Clinical placements expose nursing students to patient safety incidents and provide important opportunities for learning about safe care. This study explored how nursing students in four countries recognized and interpreted patient safety incidents encountered or witnessed during clinical practice, including perceived contributing factors. A secondary qualitative content analysis was conducted using narrative data from 1442 undergraduate nursing students in the Czech Republic, Italy, Slovakia, and Türkiye. In total, 287 incident descriptions and 263 explanations of perceived reasons were analyzed using an inductive-deductive approach supported by descriptive frequency counts. Medication safety incidents and patient falls were most frequently reported, alongside infection prevention breaches, missed or inadequate care, communication failures, adverse outcomes, and environmental hazards. Students described incidents as multifactorial, involving patient and contextual factors, organizational and system conditions, and human and professional factors. Cross-country differences reflected patterns within the analyzed narratives rather than differences in incident prevalence or quality of care. The findings support practice-integrated patient safety education, effective supervision, structured reflection and debriefing, clear reporting pathways, and psychologically and emotionally safe, nonpunitive learning environments.
Immunology and allergy clinics of North AmericaMargaret Redmond
This article uses a hypothetical quality improvement project to discuss the process of the Model for Improvement and ways to incorporate this into allergy practice.
Nursing in critical careEbru Önler, Fatma Nair Aktaş, Louise Hull, Mandeep Sekhon, Nick Sevdalis
BACKGROUND: Poor handovers from ICU to general surgical wards cause communication and teamworking challenges, loss of information, readmission to the ICU within 48 h and increased hospital stay and may result in unexpected death. AIMS: The primary aim of this research was to evaluate the effects of implementing a standardized patient handover process, supported by a structured handover checklist, on postoperative handovers from the Surgical Intensive Care Unit (SICU) to surgical wards among nurses. The secondary aim was to evaluate nurses' perceptions of the acceptability, feasibility and appropriateness of the standardized handover process. STUDY DESIGN: This study was conducted in the general surgery ICU (SICU) and the general surgical ward of a 900-bed public hospital in Türkiye. A total of 100 patient handovers from the SICU to the ward were observed (50 pre-implementation, 50 post-implementation). Following pre-implementation data collection, nurses received training on the standardized handover process. Nurses completed validated implementation outcome surveys at 1- and 10-month post-implementation to evaluate the acceptability, feasibility and appropriateness of the handover standardization; they also completed a satisfaction questionnaire administered 1-month post-implementation. RESULTS: A total of 39 nurses participated in the study. Following implementation of the standardized handover, coverage of patient care elements increased, with the largest and statistically significant improvements with significant improvements in patient identification and drain/catheter information (p < 0.001). Handover duration increased, but the difference was not statistically significant (p = 0.051). Interruptions were observed in 50% of handovers before implementation and in 48% of handovers after implementation. Nurses reported high satisfaction with the standardized handover process and perceived implementability-including acceptability, feasibility and appropriateness-was high at both 1- and 10-month post-implementation. CONCLUSIONS: The implementation of a standardized patient handover process improved information transfer and was perceived as satisfactory, acceptable, feasible and appropriate by nurses. RELEVANCE TO CLINICAL PRACTICE: This study is relevant to clinical practice as it presents a newly developed, effective and implementable SICU-to-ward handover strategy for nurses.
PURPOSE/OBJECTIVE: This project aimed to educate nurses on teaching patients about the safe management and removal of Jackson-Pratt (JP) drains at home. Using a multimodal learning approach allowed staff and patients to practice the procedure and build confidence to independently perform a JP drain removal. The project objective was to ensure that patients safely remove their own JP drain at home without complications. DESCRIPTION: After 2 extensive literature searches on the adverse effects of a delayed drain removal and the benefits of an at-home drain removal, a teaching plan was developed, which included a handout for the nurses with key teaching points, a patient education handout, and face-to-face education with staff for hands-on practice. OUTCOMES: This is an ongoing project that was initiated in February 2025. Although this is a new project, close to 100 drains have been successfully removed at home with no complications reported. CONCLUSIONS: By teaching nurses to educate their patients on JP drain management and removal at home, our staff was able to ensure patient safety and comfort. By educating patients on proper care and removal of their JP drains, bedside nurses improved patient satisfaction, reduced the risk of complications, decreased resource utilization, while not compromise patient outcomes.
Clinical nurse specialist CNSMichael Gnidovec, Deb L Lindell
PURPOSE/OBJECTIVES: The project aimed to improve the safety of hospitalized tracheostomy and laryngectomy adults by reducing the time to initial respiratory therapist assessment and the delivery of emergency equipment to the bedside. DESCRIPTION: Tracheostomy and laryngectomy patients are classified as a low-volume, high-risk patient population. The specialized care and equipment needed for them are essential, especially in an acute care setting like a hospital. The ability to ensure safety equipment compliance at the time of admission is a challenge as it relies heavily on communication, which can be subject to human error. Three months of retrospective data were analyzed, which led the team to identify a gap in the notification process. The project team created an automated pager notification of new patients needing assessment and delivery of emergency equipment, triggered by an EHR notification when the patient's status changed to admitted. OUTCOME: A Kruskal-Wallis test compared time to assessment between the 2 groups and established that the difference was not statistically significant (P=0.121). However, the lower mean and median times to assessment in the postintervention group are clinically significant for this population. CONCLUSIONS: Automated notifications were effective in reducing delays in care and delivery of emergency equipment for this vulnerable population. .
