Developing surgical and anesthesia resident patient safety competencies through systems-based event analysis. Guide to curricular development and evaluation of longer-term resident perceptions.

Previous studies have demonstrated that residents participating in patient safety event investigations become more engaged in future patient safety activities. Currently, there is a gap in resident participation in patient safety event analyses. The objective was to develop and implement a sustainable, faculty-led curriculum for resident participation in patient safety event investigations and to evaluate resident perceptions of the training at least one year following completion of the training. One hundred sixty-five residents from three specialties participated in a formal RCA2 training curriculum from 2013 to 2019. In November 2019, the same residents were asked to complete a survey which examined their perception of the training including the tools and techniques such as event mapping, cause-and-effect diagramming, and developing action plans for solving problems and unsafe conditions. The survey response rate was 36 % (60/165). Sixty-three percent (38/60) of the residents responding to the survey believed that RCA2 training should be provided to all residents. Former residents rated the RCA2 training tools and skills favorably, 3.6 median score (3.5-3.7, 95 % C.I.). Forty-eight percent of responding residents (29/60) believed that the previous RCA2 training improved the way they identify and solve problems. The curriculum and faculty development program provides an effective intervention to address the current, identified gaps in patient safety in graduate medical education.

The Pursuing Excellence Collaborative: Engaging First-Year Residents and Fellows in Patient Safety Event Investigations.

OBJECTIVES: Resident and fellow engagement in patient safety event investigations (PSEIs) can benefit both the clinical learning environment's ability to improve patient care and learners' problem-solving skills. The goals of this collaborative were to increase resident and fellow participation in these investigations and improve PSEI quality. METHODS: This collaborative involved 18 sites-8 sites that had participated in a similar previous collaborative (cohort I) and 10 "new" sites (cohort II). The 18-month collaborative included face-to-face and virtual learning sessions, check-ins, and coaching calls. A validated assessment tool measured PSEI quality, and sites tracked the percentage of first-year residents and fellows included in a PSEI. RESULTS: Sixteen of the 18 sites completed the 18-month collaborative. Baseline was no first-year resident or fellow participation in a PSEI. Among these 16 clinical learning environments, 1237 early learners participated in a PSEI by the end of the collaborative. Six of these 16 sites (38%) reached the goal of 100% participation of first-year residents and fellows. As a percentage of total first-year residents and fellows, larger institutions had less resident and fellow participation. Six of the 9 cohort II sites submitted PSEIs for independent review at 6 months and again at the end of the collaborative. The PSEI quality scores increased from 5.9 ± 1.8 to 8.2 ± 0.8 ( P ≤ 0.05). CONCLUSIONS: It is possible to include all residents and fellows in PSEIs. Patient safety event investigation quality can improve through resident and fellow participation, use of standardized processes during training and investigations, and review of PSEI quality scores with a validated tool.

Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem.

OBJECTIVES: The aims of this study were to investigate the demographics, causes, and contributing factors of retained guidewires (GWs) and to make specific recommendations for their prevention. METHODS: The Veterans Administration patient safety reporting system database for 2000-2016 was queried for cases of retained GWs (RGWs). Data extracted for each case included procedure location, provider experience, insertion site, urgency, time to discovery, root causes, and corrective actions taken. RESULTS: There were 101 evaluable cases of RGWs. Resident trainee (36%), critical care unit (38%), femoral vein (44%), and nonemergent placement (79%) were the conditions most frequently associated with a RGW. While discovery occurred almost immediately (30%) or in next 24 hours (31%), there were instances of RGWs found months (2%) or years (3%) later. Common root causes included inexperience (46%), lack of standardization (35%), distractions (25%), and lack of a checklist (23%). CONCLUSIONS: The results demonstrate the result of human factors-based errors such as posttask completion errors. We recommend human factor-based interventions such as checklists and devices employing forcing functions that do not allow clinicians to complete the insertion process without first removing the GW.

