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Background: Although patients' and care partners' perspectives on patient safety can guide health care learning and improvements, this information remains underutilized. Efforts to leverage this valuable data require challenging the narrow focus of safety as the absence of harm., Purpose: The purpose of this study was to gain a broader insight into how patients and care partners perceive and experience safety., Methods: We used a mixed-methods approach that included a literature review and interviews and focus groups with patients, care partners, and health care providers. An emergent coding schema was developed from triangulation of the 2 data sets., Results: Two core themes-feeling unsafe and feeling safe-emerged that collectively represent a broader view of safety., Conclusion: Knowledge from patients and care partners about feeling unsafe and safe needs to inform efforts to mitigate harm and promote safety, well-being, and positive outcomes and experiences., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Patient safety provides an important foundation for high-quality care. Research in Canada and elsewhere has identified substantial levels of harm in hospitals and other settings; these results spurred the development and spread of safety practices, along with strategies to strengthen organizational training, incident reporting and analysis and a host of resources intended to reduce the burden of harm. Yet, despite these efforts, 20 years after the publication of the Canadian Adverse Event study (Baker et al. 2004) and other studies, many leaders believe progress in patient safety has stalled (NEJM Catalyst 2023). Indeed, some recent studies indicate that the levels of harm have increased. One notable study by David Bates and colleagues (2023), building on approaches used in earlier studies, identified at least one adverse event in 23.6% of a random sample of patients in Massachusetts hospitals in 2018. Among 978 events, 22.7% were judged preventable and one-third required at least substantial intervention or prolonged recovery., (Copyright © 2024 Longwoods Publishing.)

Background: Substantial expenditures on health care safety programs have been justified by their goal of reducing health care associated-harm (adverse events), but adverse event rates have not changed over the past 4 decades. The objective of this study is to describe hospital-level factors that are relevant to safety in Canadian hospitals and the impact of these factors on hospital adverse events., Methods: This is a protocol for a national cohort study to describe the association between hospital-level factors and adverse events. We will survey at least 90 (35%) Canadian hospitals to describe 4 safety-relevant domains, chosen based on the literature and expert consultation, namely patient safety culture, safety strategies, staffing, and volume and capacity. We will retrospectively identify hospital adverse events from a national data source. We will evaluate organization-level factors using established scales and a survey, codesigned by the study team and hospital leaders. Hospital leaders, clinical unit leaders and front-line staff will complete the surveys once a year for 3 years, with an anticipated start date of winter 2022. We will use national health administrative data to estimate the rate and type of hospital adverse events corresponding to each 1-year survey period., Interpretation: Analysis of data from this project will describe hospital organizational factors that are relevant to safety and help identify organizational initiatives that improve hospital patient safety. In addition to biyearly reports to the leaders of the participating hospitals, we have a multifaceted and tailored dissemination strategy that includes integrating the knowledge users into the study team to increase the likelihood that our study will lead to improved hospital patient safety., Competing Interests: Competing interests: Christopher Parshuram reports holding shares in Bedside Clinical Systems. No other competing interests were declared., (© 2021 CMA Joule Inc. or its licensors.)

To lead effectively within their organizations, nurse executives must possess quality and safety literacy and be able to engage and motivate clinicians to participate in safety and quality initiatives. Given the paucity of research in Canada, a study was undertaken to explore nurse executives' understanding of the key concepts and strategies associated with patient safety and quality improvement, and their engagement with patient safety and quality improvement in their hospitals and healthcare systems. This study used an exploratory qualitative design with a content analysis approach on 20 nurse executives working in hospitals in Ontario. Three key themes emerged from the narrative data set including: (1) being a strategic and system thinker while possessing the emotional intelligence to influence staff; (2) building credibility and relationships with point-of-care staff, board of directors, and leadership team and (3) creating a culture of safety and high reliability. Study findings can be useful in informing future learning opportunities for nurse executives and nurses leaders at all levels to enhance their quality and safety literacy., (Copyright © 2018 Longwoods Publishing.)

