Resident physicians' advice seeking and error making: A social networks approach.

BACKGROUND: Resident physicians are especially at risk of being involved in medical errors because they bear tremendous responsibility for patient care yet are still in the process of learning and mastering their profession. To increase knowledge and gain information, they create a professional-instrumental network, that is, the deliberate initiation of advice ties with senior physicians. PURPOSE: We aim to explore whether and how residents' networking with senior physicians is associated with their error rates. Specifically, we aim to identify whether the centralities of residents (advice seekers) and senior physicians (advice givers) in the social network are associated with residents' error rates. METHODOLOGY: We surveyed 142 resident physicians working in 22 wards in two general hospitals about whom and how frequently they consult using a sociometric technique. Information about errors made in a 3-month period was collected independently. RESULTS: Residents made less errors when they sought advice from few senior physicians but consulted more frequently with focal senior physicians (those whom many other advice seekers frequently consult). However, when residents sought advice from many senior physicians, their frequency of consultation with focal senior physicians was not associated with their number of errors. These effects were more pronounced for residents at the beginning of their residency period. CONCLUSIONS: Results of this study provide evidence of a specific association between resident physicians' consultation patterns and their error rates. PRACTICE IMPLICATIONS: Results inform ward managers about ways to leverage opportunities and remove constraints for residents to ask for advice and for focal physicians to provide it.

Examining innovation in hospital units: a complex adaptive systems approach.

BACKGROUND: We are in an innovation age for healthcare delivery. Some note that the complexity of healthcare delivery may make innovation in this setting more difficult and may require more adaptive solutions. The aim of this study is to examine the relationship between unit complexity and innovation, using a complex adaptive systems approach in a hospital setting. METHODS: We conducted a quantitative study of 31 hospital units within one hospital and use complex adaptive systems (CAS) theory to examine how two CAS factors, autonomy and performance orientation, moderate the relationship between unit complexity and innovation. RESULTS: We find that unit complexity is associated with higher innovation performance when autonomy is low rather than high. We also find that unit complexity is associated with higher innovation performance when performance orientation is high rather than low. Our findings make three distinct contributions: we quantify the influence of complexity on innovation success in the health care sector, we examine the impact of autonomy on innovation in health care, and we are the first to examine performance orientation on innovation in health care. CONCLUSIONS: This study tackles the long debate about the influence of complexity on healthcare delivery, particularly innovation. Instead of being subject to the influence of complexity with no means of making progress or gaining control, hospitals looking to implement innovation programs should provide guidance to teams and departments regarding the type of innovation sought and provide support in terms of time and management commitment. Hospitals should also find ways to promote and make successful pilot implementations of such innovations visible in the organization. A close connection between the targeted innovation and the overall success and performance of the hospital unit is ideal.

Employee safety single vs. dual priorities: When is the rate of work-related driving accidents lower?

Applying both occupational safety and ambidexterity theories, we investigate which situation in organizations leads to a lower number of work-related road accidents: a single-priority situation focused on road safety, or a dual-priority situation in which both road safety and customer service are priorities. Occupational safety theory puts forward an 'either-or' approach in which employee safety must be the first priority, above and beyond all others. In contrast, the ambidexterity theory's 'both-and' approach suggests a simultaneous coexistence of priorities. Results from forty-three units in three organizations that make intensive use of work-related driving and aim to deliver good customer service are described. The results suggest that when the level of customer service priority was low, an increase in the level of road safety priority significantly decreased the number of road accidents. However, when the level of customer service priority was high, an increase in the level of road safety priority was not associated with less road accidents. The results show that work-related road accidents would be lower in a safety-first, single-priority situation compared to a dual-priority situation encompassing both road safety and customer service. We discuss the theoretical and practical implications of these results.

How do integrative practices influence patient-centered care?: An exploratory study comparing diabetes and mental health care.

