Jason M Etchegaray

‘Speaking up’ about patient safety concerns and unprofessional behaviour among residents: validation of two scales

Objective To develop and test the psychometric properties of two new survey scales aiming to measure the extent to which the clinical environment supports speaking up about (a) patient safety concerns and (b) unprofessional behaviour. Method Residents from six large US academic medical centres completed an anonymous, electronic survey containing questions regarding safety culture and speaking up about safety and professionalism concerns. Results Confirmatory factor analysis supported two separate, one-factor speaking up climates (SUCs) among residents; one focused on patient safety concerns (SUC-Safe scale) and the other focused on unprofessional behaviour (SUC-Prof scale). Both scales had good internal consistency (Cronbachs α>0.70) and were unique from validated safety and teamwork climate measures (r<0.85 for all correlations), a measure of discriminant validity. The SUC-Safe and SUC-Prof scales were associated with participants’ self-reported speaking up behaviour about safety and professionalism concerns (r=0.21, p<0.001 and r=0.22, p<0.001, respectively), a measure of concurrent validity, while teamwork and safety climate scales were not. Conclusions We created and provided evidence for the reliability and validity of two measures (SUC-Safe and SUC-Prof scales) associated with self-reported speaking up behaviour among residents. These two scales may fill an existing gap in residency and safety culture assessments by measuring the openness of communication about safety and professionalism concerns, two important aspects of safety culture that are under-represented in existing metrics.

Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.

Background Open communication between healthcare professionals about care concerns, also known as ‘speaking up’, is essential to patient safety. Objective Compare interns and residents experiences, attitudes and factors associated with speaking up about traditional versus professionalism-related safety threats. Design Anonymous, cross-sectional survey. Setting Six US academic medical centres, 2013–2014. Participants 1800 medical and surgical interns and residents (47% responded). Measurements Attitudes about, barriers and facilitators for, and self-reported experience with speaking up. Likelihood of speaking up and the potential for patient harm in two vignettes. Safety Attitude Questionnaire (SAQ) teamwork and safety scales; and Speaking Up Climate for Patient Safety (SUC-Safe) and Speaking Up Climate for Professionalism (SUC-Prof) scales. Results Respondents more commonly observed unprofessional behaviour (75%, 628/837) than traditional safety threats (49%, 410/837); p<0.001, but reported speaking up about unprofessional behaviour less commonly (46%, 287/628 vs 71%, 291/410; p<0.001). Respondents more commonly reported fear of conflict as a barrier to speaking up about unprofessional behaviour compared with traditional safety threats (58%, 482/837 vs 42%, 348/837; p<0.001). Respondents were also less likely to speak up to an attending physician in the professionalism vignette than the traditional safety vignette, even when they perceived high potential patient harm (20%, 49/251 vs 71%, 179/251; p<0.001). Positive perceptions of SAQ teamwork climate and SUC-Safe were independently associated with speaking up in the traditional safety vignette (OR 1.90, 99% CI 1.36 to 2.66 and 1.46, 1.02 to 2.09, respectively), while only a positive perception of SUC-Prof was associated with speaking up in the professionalism vignette (1.76, 1.23 to 2.50). Conclusions Interns and residents commonly observed unprofessional behaviour yet were less likely to speak up about it compared with traditional safety threats even when they perceived high potential patient harm. Measuring SUC-Safe, and particularly SUC-Prof, may fill an existing gap in safety culture assessment.

