One size fits all? Challenges faced by physicians during shift handovers in a hospital with high sender/recipient ratio.

INTRODUCTION: The aim of the present study was to investigate the challenges faced by physicians during shift handovers in a university hospital that has a high handover sender/recipient ratio. METHODS: A multifaceted approach was adopted, comprising recording and analysis of handover information, rating of handover quality, and shadowing of handover recipients. Data was collected at the general medical ward of a university hospital in Singapore for a period of three months. Handover information transfer (i.e. senders' and recipients' verbal communication, and recipients' handwritten notes) and handover environmental factors were analysed. The relationship between 'to-do' tasks, and information transfer, handover quality and handover duration, were examined using analysis of variance. RESULTS: Verbal handovers for 152 patients were observed; handwritten notes on 102 (67.1%) patients and handover quality ratings for the handovers of 98 (64.5%) patients were collected. Although there was good task prioritisation (information transfer: p < 0.005, handover duration: p < 0.01), incomplete information transfer and poor implementation of nonmodifiable identifiers were observed. The high sender/recipient ratio of the hospital made face-to-face and/or bedside handover difficult to implement. Although the current handover method (i.e. use of telephone communication), allowed interactive communication, it resulted in systemic information loss due to the lack of written information. The handover environment was chaotic in the high sender/recipient ratio setting, and the physicians had no designated handover time or location. CONCLUSION: Handovers in high sender/recipient ratio settings are challenging. Efforts should be made to improve the handover processes in such situations, so that patient care is not compromised.

Radiology department, human factors and organizational perspectives: using action research to improve patient safety.

BACKGROUND: Action research is a participatory research method based on active cooperation between researchers and subjects. In clinical practice, action research enables active involvement of workers in developing and implementing actions promoting patient safety. This article describes a participatory action research project that was conducted in the radiology department of a tertiary care university hospital. The main objectives were: identifying potential adverse events in the department of radiology, and offering a proactive approach to improving patient safety. METHODS: Phase one of the study included observing 100 patients in three units of the department and identifying potential adverse events using an observation form. According to the data obtained from the observations, multidisciplinary research teams developed and initiated, together with front-line workers, four types of interventions: ergonomic interventions in work environment design, interventions in work procedure and task design, training and guidance, and managerial interventions. Phase two included evaluation of the interventions after six months of implementation. RESULTS: Results showed different weaknesses in each of the three radiology units tested, including incomplete medical information necessary for performing the radiological procedure, and discontinuity of care. Post-intervention observations showed a significant reduction in the prevalence of potential adverse events. At the Angiography unit, potential adverse events related to incomplete medical information dropped from 50% to 32%, and at the CT unit they dropped from 70% to 23%. At the MRI unit potential adverse events related to discontinuity of care dropped from 61% to 19%. CONCLUSIONS: The current study demonstrates the value of action research in non-hospitalizing health units and the benefits of cooperation between medical teams and human factor professionals in promoting patient safety. Methods similar to those described in the current paper are applicable to medical work teams in a broad range of practices.

Creating patient safety capacity in a nation's health system: A comparison between Israel and Canada.

Injuries to patients by the healthcare system (i.e., adverse events) are common and their impact on individuals and systems is considerable. Over the last decade, extensive efforts have been made worldwide to improve patient safety. Given the complexity and extent of the activities required to address the issue, coordinating and organizing them at a national level is likely beneficial. Whereas some capacity and expertise already exist in Israel, there is a considerable gap that needs to be filled. In this paper two countries, Canada and Israel, are examined and some of the essential steps for any country are considered. Possible immediate next steps for Israel are suggested.

Nasogastric tube, temperature probe, and bougie stapling during bariatric surgery: a multicenter survey.

BACKGROUND: An adverse event in laparoscopic bariatric surgery that has not received much scrutiny involves tube/probe stapling or suturing during gastrectomy or gastroenterostomy. METHODS: A retrospective analysis was performed using a questionnaire sent to all bariatric surgeons (n = 43) in Israel. RESULTS: Eight surgeons reported on 17 cases in which intraoperative nasogastric/orogastric tube (n = 8), temperature probe (n = 6), or bougie stapling (n = 3) was identified. Laparoscopic sleeve gastrectomy was performed in 14 patients and laparoscopic gastric bypass in 3 patients. The patient demographics, operative details, and postoperative results are reported. CONCLUSION: Tube/probe complications can occur during laparoscopic bariatric surgery but are seldom reported. However, they can be associated with significant morbidity. The treatment options are dependent on the situation. More importantly, prevention strategies must include constant communication with the anesthesiologist and removal or relocation of a tube before stapling or suturing.