A Review of Adverse Event Reports From Emergency Departments in the Veterans Health Administration.

BACKGROUND: Previous work assessing the frequency of adverse events in emergency medicine has been limited. The emergency department (ED) provides an initial point of care for millions of patients. Given the volume of patient encounters and the complexity of medical conditions treated in the ED, it is necessary to determine the system-based issues and associated contributing factors impacting patient safety. OBJECTIVES: The aim of this retrospective study were to use root cause analysis reports of adverse events occurring in Veterans Health Administration EDs to understand the range of events that were happening and to determine the primary causes of these events as well as actions to prevent them. METHODS: Retrospective safety reports from EDs from Veterans Health Administration medical centers across the nation for a 2-year period (2015-2016) were coded by event type, root cause, and recommended actions. RESULTS: One hundred forty-four cases were included for analysis. The most common adverse events were as follows: delays in care (n = 38, 26.4%), elopements (n = 21, 14.6%), suicide attempts and deaths by suicide (n = 15, 10.4%), inappropriate discharges (n = 15, 10.4%), and errors in following procedures (n = 14, 9.7%). Overall, the most common root cause categories leading to adverse events were knowledge/educational deficits (11.4%), policies/procedures needing improvement (11.1%), and lack of standardized policies/procedures (9.4%). DISCUSSION: Root cause analysis reports are a useful tool to determine the primary systems-based factors of common adverse events in the ED. Recommendations made in this article for addressing these root causes and potentially ameliorating these events will be useful to EDs and related health systems.

Sharing Lessons Learned to Prevent Adverse Events in Anesthesiology Nationwide.

OBJECTIVES: The Veterans Health Administration (VHA) lessons learned process for Anesthesia adverse events was developed to alert the field to the occurrences and prevention of actual adverse events. This article details this quality improvement project and perceived impact. METHODS: As part of ongoing quality improvement, root cause analysis related to anesthesiology care are routinely reported to the VHA National Center for Patient Safety. Since May 2012, the National Anesthesia Service subject matter experts, in collaboration with National Center for Patient Safety, review actual adverse events in anesthesiology and detailed lessons learned are developed. A survey of anesthesiology chiefs to determine perceived usefulness and accessibility of the project was conducted in April 2018. RESULTS: The distributed survey yielded a response rate of 69% (84/122). Most of those who have seen the lessons learned (85%, 71/84) found them valuable. Ninety percent of those aware of the lessons learned (64/71) shared them with staff and 75% (53/71) reported a changed or reinforced patient safety behavior in their facility. The lessons learned provided 72% (51/71) of chiefs with new knowledge about patient safety and 75% (53/71) gained new knowledge for preventing adverse events. CONCLUSIONS: This nationwide VHA anesthesiology lessons learned project illustrates the tenets of a learning organization. implementing team and systems-based safeguards to mitigate risk of harm from inevitable human error. Sharing lessons learned provides opportunities for clinician peer-to-peer learning, communication, and proactive approaches to prevent future similar errors.

How Should Risk Managers Respond to Cases for Which No Risk Profile Exists?

Rapid innovation makes some devices available for patient implantation prior to extensive preclinical trials. This article reviews information that risk managers can utilize to help patient-subjects and clinician-researchers make informed decisions about new device implantation in the absence of preclinical trial data. Novel devices should be regarded by risk managers as sources of unknowns with potential for procedural complications and other harms. Risk-benefit analyses during informed consent should include patient-subjects' preferences, experience of the implanting surgical team, disclosure of conflicts of interest, and postprocedure follow-up planning. Checklists can help risk managers facilitate critical conversations and decision making about whether to implant devices with no extant risk profile.

Root Cause Analyses of Reported Adverse Events Occurring During Gastrointestinal Scope and Tube Placement Procedures in the Veterans Health Association.

