August 2016
RISK WATCH
Selected research, publications, and resources to promote evidence-informed risk management in Canadian healthcare organizations. Prepared by Healthcare Risk Management staff at the Healthcare Insurance Reciprocal of Canada (HIROC). Titles with
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indicate that a publication is open access. For all others a subscription or library access is required; the
librarian at our organization may be able to assist you. Please contact [email protected] for assistance if required.
HOT OFF THE PRESS
CREW RESOURCE MANAGEMENT Cultural transformation after implementation of crew resource management: is it really
possible?
Hefner J, Hilligoss B, Knupp A, et al. Am J Med Qual. 2016 (online July):1-7.
Study examining the impact of a systematic implementation of crew resource management (CRM) across
eight departments in three hospitals in the US. Implementation of CRM included facilitated training
which involved role playing and development of system-wide internal monitoring processes to monitor
adoption of safety tools. A patient safety culture survey was administered to all employees before
implementation of CRM and two years post implementation. Results showed a statistically significant
increase in composite scores for ten of twelve survey dimensions including teamwork within units;
organizational learning; overall perceptions of patient safety; handoffs and transitions; and nonpunitive
response to errors.
PRIMARY CARE/TRIGGER TOOLS Implementation of the trigger review method in Scottish general practices: patient safety
outcomes and potential for quality improvement
de Wet C, Black C, Luty S, et al. BMJ Qual Saf. 2016 (online April):1-8.
Study reporting on the implementation of a trigger review method (TRM) in primary care in Scotland (two
National Health Service Boards) with a particular focus on its impact on patient safety-related findings.
Scottish general practices were incentivised for applying the TRM on two occasions over a 12 month period. Reviewers looked at random samples of electronic medical records of predefined high risk patient
groups for the presence of predefined triggers. Results showed 274 eligible practices returned 536 TRM
summary reports which outlined findings from the reviews of 13,351 electronic patient records. A total of
14% of patient safety incidents were reported; 14% caused severe harm while 44% caused mild to moderate harm. A total of 46% of patient safety incidents were rated as preventable or potentially preventable. Reviewers indicated completing one or more improvement actions during the TRM process in 86% of
the summary reports with feedback to colleagues being the most common type (41%).
PRIMARY CARE/RESULTS REPORTING Communicating findings of delayed diagnostic evaluation to primary care providers
Meyer A, Murphy D, Singh H. J Am Board Fam Med. 2016 (Jul-Aug);29(4):469-473.
Study examining the effectiveness of various communication strategies to inform primary care providers
(PCPs) about delayed follow-up of cancer-related abnormal findings. Through electronic health recordbased algorithms and patient care record reviews, researchers identified follow-up delays. Analysis and
evaluation of the communication strategies incorporated a three step escalation process (step 1 - send
secure emails; step 2 - telephone call to PCPs or their nurses; and step 3 - clinic directors informed). Results
showed secure emails led to follow-up in 11% of cases; telephone calls led to follow-up in 69% of cases and
contacting clinic directors led to follow-up in five of eleven cases in which communication escalated to this
level. Authors conclude strategies to communicate to PCPs about information on delayed follow-up of
findings suspicious of cancer were useful, but not fail-safe. Furthermore, the authors propose that using a
case coordinator as an additional back-up strategy may be needed.
The content does not necessarily reflect HIROC’s views. For queries contact [email protected]
August 2016
RISK WATCH
CRITICAL INCIDENT ANALYSIS Effect size of contributory factors on adverse events: an analysis of RCA series in a
teaching hospital
Najafpour Z, Jafary M, Saeedi M, et al. J Diabetes Metab Disord. 2016 (online July):1-9.
