Henning Boje Andersen

Factors that impact on the safety of patient handovers: An interview study

Aims: Improvement of clinical handover is fundamental to meet the challenges of patient safety. The primary aim of this interview study is to explore healthcare professionals’ attitudes and experiences with critical episodes in patient handover in order to elucidate factors that impact on handover from ambulance to hospitals and within and between hospitals. The secondary aim is to identify possible solutions to optimise handovers, defined as “situations where the professional responsibility for some or all aspects of a patient’s diagnosis, treatment or care is transferred to another person on a temporary or permanent basis”. Methods: We conducted 47 semi-structured single-person interviews in a large university hospital in the Capital Region in Denmark in 2008 and 2009 to obtain a comprehensive picture of clinicians’ perceptions of self-experienced critical episodes in handovers. We included different types of handover processes that take place within several specialties. A total of 23 nurses, three nurse assistants, 13 physicians, five paramedics, two orderlies, and one radiographer from different departments and units were interviewed. Results: We found eight central factors to have an impact on patient safety in handover situations: communication, information, organisation, infrastructure, professionalism, responsibility, team awareness, and culture. Conclusions: The eight factors identified indicate that handovers are complex situations. The organisation did not see patient handover as a critical safety point of hospitalisation, revealing that the safety culture in regard to handover was immature. Work was done in silos and many of the handover barriers were seen to be related to the fact that only few had a full picture of a patient’s complete pathway.

A human error taxonomy for analysing healthcare incident reports: assessing reporting culture and its effects on safety performance

The present paper reports on a human error taxonomy system developed for healthcare risk management and on its application to evaluating safety performance and reporting culture. The taxonomy comprises dimensions for classifying errors, for performance‐shaping factors, and for the maturity of reporting culture contained in incident reports. Applying several dimensions in the taxonomy, we propose on the one hand two safety performance measures, i.e., the rate of near‐miss reporting and the rate of near‐miss detection by safety procedure, and on the other, measures for diagnosing reporting culture including average descriptive depth in reports. We applied the taxonomy to a total of 3749 incident cases collected from two Japanese hospitals, which were at different stages of patient safety activities: Hospital A initiated organisation‐wide initiatives several years before the survey period, while such safety‐related activities had just commenced in Hospital B. The hospitals also differed in their reporting rates of incidents per nurse: 3.05 (A) vs. 0.65 (B). Results show that the taxonomy can identify differences between these hospitals both in terms of safety performance and reporting culture. In addition, a correlation trend was observed between these two measures.

Promoters and barriers in hospital team communication. A focus group study

Abstract Purpose Poor teamwork and communication in healthcare teams have been correlated to adverse events and higher patient morbidity and mortality. However, detailed insight into the link between team communication and medical error is still lacking. The objective of this study is to identify the common characteristics of team communication among multiprofessional teams at four Danish acute care university hospitals. Method Four focus group interviews with multiprofessional hospital teams (N = 24). Results Communication is particularly vulnerable during handover of patient information between shifts or units, when a team has to establish skills and roles during teamwork and when staff has to await and combine information from different chart systems. Established frameworks for communication, mutual knowledge, ease of speaking up, experience in getting the message through, and focus on teamwork and communication promote safe information exchange. Lack of standard assignments and procedures, a flat hierarchy that leaves responsibility unclear, different agendas for the treatment of the patient, interruptions, and multitasking, inhibit safe information exchange. Conclusion Power distance, team structure, and hospital organization influence team communication and vary between settings and national cultures. These factors must be accounted for before developing or adapting team communication interventions to improve patient safety.

Validating the Danish adaptation of the World Health Organization's International Classification for Patient Safety classification of patient safety incident types

Objectives Validation of a Danish patient safety incident classification adapted from the World Health Organizatons International Classification for Patient Safety (ICPS-WHO). Design Thirty-three hospital safety management experts classified 58 safety incident cases selected to represent all types and subtypes of the Danish adaptation of the ICPS (ICPS-DK). Outcome Measures Two measures of inter-rater agreement: kappa and intra-class correlation (ICC). Results An average number of incident types used per case per rater was 2.5. The mean ICC was 0.521 (range: 0.199–0.809) and the mean kappa was 0.513 (range: 0.193–0.804). Kappa and ICC showed high correlation (r = 0.99). An inverse correlation was found between the prevalence of type and inter-rater reliability. Results are discussed according to four factors known to determine the inter-rater agreement: skill and motivation of raters; clarity of case descriptions; clarity of the operational definitions of the types and the instructions guiding the coding process; adequacy of the underlying classification scheme. Conclusions The incident types of the ICPS-DK are adequate, exhaustive and well suited for classifying and structuring incident reports. With a mean kappa a little above 0.5 the inter-rater agreement of the classification system is considered ‘fair’ to ‘good’. The wide variation in the inter-rater reliability and low reliability and poor discrimination among the highly prevalent incident types suggest that for these types, precisely defined incident sub-types may be preferred. This evaluation of the reliability and usability of WHOs ICPS should be useful for healthcare administrations that consider or are in the process of adapting the ICPS.

Evaluating and Managing Safety Barriers in Major Hazard Plants

The European ARAMIS project (Hourtolou and Salvi, 2003) is developing an integrated approach to the modelling and management of major hazard risks for major hazard plants. Central to the model being used is the concept of safety functions and barriers.

