Risk Watch (September '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.

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Editor's Note

Sara Chow headshot
                       Sara Chow

Two themes in the September issue of Risk Watch include medication safety and electronic health records (EHR). Westbrook et al. found no association between double-checks of medication doses and administration errors. Further, in over 90% of cases, nurses who were doing the independent double-check received information that may have influenced the checking. Instead of calling for more training and education, “an alternative response is to question whether independent double-checking on a large scale is practically possible in busy clinical environments”, alluding to the ‘work as imagined versus work as done’ concept.

This concept dovetails with the findings of a literature review by Fraczkowski et al. of nurse workarounds in the EHR. In looking at the probable causes for workarounds, they found that 75% of the studies reported poor usability, which includes problems such as difficult to use hardware, information located in several screens, and font size or screens too small. They noted these problems make the case for investments and innovative solutions that promote more useable health information technologies. “The widespread use of workarounds by the largest group of healthcare providers subverts quality health care at every level of the healthcare system.”

If you have comments about any of the articles, please email me at schow@hiroc.com.

Hot Off the Press


Barriers and facilitators to optimal supportive end-of-life palliative care in long term care facilities: a qualitative descriptive study of community-based and specialist palliative care physicians’ experiences, perceptions and perspectives
Harasym P, Brisbin S, Afzaal M, et al. BMJ Open. 2020 (online, August):1-7.

Study from Canada to identify barriers and facilitators to optimal supportive end-of-life care for adults from the perspective of community-based and specialist physicians in the residential long term care setting. Authors stated the study adds to the knowledge of how the physicians modify their care practices in the face of organisational barriers to optimal care, and recommended that long term care facilities focus on the specific communication strategies that strengthen relationships, the development and use of assessment tools, palliative care training and mentorship, and physical and cultural re-design.


Changing hospital organisational culture for improved patient outcomes: developing and implementing the leadership saves lives intervention
Linnander E, McNatt Z, Boehmer K, et.al. BMJ Qual Saf. 2020 (online, July):1-9.

Article from the US describing in detail three components of an intervention designed to equip organizations to identify and address root causes of acute myocardial infarction mortality and improve organisational culture. Authors noted the intervention is the first successful longitudinal intervention to prospectively change aspects of hospital organisational culture associated with patient outcomes.


Responding to the COVID-19 pandemic: a new surgical patient flow utilizing the preoperative evaluation clinic
Pai S, Irizarry-Alvarado J, Pitruzzello N, et al. Am J Med Qual. 2020 (online, August):1-6.

Quality improvement initiative in the US to streamline the surgical patient flow process and increased the percentage of COVID-19 testing results to be returned before surgery from 10% to 100%. “The POE [preoperative evaluation] clinic served as an important centralized location to alert surgical staff to potentially infected patients before they arrive at the institution for evaluation, thus avoiding further contagion” (p. 3). A process map of the redesigned patient flow is provided.  


Associations between double-checking and medication administration errors: a direct observational study of paedicatric inpatients
Westbrook J, Li L, Raban M, et al. BMJ Qual Saf. 2020 (online, August):1-9. 

Study in Australia to measure the association between double-checking, and the occurrence and potential severity of medication administration errors. Authors found no significant association between mandatory double-checking and occurrence of errors or potential severity or errors, and noted, “nurses will use their clinical judgement as to when a double-check may be warranted, and in such situations the process may be more likely to confer a benefit” (p. 7).


The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support
Co Z, Holmgren AJ, Classen D, et al. J Am Med Inform Assoc. 2020 (online, July):1-7.

Study in the US to evaluate the performance of 1599 hospitals that used the Computerized Physician Order Entry (CPOE) Evaluation Tool, a timed online assessment to evaluate the safety of electronic health records (EHR) and CPOE systems, as well as their performance against fatal orders (medication orders that have killed a patient previously) and nuisance orders (medication combinations that should not trigger an alert). Authors concluded, “It is evident that how an EHR is implemented and used, is crucial to how hospitals perform on the test… simply having an EHR is not enough, and that implementation is far more important” (p. 6).


Nurse workarounds in the electronic health record: an integrative review
Fraczkowski D, Matson J, Dunn Lopez K. J Am Med Inform Assoc. 2020 (July);27(7):1149-1165.

Study to synthesize literature on direct care nurses’ use of workarounds related to electronic health records (EHR). Thirty-three studies identified eight workaround strategies: 1) paper as a cognitive tool, 2) bypassing patient identification checks, 3) data entry strategies, 4) bypassing EHR medication safety measures, 5) workarounds to the ordering process, 6) assisting physician’s workflow, 7) bypassing information in the EHR, 8) scanning violations. The most frequent cause of nurses’ workarounds was usability. 


“The doctor was rude, the toilets are dirty. Utilizing ‘soft signals’ in the regulation of patient safety”
Kok J, Wallenburg I, Leistikow I, et al. Saf Sci. 2020 (online, July):1-9.

Article from the Netherlands using qualitative interviews, observations and document analyses in a multi-year research project to show that soft signals, indicators “that something might be wrong within an organization with the possible consequence of inflicting harm”, are vital to everyday regulatory practices as they provide context to ‘hard’ signals and help to make sense of and weigh risks. Authors identified that signals are not by themselves hard or soft, but their hardness is a consequence of sensemaking practices. “As ‘tin-openers’, soft signals can point to safety risks or fallibilities in a healthcare organization but they may also function as ‘tin-closers’, instilling an inspector with a sense of trust and confidence that the organizational leaders are competent and in control” (p. 8).

Other Resources of Interest