BACKGROUND: Protected sleep is a core component of developmental supportive care in neonates. However, the overstimulating neonatal intensive care unit (NICU) environment and procedures often disrupt neonatal sleep periods. With improving neonatal survival rates in low- and middle-income countries like India, focus must shift towards ensuring neurologically intact outcomes. We implemented a point of care quality improvement initiative using environmental modification to improve sleep duration in neonates admitted to the low dependency unit (LDU) of our NICU. METHODS: This prospective quality improvement study was conducted at a tertiary care teaching hospital in North India from May to August 2024. All stable neonates admitted to the LDU during the study period were enrolled. Four sequential plan-do-study-act (PDSA) cycles were implemented, targeting cyclic lighting, noise reduction through alarm management and equipment repair, staff sensitisation and caregiver involvement. The primary outcome was the proportion of neonates achieving adequate sleep duration of more than 16 hours/day. RESULTS: A total of 625 neonates were enrolled across three phases (baseline: n=115; implementation: n=312; post implementation: n=198). The proportion of neonates achieving adequate sleep increased from 15.7% at baseline to 62.2% during implementation and sustained at 58.1% post implementation. Mean sleep duration increased significantly from 12.95±3.22 to 16.38±3.12 hours/day (p<0.001). Environmental parameters also improved, with daytime mean light intensity reducing from 486±124 to 285±98 lux and mean noise levels decreasing from 62.4±8.3 to 52.8±6.5 dB. CONCLUSION: Simple, low-cost environmental modifications implemented through sequential PDSA cycles can significantly improve sleep duration in NICU neonates.
Journal of medical Internet researchBenjamin Michaels, Jessica Pourian
BACKGROUND: Assessing medication adherence is central to quality care, yet linking electronic health record (EHR) medication orders to outpatient pharmacy dispense data remains technically complex. OBJECTIVE: This study aimed to present a generalized, reproducible tutorial for linking EHR medication orders to pharmacy dispense data that can be used to assess medication dispense proportions. METHODS: We developed and validated a structured query approach to link EHR medication orders to external pharmacy dispense data using patient identifiers, medication-level identifiers, pharmacy identifiers, and temporal constraints. The tutorial emphasizes key design decisions, including handling multiple triggering events, deduplication across vendors, and managing formulation changes. A retrospective cohort of pediatric acute otitis media encounters (January 1, 2021, to January 1, 2024) was used as an illustrative example. RESULTS: Overall, 98.3% (302/307) of pharmacies in the cohort returned at least 1 dispense record during the study period and were therefore classified as reporting pharmacies. Among 3404 orders, 2616 (76.9%) had a recorded dispense. CONCLUSIONS: EHR-integrated pharmacy data provide a feasible, timely proxy for assessing medication adherence. This tutorial provides a scalable framework for linking EHR and pharmacy data for medication adherence studies, while highlighting key methodological considerations for SQL coding.
BMJ open qualityMohamed A Mansour, Ali Al-Kulabi, Minaam Abbas, Layth Qaraqe, Sade Uwaoma, Ahmad Al-Sukaini, Lora Young, Sue Deakin
INTRODUCTION: Managing musculoskeletal (MSK) injuries requires effective communication and collaboration between the emergency department (ED) and orthopaedic teams. A quality improvement project analysing virtual fracture clinic (VFC) referrals, staff challenges and the impact of the novel digital solution, Virtual Bones (VB), was undertaken at the West Suffolk Hospital. VB is a digital platform, available at the point of care, that guides clinicians in the assessment and management of MSK injury presentations in ED and referral to VFC. METHODS: VFC outcome data were collected between 2017 and 2022, with a 2-week focused data collection gathering diagnosis, ED processing times, patient leaflet distribution, VFC decisions and referral quality. An ED survey was distributed to explore staff challenges in the management of MSK injuries. Virtual Bones, a novel digital solution, was developed and deployed to enable clinicians to comprehensively digitalise MSK injury management pathways from first patient encounter to referral/discharge. Subsequent data collection cycles compared baseline to post deployment results. RESULTS: The Virtual Bones pilot (undertaken May-July 2023) involved 352 users, 2400 sessions and 56 700 page views. The initial 2-week cycle included 260 patients while the subsequent cycles included a total of 258. Mean ED processing times decreased from 166 to 122 min, with an up to 90 min reduction in the Foundation Doctors' group (p<0.0001). Inappropriately referred dischargeable injuries decreased from 23 to 10. Improper documentation decreased from 58% to 30% (p<0.0001). The VFC discharge rate increased from 39% to 48% (p=0.021). Patient information leaflet use increased from 27% to 41% (p=0.032). The ED staff survey demonstrated improved staff confidence in the revealed challenges, including navigating local guidelines, locating equipment, applying immobilisation devices and supplying information leaflets. CONCLUSION: Robust engagement with Virtual Bones, along with improved metrics, suggests that this digital solution effectively streamlined MSK injury pathways and helped staff manage challenges.
British journal of community nursingIoulia Mariaki, Rory McDermott
BACKGROUND: Community-based models of care, including respiratory virtual wards and Hospital at Home services, continue to expand across the NHS as part of wider efforts to reduce hospital admissions and deliver acute care closer to home. Alongside increasing clinical acuity, community clinicians are increasingly caring for patients with significant psychosocial complexity, including substance use, safeguarding concerns, unstable housing, poor engagement with treatment and environmental risks. While national policy has focused on expanding community-based models of care, comparatively little guidance exists to support frontline clinicians managing the intersection of clinical, psychosocial, safeguarding and workforce safety risks within patients' homes. AIMS: This article describes the development and early implementation of a structured risk-assessment framework designed to support safer, more consistent and defensible decision making when managing patients with complex psychosocial and environmental needs in a respiratory virtual ward. METHODS: The framework was developed as a practice-based quality improvement initiative through frontline clinical experience, multidisciplinary collaboration, reflective practice, review of governance processes and relevant national guidance relating to safeguarding, lone working and workforce safety. Following implementation, a 3-month feasibility pilot involving seven patients presenting with complex clinical, psychosocial and safeguarding needs was undertaken to evaluate the framework's usability in routine practice and inform future service evaluation. FINDINGS: Early implementation improved consistency of decision making, multidisciplinary communication, documentation and staff confidence when managing complex situations. Formal evaluation of patient-level and service-level outcomes is planned. CONCLUSIONS: As community-based healthcare continues to evolve, structured operational frameworks may support safer clinical decision making while balancing patient-centred care, safeguarding responsibilities and workforce safety. Further evaluation is required to determine the framework's effectiveness and wider applicability across community healthcare services. IMPLICATIONS FOR PRACTICE: The pilot indicates that the framework is feasible for implementation and can be applied consistently in routine clinical practice, supporting structured multidisciplinary discussions, tailored risk mitigation strategies and strengthened governance oversight.