BACKGROUND: Integration between organizational units to achieve common goals has been of interest to health systems because of the potential to improve patient-centered care. However, the means by which integrative practices actually influence patient-centered care remain unclear. Whereas many studies claim a positive association between implementation of integrative practices and patient-centered care, others raise concerns that integrative practices may not necessarily improve patient-centered care. PURPOSE: The aim of this study was to explore the mechanism by which integrative practices influence patient-centered care and to suggest a systematic approach for effective integration. APPROACH: We conducted a qualitative study comparing diabetes and mental health services through focus groups with 60 staff members from one health maintenance organization. We developed quantitative indicators to support the suggested model. FINDINGS: We identified a five-category framework of integrative practices that each directly and distinctively influences patient-centered care. Moreover, our findings suggest that integrative practices influence patient-centered care indirectly through creation of interdependent treatment competence, which enables providers to repeatedly deliver interdependent treatment in a flexible and adaptive way. PRACTICAL IMPLICATIONS: Providers should carefully implement integrative practices considering patient and disease characteristics, as our findings suggest that more implementation of integrative practices is not necessarily better for patient-centered care. Specifically, optimal implementation refers to the collective implementation of different integrative practices and thus encompasses both the extent (i.e., the amount of currently implemented practices out of those considered important to implement) and the extensiveness (i.e., the amount relative to the implementation of other practices) that may lead to interdependent treatment competence and higher patient-centered care. We suggest a creative measurement method of comparing the relative implementation of integrative practices that may assist managers and policy makers in developing interdependent treatment competence.

A longitudinal study of an intervention to improve road safety climate: climate as an organizational boundary spanner.

This study presents and tests an intervention to enhance organizational climate and expands existing conceptualization of organizational climate to include its influence on employee behaviors outside the organization's physical boundaries. In addition, by integrating the literatures of climate and work-family interface, the study explored climate spillover and crossover from work to the home domain. Focusing on an applied practical problem within organizations, we investigated the example of road safety climate and employees' and their families' driving, using a longitudinal study design of road safety intervention versus control groups. Results demonstrated that the intervention increased road safety climate and decreased the number of traffic violation tickets and that road safety climate mediated the relationship between the intervention and the number of traffic violation tickets. Road safety climate spilled over to the family domain but did not cross over to influence family members' driving.

Resident physicians' clinical training and error rate: the roles of autonomy, consultation, and familiarity with the literature.

Resident physicians' clinical training poses unique challenges for the delivery of safe patient care. Residents face special risks of involvement in medical errors since they have tremendous responsibility for patient care, yet they are novice practitioners in the process of learning and mastering their profession. The present study explores the relationships between residents' error rates and three clinical training methods (1) progressive independence or level of autonomy, (2) consulting the physician on call, and (3) familiarity with up-to-date medical literature, and whether these relationships vary among the specialties of surgery and internal medicine and between novice and experienced residents. 142 Residents in 22 medical departments from two hospitals participated in the study. Results of hierarchical linear model analysis indicated that lower levels of autonomy, higher levels of consultation with the physician on call, and higher levels of familiarity with up-to-date medical literature were associated with lower levels of resident's error rates. The associations varied between internal and surgery specializations and novice and experienced residents. In conclusion, the study results suggested that the implicit curriculum that residents should be afforded autonomy and progressive independence with nominal supervision in accordance with their relevant skills and experience must be applied cautiously depending on specialization and experience. In addition, it is necessary to create a supportive and judgment free climate within the department that may reduce a resident's hesitation to consult the attending physician.

Antecedents of willingness to report medical treatment errors in health care organizations: a multilevel theoretical framework.

BACKGROUND: To avoid errors and improve patient safety and quality of care, health care organizations need to identify the sources of failures and facilitate implementation of corrective actions. Hence, health care organizations try to collect reports and data about errors by investing enormous resources in reporting systems. However, despite health care organizations' declared goal of increasing the voluntary reporting of errors and although the Patient Safety and Quality Improvement Act of 2005 (S.544, Public Law 109-41) legalizes efforts to secure reporters from specific liabilities, the problem of underreporting of adverse events by staff members remains. PURPOSE: The purpose of the paper is to develop a theory-based model and a set of propositions to understand the antecedents of staff members' willingness to report errors based on a literature synthesis. The model aims to explore a complex system of considerations employees use when deciding whether to report their errors or be silent about them. The model integrates the influences of three types of organizational climates (psychological safety, psychological contracts, and safety climate) and individual perceptions of the applicability of the organization's procedures and proposes their mutual influence on willingness to report errors and, as a consequence, patient safety. PRACTICE IMPLICATIONS: The model suggests that managers should try to control and influence both the way employees perceive procedure applicability and organizational context-i.e., psychological safety, no-blame contracts, and safety climate-to increase reporting and improve patient safety.