Quality improvement and patient safety (QIPS) has become increasingly important in the practice of medicine, particularly since the Institute of Medicine's report, "To Err is Human." Despite surgery having been initially at the forefront in instituting QIPS, there has been a lag in promoting its importance until recently. A short history of QIPS is presented along with an introduction to the SQUIRE guidelines used for standardizing QIPS publications. As surgeons we are becoming even more accountable in promoting value in health care. As such, knowledge of QIPS will become an increasingly important component of our future practices and publications., (Copyright © 2017. Published by Elsevier Ltd.)

Background: Early identification of patients at who have a higher risk for the occurrence of harm can provide patient safety improvement opportunities. Patient factors contribute to adverse event occurrence. The study aim was to identify a single, parsimonious model of home care patient factors that, regardless of location and differences in home care program management and design factors, could provide a means of locating patients at higher and lower risk of harm., Methods: Split modeling using secondary analyses of data from two recent Canadian home care patient safety studies was undertaken. Patient factors from the Minimum Data Set Resident Assessment Instrument (RAI) for Home Care and diagnoses consistent with ICD-10 and RAI-Mental Health assessment were used. Continuous and categorical measures of factors were considered. Adverse events were defined using World Health Organization taxonomy and measured on a dichotomous yes/no scale. Patient factors significantly associated (Pearson's Chi Square, p ≤ .05) with the occurrence of adverse events in both earlier studies were entered in forward selection regression analyses to locate factors predictive of adverse event occurrence., Results: Instrumental activities of daily living dependency and escalating co-morbidity counts are associated with patient vulnerability to adverse events., Conclusions: Instrumental activities of daily living dependency and burden of illness, both easily identifiable early in the episode of care, are significantly associated with the risk of adverse event occurrence, however there is regional variability in the relationships.

Background: With the knowledge that patient safety incidents can significantly impact patients, providers and health-care organizations, greater emphasis on patient involvement as a means to mitigate risks warrants further research., Objective: To understand whether patient perceptions of patient safety play a role in patient involvement in factual and challenging patient safety practices and whether the constructs of the Health Belief Model (HBM) help to explain such perceptions., Design: Partial least squares (PLS) analysis of survey data., Setting and Participants: Four inpatient units located in two tertiary hospitals in Atlantic Canada. Patients discharged from participating units between November 2010 and January 2011., Intervention: None., Results: A total of 217 of the 587 patient surveys were returned for a final response rate of 37.0%. The PLS analysis revealed relationships between patient perceptions of threat and self-efficacy and the performance of factual and challenging patient safety practices, explaining 46 and 42% of the variance, respectively., Discussion: The results from this study provide evidence for the constructs and relationships set forth by the HBM. Perceptions of patient safety were shown to influence patient likelihood for engaging in selected patient safety practices. While perceptions of barriers and benefits and threats were found to be a contributing factor to patient involvement in patient safety practices, self-efficacy plays an important role as a mediating factor., Conclusions: Overall, the use of the HBM within patient safety provides for increased understanding of how such perceptions can be influenced to improve patient engagement in promoting safer health care., (© 2014 John Wiley & Sons Ltd.)