BMJ openRitah Nantale, David Mukunya, Julius N Wandabwa, Agnes Napyo, Albert Ssesanga, Eunice Akello, Kenneth Tulya-Muhika Mugabe, Brenda Nambozo, Faith Oguttu, John S…
OBJECTIVE: To assess the effect of introducing the Moyo device for continuous intrapartum fetal heart rate monitoring (FHRM) on the detection of abnormal fetal heart rate patterns and perinatal mortality. DESIGN: We conducted a quasi-experimental quality improvement project using a before-and-after approach. During the preimplementation phase, intermittent FHRM was done using the existing standard of care (Pinard or a hand-held fetal Doppler). In the postimplementation phase, we introduced the Moyo device (Laerdal Global Health, Stavanger, Norway) for continuous intrapartum FHRM. We used the non-participant observation technique to collect data. SETTING: Mbale Regional Referral Hospital in Eastern Uganda, 6 November 2023 to 17 August 2024. PARTICIPANTS: We enrolled 1544 women with high-risk pregnancies. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was perinatal mortality, defined as death in labour and up to 24 hours postnatal. The secondary outcomes included detection of abnormal fetal heart rates, Apgar scores less than 7 at 1 and 5 min and mode of birth. We conducted generalised linear regression models of the binomial family with a log link and robust variance estimation. RESULTS: Mortality preimplementation was 5.1%; following the introduction of the Moyo device, it fell to 3.2%, a non-statistically significant reduction of 37% (adjusted prevalence ratios (aPRs): 0.63 (95% CI 0.39 to 1.02)). There was a 14.8% increase in the number of women whose fetal heart rate was monitored and documented during the postimplementation period (81.1% vs 95.9%) and detection of abnormal fetal heart rate was increased by 41% (aPR: 1.41 (95% CI 1.10 to 1.82)). The rate of caesarean section deliveries was similar in the preimplementation and postimplementation period (59.5% vs 63.1%, p=0.144). Newborn morbidities were lower in the postimplementation phase compared with the preimplementation phase: Apgar score <7 at 1 min (aPR: 0.67; 95% CI 0.54 to 0.85), Apgar score <7 at 5 min (aPR: 0.57; 95% CI 0.39 to 0.84), transfer of newborn to postnatal ward (aPR: 1.11; 95% CI 1.05 to 1.17), and transfer of newborn to the neonatal unit (aPR: 0.72; 95% CI 0.59 to 0.87). CONCLUSIONS: Introduction of the Moyo device for continuous FHRM was associated with a reduction in perinatal morbidity among women with high-risk pregnancies. We recommend a stepped-wedge trial to evaluate the cost-effectiveness of scaling up the use of Moyo in lower-health facilities.
Connected procedural care is increasingly evaluated product by product, although performance emerges from interactions across technologies, organizations, and clinical workflows. This paper proposes System Performance Readiness (SPR) as a capability for understanding system performance across product boundaries. Its defining requirement is that a connected procedural episode be reconstructable, so that any legitimate participant, whether a health system, manufacturer, clinician, or regulator, can understand how the connected system performed. Rather than creating a new regulatory layer or data platform, the framework specifies what a system should be able to know, who is responsible for the relevant evidence, and how learning can occur across platforms and sites. A reconstructable record of the connected episode makes it possible to understand how the system performed, so that learning, not blame, drives improvement.
Journal of applied clinical medical physicsVictoria Bry, Angelia Tran, Tamara Egan, Eric Ford, Juergen Meyer
BACKGROUND: Surface Guided Radiation Therapy (SGRT) has become an increasingly important tool that complements x-ray imaging to improve patient safety for setup, respiratory tracking, and motion monitoring. As SGRT is integrated into clinical workflows, its complexity can introduce potential risk of process-related errors. These risks may depend on workflow design, system integration, equipment configuration, and technology specific features. As SGRT continues to expand across a wider range of treatment sites and clinical applications, comprehensive evaluation of institutional workflows is recommended to support safe and effective implementation. PURPOSE: This study aimed to identify and evaluate safety risks associated with the clinical use of SGRT using Failure Mode and Effects Analysis (FMEA). Emphasis was placed on workflow processes, system integration, and equipment-specific characteristics within a clinical environment to inform risk mitigation strategies and support safe implementation. METHODS: A multidisciplinary team performed an FMEA of SGRT related procedures and workflows. A process map was developed to define the scope of clinical applications, including tattoo free setup, free-breathing and deep-inspiration breath-hold (DIBH) breast treatments, prone patient positioning and real-time motion monitoring for stereotactic body radiation therapy (SBRT) patients across body sites. For each process step, team members identified potential failure modes associated with the clinical workflow and environment, including the integration of a C-RAD SGRT system with Elekta linear accelerators. Scoring was performed according to AAPM TG-100 guidelines, using severity (S), occurrence (O), and detectability (D) to calculate the Risk Priority Number (RPN). Failure modes were then ranked by RPN, and those with scores greater than or equal to 100 were selected for further analysis and development of mitigation strategies. RESULTS: Thirty-eight failure modes were identified, with nine having RPN scores greater than or equal to 100 (S = 5-8, O = 2-5, and D = 5-9). High risk failure modes were most associated with the DIBH workflow, particularly respiratory trace acquisition, respiratory trace configuration, and x-ray image verification. Additional high risk failure modes were identified in treatment preparation and system quality assurance processes, including manual data import, template selection, calibration, and daily QA procedures. These risks were primarily associated with workflow-dependent processes involving user interaction and coordination between integrated clinical systems. CONCLUSIONS: This FMEA identified workflow, system integration and equipment related vulnerabilities associated with SGRT implementation. The findings emphasize the importance of risk assessments tailored to specific clinical workflows and treatment environments and support the development of targeted mitigation strategies for safe clinical use.