OBJECTIVE: This study describes reported adverse events related to gastrointestinal (GI) scope and tube placement procedures (between January 2010 and June 2012), in the Veterans Health Administration. Adverse events, including those related to GI procedures resulting in preventable harm, continue to occur. METHODS: This is a descriptive review of root cause analysis reports of GI scope and tube placement procedures from the National Center for Patient Safety database. Adverse event type, procedure, location, severity, and frequency were extracted. Spearman ρ was used to determine associations between types of adverse events and harm levels. RESULTS: We reviewed 27 cases of reported adverse events related to GI invasive procedures. Of the adverse events for which we could determine location (n = 25), 10 (40%) were in the operating room and 15 (60%) occurred in a nonoperating room. Endoscopies were associated with the least amount of harm. The most frequently reported adverse event types were human factors (22.22%, n = 6) and retained items (18.52%, n = 5). Retained item events were associated with the most harm. The most common root causes were lack of standardization in the process of care and suboptimal communication. CONCLUSIONS: Retained items after invasive procedures and human factors errors were the most common and harmful type of adverse event in this study. Efforts to reduce adverse events during GI invasive procedures include improving situational awareness of the risk of retained items, standardization of care, communication between providers, and inspection of instruments for intactness before and after procedures.

Wrong Site Spine Surgery in the Veterans Administration.

STUDY DESIGN: Basic descriptive analysis was performed for the incident characteristics of wrong level spinal surgery in the Veterans Health Administration (VHA). OBJECTIVE: To determine the frequency of reported occurrence of incorrect spine level surgery in the VHA, causal factors for the events, and propose solutions to the issue. SUMMARY OF BACKGROUND DATA: Wrong site surgery is one of the most common events reported to The Joint Commission. It has been reported that 50% of spine surgeons experience at least 1 wrong site surgery in their career, with events leading to signficant harm to patients. MATERIALS AND METHODS: We examined incorrect level spine surgery adverse events reported to the VHA National Center for Patient Safety (NCPS) from 2000 to 2017. A rate of wrong site spine surgery was determined by dividing the number of wrong site cases by the total number of spine surgeries during the study period. Similarly, a rate of wrong site surgery by orthopedist and neurosurgeons was calculated. RESULTS: There were 32 reported cases of wrong site spine surgery between 2000 and 2017. Fourteen cases involved the cervical region, 13 the lumbar region, and 5 the thoracic region. The majority of the root causes (69% or 48 of 69 root causes) fell into 2 broad categories: problems with the radiograph or problems with the intraoperative marker. These were not mutually exclusive and several root cause analyses involved >1 of these issues. CONCLUSIONS: Wrong level surgery of the spine is a significant safety issue facing the field that continues to occur despite surgical teams following guidelines. As poor radiograph quality and interpretability were the most common root causes of these events, interventions aimed at optimizing image quality and accurate interpretation would be a logical first action.

How Well Do Incident Reporting Systems Work on Inpatient Psychiatric Units?

BACKGROUND: Adverse events and medical errors have been shown to be a persistent issue in health care. However, little research has been conducted regarding the efficacy of incident reporting systems, particularly within an inpatient psychiatry setting. METHODS: The medical records from a random sample of 40 psychiatric units within Veterans Health Administration (VHA) medical centers were screened and evaluated by physicians for 9 types of safety events. The abstracted safety events were then evaluated to assess if they were caused by an error and if they caused harm to the patient. These safety events were then matched to incidents that were reported to the VHA Adverse Event Reporting System (AERS), which includes all reported adverse events, close calls, and root cause analyses that occur within the VHA health system. RESULTS: Overall, 37.4% (95% confidence interval [CI] = 33.5%-41.5%) of safety events detected in the medical record were reported to the AERS. Among the patient safety events identified, the most commonly reported to the AERS were patient falls (52.3%), assaults (46.2%), and elopements (42.3%). Reporting rates increased when the patient safety event resulted in harm to the patient (48.2%; CI = 41.6%-55.0%). CONCLUSION: The majority of patient safety events that occur on VHA inpatient psychiatric units do not get reported to the VHA's Adverse Event Reporting System. These findings suggest that self-reporting is not a reliable method of tracking patient safety events. Future efforts should target the barriers to inpatient psychiatric reporting and develop mechanisms to overcome these barriers.

Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration.

This quality improvement project describes 22 OR patient falls reported in the Veterans Health Administration between January 2010 and February 2016. Most (n = 15; 68%) involved patient falls from the OR bed. Other patient falls (n = 6; 27%) occurred when the patient was transferred to or from the OR bed, and one fall (5%) occurred at another time. Root causes of the falls included tilting of the OR bed, issues with safety restraints, malfunctioning OR bed or gurney locks, inadequate patient sedation, and poor communication among team members. One fall (5%) resulted in a major injury, four falls (18%) resulted in minor injuries, six falls resulted in no injury, and 11 falls (50%) had no reported outcome. Falls in the OR, although rare, can be injurious. We drafted recommendations based on the root causes that include specific guidance on communication, teamwork, best practices, restraints and equipment, and training.

Root Cause Analysis of Oncology Adverse Events in the Veterans Health Administration.

PURPOSE: Oncology providers are leaders in patient safety. Despite their efforts, oncology-related medical errors still occur, sometimes resulting in patient injury or death. The Veterans Health Administration (VHA) National Center of Patient Safety used data obtained from root cause analysis (RCA) to determine how and why these adverse events occurred in the VHA, and how to prevent future reoccurrence. This study details the types of oncology adverse events reported in VHA hospitals and their root causes and suggests actions for prevention and improvement. METHODS: We searched the National Center for Patient Safety adverse event reporting database for RCA related to oncology care from October 1, 2013, to September 8, 2017, to identify event types, root causes, severity of outcomes, care processes, and suggested actions. Two independent reviewers coded these variables, and inter-rater agreement was calculated by κ statistic. Variables were evaluated using descriptive statistics. RESULTS: We identified 48 RCA reports that specifically involved an oncology provider. Event types included care delays (39.5% [n = 19]), issues with chemotherapy (25% [n = 12]) and radiation (12.5% [n = 6]), other (12.5% [n = 6]), and suicide (10.5% [n = 5]). Of the 48 events, 27.1% (n = 13) resulted in death, 4.2% (n = 2) in severe harm, 18.8% (n = 9) in temporary harm, 20.8% (n = 10) in minimal harm, and 2.1% (n = 1) in no harm. The majority of root causes identified a need to improve care processes and policies, interdisciplinary communication, and care coordination. CONCLUSION: This analysis highlights an opportunity to implement system-wide changes to prevent similar events from reoccurring. These actions include comprehensive cancer clinics, usability testing of medical equipment, and standardization of processes and policies. Additional studies are necessary to assess oncologic adverse events across specialties.

Curriculum Development and Implementation of a National Interprofessional Fellowship in Patient Safety.

OBJECTIVES: Developing a workforce skilled in improving the safety of medical care has often been cited as an important means to achieve safer care. Although some educational programs geared toward patient safety have been developed, few advanced training programs have been described in the literature. We describe the development of a patient safety fellowship program. METHODS: We describe the development and curriculum of an Interprofessional Fellowship in Patient Safety. The 1-year in residence fellowship focuses on domains such as leadership, spreading innovations, medical improvement, patient safety culture, reliability science, and understanding errors. RESULTS: Specific training in patient safety is available and has been delivered to 48 fellows from a wide range of backgrounds. Fellows have accomplished much in terms of improvement projects, educational innovations, and publications. After completing the fellowship program, fellows are obtaining positions within health-care quality and safety and are likely to make long-term contributions. CONCLUSIONS: We offer a curriculum and fellowship design for the topic of patient safety. Available evidence suggests that the fellowship results in the development of patient safety professionals.