Active learning: when is more better? The case of resident physicians' medical errors.

An active learning climate facilitates new knowledge acquisition by encouraging employees to ask questions, seek feedback, reflect on potential results, explore, and experiment. These activities, however, also increase a learner's chances of erring. In high-reliability organizations, any error is unacceptable and may well be life threatening. The authors use the example of resident physicians to suggest that by adjusting the conditions of priority of safety and managerial safety practices, organizations can balance these potentially conflicting activities. Participants in the study were 123 residents from 25 medical wards. Results demonstrated that the positive linear relationship between priority of safety and safety performance, demonstrated in earlier studies, existed only when the active learning climate was low. When the active learning climate was high, results demonstrated a U-shaped curvilinear relationship between priority of safety and number of errors. In addition, high managerial safety practices mitigated the number of errors as a result of the active learning climate.

The cardiovascular effect of local anesthesia with articaine plus 1:200,000 adrenalin versus lidocaine plus 1:100,000 adrenalin in medically compromised cardiac patients: a prospective, randomized, double blinded study.

OBJECTIVES: This study compared cardiovascular safety profiles of 2 local anesthetics (LA): articaine (Ubistesine) versus standard lidocaine solution in cardiovascular patients. STUDY DESIGN: Fifty cardiovascular patients were randomly assigned to dental treatment using 1.8 mL of one of two LA injections: articaine 4% and adrenalin 1:200,000 or lidocaine 2% and adrenalin 1:100,000. A computerized system enabled continuous longitudinal data collection: electrocardiography (ECG), O(2)-saturation, blood pressure (BP), and heart rate (HR). Patients scored pain level at the end of the LA injection (on a 0 to 10 scale). RESULTS: There were no clinical severe adverse effects. One transient local parasthesia occurred (lidocaine group), which lasted 4 weeks. There were no statistically significant differences between the 2 groups in HR, systolic or diastolic-BP, and O(2) saturation. Age, gender, jaw treated, treatment duration, and the pain level did not influence the results of the comparison. In 3 patients asymptomatic ischemic changes were noted on ECG (1 in the lidocaine group and 2 in the articaine group). CONCLUSIONS: LA with articaine 4% with adrenalin 1:200,000 was comparably as safe as LA with standard concentrations of lidocaine and adrenalin in cardiovascular patients. Cardiac ischemic changes on ECG did not appear to be related to the LA.

Safety self-efficacy and safety performance: potential antecedents and the moderation effect of standardization.

PURPOSE: The purpose of this paper is to suggest a new safety self-efficacy construct and to explore its antecedents and interaction with standardization to influence in-patient safety. DESIGN/METHODOLOGY/APPROACH: The paper used a survey of 161 nurses using a self-administered questionnaire over a 14-day period in two large Israeli general hospitals. Nurses answered questions relating to four safety self-efficacy antecedents: enactive mastery experiences; managers as safety role models; verbal persuasion; and safety priority, that relate to the perceived level of standardization and safety self-efficacy. Confirmatory factor analysis was used to assess the scale's construct validity. Regression models were used to test hypotheses regarding the antecedents and influence of safety self-efficacy. FINDINGS: Results indicate that: managers as safety role models; distributing safety information; and priority given to safety, contributed to safety self-efficacy. Additionally, standardization moderated the effects of safety self-efficacy and patient safety such that safety self-efficacy was positively associated with patient safety when standardization was low rather than high. Hospital managers should be aware of individual motivations as safety self-efficacy when evaluating the potential influence of standardization on patient safety. ORIGINALITY/VALUE: Theoretically, the study introduces a new safety self-efficacy concept, and captures its antecedents and influence on safety performance. Also, the study suggests safety self-efficacy as a boundary condition for the influence of standardization on safety performance. Implementing standardization in healthcare is problematic because not all processes can be standardized. In this case, self-efficacy plays an important role in securing patient safety. Hence, safety self-efficacy may serve as a "substitute-for-standardization," by promoting staff behaviors that affect patient safety.

The moderate success of quality of care improvement efforts: three observations on the situation.

Why is the health care system still unable to achieve a breakthrough in its quality performance? This commentary offers three observations on the problem of the moderate success of quality of care improvement efforts. We based our discussion on theoretical models from management theory and research. We conclude that health care organizations invest efforts in quality improvement initiatives; however, there is a potential in improving the fit between these efforts and the specific problems these organizations face.