Journal of evaluation in clinical practiceMohammed Musaed Al-Jabri, Amina Hemida Salem Ghattas, Marwa Samir Sorour, Amal Diab Ghanem Atalla
BACKGROUND: Incident reporting is a cornerstone of patient safety, particularly in critical care settings where patients are highly vulnerable to adverse events. Despite international efforts to promote safety reporting, underreporting persists, especially in low- and middle-income countries. Nurses, as frontline providers, are central to detecting and reporting incidents; however, psychological, organizational, and cultural factors often limit their engagement in reporting processes. AIM: To explore barriers to incident reporting among nurses working in critical care units and identify nurse-informed solutions to strengthen reporting practices and patient safety culture. METHODS: A convergent mixed-methods design was employed. A convenience sample of 251 critical care nurses was recruited from eight critical care units of a university hospital. Quantitative data were collected using the researcher-developed Incident Reporting Survey (IRS), which underwent content validation and reliability testing. Descriptive statistics, t-tests, ANOVA, correlation analysis, and multiple linear regression were performed using SPSS version 23. Qualitative data were obtained through two open-ended survey questions and analyzed using Braun and Clarke's thematic analysis framework. Quantitative and qualitative findings were integrated during interpretation through triangulation to generate a comprehensive understanding of reporting barriers and potential solutions. RESULTS: Nurses reported limited awareness of reporting procedures and reluctance to submit reports. Major barriers included fear of blame and punishment, lack of anonymity, heavy workload, inadequate training, and limited managerial support. Qualitative findings reinforced these issues and further highlighted concerns about professional reputation, ineffective feedback mechanisms, and complex reporting systems. CONCLUSION: Incident reporting remains insufficient due to interconnected individual and organizational barriers. Cultural, educational, and system-level interventions-particularly non-punitive policies and leadership support-are essential to enhance reporting behaviors and strengthen patient safety outcomes.
Perioperative nurses use evidence-based practice to achieve optimal outcomes when caring for patients. Translating evidence-based guidelines into practice, however, can be difficult, especially when barriers to compliance are present. Compliance barriers may arise from organizational culture, knowledge deficits, absence of policy, shortcuts, competing priorities, time constraints, physician pushback, or system-level barriers. When evidence-based practices are not followed, patient safety events and suboptimal outcomes may occur. This article addresses how legislative advocacy and policy provide solutions when barriers prevent full compliance or efforts fail. Even with organizational policy solutions, barriers to implementation may still exist. Perioperative nurses should therefore advocate in policy arenas to promote change that results in optimal quality and safety outcomes for themselves, their team, and their patients. Compliance, barriers, and advocacy are explored to navigate the intersections of policy, quality, and safety.
Health promotion journal of Australia : official journal of Australian Association of Health Promotion ProfessionalsLaura J Kennedy, Sara F L Kirk, Alisson Dykeman, Meaghan Sim, Jeanna Parsons Leigh, Catherine L Mah
BACKGROUND: Healthy eating policies are of growing importance to the management of retail food environments in healthcare (e.g., hospital cafeterias). Several researchers have begun to analyse health promoting benchmarks within these policies. However, little is understood about the relationship between policy and continuous quality improvement (CQI) for health promotion in healthcare. Furthering our understanding of benchmarks within these policies could provide insight into how we can measure and create standards in health promotion. This policy analysis examined publicly accessible healthcare healthy eating policies in Canadian health authority jurisdictions, up until November 22, 2022. METHODS: Data was extracted using a monitoring and evaluation framework for evaluating nutrition policies in publicly funded institutions, with adaptations based on organisational CQI concepts. Policy components analysed included: policy design, nutrient profiling systems, nutrition standards, evaluation, and monitoring. A second reviewer independently extracted data and peer debriefing was completed on the extractions. RESULTS: This analysis identified five healthy eating policies meeting the inclusion criteria, from Alberta, British Columbia, Newfoundland and Labrador, Nova Scotia, and Winnipeg, Manitoba. Policies included nutrient profiling, including benchmarks for selling healthy, moderately healthy, and less healthy food and beverages. Other benchmarks were mentioned but contained fewer indicators (e.g., fundraising, catering, and advertising). Policies included benchmarks about product and placement (e.g., healthier items in visible places) but less about price. The included policies promoted collaboration amongst healthcare providers but lacked details about evaluation and monitoring. CONCLUSION: This policy analysis suggests that different healthcare settings may require different benchmarks, tailored to their contexts. Furthermore, standardisation may not be optimal if further experimentation is needed to identify benchmarks for health promotion practices, as is common in healthcare CQI. Policy implementation requires a combination of top-down and bottom-up approaches, and collaboration with multiple partners may be necessary for success. Benchmarking processes are a potential strategy for understanding improvements to other aspects of the food environment beyond nutrient standards. SO WHAT: CQI and retail food environments each focus on customer satisfaction and costs, thus sharing alignments. CQI benchmarking processes are a potential strategy for understanding improvements to other aspects of the food environment beyond nutrient standards. Further exploration is needed to implement and monitor benchmarks over time.