Study reviewing root cause analysis (RCA) reports by a single team to determine the effect size of
contributory factors on adverse events through an organizational perspective in Iran. Methods
included interviewing patients and staff, reviewing health records and associated policies,
determining incident chronology, determining problems using fishbone diagrams, and creating action
plans. Results showed that after a review of 16 adverse events including unsafe patient transfers and
falls from the patient’s bed, 317 contributory factors and underlying causes were identified. The most
important contributory factors included task factors (19%), education and training factors (16%),
communication factors (14%), and team factors (13%). Authors conclude service and care delivery
problems were attributed to preferences for individualism instead of team work and weak leadership
skills to control and guide service and care providers.
RISK MANAGEMENT/LIABILITY Vicarious liability: is it an issue for your organization?
West J. J Healthc Risk Manag. 2016 (Jul);36(1):25-34.
Article describing how vicarious liability is a concern for hospitals and healthcare entities. Key findings
include: two forms of vicarious liability exist (agency—liability for nonemployees who appear to be the
agent of the hospital/entity and respondeat superior— liability for an employee’s actions). Vicarious
liability is imposed for the actions of persons who are not the employees of the hospital, but who
appear to be employees of the hospital, e.g. physicians, residents/fellows, and staffing agency
personnel (nurses). Author concludes there is no guarantee the hospital/entity, despite its diligent
efforts, will never be liable for the actions of its agents.
“Potential agents have 1 thing in common—they are all professionals that the health care entity
appears to have supplied to provide care for the patient” (p. 29).
PATIENT SAFETY/NIGHT-SHIFT SLEEPINESS Napping on the night shift: a two-hospital implementation project
Geiger-Brown J, Sagherian K, Zhu S, et al. Am J Nurs. 2016 (May);116(5):26-33.
Study describing the implementation of risk management fatigue initiatives on six nursing units at
two US hospitals. Authors note sleep scientists have been writing about the benefits of napping to
reduce night-shift sleepiness for decades and many safety-sensitive industries have adopted napping
as an effective countermeasure to sleepiness and fatigue. However, there has not been widespread
acceptance in nursing. Authors assessed the barriers to successful implementation of night-shift
naps and described the nap experience of night-shift nurses who took naps. Authors concluded the
study has several implications for nursing practice. Specifically, napping is unlikely to be successful
unless staff nurses are willing to take completely relieved breaks, with the confidence there will be
adequate coverage to ensure patients will not suffer. In addition, the nurse manager’s perception of
and concerns about napping often stymied implementation requiring a deeper understanding and
potential opportunity for further research.
“We observed that nurses’ reluctance to take breaks seemed to stem as much from a unit’s culture
as from staffing issues” (p. 31).
The content does not necessarily reflect HIROC’s views. For queries contact [email protected]
August 2016
RISK WATCH
QUALITY IMPROVEMENT/OBSTETRICS Scorecard implementation improves identification of postpartum patients at
risk for venous thromboembolism
Berkin J, Lee C, Landsberger E, et al. J Healthc Risk Manag. 2016 (July);36(1):8-13.
Study evaluating the implementation of an intensive educational intervention for the use of a
standardized venous thromboembolism (VTE) risk assessment tool (scorecard) to improve physician
identification and chemoprophylaxis of postpartum patients at risk for VTE. Intervention was
implemented over a period of two-months. Results showed at-risk patients with completed scorecards
had 2.6 times more orders for chemoprophylaxis than at-risk patients without scorecards. Results
showed the educational intervention was successful in significantly improving the rates of scorecard
completion amongst involved practitioners. Authors conclude utilization of a VTE scorecard, coupled
with an educational intervention for healthcare providers, increases detection and chemoprophylaxis
orders for at-risk patients. However, authors suggest that educational interventions to promote practice
changes vary in efficacy according to healthcare field and setting, with multi-faceted strategies emerging
as the most effective.
CYBERSECURITY/RISK MANAGEMENT When it comes to securing patient health information from breaches, your best
medicine is a dose of prevention: a cybersecurity risk assessment checklist
Blanke S, McGrady E. J Healthc Risk Manag. 2016 (July); 36(1): 14-24.
