Patterns of mortality risk among patients with substance use disorder: an opportunity for proactive patient safety?

BACKGROUND: Patients with substance use disorder (SUD) suffer from excess mortality compared to the overall population. This study aims to identify patterns in death rates among patients with SUD visiting a SUD emergency ward and to explore whether this knowledge can be used as input to identify patients at risk and increase patient safety. METHODS: Hospital visit data to a SUD emergency ward were collected between 2010 and 2020 through medical records. Data included gender, age, SUD diagnosis, and the time of death. The Kruskal-Wallis rank sum test was used to test between ordinal variables, and risk ratio was used to quantify the difference in mortality risk. All statistical tests were two-sided, with a 95% confidence interval and a minimum significance level of 0.05. RESULTS: The male patients in the study group had 1.41-1.59 higher mortality risk than the female patients. The study revealed an average death rate of 0.14 among all patients during the study period. Although patients with a diagnosed alcohol use disorder constituted 73.7% of the cohort, having an opioid use disorder or sedative hypnotics use disorder was associated with the highest death rates; 1.29-1.52 and 1.47-1.74 higher mortality risk than those without such diagnoses. CONCLUSION: This study demonstrates that data from visits to SUD emergency wards can be used to identify mortality risk factors, such as gender, type of diagnosis, number of diagnoses, and number of visits to the SUD emergency ward. Knowledge about patterns of patient visits and mortality risk could be used to increase patient safety through a decision support tool integrated with the electronic medical records. An improved system for early detection of increased mortality risk offers an opportunity for an adaptive patient safety system.

The impact of "To Err Is Human" on patient safety in anesthesiology. A bibliometric analysis of 20 years of research.

Background: Patient safety gained public notoriety following the 1999 report of the Institute of Medicine: To Err is Human - Building a Safer Health System which summarized a culminated decades' worth of research that had so far been largely ignored. The aim of this study was to analyze the report's impact on patient safety research in anesthesiology. Methods: A bibliometric analysis was performed on all anesthesiologic publications from 2000 to 2019 that referenced To Err Is Human. In bibliometric literature, references are understood to represent an author's conscious decision to express a relationship between his own manuscript and the cited document. Results: The anesthesiologic data base contained 1.036 publications. The journal with the most references to the IOM report is Anesthesia & Analgesia. By analyzing author keywords and patterns of collaboration, changes in the patient safety debate and its core themes in anesthesiology over time could be visualized. The generic notion of "error," while initially a central topic in the scientific discourse, was subsequently replaced by terms representing a more granular, team-oriented, and educational approach. Patient safety research in anesthesia, while profiting from a certain intellectual and conceptual head start, showed a discursive shift toward more managerial, quality-management related topics as observed in the health care system as a whole. Conclusions: Over the last 20 years, the research context expanded from the initial focus set forth by the IOM report, which ultimately led to an underrepresentation of research on critical incident reporting and systemic approaches to safety. Important collaborations with safety researchers from outside of health care dating back to the 1990's were gradually reduced, while previous research within anesthesiology was aligned with a broader, more managerial patient safety agenda.

Emergence of power and complexity in obstetric teamwork.

BACKGROUND: Recently, increasing attention has been paid to team processes in peripartum care settings with the aim to improve fetomaternal outcomes. However, we have yet to understand how the perception of teamwork in peripartum care is shaped in a complex, multi-disciplinary environment. METHODS: The aim of this study was to approach the question using qualitative social-scientific methodology. The theoretical foundation of the study was that obstetric teamwork is the result of a balancing act in which multiple goal conflicts are continuously negotiated and managed right at the boundary of acceptable performance in a complex adaptive system. We explored this theory by gathering lived experiences of successful management of peripartum emergencies. Based on our analysis we generated an understanding of teamwork as a phenomenon emerging from interpersonal relationships, complex relations of power, and the enactment of current quality management practices. RESULTS: Caregivers define teamwork through the quality of their collaboration, defined by respect and appreciation, open communication, role distribution, and shared experiences. However, teamwork also becomes the framework for negotiation of many conflicts that originated elsewhere. Power was the core theme that emerged in the analysis of our participants' narratives, which is in stark contrast to the otherwise promoted egalitarian rhetoric of team training. While our participants generally reverted to explanations based on their professional identities, traditions or cultures, interesting dynamics become visible when work is viewed through the power lens. CONCLUSIONS: Our study paints the convoluted picture of a work environment with all its intricacies, constraints, interpersonal relations and hierarchical struggles that are much more representative of a complex system rather than the easily tractable environment that so many stakeholders would like healthcare practitioners to believe in. The issue of power emerged as a decisive factor in the social dynamics at the workplace, revealing hidden agendas in the teamwork discourse.

Decision-making during obstetric emergencies: A narrative approach.