Background: Retrospective record review using trigger tools remains the most widely used method for measuring adverse events (AEs) to identify targets for improvement and measure temporal trends. However, medical records often contain limited information about factors contributing to AEs. We implemented an augmented trigger tool that supplemented record review with debriefing front-line staff to obtain details not included in the medical record. We hypothesised that this would foster the identification of factors contributing to AEs that could inform improvement initiatives., Method: A trained observer prospectively identified events in consecutive patients admitted to a general medical ward in a tertiary care academic medical centre (November 2010 to February 2011 inclusive), gathering information from record review and debriefing front-line staff in near real time. An interprofessional team reviewed events to identify preventable and potential AEs and characterised contributing factors using a previously published taxonomy., Results: Among 141 patients, 14 (10%; 95% CI 5% to 15%) experienced at least one preventable AE; 32 patients (23%; 95% CI 16% to 30%) experienced at least one potential AE. The most common contributing factors included policy and procedural problems (eg, routine protocol violations, conflicting policies; 37%), communication and teamwork problems (34%), and medication process problems (23%). However, these broad categories each included distinct subcategories that seemed to require different interventions. For instance, the 32 identified communication and teamwork problems comprised 7 distinct subcategories (eg, ineffective intraprofessional handovers, poor interprofessional communication, lacking a shared patient care, paging problems). Thus, even the major categories of contributing factors consisted of subcategories that individually related to a much smaller subset of AEs., Conclusions: Prospective application of an augmented trigger tool identified a wide range of factors contributing to AEs. However, the majority of contributing factors accounted for a small number of AEs, and more general categories were too heterogeneous to inform specific interventions. Successfully using trigger tools to stimulate quality improvement activities may require development of a framework that better classifies events that share contributing factors amenable to the same intervention., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Shorter resident duty periods are increasingly mandated to improve patient safety and physician well-being. However, increases in continuity-related errors may counteract the purported benefits of reducing fatigue. We evaluated the effects of 3 resident schedules in the intensive care unit (ICU) on patient safety, resident well-being and continuity of care., Methods: Residents in 2 university-affiliated ICUs were randomly assigned (in 2-month rotation-blocks from January to June 2009) to in-house overnight schedules of 24, 16 or 12 hours. The primary patient outcome was adverse events. The primary resident outcome was sleepiness, measured by the 7-point Stanford Sleepiness Scale. Secondary outcomes were patient deaths, preventable adverse events, and residents' physical symptoms and burnout. Continuity of care and perceptions of ICU staff were also assessed., Results: We evaluated 47 (96%) of 49 residents, all 971 admissions, 5894 patient-days and 452 staff surveys. We found no effect of schedule (24-, 16- or 12-h shifts) on adverse events (81.3, 76.3 and 78.2 events per 1000 patient-days, respectively; p = 0.7) or on residents' sleepiness in the daytime (mean rating 2.33, 2.61 and 2.30, respectively; p = 0.3) or at night (mean rating 3.06, 2.73 and 2.42, respectively; p = 0.2). Seven of 8 preventable adverse events occurred with the 12-hour schedule (p = 0.1). Mortality rates were similar for the 3 schedules. Residents' somatic symptoms were more severe and more frequent with the 24-hour schedule (p = 0.04); however, burnout was similar across the groups. ICU staff rated residents' knowledge and decision-making worst with the 16-hour schedule., Interpretation: Our findings do not support the purported advantages of shorter duty schedules. They also highlight the trade-offs between residents' symptoms and multiple secondary measures of patient safety. Further delineation of this emerging signal is required before widespread system change., Trial Registration: ClinicalTrials.gov, no. NCT00679809., (© 2015 Canadian Medical Association or its licensors.)

Objective: To assess which client events should be considered reportable and preventable in home care (HC) settings in the opinion of HC safety experts., Background: Patient safety in acute care settings has been well documented; however, there are limited data about this issue in HC. While many organizations collect information about 'incidents', there are no standards for reporting and it is challenging to compare incident rates among organizations., Design: A 29-item electronic survey that included potential HC safety issues was used in a two-round Delphi study., Setting and Participants: Twenty-four pan-Canadian HC safety experts participated in an electronic survey., Main Outcome Measures: Perceived reportability and preventability of patient safety events, HC., Results: The events that were perceived as being most reportable and preventable included the following: a serious injury related to inappropriate client service plan (e.g. incomplete/inaccurate assessments, poor care plan design, flawed implementation); an adverse reaction requiring emergency room visit or hospitalization related to a medication-related event; a catheter-site infection (e.g. a new peritoneal dialysis infection or peritonitis); any serious event related to care or services that are contrary to current professional or other practice standards (e.g. incorrect treatment regimen, theft, retention of a foreign object in a wound, individual practicing outside scope or competence)., Conclusion: These data represent an important step in the development and validation of standard metrics about client safety in HC. The results address an expanding area of health services where there is a need to improve standardization and reporting.