Medical science monitor : international medical journal of experimental and clinical researchMarcin Rabijewski, Anna Kurek, Marcin Muża, Sławomir Paszek, Zofia Frączek, Michał Rabijewski
Adverse medical events remain a serious concern worldwide; deficiencies in human factors contribute to a large proportion of medical incidents and preventable patient harm. In anesthesiology, where high-risk and complex clinical events are routine, non-technical skills (NTS)-including communication, teamwork, situational awareness, and decision-making-play a critical role in preventing errors during high-acuity emergencies. Furthermore, Crisis Resource Management (CRM) provides a structured framework for enhancing team performance and coordination during medical crises by emphasizing effective leadership, task management, and the optimal allocation of resources within a multidisciplinary team. Simulation-based training is central to teaching and assessing NTS; validated tools such as the Anesthetists' Non-Technical Skills (ANTS) system allow objective evaluation of team performance and behaviors across various clinical scenarios. This modality is particularly effective because it incorporates structured debriefing, enabling practitioners to reflect on their clinical performance in a safe, risk-free environment. Evidence shows that CRM- and NTS-focused simulation training improves crisis response, adherence to protocols, and clinical outcomes. Despite widespread international adoption, CRM and NTS training in Poland remains limited because of institutional and systemic barriers. Implementation of structured CRM and NTS curricula in Poland could enhance patient safety, foster effective teamwork, and reduce medical errors, particularly in high-risk clinical settings, thus aligning Polish medical education with international standards. This narrative review synthesizes global evidence regarding the effectiveness of CRM and NTS training, highlights the benefits of simulation-based training and its impact on long-term skill decay, and identifies gaps in Polish residency programs.
Mayo Clinic proceedingsPritish K Tosh, Brian W Decker, Ashton L Boon
Cybersecurity has become a critical determinant of patient safety, business continuity, and organizational resilience in health care. Health care organizations are increasingly targeted by ransomware, data theft, and related attacks that disrupt clinical operations, threaten patient safety, delay care, and compromise sensitive information. Although often viewed as technical failures, many incidents originate in routine human behaviors, including phishing responses, credential misuse, unsafe downloads, and inappropriate use of personal devices or applications. This review focuses on clinician-level actions that can reduce both personal and organizational risk, including strong and unique passwords, multifactor authentication, phishing recognition and reporting, timely software updates, secure network use, careful management of personal devices and apps, and avoidance of risky removable media or untrusted downloads. It also emphasizes preparedness for extended network downtime, including familiarity with business continuity processes for documentation, ordering, communication, and care coordination when core digital systems are unavailable.
Journal of human nutrition and dietetics : the official journal of the British Dietetic AssociationRebekah Sandhu, Delara Saran, Treeva Elliott
INTRODUCTION: Dietitian managers are routinely asked to provide recommendations for dietitian staffing ratios (i.e., the number of patients a dietitian 1.0 full-time equivalent (FTE) position can adequately serve). These recommendations are used as a benchmark when advocating for improving dietitian service levels, future hospital planning, and ultimately guide the FTE for which the department is budgeted. To date, there is limited empirically based evidence supporting dietitian staffing ratios for multiple care areas. The purpose of this quality improvement project is to develop consensus on the dietitian staffing ratios for inpatient, ambulatory, and long-term care areas within a large Canadian health authority. METHODS: A modified RAND/UCLA method of consensus was used. A draft document of dietitian staffing ratios was informed by a literature review. Next, iterative rounds of anonymous surveys and virtual meetings were conducted until consensus on the dietitian staffing ratios for each care area was achieved. Consensus was defined as > 70% of respondents indicating they rated an item at least slightly agree on a 7-point Likert scale. RESULTS: Eighty percent (12/15) dietitian leaders participated in the consensus process. The leaders had an average of 5.8 ± 6.3 years experience supervising a median of 8.0 FTE [1-42] of dietitian positions. Consensus was achieved after 3 rounds of surveys and meetings. The final document provides dietitian staffing ratios for 35 different practice areas. CONCLUSION: This quality improvement project is the first to provide a comprehensive list of dietitian staffing ratios for inpatient, outpatient, and long-term care areas. It provides dietitian managers in other locations with insight into a process by which they could produce their own locally relevant dietitian staffing ratios.
Japan journal of nursing science : JJNSZehra Aydin, Arzu Kader Harmancı Seren
BACKGROUND: Home-based peritoneal dialysis treatment offers greater autonomy and flexibility. However, it also introduces unique patient safety risks. Despite these risks, there is no validated tool to assess patient safety in home settings. OBJECTIVES: To develop and validate a scale to assess environmental, behavioral, and procedural safety risks in peritoneal dialysis (PD). METHODS: This study was conducted with 600 patients across eight hospitals. Item generation was informed by literature review, clinical guidelines, existing instruments, and expert consultation, resulting in an initial 50-item pool. Content validity was established through expert opinions. The final analytic sample was randomly divided into two independent subsamples: exploratory factor analysis was conducted with Sample I (n = 300), and confirmatory factor analysis was conducted with Sample II (n = 300). Internal consistency, test-retest reliability, and convergent and discriminant validity were evaluated. RESULTS: The final scale consisted of 42 items across four factors: Safe Dialysis Practices, Infection Prevention and Complication Monitoring, Treatment Follow-up and Safety Preparedness, and Fall Prevention and Safety, explaining 80.5% of the total variance. The CFA results confirmed good model fit (χ2/df = 2.487; CFI = 0.968; RMSEA = 0.035). The scale demonstrated excellent internal consistency (α = 0.939) and strong test-retest reliability (ICC = 0.938). Convergent and discriminant validity criteria were satisfied. CONCLUSION: The scale is a valid and reliable instrument for assessing patient safety in peritoneal dialysis. It addresses critical domains aligned with international safety frameworks and can support clinicians in identifying safety risks, guiding interventions, and improving outcomes in home dialysis.