Article describing healthcare breaches of protected information, analyzing the hazards and
vulnerabilities of reported breach cases, and prescribing best practices of managing risk through
security controls and countermeasures. Article explores specific examples of three major types of
cyber breach hazards: portable devices, insider, and physical breaches. Article includes a 25-item
checklist healthcare organizations can use to assess existing practices and identify security gaps
requiring improvement.
“What gets measured gets done. Though all parties in health care services play an important role in
maintaining a secure environment, the ultimate responsibility for organizational risk from security
breaches resides with management” (p. 22).
PAEDIATRICS/PATIENT ENGAGEMENT Using an inpatient portal to engage families in pediatric hospital care
Kelly M, Hoonakker P, Dean S. J Am Med Inform Assoc. 2016 (online June):1-9.
Study evaluating what happened when parents of children hospitalized on a medical/surgical unit at a US
tertiary children’s hospital were provided with a tablet portal application to use throughout the duration of
their child’s course of admission. Intervention was implemented over a period of six months and involved
296 parents who accepted access to the tablet portal application. Results showed parent participants were
satisfied with the portal. Parents reported the portal was easy to use, that care improved, and that the
portal gave them access to information that helped them monitor, understand, make decisions and care
for their child. Parents reported appreciating the functionalities of the portal, which allowed them access
to real-time patient vitals, medications, schedules, lab results, education, descriptions and pictures of
healthcare team members, as well as request and messaging features. Authors conclude patient portals
may be a feasible and effective way to engage parents in hospital care. Authors also suggest patient portals
tethered to inpatient electronic health records may provide a mechanism for parents to identify
medication errors during a child’s hospital stay.
The content does not necessarily reflect HIROC’s views. For queries contact [email protected]
August 2016
RISK WATCH
Other Resources of Interest (all
)
Achieving health equity: a guide for health care organizations. (August 2016). Institute for Healthcare Improvement (US)
whitepaper; includes how to measure health equity, case study, and a self–assessment tool (free with log-in).
Adverse events in rehabilitation hospitals: national incidence among Medicare beneficiaries. (July 2016). Department of
Health & Human Services (US) study; results showed 29% of patients experienced an adverse event during their stay.
Engaging with patients: stories and successes from the 2015/2016 Quality Improvement Plans (2016). Health Quality Ontario
report informing healthcare organizations about methods to engage patients in the health system.
Learning through debriefing. (June 2016). Agency for Healthcare Research and Quality (US) patient safety primer on the value
of debriefing; includes a framework for clinical event debriefing.
Medical assistance in dying: policy statement #4 –16 (June 2016). College of Physicians and Surgeons of Ontario policy
articulating the legal obligations and professional expectations for physicians with respect to medical assistance in dying.
Medical assistance in dying: frequently asked questions. (June 2016). College of Physicians and Surgeons of Ontario
document addressing common questions around medical assistance in dying.
Patient safety improves when providers feel psychologically safe. (July 2016). Hospitals & Health Networks (US) three minute
video featuring Amy Edmonson, Harvard professor, taken during the 2016 National Patient Safety Foundation Congress.
Physician behaviour in the professional environment. (May 2016). College of Physicians and Surgeons of Ontario policy
overviewing the College’s expectations of physician behaviour in the professional environment.
The newborn with jaundice: we can do better. (June 2016). Canadian Medical Protective Association opinion piece suggesting
actions hospitals and providers can take to reduce the risk of severe hyperbilirubinemia.
HIROC Healthcare Risk Management
HIROC Monthly Risk Management Webinars – 2016 Upcoming Topics – Save the dates!
September 15 Boiler Trends, Issues, and Best Practices in the Healthcare Industry
October 20
Surgical Safety in Canada
November 10
Agency Agreements—Is Your Organization Protected?
November 17
Quality & Safety of Obstetrics in Canada
December 8
Primary Care
For an up-to-date list of HIROC’s 2016 webinars please click here.
The content does not necessarily reflect HIROC’s views. For queries contact [email protected]