Background: Changes in resident duty hours in Europe and North America have had a major impact on the internal organizational dynamics of health care organizations. This paper examines, and assesses the impact of, organizational interventions that were a direct response to these duty hour reforms., Methods: The academic literature was searched through the SCOPUS database using the search terms "resident duty hours" and "European Working Time Directive," together with terms related to organizational factors. The search was limited to English-language literature published between January 2003 and January 2012. Studies were included if they reported an organizational intervention and measured an organizational outcome., Results: Twenty-five articles were included from the United States (n=18), the United Kingdom (n=5), Hong Kong (n=1), and Australia (n=1). They all described single-site projects; the majority used post-intervention surveys (n=15) and audit techniques (n=4). The studies assessed organizational measures, including relationships among staff, work satisfaction, continuity of care, workflow, compliance, workload, and cost. Interventions included using new technologies to improve handovers and communications, changing staff mixes, and introducing new shift structures, all of which had varying effects on the organizational measures listed previously., Conclusions: Little research has assessed the organizational impact of duty hour reforms; however, the literature reviewed demonstrates that many organizations are using new technologies, new personnel, and revised and innovative shift structures to compensate for reduced resident coverage and to decrease the risk of limited continuity of care. Future research in this area should focus on both micro (e.g., use of technology, shift changes, staff mix) and macro (e.g., culture, leadership support) organizational aspects to aid in our understanding of how best to respond to these duty hour reforms.

This paper explores the policies and practices that are needed to improve the safety of home care in light of the most recent evidence about home care safety in Canada. Four areas for policy and practice change are addressed: 1) the promotion of effective communication processes in home care through cross-sector collaboration, case management and technology innovations; 2) screening for safety risk factors; 3) standardizing care processes, packaging and equipment; and 4) supporting family/caregivers and strengthening clients' ability to engage in therapeutic self-care. Evidence-based strategies for change are presented within the context of the evidence about home care safety issues., (Copyright © 2014 Longwoods Publishing.)

Objective: Incidence of adverse events (AEs) among home care patients and preventability ratings were estimated. Risk factors, AE types and factors associated with AEs were identified., Design: This study used a stratified, randomized sample of home care patients discharged in the fiscal year 2004/05. Trained nurse reviewers completed retrospective chart abstractions; charts for cases that were positive for screening criteria suggesting the presence of AEs were reviewed by trained physicians to determine the presence of and preventability of AEs., Setting: Three publicly funded home care programs in Ontario, Canada., Main Outcome Measures: Prevalence and types of AEs; ratings of preventability., Results: At least one screening criterion was positively identified in 286 (66.5%) of 430 cases. Physician reviewers identified 61 AEs in 55 (19.2%) of the 286 (12.8% of the 430) cases. The AE rate was 13.2 per 100 home care cases [95% confidence interval (CI): 10.4-16.6%, standard error 1.6%]. 32.7% (20 of 61 AEs) of the AEs were rated as having >50% probability of preventability; 6 deaths (10.9% of patients with an AE; 1.4% of all patients) occurred in AE-positive patients. The most common AEs were falls and adverse drug events., Conclusions: Providing health care through home care programs creates unintended harm to patients. The incidence rate of AEs of 13.2% suggests a significant number of home care patients experience AEs, one-third of which were considered preventable. Improvements in patient and informal caregiver education, skill development and clinical planning may be useful interventions to reduce AEs.

Despite the focus on patient safety and quality health care for the last two decades, there is still limited understanding of how interprofessional interactions at an organizational or work unit level influence how clinicians perceive and respond to safety events and errors. Within the rubric of safety events, there has been a growing interest in near misses as precursors to adverse events in health care. Given the interactive nature of the variety of professionals working together in the delivery of health care, understanding how the different clinicians experience and respond to near misses in practice is important. A constructivist grounded theory approach was employed for this study which included semi-structured interviews with 24 participants in a large teaching hospital in Canada. Findings from this study provide a deeper understanding into how different clinicians experience and respond to near misses in clinical practice. This understanding indicates that collective vigilance can potentially create risk by eroding individual professional accountability through reliance on other team members to catch and correct their errors. Further research is needed to explore in more depth the trade-offs between collective vigilance and individual accountability by relying on others to catch and correct the potentially harmful errors and avert negative outcomes.