Financial performance, ISO 9000 standard and safe driving practices effects on accident rate in the U.S. motor carrier industry.

The question this research address is if voluntary certification with ISO 9000 standards can reduce the number of accidents large trucks have. Certification might have a positive effect depending upon the actions a company takes as a result of being certified, for instance, a company may change driver training and maintenance and how it carries out corrective action. We identified 40 ISO 9002: 1994 certified U.S. trucking companies and compared their safety performance before and after ISO certification. We also compared them to a group of motor carriers that had similar characteristics but were not certified. The safety performance of the certified carriers was significantly better after certification than before, and it also was significantly better than that of non-certified carriers, findings that we believe can be useful to carriers, shippers and regulators who wish to better understand the value of certification.

Readiness to report medical treatment errors: the effects of safety procedures, safety information, and priority of safety.

BACKGROUND: Medical error reporting is an essential component of patient safety enhancement. However, increasingly, the literature points to a problem of underreporting of treatment errors, mainly as a result of the fear of malpractice lawsuits and limited formal data collection systems. Few studies, if any, have examined the influence of informal aspects of the organization, such as safety climate, on employees' willingness to report errors. OBJECTIVES: This study investigated the relationship between safety climate aspects and personnel readiness to report treatment errors in different hospital departments. METHOD: The model was tested in 3 hospitals (n = 632 in 44 medical departments of 3 types; internal medicine, surgery, and intensive care). Three safety climate aspects were measured using questionnaires: the way employees perceive the safety procedures, the safety information flow within their department, and the relative priorities given to safety in the department. Readiness to report was measured by tallying each department's annual number of treatment errors reported to the hospitals' risk management systems. RESULTS: Negative binomial regression analysis indicated that the more personnel perceive procedures as suitable and safety information as available, the higher was their willingness to report treatment errors. These relationships significantly differed depending on the department type. CONCLUSIONS: Hospitals should take into account the perceptions of personnel regarding safety procedures and information and understand that these perceptions operate differently in different department types in their effect on the staff's willingness to report treatment errors.

How quality improvement programs can affect general hospital performance.

PURPOSE: Given the enormous size of the health care industry, the problem of developing high-quality, cost-effective health care delivery systems is growing in importance. There is general consensus that health care systems require a continuous process of quality improvement (QI). Less agreement, however, surrounds the mechanisms to be implemented so that such a process is effective. This study aims to bring empirical evidence to support the hypothesis that a QI program in a general hospital - a special context of the health care delivery system - does not necessarily lead to better overall organizational performance results. DESIGN/METHODOLOGY/APPROACH: The study was done at the hospital level, and included all acute care hospitals in Israel. Data was collected in 16 of the country's 23 hospitals, a 70 percent response rate. The study compared hospital performance before and after the QI program implementation. FINDINGS: The study shows that QI creates meaningful improvement events. In addition, the research supports the hypothesis that increasing the number of QI activities (items) included in the QI program brings about more improvement events. The results do not support the hypothesis that high, rather than low, intensive implementation of QI activities leads to more improvement events. ORIGINALITY/VALUE: The special context of general hospitals decreases the effects of a QI program on overall hospital performance, whereas QI activities function as triggers in initiating improvement events.

A survey of pain, pressure, and discomfort induced by commonly used oral local anesthesia injections.

Intraoral local anesthesia is essential for delivering dental care. However, it is often perceived by some patients as the most painful and in some instances as the only painful part of the treatment, leading in extreme cases to avoidance of dental care. The present study measured the variables of pain, pressure, and discomfort caused by 4 commonly used local anesthesia injections: local infiltration, mental nerve block, inferior alveolar nerve block, and periodontal ligament injections. Patients were asked to grade pain, discomfort, and pressure on a visual analog scale as associated with needle insertion, operator finger position in the mouth, and pressure at injection. The inferior alveolar injection was graded to be the most painful followed by periodontal ligament and then mental nerve block injections. The periodontal ligament injections yielded the highest pressure scores. The inferior alveolar block injection yielded significantly more discomfort than local infiltration and mental nerve block injections when comparing finger and needle position. Local infiltration in the anterior maxillary region yielded the highest needle insertion and finger position discomfort scores. The present study suggests that the dental operator should be aware of local anesthesia injection pain, pressure, and discomfort together with efficacy of technique.