Category: Patient Safety

Problem Statement

Patient safety is one of the central factors that hospitals aim to improve. In settings where the number of patients greatly increases, the clinical handover process becomes an issue of quality. The lack of structure and systematized information transfer is related to several adverse outcomes for patients, including medication errors, the loss of patient data, pressure injuries, and falls (Hada et al., 2021). Moreover, other studies report potential problems in healthcare providers handoff efficiency and the use of available resources (Fealy et al., 2018; Rodriguez et al., 2021). Different approaches to sharing patient data between clinicians potentially lead to inconsistency in reporting adverse events and handoff quality. As an outcome, there exists a lack of studies analyzing the potential effect of establishing a system for handover that could become a standard of care and help healthcare providers improve patient safety.

Nevertheless, no nationwide or international standardized system of clinical handover exists presently. Moreover, while such countries as the United States or Canada follow specific protocols for handover, studies demonstrate that some nations do not have a singular system on which they could rely. Thus, healthcare organizations have to determine the procedure for patient handoff based on the existing research and the available evidence. Thus, the question of whether a standardized system could lead to improvements in patient safety and a decrease in adverse events arises.

In particular, the evidence discussed above suggests that change projects investigating the implementation of standardized procedures are significant for several reasons. First, they enrich the existing scholarship and add more evidence in favor of or opposition to the use of a national clinical patient handover process. Second, as PICOT projects are likely to explore different practice settings, they test the interventions applicability in a variety of settings, strengthening the overall quality of evidence. Thus, the proposed PICOT question for this particular setting is the following: (P) In the Acute Care Setting, (I) does the utilization of a unit-based standardized handoff checklist, (C) compared to not utilizing a standardized handoff checklist (O) reduce the likelihood of adverse events and the omission of important patient information?

Literature Review

The available evidence differs in structure, approach, and quality, arriving at a range of conclusions as a result. The studies reviewed for the proposed PICOT question include qualitative analyses, randomized controlled trials, and quasi-experimental studies, suggesting the lack of evidence of the highest quality. The majority of the examined sources present quantitative evidence gathered from intervention implementation. Qualitative information is collected through discussions with experienced healthcare professionals sharing their personal experiences and opinions on the procedure and quality of patient handovers (Fealy et al., 2018). Thus, the subjects of the studies are medical teams, nursing staff, and healthcare practitioners, which shows a focus on staff performance. Similarly, the settings primarily include acute care facilities, although one study focuses on pediatric care. Variables range greatly  studies analyze the potential impact of handover process standardization on patient safety, adverse outcomes, and professionals performance and efficiency. Notably, among the available articles, all studies analyzed for this PICOT question consider a unique set of variables.

Variables are collected through inpatient chart review, self-reporting, observation, and discussion. The results of the analyses depend on the chosen variables and the type of data collection. In qualitative discussions, the focus on the practice need for a standardized handover tool results in a consensus that such a practice would lead to better patient outcomes (Fealy et al., 2018). Nevertheless, the quantitative studies demonstrate mixed results  medical errors are either not reduced significantly (Tam et al., 2018) or are lowered significantly (6.26 (SD = 2.66) compared to 4.78 (SD = 2.84)) as a result of implementing a standardized handover practice (Hada et al., 2021, p. 466). The efficiency and the accuracy of the handover procedure do not improve (Rodriguez et al., 2021), although an increase in the number of patient handover rates is noted (Tam et al., 2018). Overall, the mixed results imply a need for further investigation and a discussion of how similar projects can be implemented in the future.

Application to Practice

The appraisal of the studies for the proposed PICOT question shows some problems with their validity, reliability, and potential biases. In quantitative investigations, the choice of variables and analyses suggests the high overall validity of findings. However, the settings offer limited usability of results  locations have different national standards for handover practices, and units have varying numbers and types of patients. Furthermore, the use of observation in several sources increases the risk of the Hawthorne effect and may negatively affect the applicability of evidence in future projects. Based on the SORT Criteria, the overall quality of studies is limited as they have inconsistent findings and rely on observation. Furthermore, there exists a lack of patient-oriented evidence, as only two of the four sources present clear variables related to the rate of medication errors and patient safety.

Based on the evaluation of the sources and the use of the SORT criteria, the evidence for practice change is insufficient to make a recommendation. The main strength of the evidence is the presence of several quantitative analyses focused on patient outcomes, although their results are inconsistent. The weak point in this investigation is the absence of high-quality evidence, such as systematic reviews or meta-analyses. These conclusions suggest that more research and projects are necessary to make decisions regarding the use of standardized handover checklists.

References

Fealy, G., Donnelly, S., Doyle, G., Brenner, M., Hughes, M., Mylotte, E., Nicholson, E., & Zaki, M. (2018). Clinical handover practices among healthcare practitioners in acute care services: A qualitative study. Journal of Clinical Nursing, 28(1-2), 8088. Web.