Critical care nurseWei Jun Dan Ong, Eleanor Dela Peña, Faheem A Khan, Woon Hean Keenan Chong, Lawrence Ace Azul
BACKGROUND: Noninvasive ventilation is increasingly delivered outside intensive care units; however, ventilator alarm management, documentation, and competency validation remain inconsistent when paper-based processes are used. Delayed or inconsistent responses to actionable alarms may contribute to clinical deterioration and escalation of care. LOCAL PROBLEM: Nurses and respiratory therapists reported fragmented documentation, limited access to standardized troubleshooting guides, and time-consuming competency tracking for noninvasive ventilation devices in acute medical units that provide intermediate-level care. METHODS: This quality improvement project, which used a pre-post design, involved implementation of a digital ventilator safety workflow using QR code-linked alarm guidance and a secure online checklist. Data were collected during a 6-month baseline period and a 6-month postimplementation period. Clinical content, workflow mapping, and alarm-guidance pathways were developed in-house by the respiratory therapy department and deployed through AskVijay, a digital clinical guidance platform. Competency validation was conducted during onboarding and annual assessment. RESULTS: Digital implementation was associated with an increase in checklist completion compliance from 80% to 100% and a reduction in checklist completion time from a median of 8.5 minutes to 3.9 minutes. Use of required digital fields supported more complete documentation. Centralized electronic records enabled consolidated competency documentation and facilitated tracking of checklist and competency completion. CONCLUSION: A digital ventilator safety workflow supported standardized documentation, point-of-care access to alarm guidance, and competency tracking for unit-based noninvasive ventilation care. In-house clinical development enabled iterative refinement to align with local practice needs and workflows.
Nursing inquiryElaine Lazaro Alcantara, Camila Pureza Guimarães da Silva, Antonio José de Almeida Filho, Hanna Carolina Neto Cavalcanti, Sabrina da Costa Machado Duarte, Tâni…
This paper critically examines Florence Nightingale's legacy and its ongoing relevance to contemporary patient safety. Drawing on Notes on Nursing, the study highlights Nightingale's emphasis on hygiene, cleanliness, environmental factors, and systematic care as foundational to reducing harm and improving patient outcomes. Her insights laid the groundwork for infection prevention and control practices that remain central to modern nursing and healthcare safety protocols. Nightingale's principles align closely with current patient safety frameworks and global initiatives, such as the World Health Organization's Global Action Plan, emphasizing the social responsibility of healthcare professionals. Despite scientific advances and evolving healthcare systems, her legacy continues to influence nursing practices by reinforcing systematized, ethical, and patient-centered care. This enduring relevance underscores the critical role of nursing in safeguarding health and promoting safety in diverse clinical settings. This study advocates for ongoing recognition and integration of Nightingale's principles to enhance patient safety and care quality in modern healthcare. Her legacy remains an epistemological and practical resource for advancing nursing theory, patient-centered care, and critical reflection in healthcare. Trial Registration: Not applicable.
International journal of mental health nursingErin Farmer, Marianne Wyder, Nahid Choudhury, Sarah Cox, Nicola Geffen, Jeremy Anson, Nomthandazo Masuku, Emma Lakin, Manaan Kar Ray
Post-discharge suicide risk remains highest among psychiatric inpatients, yet structured safety planning is rarely embedded into inpatient care. As part of a quality improvement project, in 2022, a major metropolitan hospital in Australia rolled out the 7 SAFE STEPS Programs to address this gap. The training included safety conversations and safety plans, which were introduced to become part of the discharge process. This mixed-methods study evaluated whether the structured safety planning was embedded into inpatient routine practice and explored staff and consumer experiences to identify barriers and enablers to meaningful implementation. A numerical count of the safety plans was undertaken. The quality of safety plans produced was assessed through an audit and benchmarking these to the essential components (recognising early warning signs, identifying adaptive internal coping mechanisms, engaging external supports, accessing professional services, addressing means restriction, and reaffirming reasons for living). Safety plans were given a numerical value based on if these were present or absent. Qualitative data about their experiences with the safety plans was also gathered through interviews and focus groups with nursing staff, peer workers, and recently discharged consumers. The qualitative component of the study was designed and reported according to the EQUATOR Network guidelines for qualitative research (COREQ). While there was an increase in the number of safety plans completed on the ward, the overall quality of these was low (average score of 7.67 out of 22). Themes from the qualitative data identified barriers to the introduction, which included time pressures, training gaps, and procedural drift. Nursing staff and consumers discussed the value of these plans and made suggestions for changes.
Emergency medicine Australasia : EMAJasmine Poonian, Katie O'Halloran, Thomas Kilner, David Krieser
OBJECTIVE: To evaluate the acceptability and feasibility of implementing a structured 'hot debrief' tool, and its impact on team effectiveness, staff well-being and identification of system-level issues following critical events in two EDs. METHODS: We conducted a multi-site quality improvement study across two metropolitan Australian EDs from 2023 to 2025. A standardised hot debrief process was implemented following predefined critical events, with senior staff trained as facilitators. Staff perceptions were assessed using anonymous pre-, post- and final-implementation surveys, with quantitative data analysed descriptively. Completed debrief proformas from two 6-month trial periods were analysed using reflexive thematic analysis to identify recurring themes related to team function, well-being and system issues. RESULTS: A total of 46 hot debriefs were conducted. In the final survey, 60 of 121 respondents (50%) had attended at least one debrief in the preceding 6 months. Amongst attendees, 98% reported that debriefs created a psychologically safe space, and 59 of 60 found them useful overall. Likert-scale responses indicated high perceived value, with most rating debriefs four or five out of five for team building, learning, issue identification and emotional processing. Thematic analysis identified five key system-level issues: interdepartmental communication, medication dosing in rare events, staffing and handover pressures, staff safety during behavioural emergencies and environmental and crowd-control challenges. CONCLUSIONS: A structured hot debrief tool was feasible and well accepted. It supported team reflection, staff well-being and identification of recurrent system issues. Further research is needed to assess sustainability and downstream impacts on staff well-being and patient safety.