Examining Wrong Eye Implant Adverse Events in the Veterans Health Administration With a Focus on Prevention: A Preliminary Report.

OBJECTIVE: The study goals were to examine wrong intraocular lens (IOL) implant adverse events in the Veterans Health Administration (VHA), identify root causes and contributing factors, and describe system changes that have been implemented to address this challenge. DESIGN: This study represents collaboration between the VHA's National Center for Patient Safety (NCPS) and the National Surgery Office (NSO). PARTICIPANTS: This report includes 45 wrong IOL implant surgery adverse events reported to established VHA NCPS and NSO databases between July 1, 2006, and June 31, 2014. There are approximately 50,000 eye implant procedures performed each year in the VHA. METHODS: Wrong IOL implant surgery adverse events are reported by VHA facilities to the NCPS and the NSO. Two authors (A.C. and J.N.) coded the reports for event type (wrong lens or expired lens) and identified the primary contributing factor (coefficient κ = 0.837). A descriptive analysis was conducted, which included the reported yearly event rate. MAIN OUTCOME MEASURE: The main outcome measure was the reported wrong IOL implant surgery adverse events. RESULTS: There were 45 reported wrong IOL implant surgery adverse events. Between 2011 and June 30, 2014, there was a significant downward trend (P = 0.02, R = 99.7%) at a pace of -0.08 (per 10,000 cases) every year. The most frequently coded primary contributing factor was incomplete preprocedure time-out (n = 12) followed by failure to perform double check of preprocedural calculations based upon original data and implant read-back at the time the surgical eye implant was performed (n = 10). CONCLUSIONS: Preventing wrong IOL implant adverse events requires diligence beyond performance of the preprocedural time-out. In 2013, the VHA has modified policy to ensure double check of preprocedural calculations and implant read-back with positive impact. Continued analysis of contributing human factors and improved surgical team communication are warranted.

The effects of crew resource management on teamwork and safety climate at Veterans Health Administration facilities.

Communication failure is a significant source of adverse events in health care and a leading root cause of sentinel events reported to the Joint Commission. The Veterans Health Administration National Center for Patient Safety established Clinical Team Training (CTT) as a comprehensive program to enhance patient safety and to improve communication and teamwork among health care professionals. CTT is based on techniques used in aviation's Crew Resource Management (CRM) training. The aviation industry has reached a significant safety record in large part related to the culture change generated by CRM and sustained by its recurrent implementation. This article focuses on the improvement of communication, teamwork, and patient safety by utilizing a standardized, CRM-based, interprofessional, immersive training in diverse clinical areas. The Teamwork and Safety Climate Questionnaire was used to evaluate safety climate before and after CTT. The scores for all of the 27 questions on the questionnaire showed an increase from baseline to 12 months, and 11 of those increases were statistically significant. A recurrent training is recommended to maintain the positive outcomes. CTT enhances patient safety and reduces risk of patient harm by improving teamwork and facilitating clear, concise, specific and timely communication among health care professionals.

Anesthesia Adverse Events Voluntarily Reported in the Veterans Health Administration and Lessons Learned.