Accuracy of the Safer Dx Instrument to Identify Diagnostic Errors in Primary Care

ABSTRACTIMPORTANCEDiagnostic errors are common and harmful, but difficult to define and measure. Measurement of diagnostic errors often depends on retrospective medical record reviews, frequently resulting in reviewer disagreement.OBJECTIVESWe aimed to test the accuracy of an instrument to help detect presence or absence of diagnostic error through record reviews.DESIGNWe gathered questions from several previously used instruments for diagnostic error measurement, then developed and refined our instrument. We tested the accuracy of the instrument against a sample of patient records (nu2009=u2009389), with and without previously identified diagnostic errors (nu2009=u2009129 and nu2009=u2009260, respectively).RESULTSThe final version of our instrument (titled Safer Dx Instrument) consisted of 11 questions assessing diagnostic processes in the patient–provider encounter and a main outcome question to determine diagnostic error. In comparison with the previous sample, the instrument yielded an overall accuracy of 84xa0%, sensitivity of 71xa0%, specificity of 90xa0%, negative predictive value of 86xa0%, and positive predictive value of 78xa0%. All 11 items correlated significantly with the instrument’s error outcome question (all p valuesu2009≤u20090.01). Using factor analysis, the 11 questions clustered into two domains with high internal consistency (initial diagnostic assessment, and performance and interpretation of diagnostic tests) and a patient factor domain with low internal consistency (Cronbach’s alpha coefficients 0.93, 0.92, and 0.38, respectively).CONCLUSIONSThe Safer Dx Instrument helps quantify the likelihood of diagnostic error in primary care visits, achieving a high degree of accuracy for measuring their presence or absence. This instrument could be useful to identify high-risk cases for further study and quality improvement.

Patients as Partners in Learning from Unexpected Events.

IMPORTANCEnPatient safety experts believe that patients/family members should be involved in adverse event review. However, it is unclear how aware patients/family members are about the causes of adverse events they experienced.nnnOBJECTIVEnTo determine whether patients/family members interviewed could identify at least one contributing factor for the event they experienced. Secondary objectives included understanding the way patients/family members became aware of adverse events, the types of contributing factors patients/family members identified for different types of adverse events, and recommendations provided by patients/family members to address the contributing factors.nnnDESIGNnWe interviewed patients/family members using semistructured interviews to understand their perceptions about why these adverse events occurred. The adverse events occurred between 1991 and 2014.nnnSETTINGnParticipants described adverse events that occurred in various types of health care organizations (i.e., hospitals, ambulatory facilities/clinics, and dental clinics).nnnPARTICIPANTSnWe interviewed 72 patients and family members who each described a unique adverse event. Eligibility requirements were that patients/family members spoke English or Spanish and were aware of an adverse event that happened to them or a loved one. INTERVENTION(S) FOR CLINICAL TRIALS OR EXPOSURE(S) FOR OBSERVATIONAL STUDIES: N/A.nnnMAIN OUTCOME(S) AND MEASURE(S)nThe main outcome was determining whether patients/family members could identify at least one contributing factor they perceived as related to the adverse event they described.nnnRESULTSnEach participant identified at least one contributing factor and on average identified 3.67 contributing factors for their event. The most frequently mentioned contributing factors were Staff Qualifications/Knowledge (79 percent), Safety Policies/Procedures (74 percent), and Communication (64 percent). Participants knew about the contributing factors from personal observation only (32 percent), personal reasoning (11 percent), personal research (7 percent), record review (either their own medical records or reports they received in their own investigation; 6 percent), and being told by a physician (5 percent). Finally, patients/family members were able to provide recommendations that address each of the nine contributing factors we examined.nnnCONCLUSIONS AND RELEVANCEnPatients/family members identified contributing factors related to their adverse event. Given that these contributing factors might not be known to health care organizations because most participants stated that they were not involved in the analysis process, opportunities for organizational learning from patients are potentially being missed. Health care organizations should interview patients/family about the event that harmed them to help ensure a full understanding of the causes of the event.