This study aims to explore how physicians make sense of and give meaning to their decision-making during obstetric emergencies. Childbirth is considered safe in the wealthiest parts of the world. However, variations in both intervention rates and delivery outcomes have been found between countries and between maternity units of the same country. Interventions can prevent neonatal and maternal morbidity but may cause avoidable harm if performed without medical indication. To gain insight into the possible causes of this variation, we turned to first-person perspectives, and particularly physicians' as they hold a central role in the obstetric team. This study was conducted at four maternity units in the southern region of Sweden. Using a narrative approach, individual in-depth interviews ignited by retelling an event and supported by art images, were performed between Oct. 2018 and Feb. 2020. In total 17 obstetricians and gynecologists participated. An inductive thematic narrative analysis was used for interpreting the data. Eight themes were constructed: (a) feeling lonely, (b) awareness of time, (c) sense of responsibility, (d) keeping calm, (e) work experience, (f) attending midwife, (g) mind-set and setting, and (h) hedging. Three decision-making perspectives were constructed: (I) individual-centered strategy, (II) dialogue-distributed process, and (III) chaotic flow-orientation. This study shows how various psychological and organizational conditions synergize with physicians during decision-making. It also indicates how physicians gave decision-making meaning through individual motivations and rationales, expressed as a perspective. Finally, the study also suggests that decision-making evolves with experience, and over time. The findings have significance for teamwork, team training, patient safety and for education of trainees.

Visualizing healthcare system variability and resilience: a longitudinal study of patient movements following discharge from a Swedish psychiatric clinic.

BACKGROUND: As healthcare becomes increasingly complex, new methods are needed to identify weaknesses in the system that could lead to increased risk. Traditionally, the focus for patient safety is to study incident reports and adverse events, but that starting point has been contested with a new era of safety investigations: the analysis of everyday clinical work, and the resilient healthcare. This study introduces a new approach of system monitoring as a way to strengthen patient safety and has focused on discharge in psychiatry as a risk for adverse outcomes. The aim was to analyse a psychiatric clinic's everyday 'normal' performance variability of discharge from inpatient psychiatric care to outpatient care. METHOD: A retrospective longitudinal correlation study with a strategic selection. Data consist of 70,797 patient visits within one psychiatric clinic, and the visits were compared between 81 different wards in Stockholm County by using a model of time-lapse visualization. RESULTS: The time-lapse visualization shows a discrepancy in types of visits and the proportion of cancelled visits to the outward units. 42% of all patients that were scheduled as an outward patient, did not complete this transition, but instead, they revisit the clinics' emergency ward and did not receive the planned care treatment. The patients who visit the emergency ward instead of their planned outpatient visit did this within 20 days. CONCLUSIONS: The findings show a potential increased demand for emergency psychiatric care from 2010 to 2018 within the clinic. It also suggests that the healthcare system creates a space of temporal as well as functional variability, and that patients use this space to adapt to their changing conditions. This understanding can assist management in prioritising allocation of resources and thereby strengthen patient safety. Today's incident reporting systems in healthcare are ineffective in monitoring patterns of more cancelled visits in outward units and sooner visit to the emergency ward. By using time-lapse visualization of patient interactions, stakeholders might analyse current-, and estimate future, stressors within the system to identify and understand potential system migration towards risk in healthcare. This could help healthcare management understand where resources should be prioritized.

A socio-technical analysis of functional properties in a joint cognitive system: a case study in an aircraft cockpit.

In a socio-technical work domain, humans, device interfaces and artefacts all affect transformations of information flow. Such transformations, which may involve a change of auditory to visual information & vice versa or alter semantic approximations into spatial proximities from instruments readings, are generally not restricted to solely human cognition. This paper applies a joint cognitive system approach to explore a socio-technical system. A systems ergonomics perspective is achieved by applying a multi-layered division to transformations of information between, and within, human and technical agents. The approach uses the Functional Resonance Analysis Method (FRAM), but abandons the traditional boundary between medium and agent in favour of accepting aircraft systems and artefacts as agents, with their own functional properties and relationships. The joint cognitive system perspective in developing the FRAM model allows an understanding of the effects of task and information propagation, and eventual distributed criticalities, taking advantage of the functional properties of the system, as described in a case study related to the cockpit environment of a DC-9 aircraft. Practitioner Summary: This research presents the application of one systemic method to understand work systems and performance variability in relation to the transformation of information within a flight deck for a specific phase of flight. By using a joint cognitive systems approach both retrospective and prospective investigation of cockpit challenges will be better understood. Abbreviations: ATC: air traffic control; ATCO: air traffic controller; ATM: air traffic management; CSE: cognitive systems engineering; DSA: distributed situation awareness; FMS: flight management system; FMV: FRAM model visualize; FRAM: functional resonance analysis method; GF: generalised function; GW: gross weight; HFACS: human factors analysis and classification system; JCS: joint cognitive systems; PF: pilot flying; PNF: pilot not flying; SA: situation awareness; SME: subject matter expert; STAMP: systems theoretic accident model and processes; VBA: visual basic for applications; WAD: work-as-done; WAI: work-as-imagined; ZFW: zero fuel weight.