International journal of mental health nursingKaren Dixon, Melissa Petrakis, Ellie Fossey, Linda Barclay
The sexual safety of people in mental health inpatient units is an increasingly important concern. Following provision of a co-designed staff training package (the Welcome Project) to support sexual safety on an Australian adult mental health inpatient unit, this qualitative study aimed to gain an understanding of barriers and enablers to implementation of sexual safety practices from the perspective of staff in this setting. Data was collected through semi-structured interviews with eleven clinicians. Directed content analysis was used to map data against the Consolidated Framework for Implementation Research and the Capability Opportunity and Motivation Model of behaviour change. The findings describe barriers and enablers to sexual safety related to key aspects of these frameworks: knowledge about sexual safety, knowledge about trauma-informed care, time to talk about sexual safety, role clarity, reluctance to talk about sexual safety, culture, leadership, physical environment, staffing, consumer and carer peer workers, and acuity. While training improved awareness, results from this study suggest that education alone was insufficient to support routine sexual safety discussions. Future implementation requires a multilevel approach that combines targeted training with clear role expectations, as well as adequate staffing, supportive leadership, and organisational commitment to sexual safety. In conclusion, while staff knowledge is important, the physical environment and leadership need to be considered and strategies in place to support clinicians to implement sexual safety training and routinely have conversations with consumers about sexual safety during inpatient admissions.
BACKGROUND: Pre-emptive kidney transplantation is the preferred treatment in patients with end-stage kidney disease (ESKD); however, many patients must unavoidably initiate dialysis prior to transplantation. Prolonged dialysis exposure is associated with increased morbidity and mortality, mandating prompt transition to transplant when possible. Delays in transplant readiness are unfortunately prevalent and are often driven by fragmented communication, limited education, and system-level barriers. OBJECTIVE: To reduce time from dialysis initiation to deceased donor kidney transplant (DDKT) activation among pediatric patients through a single-center quality improvement initiative. METHODS: This quality improvement (QI) project was conducted at a tertiary children's hospital affiliated with a pediatric outpatient dialysis unit. Baseline data from 2023 demonstrated a median dialysis-to-DDKT activation time of 211.5 days. Interventions were implemented in 2024 through three Plan-Do-Study-Act cycles (PDSA): (1) establishment of a multidisciplinary Guidance and Planning clinic for early transplant education; (2) implementation of biweekly transplant-dialysis coordination meetings supported by expanded transplant coordinator staffing; (3) distribution of a bilingual patient education booklet at dialysis initiation. The primary outcome measure was time to DDKT activation. Trends were evaluated using descriptive statistics and a run chart. RESULTS: In 2024, 10 patients initiated dialysis during the intervention phase. Excluding 2 patients who were activated for transplantation prior to outpatient dialysis initiation, the median time from dialysis initiation to DDKT activation decreased by 38%, from 211.5 days in 2023 to 130.5 days in 2024. Sixty percent of patients initiating dialysis in 2024 underwent transplantation within the same calendar year. Process measures demonstrated successful implementation of interventions. CONCLUSIONS: Implementation of a structured quality improvement approach was associated with reduced time to transplant activation in pediatric dialysis patients. Improved communication, education, and transplant coordination may represent modifiable factors that may enhance transplant readiness and outcomes.
Global health actionHelena Hildenwall, Dorothy Akongo, Emmanuel Tenywa, Svante Norgren, Moses Kyangwa, Alfred Yayi, William Mugowa Waibi, Viveka Nordberg, Agnes Linnér, Eva Svenss…
Despite major global progress in child health, significant inequalities remain between low- and high-income countries. In Uganda's Busoga region, child mortality is still high, largely due to preventable conditions and limited healthcare resources. In response, a paediatric health partnership was established in 2021 between the Busoga region and Stockholm, Sweden. Following a quality-of-care assessment in two Ugandan hospitals, the collaboration identified four priority areas: paediatric emergency care, neonatology, child neurology with a focus on epilepsy, and child rights. Over 3 years, 63 staff exchanges have taken place, enabling joint reviews of clinical practices and identification of improvement needs. A key achievement is the implementation of the WHO Emergency Triage, Assessment and Treatment Plus (ETAT+), supported by training 14 national facilitators who now serve as focal persons in their facilities. Initiatives in neonatology have strengthened early interventions for premature and low birth weight infants such as improved nursing care, infection prevention, and nutrition practices. In neurology, the introduction of an epilepsy registry and education programmes has reduced stigma and improved management. The child rights initiative has trained more than 80 ambassadors and fostered child-friendly hospital environments that promote participation. The in-hospital mortality dropped over the project period (2020-2025) from 26.4% to 21.7% for neonates (p = 0.021) and from 3.8% to 2.8% (p = <0.01) for children less than five outside the neonatal period. Despite resource constraints, the partnership has benefited both regions. This twinning model highlights how equitable international collaborations can sustainably advance child health and reinforce healthcare systems in diverse settings.