Comparing NICU teamwork and safety climate across two commonly used survey instruments

Background and objectives Measurement and our understanding of safety culture are still evolving. The objectives of this study were to assess variation in safety and teamwork climate and in the neonatal intensive care unit (NICU) setting, and compare measurement of safety culture scales using two different instruments (Safety Attitudes Questionnaire (SAQ) and Hospital Survey on Patient Safety Culture (HSOPSC)). Methods Cross-sectional survey study of a voluntary sample of 2073 (response rate 62.9%) health professionals in 44 NICUs. To compare survey instruments, we used Spearmans rank correlation coefficients. We also compared similar scales and items across the instruments using t tests and changes in quartile-level performance. Results We found significant variation across NICUs in safety and teamwork climate scales of SAQ and HSOPSC (p<0.001). Safety scales (safety climate and overall perception of safety) and teamwork scales (teamwork climate and teamwork within units) of the two instruments correlated strongly (safety r=0.72, p<0.001; teamwork r=0.67, p<0.001). However, the means and per cent agreements for all scale scores and even seemingly similar item scores were significantly different. In addition, comparisons of scale score quartiles between the two instruments revealed that half of the NICUs fell into different quartiles when translating between the instruments. Conclusions Large variation and opportunities for improvement in patient safety culture exist across NICUs. Important systematic differences exist between SAQ and HSOPSC such that these instruments should not be used interchangeably.

Improving Communication and Resolution Following Adverse Events Using a Patient-Created Simulation Exercise

OBJECTIVEnThe response to adverse events can lack patient-centeredness, perhaps because the involved institutions and other stakeholders misunderstand what patients and families go through after care breakdowns.nnnSTUDY SETTINGnWashington and Texas.nnnSTUDY DESIGNnThe HealthPact Patient and Family Advisory Council (PFAC) created and led a five-stage simulation exercise to help stakeholders understand what patients experience following an adverse event. The half-day exercise was presented twice.nnnDATA COLLECTION AND ANALYSISnLessons learned related to the development and conduct of the exercise were synthesized from planning notes, attendee evaluations, and exercise discussion notes.nnnPRINCIPAL FINDINGSnOne hundred ninety-four individuals attended (86 Washington and 108 Texas). Take-homes from these exercises included the fact that the response to adverse events can be complex, siloed, and uncoordinated. Participating in this simulation exercise led stakeholders and patient advocates to express interest in continued collaboration.nnnCONCLUSIONSnA PFAC-designed simulation can help stakeholders understand patient and family experiences following adverse events and potentially improve their response to these events.

Creating a comprehensive, unit-based approach to detecting and preventing harm in the neonatal intensive care unit

Background Error detection and analysis alone cannot create or sustain a culture of safe, high-quality, compassionate care for patients. Some experts have endorsed a unit-based approach to improving quality, but there are few examples and those rarely focus on reducing all preventable harms and engaging frontline clinicians, patients, and families. Approach: We implemented a unit-based approach comprising seven building blocks for creating a comprehensive approach to detect and prevent harm at the unit level within a hospital: (1) unit quality council and stakeholder buy-in, (2) parent engagement and advisory council, (3) frontline clinician and parent quality improvement training, (4) measurement of organizational contextual factors, (5) electronic health record trigger development and synthesis of harm measures, (6) subcommittees to review harm, and (7) quality improvement teams. Challenges and Lessons Learned: Challenges include conceptualizing triggers for a unit unfamiliar with this methodology, establishing unit resources for collecting and analyzing data, and creating processes to integrate parents in unit quality efforts. The seven essential building blocks helped overcome these challenges and could be adopted by other healthcare organizations. Conclusion These building blocks create a generalizable foundation for establishing a unit-based approach to detecting and preventing harm.

Steps in Developing a Patient-Centered Measure of Hospital Design Factors

Patients and families are at the center of care and have important perspectives about what they see occurring surrounding their healthcare, yet organizations do not routinely collect such perspectives from patients/families. Creating patient-centered measures is essential to understanding what they perceive about the environment as well as achieving the goal of patient-centered care. We focus this research methodology column on describing a four-step medical ethnography approach that can be used in developing patient-centered measures of interest to those studying built environments. In this column, we use this approach to illustrate how one might develop a measure that can be used to understand parent perceptions of the safety culture in neonatal intensive care units.