The passage of the Excellent Care for All Act, 2010 (ECFA Act) in Ontario has confirmed the responsibilities of hospital boards for quality of care and reinforced expectations that they will monitor performance and establish strategic aims in this area. Quality of care and patient safety have created a new agenda for many healthcare boards that had only a limited focus on these issues. Here, we report on interviews with five Ontario healthcare organizations identified by experts as having high-performing boards. Our question was, how has the ECFA Act influenced Ontario healthcare organizations' governance practices relating to quality and safety? While the act has raised the profile of these issues, in the short-term it may have blunted the effectiveness of some boards that had already developed a clear strategic focus on quality and patient safety. Executive compensation was the most contentious issue; the introduction of pay for performance was considered poor timing, given the Ontario government's pay freeze. Overall, the act is an important step in increasing responsible governance and has helped align governance activities with the core work of hospitals--delivering high-quality care. However, effective policy must create an environment where all organizations focus on improvement, but where regulation does not limit the capabilities of leading organizations to achieve even higher performance., (Copyright © 2012 Longwoods Publishing.)

Background The Measurement and Monitoring of Safety Framework (MMSF) aims to move beyond a narrow focus on measurement and past harmful events as the major focus for safety in healthcare organisations. There is limited evidence of MMSF implementation and impact. Objective We aimed to examine participants' perspectives and experiences to increase understanding of the adaptive work of implementing the MMSF through a learning collaborative programme in diverse healthcare contexts across Canada. Methods The Collaborative consisted of 11 teams from seven provinces. We conducted a qualitative study involving interviews with 36 participants, observations of 5 sites and learning sessions, and collection of documents. Results Collaborative sessions and coaching allowed participants to explore reliability, sensitivity to operations, anticipation and preparedness, and integration and learning, in addition to past harm, and move beyond a project and measurement oriented safety approach. Participants noted the importance of time dedicated to engaging stakeholders in talk about MMSF concepts and their significance to their settings, prior to moving to implementing the Framework into practice. While participants generally started with a small number of ways of integrating the MMSF into practice such as rounds or huddles, many teams continued to experiment with incorporating the MMSF into a range of practices. Participants reported changes in thinking about safety, discussions and behaviours, which were perceived to impact healthcare processes. However, participants also reported challenges to sharing the Framework broadly and moving beyond its surface implementation, and difficulties with its sustained and widespread use given misalignments with existing quality and safety processes. Conclusion The MMSF requires a dramatic departure from traditional safety strategies that focus on discrete problems and emphasise measurement. MMSF implementation requires extensive discussion, coaching and experimentation. Future implementation should consider engaging local leaders and coaches and an organisation or system approach to enable broader reach and systemic change. [ABSTRACT FROM AUTHOR]

Background Healthcare leaders look to high-reliability organisations (HROs) for strategies to improve safety, despite questions about how to translate these strategies into practice. Weick and Sutcliffe describe five principles exhibited by HROs. Interventions aiming to foster these principles are common in healthcare; however, there have been few examinations of the perceptions of those who have planned or experienced these efforts. Objective This single-site qualitative study explores how healthcare professionals understand and enact the HRO principles in response to an HRO-inspired hospital-wide safety programme. Methods We interviewed 71 participants representing hospital executives, programme leadership, and staff and physicians from three clinical services. We observed and collected data from unit and hospital-wide quality and safety meetings and activities. We used thematic analysis to code and analyse the data. Results Participants reported enactment of the HRO principles 'preoccupation with failure', 'reluctance to simplify interpretations' and 'sensitivity to operations', and described the programme as adding legitimacy, training, and support. However, the programme was more often targeted at, and taken up by, nurses compared with other groups. Participants were less able to identify interventions that supported the HRO principles 'commitment to resilience' and 'deference to expertise' and reported limited examples of changes in practices related to these principles. Moreover, we identified inconsistent, and even conflicting, understanding of concepts related to the HRO principles, often related to social and professional norms and practices. Finally, an individualised rather than systemic approach hindered collective actions underlying high reliability. Conclusion Our findings demonstrate that the safety programme supported some HRO principles more than others, and was targeted at, and perceived differently across professional groups leading to inconsistent understanding and enactments of the principles across the organisation. Combining HRO-inspired interventions with more targeted attention to each of the HRO principles could produce greater, more consistent high-reliability practices. [ABSTRACT FROM AUTHOR]

