and verify data. Results showed completeness of charts increased from around 20% to 70%, and the average time to prepare the visit was 14 minutes per patient. Patients were satisfied with the personal approach and physicians valued the reduced administrative burden.

Documentation/Long Term Care

Lack of focus on nutrition and documentation in nursing homes, home care- and home nursing: the selfperceived
views of primary care workforce

Håkonsen S, Pedersen P, Bygholm A, et al. BMC Health Serv Res. 2019 (September);19(1):642-657.
Study in Denmark involving interviews with 14 healthcare providers to explore nutritional care competencies, documentation, and how organizational factors influence daily work and quality of care provided. Six categories and two explanatory themes were identified, including the lack of common understanding of clinical terms and terminology, leading to inadequate information transfer, and a wide variation in daily routines. Nutritional screening instruments were not consistently integrated into home care, leading to differences in quality of care.

Safety Culture/Leaders

Factors influencing the Implementation of a hospitalwide intervention to promote professionalism and build a
safety culture: A qualitative study.

McKenzie L, Shaw L, Jordan J, et.al. Jt Comm J Qual Patient Saf. 2019 (online, August):1-12.
Study to explore factors influencing implementation of an Australian hospital safety culture program which aimed to change staff behaviour. Authors noted “health care leaders have a substantial influence over implementation and can drive change by steadfast commitment to both safety and professionalism. To demonstrate this commitment, leaders can consistently model behaviors that promote a safety culture, adopt a zero tolerance approach to unprofessional conduct, and support frontline teams to resolve safety-related concerns perceived as misaligned with intervention aims” (p.9).

Medication Reconciliation/Community

Community pharmacy medication review, death and re-admission after hospital discharge; a propensity scarematched
cohort study

Lapointe-Shaw L, Bell C, Austin P, et al. BMJ Qual Saf. 2019 (online, August):1-11.
Study in Canada to explore whether a post discharge community pharmacy-based medication reconciliation and adherence review is associated with a reduced risk of death or re-admission based on patients discharged home from an acute hospital over a 9 year period. Authors conclude among older adults, a community pharmacy-based medication reconciliation and adherence review was associated with a small reduced risk of short-term death or readmission.

Paediatrics/Patient-Centred Care

A bit about me: bedside boards to create a culture of patient-centered care in pediatric intensive care units

Spazzapan M, Vijayakumar B, Stewart C. J Healthc Risk Management. 2019 (online, August):1-9.
Project in a paediatric intensive care unit in a UK hospital to explore the use of bedside boards containing nonmedical information including each child’s personal qualities and preferences to help improve patient centred-care and patient safety. Authors concluded there was an improvement in all parameters assessed and bedside boards containing nonmedical information can help healthcare professionals understand their patients’ needs and tailor their treatment.

Research Capacity/Community

Fostering community hospital research
Gehrke P, Binnie A, Chan S, et al. CMAJ. 2019 (September);191(35):E962-E966.
Article discussing benefits of fostering research culture in Canadian community hospitals, and challenges community hospitals face in conducting clinical research. Authors proposed the creation of community hospital research networks to build and sustain research programs. Factors that could facilitate research include developing research-related organizational policies and procedures, relationships with academic hospitals, universities, and national research networks, and engagement with local community leaders and partners.

Other Resources of Interest

Borden Ladner Gervais LLP (CDN) series of articles to assist Ontario healthcare organizations to understand and develop governance options as they work toward Ontario Health Team implementation:

FDA recommends health care facilities and manufacturers begin transitioning to duodenoscopes with disposable components to reduce risk of patient infection (August 2019). The Food and Drug Administration (US) announcement with recommendations for health care facilities and manufacturers.

Getting the diagnosis both right and wrong (September 2019). Agency for Healthcare Research and Quality (US) web M&M case with an overview of diagnostic reasoning including types of cognitive biases that lead to errors.

‘It’s not part of the job’: how MUSC is combating workplace violence (August 2019). Becker’s Hospital Review (US) article on new initiatives a hospital in the US is rolling out to target workplace violence.

Safe administration of oxytocin (September 2019). Provincial Council for Maternal and Child Health (CDN) best practice recommendations for the safe administration of oxytocin used in augmentation or induction of labour.