The value of 'gentle reminder' on safe medical behaviour.

BACKGROUND: Based on knowledge and methods from cognitive psychology and behavioural economics we introduced 'Gentle reminder.' This procedure calls for public planning of safety norms, and an agreement of all team members to help each other to adhere to this plan. METHODS: Team members agree to gently remind their coworkers every time they deviate from the safety norm. For the study, we observed the use of gloves during intravenous insertion and blood withdrawal. RESULTS AND DISCUSSION: During the 2 years of observation, safe behaviour increased, if safe behaviour before implementation of the 'gentle reminder' was 55% in one ward; it increased after 2 months to above 80%; 2 months later, it was 83% and 90%; and finally it stabilised on 90%. A similar pattern was documented in all wards. This is one recommended way to overcome unsafe behaviour.

Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety.

Contemporary preoperative team briefings conducted to improve patient safety focus mainly on supplying identification details regarding the patient and the surgical procedure. Drawing on cognitive theory principles, in this study a briefing protocol was developed that presents a broader perspective model of the patient and the planned procedure. In addition to customary identification details and drug sensitivities, the new briefing also includes review of significant background information, needed equipment, planned surgery stages, and so forth. The briefing content was developed following 130 continuous, nonstructured observations conducted in gynecologic and orthopedic operating rooms. The briefing form was designed as a large poster hung in a visible position on the operating room wall. The poster guides the team members (ie, nurses, surgeons, and anesthesiologists) in their conduct. Briefing is conducted orally, and no written records are required. The number of nonroutine events (ie, situations that, if not corrected, might lead to patient harm) observed in the 130 surgeries conducted without briefing was compared with the number of events in 102 surgeries in which briefing was conducted. There was a 25% reduction in the number of nonroutine events when briefing was conducted and a significant increase in the number of surgeries in which no nonroutine event was observed. Team members evaluated the briefing as most valuable for their own work, the teamwork, and patient safety. Following the study, the new briefing format was accepted and adopted for routine use. Team briefings designed to supply a broader-perspective surgery model may be an easy-to-apply tool to reduce the number of nonroutine events during surgery and increase patient safety.

Healthcare climate: a framework for measuring and improving patient safety.

OBJECTIVES: Reviews of patient safety efforts suggest that technical/administrative change must be augmented by global factors such as organizational culture and climate. The objective was to outline a comprehensive model for healthcare climate and test one of its elements, the nursing subclimate, in terms of several patient safety outcomes. DESIGN: Measure organizational climate in nursing units, followed by random sampling of patient safety practices in each unit 6 months later. SETTING: Sixty-nine inpatient units in three hospitals that make up the entire tertiary care system in one metropolitan area. SUBJECTS: A total of 955 nurses. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A two-part Nursing Climate Scale referring to hospital- and unit-level climates, followed by five randomly timed observations of patient safety practices covering routine and emergency care in each unit. Climate scales met the criteria of internal reliability, within-unit agreement, and between-unit variability, using standard statistics of climate research. Both the hospital and unit nursing climates exhibited significant variation, which predicted the routine medication safety scores (Z = 2.65 and 2.93 accordingly, p < .01), with similar results for emergency safety scores. A significant interaction (Z = 2.78, p < .01) indicated that best/worst safety is obtained when the unit and hospital climates are aligned (for better or worse) and that positive unit climate can compensate for the detrimental effect of poor hospital climate. Furthermore, climate's strength increased its predictive power with regard to patient safety practices (Z = 3.64 for medication and 2.28 for emergency safety; p < .01). The small number of participating hospitals limits organization-level analyses. CONCLUSIONS: The nursing climate identifies units where the likelihood of adverse events is greater or lower than the hospital's average. Such information can guide prevention efforts in selected units. These data encourage the development of additional climate subscales subsumed under the healthcare climate model (e.g., physicians subclimate).

Air transportation of patients with end-stage liver disease to distant liver transplantation centers.