BACKGROUND: Anesthesia providers have long been pioneers in patient safety. Despite remarkable efforts, anesthesia errors still occur, resulting in complications, injuries, and even death. The Veterans Health Administration (VHA) National Center of Patient Safety uses root cause analysis (RCA) to examine why system-related adverse events occur and how to prevent future similar events. This study describes the types of anesthesia adverse events reported in VHA hospitals and their root causes and preventative actions. METHODS: RCA reports from VHA hospitals from May 30, 2012, to May 1, 2015, were reviewed for root causes, severity of patient outcomes, and actions. These elements were coded by consensus and analyzed using descriptive statistics. RESULTS: During the study period, 3228 RCAs were submitted, of which 292 involved an anesthesia provider. Thirty-six of these were specific to anesthesia care. We reviewed these 36 RCA reports of adverse events specific to anesthesia care. Types of event included medication errors (28%, 10), regional blocks (14%, 5), airway management (14%, 5), skin integrity or position (11%, 4), other (11%, 4), consent issues (8%, 3), equipment (8%, 3), and intravenous access and anesthesia awareness (3%, 1 each). Of the 36 anesthesia events reported, 5 (14%) were identified as being catastrophic, 10 (28%) major, 12 (34%) moderate, and 9 (26%) minor. The majority of root causes identified a need for improved standardization of processes. CONCLUSIONS: This analysis points to the need for systemwide implementation of human factors engineering-based approaches to work toward further eliminating anesthesia-related adverse events. Such actions include standardization of processes, forcing functions, separating storage of look-alike sound-alike medications, limiting stock of high-risk medication strengths, bar coding medications, use of cognitive aids such as checklists, and high-fidelity simulation.

Assessment of Incorrect Surgical Procedures Within and Outside the Operating Room: A Follow-up Study From US Veterans Health Administration Medical Centers.

Importance: Reducing wrong-site surgery is fundamental to safe, high-quality care. This is a follow-up study examining 8 years of reported surgical adverse events and root causes in the nation's largest integrated health care system. Objectives: To provide a follow-up description of incorrect surgical procedures reported from 2010 to 2017 from US Veterans Health Administration (VHA) medical centers, compared with the previous studies of 2001 to 2006 and 2006 to 2009, and to recommend actions for future prevention of such events. Design, Setting, and Participants: This quality improvement study describes patient safety adverse events and close calls reported from 86 VHA medical centers from the approximately 130 VHA facilities with a surgical program. The surgical procedures and programs vary in size and complexity from small rural centers to large, complex urban facilities. Procedures occurring between January 1, 2010, and December 31, 2017, were included. Data analysis took place in 2018. Main Outcomes and Measures: The categories of incorrect procedure types were wrong patient, side, site (including wrong-level spine), procedure, or implant. Events included those in or out of the operating room, adverse events or close calls, surgical specialty, and harm. These results were compared with the previous studies of VHA-reported wrong-site surgery (2001-2006 and 2006-2009). Results: Our review produced 483 reports (277 adverse events and 206 close calls). The rate of in-operating room (in-OR) reported adverse events with harm has continued to trend downward from 1.74 to 0.47 reported adverse events with harm per 100 000 procedures between 2000 and 2017 based on 6 591 986 in-OR procedures. When in-OR events were examined by discipline as a rate, dentistry had 1.54, neurosurgery had 1.53, and ophthalmology had 1.06 reported in-OR adverse events per 10 000 cases. The overall VHA in-OR rate for adverse events during 2010 to 2017 was 0.53 per 10 000 procedures based on 3 234 514 in-OR procedures. The most common root cause for adverse events was related to issues in performing a comprehensive time-out (28.4%). In these cases, the time-out either was conducted incorrectly or was incomplete in some way. Conclusions and Relevance: Over the period studied, the VHA identified a decrease in the rate of reported adverse events in the OR associated with harm and continued reporting of adverse event close calls. Organizational efforts continue to examine root cause analysis reports, promulgate lessons learned, and enhance policy to promote a culture and behavior that minimizes events and is transparent in reporting occurrences.

Effective followership: A standardized algorithm to resolve clinical conflicts and improve teamwork.

In healthcare, the sustained presence of hierarchy between team members has been cited as a common contributor to communication breakdowns. Hierarchy serves to accentuate either actual or perceived chains of command, which may result in team members failing to challenge decisions made by leaders, despite concerns about adverse patient outcomes. While other tools suggest improved communication, none focus specifically on communication skills for team followers, nor do they provide techniques to immediately challenge authority and escalate assertiveness at a given moment in real time. This article presents data that show one such strategy, called the Effective Followership Algorithm, offering statistically significant improvements in team communication across the professional continuum from students and residents to experienced clinicians.