Anne Skinner

A theory-driven, longitudinal evaluation of the impact of team training on safety culture in 24 hospitals

Background Effective teamwork facilitates collective learning, which is integral to safety culture. There are no rigorous evaluations of the impact of team training on the four components of safety culture—reporting, just, flexible and learning cultures. We evaluated the impact of a year-long team training programme on safety culture in 24 hospitals using two theoretical frameworks. Methods We used two quasi-experimental designs: a cross-sectional comparison of hospital survey on patient safety culture (HSOPS) results from an intervention group of 24 hospitals to a static group of 13 hospitals and a pre-post comparison of HSOPS results within intervention hospitals. Dependent variables were HSOPS items representing the four components of safety culture; independent variables were derived from items added to the HSOPS that measured the extent of team training, learning and transfer. We used a generalised linear mixed model approach to account for the correlated nature of the data. Results 59% of 2137 respondents from the intervention group reported receiving team training. Intervention group HSOPS scores were significantly higher than static group scores in three dimensions assessing the flexible and learning components of safety culture. The distribution of the adoption of team behaviours (transfer) varied in the intervention group from 2.8% to 31.0%. Adoption of team behaviours was significantly associated with odds of an individual reacting more positively at reassessment than baseline to nine items reflecting all four components of safety culture. Conclusions Team training can result in transformational change in safety culture when the work environment supports the transfer of learning to new behaviour.

Errors prevented by and associated with bar-code medication administration systems.

As expected, bar-code medication administration systems can prevent medication errors. However, health care organizations must be aware of identified failure points in bar coding that may contribute to errors.

Naturalistic decision making in after-action review meetings: The implementation of and learning from post-fall huddles

The purpose of this study was to add to our understanding of Naturalistic Decision Making (NDM) in healthcare, and how After Action Reviews (AARs) can be utilized as a learning tool to reduce errors. The study focused on the implementation of a specific form of AAR, a post-fall huddle, to learn from errors and reduce patient falls. Utilizing 17 hospitals that participated in this effort, information was collected on 226 falls over a period of 16 months. The findings suggested that the use of self-guided post-fall huddles increased over the time of the project, indicating adoption of the process. Additionally, the results indicate that the types of errors identified as contributing to the patient fall changed, with a reduction in task and coordination errors over time. Finally, the proportion of falls with less adverse effects (such as non-injurious falls) increased during the project time period. The results of this study fill a void in the NDM and AAR literature, evaluating the role of NDM in healthcare specifically related to learning from errors. Over time, self-guided AARs can be useful for some aspects of learning from errors.

Shifting the paradigm: an assessment of the quality of fall risk reduction in Nebraska hospitals

PURPOSE To assess the prevalence of evidence-based fall risk reduction structures and processes in Nebraska hospitals; whether fall rates are associated with specific structures and processes; and whether fall risk reduction structures, processes, and outcomes vary by hospital type--Critical Access Hospital (CAH) versus non-CAH. METHODS A cross-sectional survey of Nebraskas 83 general community hospitals, 78% of which are CAHs. We used a negative binomial rate model to estimate fall rates while adjusting for hospital volume (patient days) and the exact Pearson chi-square test to determine associations between hospital type and the structure and process of fall risk reduction. FINDINGS Approximately two-thirds or more of 70 hospitals used 6 of 9 evidence-based universal fall risk reduction interventions; 50% or more used 14 of 16 evidence-based targeted interventions. After adjusting for hospital volume, hospitals in which teams integrated evidence from multiple disciplines and reflected upon data and modified polices/procedures based upon data had significantly lower total and injurious fall rates per 1,000 patient days than hospitals that did not. Non-CAHs were significantly more likely than CAHs to perform 5 organizational-level fall risk reduction processes. CAHs reported significantly greater total (5.9 vs 4.0) and injurious (1.7 vs 0.9) fall rates per 1,000 patient days than did non-CAHs. CONCLUSIONS Hospital type was a significant predictor of fall rates. However, shifting the paradigm for fall risk reduction from a nursing-centric approach to one in which teams implement evidence-based practices and learn from data may decrease fall risk regardless of hospital type.