Hada, A., Jones, L. V., Jack, L. C., & Coyer, F. (2021). Translating evidence-based nursing clinical handover practice in an acute care setting: A quasi-experimental study. Nursing & Health Sciences, 23(2), 466-476. Web.

Rodriguez, G., Velardez, D., Gibbons, L., Ábalos, S., Lardone, S., Gallagher, R., Olivieri, J., Rodriguez, R., Vassallo, J. C., Landry, L. M., & García-Elorrio, E. (2021). Handoff improvement and adverse event reduction programme implementation in paediatric intensive care units in Argentina: A stepped- wedge trial. BMJ Quality & Safety, 30(10), 782791. Web.

Tam, P., Nijjar, A. P., Fok, M., Little, C., Shingina, A., Bittman, J., Raghavan, R., & Khan, N. A. (2018). Structured patient handoff on an internal medicine ward: A cluster randomized control trial. PloS One, 13(4). Web.

Introduction

Patient safety lies at the core of healthcare organization concerns. Any behavior by professionals that leads to adverse events has to be investigated by the hospital and outside organizations to determine whether a different approach should and could have been chosen to prevent a negative outcome for patient health. However, healthcare workers may be hesitant to talk about witnessed events due to the fear of retaliation. The Patient Safety and Quality Improvement Act addresses this issue by protecting the identity of the person who reports the problem and the information they share with organizations.

Event

While patient harm is always a poor care outcome, only some events happen due to negligence. For example, a possible event that can be reported is the lack of proper examination by a physician. In the case described by the Agency for Healthcare Research and Quality (AHRQ, 2019a), the provider sees a patient with rectal bleeding and completes a sigmoidoscopy without additional checks. Despite the patients persistent symptoms, the physician dismisses the problem. As the patient loses weight significantly and enters the hospital again after almost two years, it is discovered that he has colon cancer that has progressed to the liver. As a result of the investigation, the physician is found to be at fault due to negligence.

Stakeholders

The stakeholders involved in this situation are the physician, the patient, the investigating professionals, and the organization where the event happened. First, the role of the organization is to prevent such events from happening by implementing a patient safety culture (American Society for Health Care Risk Management [ASHRM], 2004). This can be achieved through a variety of approaches, including peer review, frequent training initiatives, formal checks of workers performance, and a focus on excellence and quality of care (ASHRM, 2007). Second, the physician responsible for the adverse event is a stakeholder, as his decision impacted patient health. His role in the adverse event is direct  his negligence and lack of attention to patient needs have led to the patients cancer going undiagnosed for almost two years (AHRQ, 2019a). His behavior and decision-making were some of the core elements of the problem.

Next, the patient is a stakeholder in the case, as his health was impacted by the physicians choices. The role of the patient in such cases is to receive proper care, as he is unable to understand whether the medical professional is correct. Finally, the medical professionals investigating the event are also stakeholders, as their examination of the patient and past records determines whether the physician has acted with disregard for the patients well-being.

Prevention Plan

The plan for preventing such events requires the organization to review its current safety culture and improve it. Therefore, the first step towards change is to analyze the current system, its weaknesses, and strengths and create a list of potential problems that the hospital may have (ASHRM, 2019). In this case, a possible issue is the lack of training to increase the understanding and role of patient safety in proper care. Thus, the organization needs to introduce team training for healthcare workers that focuses on quality improvement, patient safety, and values (AHRQ, 2019b). Next, a possible issue is limited transparency in communication between workers and management and reporting of adverse events. The hospital needs to adopt an approach for anonymous reporting that is non-punitive, fair, and safe for workers. By using such channels, negative events can be discovered early and help mitigate patient harm (ASHRM, 2019). Proper research of such reports by the organization is also vital to separate preventable and non-preventable issues.

Conclusion

Adverse events that occur due to negligence endanger patients and harm the organization. Preventing them is a priority for the hospital, and it can be done by improving safety culture. In the investigated case, the physicians actions are at the center of the problem, but a larger issue of a lacking reporting system and insufficient education can be found. Thus, the prevention plan should include measures to report issues anonymously and training opportunities to talk about patient safety.

References

Agency for Healthcare Research and Quality. (2019a). Adverse events, near misses, and errors. Web.

Agency for Healthcare Research and Quality. (2019b). Reporting patient safety events. Web.

American Society for Health Care Risk Management. (2004). The growing role of the patient safety officer: Implications for risk managers. Web.

American Society for Health Care Risk Management. (2007). Different roles, same goal: Risk and quality management partnering for patient safety. Web.

American Society for Health Care Risk Management. (2019). Healthcare risk management: The path forward. Web.