The Israeli population does not meet its transplantation organ needs. Therefore, liver transplantation (LTX) candidates are sometimes transported to centers abroad. We aimed to assess the demographic and clinical issues concerning this policy. Records of all candidates transported (2000-2004) were retrospectively reviewed. Data included etiology, disease severity, outcome, distances traveled and destinations, and medical complication arising en route. Forty-three candidates were transported overseas: 12 patients with fulminant hepatic failure (FHF) and 31 with cirrhosis. Average MELD score was 19.94, and the APACHE II score for patients with FHF was 20.5. Destinations included the United States, Colombia, Belgium, Germany, China, and Italy. Average distance traveled was 4,660 miles. Two patients were intubated and sedated during flight. All patients safely reached their destinations: 8 died prior to transplantation, 5 died after transplantation, 3 are awaiting transplantation, 3 recovered spontaneously, and the rest successfully underwent transplantation and returned home. In conclusion, our results suggest that long-distance transportation of patients awaiting liver transplantation is safe and technically feasible provided precaution measures are taken. Therefore, allocation regions may be broadened to include larger and more distant populations.

Anesthesiologists on ambulances: where do we stand?

PURPOSE OF REVIEW: This manuscript provides a critical review of the literature regarding the staffing of emergency medical services, with particular emphasis on anesthesiologists. RECENT FINDINGS: Significant anesthesiology contributions to prehospital care include introduction of new airway management tools and improved physiological monitoring. Contributions to quality of care include patient benefit in terms of life years gained and a specific reduction in mortality from acute myocardial infarction. Intuitive concepts regarding the advantage of anesthesiologists in intubation mishaps and management of the failed airway have yet to be proven. Personnel limitations may be regional, necessitating local evaluation of anesthesiologist availability to staff ambulances. Since a major part of cost-effectiveness research is performed in the US where only paramedics staff ambulances, insufficient data exist regarding the financial implications of such practice. Burnout may be an important factor for deciding whether anesthesiologists should work in the operating room or ambulances or on an alternate basis. SUMMARY: Further research should be performed to evaluate the clinical and financial implications of staffing ambulances with anesthesiologists or other physicians. Randomized controlled studies using standardized intubation techniques are necessary to examine whether prehospital airway management is improved when delivered by anesthesiologists.

The hostile environment of the intensive care unit.

Intensive care units (ICUs) were developed for patients with special needs and include an array of technology to support medical care. However, basic lessons in ergonomics, human factors, and human performance fail to propagate in this complex medical environment. Complicated, error-prone devices are commonly used. There are too many patient data for one person to process effectively. Lighting, ambient noise, and scheduling all result in provider and patient stress. These difficult working conditions make errors more probable and are risk factors for provider burnout and negative outcomes for patients. Auditory alarms on ICU equipment, ICU syndrome, and needle sticks are discussed as examples of such problems.

Lateral decubitus position for percutaneous nephrolithotripsy in the morbidly obese or kyphotic patient.

BACKGROUND AND PURPOSE: Morbidly obese or debilitated patients do not tolerate the prone position used for percutaneous nephrolithotripsy (PCNL) well and may suffer from severe cardiorespiratory compromise in this position. The purpose of this study is to demonstrate a simple way to overcome this difficulty. PATIENTS AND METHODS: Two morbidly obese patients, ages 48 and 32 years, with Body Mass Indices of 47.5 and 43.2 and a 68-year old patient severely debilitated by multiple cerebral infarctions, ischemic heart disease, and kyphosis suffered from relatively high renal stone burdens. For PCNL, the patients were placed in the lateral decubitus position. To obtain an anteroposterior projection in this position, the C-arm fluoroscopy unit was tilted to one side and the operating table to the other. Tract dilation, stone fragmentation, and fragment extraction were performed with the patient in this position. RESULTS: An attempt to perform PCNL in the prone position in the first patient was aborted because of severe hypoxemia and hypercarbia. In the lateral decubitus position, the procedures were easily performed in all patients without any complications. It was noted that by rotating the C-arm to a perpendicular position, it was possible to perform nephroscopy and use fluoroscopy simultaneously. CONCLUSION: We highly recommend using the lateral position for PCNL in morbidly obese patients and in patients suffering from kyphosis. This position is safe and convenient.

[Avoiding human errors in the hospital--mission possible?!].

The way to combat the high frequency of errors and mistakes that endanger both the physician and the patient is by root cause analysis of accidents as well as investigation of "near misses". There is a need for a new approach to error prevention by re-education of the medical teams. A few examples are presented on how to approach an untoward event so as to learn from it rather than punish.