Recurring themes in the legacy of Jens Rasmussen

This paper was accepted for publication in the journal Applied Ergonomics and the definitive published version is available at http://dx.doi.org/10.1016/j.apergo.2016.10.002

Analysing medical incident reports by use of a human error taxonomy

The present paper describes analysis results of incident reports collected from three Japanese hospitals. We developed a medical incident taxonomy by adapting an existing scheme in air traffic management. Its application allowed us to elicit characteristics of adverse events and errors that have occurred in health care. The taxonomy was evaluated in terms of inter-rater reliability by use of raw agreement and a tentative measure of chance corrected agreement between two judges.

Hospital Staff Attitudes to Models of Reporting Adverse Events: Implications for Legislation

The paper describes (i) results of a survey of the perceptions of doctors and nurses to models of reporting adverse events; (ii) recommendations developed by the project group behind the survey; and (iii) recently introduced legislation in Denmark prescribing a strictly confidential system of reporting safeguarding the anonymity outside their own department of doctors and nurses submitting reports of adverse events.

Perspectives on healthcare safety and quality: selected papers from the 2nd Nordic Conference on Research in Patient Safety and Quality in Healthcare

This special section of Cognition, Technology and Work is a collection of papers presented at the 2nd Nordic Conference on Research in Patient Safety and Quality in Healthcare (2012, Copenhagen). The conference was organized by the Danish Research Network for Patient Safety and Quality in Healthcare in collaboration with sister organizations in Norway, Sweden and Finland. The section illustrates and promotes research in a broad socio-technical field in which quality and safety adversely affect more people than in any other sector of society, with the exception of war and large-scale natural disasters. At the same time, the papers exemplify current multidisciplinary approaches to the study of the interaction of work, technology, patient involvement and empowerment and the management of complex processes. The majority of papers delivered at the Nordic conferences are, unsurprisingly, presented by Nordic authors, but the issues addressed and the methods of approach applied in the eight papers in this special section are not limited to a specific societal or regional context. The papers exemplify how research may point the way to reducing and sometimes even controlling risks in the broad socio-technical field of healthcare. At the same time, the papers exemplify the relevance and much needed application of multidisciplinary approaches to the study of the interaction of work, technology, patient involvement and empowerment as well as the management of complex processes. In the first paper in this Special section, Ekstedt and Ödegård report on their study of patient safety challenges of ensuring continuity of cancer care. Although based on observations garnered in a particular specialty, the study results point to a generic safety requirement: healthcare professionals’ ability to anticipate, detect and handle gaps created by the system. When factors such as resource constraints, limited contact between healthcare professionals, and unclear responsibility and accountability for care come into play, healthcare professionals’ ability to identify and mitigate the risks is essential to keep the patients safe. The study highlights the challenges related to patient treatment in complex and fragmented healthcare systems and the inherent risk when care involves different professions. The study also suggests a difference in how professionals at the sharp and the blunt end of the healthcare system approach safety, and the authors set the stage for an interesting discussion of how design of resilient care organizations may rely on management’s response to identified gaps. Another perspective on safety challenges related to care coordination is addressed in the literature review by Dyrstad, Testad, Aase and Storm, who focus on patient participation in transitions of elderly patients. This is a topical focus considering that terms such as ‘patient centeredness,’ ‘patient involvement’ and ‘patient empowerment’ are often used in headlines on health policy agendas. The trend of engaging patients is motivated not only by the expectation that when patients act as an additional safety barrier they may supplement the barriers inside the healthcare system, but also by a desire for a more profound H. B. Andersen (&) Technical University of Denmark, DTU Management Engineering Institute, 2800 Kongens Lyngby, Denmark e-mail: hebq@dtu.dk

Outcomes of a classroom-based team training intervention for multi-professional hospital staff.

We conducted a study to review the student selection methods the Taiwan medical schools have applied, and to report the related problems. There are 12 medical schools in Taiwan. In 2010 and 2011, admission information was retrieved from school official website. Surveys asking for student enrolment size, methods applied for student selection and admission procedure were distributed to each school. A focus group of school representatives then met for validation and communication on the topics of student selection. We identified three approaches in selecting medical students: Joint College Entrance Examination (JCEE), selfapplication (SA) and school recommendation (SR). For the approaches of SA and SR, multiple assessment modalities including interviews were used. The number of newly enrolled students per school ranged from 43 to 136 in 2010, and 40 to 136 in 2011, and 9.6–70.4% (mean: 41.7 13.7% in 2010, and 37.9 18.9% in 2011) of them were selected through interview-based procedures. The first step in removing unsatisfactory candidates was solely based on the JCEE score. In the second step, students were interviewed and the personal files were reviewed. Several medical schools used multi-mini interview (Tsai et al. 2008), with the number of interview stations ranging from two to ten. Personal files were composed of students’ scores of the Department Required Test, high school grades, extracurricular activities, awards and others. The size of candidate pool was found to be too small to allow selection in function. The participants expressed concerns on the inequality derived from the rural-urban disparity. They also indicated the system may select ‘good test takers’ rather than ‘good doctors’. Currently in Taiwan, multiple assessment tools including interviews have been widely applied in selecting medical students. The core values underlying the selection remained the ‘cognitive achievement-based’ scores, and a ‘real change’ is deemed difficult to achieve. The problems were derived from the system, examinations and personnel training.