Mind the gap between recommendation and implementation-principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations.

OBJECTIVES: Using the findings of incident investigations to improve patient safety management is well-established and mandatory under Swedish law. This study seeks to identify the mechanisms behind successful implementation of the recommendations of incident investigations. SETTING: This study was based in a university hospital in southern Sweden. PARTICIPANTS: A sample of 55 incident investigations from 2008 to 2010 were selected from the hospital's incident reporting system by staff in the office of the chief medical officer. These investigations were initiated by 23 different commissioning bodies and contained 289 separate recommendations. We used a three-stage method: content analysis to code the recommendations, semi-structured interviews with the commissioning bodies focusing on which recommendations had been implemented and why, and data analysis of the coded recommendations together with data from the interviews. RESULTS: We found that a clear majority (70%) of the recommendations presented to the commissioning bodies were targeted at the micro-level of the organisation. In nearly half (45%) of all recommendations, actions had been taken and a clear majority (73%) of these were at the micro-level. Changes in the management positions of the commissioning bodies meant that very little further action was taken. Other actions, independent of incident investigations, were often taken within the organisation. CONCLUSIONS: We conclude that two principles ('close in space' and 'close in time') seem to be important for bridging the gap between recommendation and implementation. The micro-level focus was expected because of the method of investigation used. Adverse events trigger organisational action independently of incident investigations.

User image mismatch in anaesthesia alarms: a cognitive systems analysis.

In this study, principles of Cognitive Systems Engineering are used to better understand the human-machine interaction manifesting in the use of anaesthesia alarms. The hypothesis is that the design of the machine incorporates built-in assumptions of the user that are discrepant with the anaesthesiologist's self-assessment, creating 'user image mismatch'. Mismatch was interpreted by focusing on the 'user image' as described from the perspectives of both machine and user. The machine-embedded image was interpreted through document analysis. The user-described image was interpreted through user (anaesthesiologist) interviews. Finally, an analysis was conducted in which the machine-embedded and user-described images were contrasted to identify user image mismatch. It is concluded that analysing user image mismatch expands the focus of attention towards macro-elements in the interaction between man and machine. User image mismatch is interpreted to arise from complexity of algorithm design and incongruity between alarm design and tenets of anaesthesia practice. PRACTITIONER SUMMARY: Cognitive system engineering principles are applied to enhance the understanding of the interaction between anaesthesiologist and alarm. The 'user image' is interpreted and contrasted from the perspectives of machine as well as the user. Apparent machine-user mismatch is explored pertaining to specific design features.

Anaesthesia monitor alarms: a theory-driven approach.

The development of physiologic monitors has contributed to the decline in morbidity and mortality in patients undergoing anaesthesia. Diverse factors (physiologic, technical, historical and medico-legal) create challenges for monitor alarm designers. Indeed, a growing body of literature suggests that alarms function sub-optimally in supporting the human operator. Despite existing technology that could allow more appropriate design, most anaesthesia alarms still operate on simple, pre-set thresholds. Arguing that more alarms do not necessarily make for safer alarms is difficult in a litigious medico-legal environment and a competitive marketplace. The resultant commitment to the status quo exposes the risks that a lack of an evidence-based theoretical framework for anaesthesia alarm design presents. In this review, two specific theoretical foundations with relevance to anaesthesia alarms are summarised. The potential significance that signal detection theory and cognitive systems engineering could have in improving anaesthesia alarm design is outlined and future research directions are suggested. PRACTITIONER SUMMARY: The development of physiologic monitors has increased safety for patients undergoing anaesthesia. Evidence suggests that the full potential of the alarms embedded within those monitors is not being realised. In this review article, the authors propose a theoretical framework that could lead to the development of more ergonomic anaesthesia alarms.

The social process of escalation: a promising focus for crisis management research.

BACKGROUND: This study identifies a promising, new focus for the crisis management research in the health care domain. After reviewing the literature on health care crisis management, there seems to be a knowledge-gap regarding organisational change and adaption, especially when health care situations goes from normal, to non-normal, to pathological and further into a state of emergency or crisis. DISCUSSION: Based on studies of escalating situations in obstetric care it is suggested that two theoretical perspectives (contingency theory and the idea of failure as a result of incomplete interaction) tend to simplify the issue of escalation rather than attend to its complexities (including the various power relations among the stakeholders involved). However studying the process of escalation as inherently complex and social allows us to see the definition of a situation as normal or non-normal as an exercise of power in itself, rather than representing a putatively correct response to a particular emergency. IMPLICATIONS: The concept of escalation, when treated this way, can help us further the analysis of clinical and institutional acts and competence. It can also turn our attention to some important elements in a class of social phenomenon, crises and emergencies, that so far have not received the attention they deserve. Focusing on organisational choreography, that interplay of potential factors such as power, professional identity, organisational accountability, and experience, is not only a promising focus for future naturalistic research but also for developing more pragmatic strategies that can enhance organisational coordination and response in complex events.