Objective To describe the process of developing and validating the Canadian Association of Paediatric Health Centres Trigger Tool (CPTT). Methods Five existing trigger tools were consolidated with duplicate triggers eliminated. After a risk analysis and modified Delphi process, the tool was reduced from 94 to 47 triggers. Feasibility of use was tested, reviewing 40 charts in three hospitals. For validation, charts were randomly selected across four age groups, half medical/half surgical diagnoses, from six paediatric academic health sciences centres. 591 charts were reviewed by six nurses (for triggers and adverse events (AEs)) and three physicians (for AEs only). The incidence of trigger- and AE-positive charts was documented, and the sensitivity and specificity of the tool to identify charts with AEs were determined. Identification of AEs by nurses and physicians was compared. The positive predictive value (PPV) of each trigger was calculated and the ratio of false- to true-positive AE predictors analysed for each trigger. Results Nurses rated the CPTT easy to use and identified triggers in 61.1% (361/591; 95% CI 57.2 to 65.0) of patient charts; physicians identified AEs in 15.1% (89/ 591, 95% CI 0.23 to 0.43). Over a third of patients with AEs were neonates. The sensitivity and specificity were 0.88 and 0.44, respectively. Nurse and physician AE assessments correlated poorly. The PPV for each trigger ranged from 0 to 88.3%. Triggers with a false/true-positive ratio of >0.7 were eliminated, resulting in the final 35-trigger CPTT. Conclusions The CPTT is the first validated, comprehensive trigger tool available to detect AEs in children hospitalised in acute care facilities. [ABSTRACT FROM PUBLISHER]

Context Medical trainees demonstrate a reluctance to ask for help unless they believe it is absolutely necessary, a situation which could impact on the safety of patients. This study aimed to develop a theoretical exploration of the pressure on medical trainees to be independent and to generate theory-based approaches to the implications for patient safety of this pressure towards independent working. Methods In Phase 1, 88 teaching team members from internal and emergency medicine were observed during clinical activities (216 hours), and 65 participants completed brief interviews. In Phase 2, 36 in-depth interviews were conducted using video vignettes. Data collection and analysis employed grounded theory methodology. Results Participants conceived that the pressure towards independence in clinical work originated in trainees’ desire to lay claim to the identity of a doctor (as a member of a group of autonomous high achievers), and in organisational issues such as heavy workloads and constant evaluations. Discussion The identity and organisational issues related to the pressure towards independence were explored through the lenses of established theories from education and psychology. Consideration of Lave and Wenger’s situated learning theory suggests that giving attention to the ‘independent doctor’ ideal, through measures such as involving trainees when their supervisors ask for help, could impact the safety of teaching team practice. Amalberti et al.’s migration model explains how pressures to maximise productivity and individual gain may cause teaching teams to migrate beyond the boundaries of safe practice and suggests that managing triggers (such as workload and high-stakes evaluations) for violations of safe practice might improve safety. Implementation and evaluation of these theory-based approaches to the safety of teaching team practice would contribute to a better understanding of the links between trainee independence and patient safety. [ABSTRACT FROM AUTHOR]

Patient safety has emerged as an important issue in Canadian health care, as reflected in the Canadian Council on Health Services Accreditation's patient/client safety goals. Achieving these goals calls for concerted efforts within health-care organizations. To assist nurse leaders in their efforts in developing a culture of safety that is receptive to reporting and learning from adverse events and near misses, the authors explore the challenges and provide four recommendations for action. By enacting these recommendations, nurse leaders can support the analysis and actions necessary to identify improvements that will create safer health-care environments. [ABSTRACT FROM AUTHOR]

Background In work for the World Alliance for Patient Safety on research methods and measures and on defining key concepts for an International Patient Safety Classification (ICPS), it became apparent that there was a need to try to understand how the meaning of patient safety and underlying concepts relate to the existing safety and quality frameworks commonly used in healthcare. Objectives To unfold the concept of patient safety and how it relates to safety and quality frameworks commonly used in healthcare and to trace the evolution of the ICPS framework as a basis of the electronic capture of the component elements of patient safety. Conclusion The ICPS conceptual framework for patient safety has its origins in existing frameworks and an international consultation process. Although its 10 classes and their semantic relationships may be used as a reference model for different disciplines, it must remain dynamic in the ever-changing world of healthcare. By expanding the ICPS by examining data from all available sources, and ensuring rigorous compliance with the latest principles of informatics, a deeper interdisciplinary approach will progressively be developed to address the complex, refractory problem of reducing healthcare-associated harm. [ABSTRACT FROM PUBLISHER]