Joint Commission journal on quality and patient safetyJonathan B Perlin
Three decades after To Err Is Human catalyzed the modern patient safety movement, roughly one in four hospitalized patients still experiences an adverse event, and nearly one in four patients who die or deteriorate in U.S. hospitals does so in the setting of a missed or delayed diagnosis. These figures have prompted an appropriately skeptical question: has patient safety made any real progress? This special article argues that the skepticism mistakes an unfinished agenda for a failed one, and that the safety field has evolved through a recognizable sequence of framings. It also argues that artificial intelligence (AI) presents a "step-change" opportunity to accelerate progress in patient safety. Building on the foundational work of Jeffrey Braithwaite and colleagues, we are beginning to evolve from find-and-fix accounting for failure ("Safety 1.0"), to studying why care succeeds ("Safety 2.0"), to a combined, 360-degree view that examines failure and success together ("Safety 3.0"). None of these framings, however, were built to operate at the speed, scale, and complexity of contemporary care, where a single intensive care unit patient can generate more than 1,000 clinically relevant data points a day, which is several orders of magnitude beyond what unaided human cognition can reliably integrate. This article proposes "Safety 4.0": the disciplined use of AI, deployed across a defined autonomy spectrum and governed by explicit guardrails as continuous safety intelligence that senses risk earlier, synthesizes complexity, predicts deterioration, and reliably integrates care needs. Drawing on evidence organized around the National Academy of Medicine's six aims for healthcare (safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness) together with case examples from sepsis surveillance, autonomous diagnostics and prescribing, among others, the article argues that the ultimate test of progress is not whether a system adopts AI, but whether care becomes reliably safe, effective, and compassionate without depending on a patient having an advocate.
AORN journalRebecca Vortman, Joanne D Muyco, Daphny Peneza, Ray-An B Talatala
Surgical care is becoming more complex, and hospitals are under amplified pressure to improve quality and prevent harm. Ongoing sentinel events, such as wrong-site surgery and retained surgical items, indicate that important safety errors persist and require system-level solutions. Doctor of nursing practice (DNP)-prepared perioperative nurses are well positioned to lead system-level improvements by using evidence-based practice, quality improvement, and implementation science to translate research into practice and develop sustainable improvements over time. This article describes how DNP-prepared perioperative nurses lead and strengthen safety and quality initiatives in the perioperative practice setting. This article applies The Essentials: Core Competencies for Professional Nursing Education by the American Association of Colleges of Nursing, with a focus on Domain 5 (Quality and Safety), to connect DNP scholarly project work to measurable perioperative safety outcomes. Practical guidance is provided to support alignment of DNP-led scholarly projects with the strategic priorities of the organization.
Critical care nurseCynthia Myo, Beth Nachtsheim Bolick, Julie Reed, Kimberly A Pyke-Grimm
BACKGROUND: Early integration of palliative care for pediatric intensive care unit patients and their families is beneficial for establishing goals of care and complex decision-making. OBJECTIVE: To implement the use of a trigger criteria process to deliver palliative care to a specific population of pediatric intensive care unit patients who would most benefit from receiving such care. METHODS: Trigger criteria were developed through a literature review and interprofessional work group discussions. Medical records were reviewed to compare the frequency of pediatric palliative care consultation 1 year before project implementation and during the 6-month project period. INTERVENTION: The pediatric palliative care trigger criteria process was integrated into 3 areas of the pediatric intensive care unit workflow. Staff members identified patients meeting the trigger criteria and initiated team discussion on the appropriateness of palliative care. A pediatric palliative care consultation was requested if the team agreed that it would be beneficial. RESULTS: Twelve of 18 patients (67%) had pediatric palliative care consultations during the 6-month project period using the trigger process, compared with 7 of 27 patients (26%) before process implementation. CONCLUSION: Implementation of a trigger criteria process to identify patients with high needs for palliative care was successful and effective in the pediatric intensive care unit in the setting of limited palliative care availability. Reassessment of trigger criteria, integration of the trigger process into the electronic health record, and ongoing staff education will be required for long-term sustainability of the project.
Health expectations : an international journal of public participation in health care and health policyCorey Adams, Lorelle Bowditch, Mia Bierbaum, Ramya Walsan, Jennifer Morris, Elizabeth Manias, Nicole Youngs, Lanii Birks, Jeffrey Braithwaite, Ashfaq Chauhan, …
BACKGROUND: The Statutory Duty of Candour (SDC) legally requires healthcare organisations to notify patients, families, and carers who experience a serious adverse patient safety event (SAPSE), provide an apology, and explain steps taken to prevent recurrence. However, despite growing international adoption of SDC, evidence on its implementation and impact on patients and families ('consumers') remains limited. This study examined consumer awareness, understanding, and lived experiences of SDC in Victoria, Australia, two years after its introduction. METHODS: A mixed-methods study integrated data from an online survey and semi-structured interviews with healthcare consumers in Victoria, Australia. Descriptive analysis was undertaken for quantitative items, while reflexive thematic analysis was applied to qualitative data from survey free-text responses and interview transcripts. RESULTS: In total, 80 consumers participated: 72 completed the survey and 13 completed interviews, with five participating in both. Although nearly two-thirds (61%) had no prior knowledge of SDC, over three-quarters (78%) perceived it as useful. Among those who had experienced an adverse event, half reported that staff were not open following the incident, over half reported that no post-incident meeting occurred, and satisfaction with meetings was low (26%). Six themes were identified: (1) Candour as Moral Reassurance; (2) Persistent Scepticism and Conditional Trust; (3) Limited Awareness and Accessibility of SDC; (4) Genuine Apology for Trust Repair; (5) Emotional Labour, Power, and the Risk of Re-traumatisation; and (6) Demonstrating Accountability with Organisational Learning and Improvement. An overarching theme, Candour as a Relational Process for Trust, described how trust was tested, repaired, or further eroded through SDC processes following an adverse event. CONCLUSION: SDC holds significant potential to repair trust following adverse events, but its impact depends on how it is enacted. When delivered with empathy and meaningful follow-up, SDC supports repair of trust. However, when experienced as procedural or defensive, SDC may compound distress and further erode trust. Therefore, SDC must be embedded not just as a regulatory requirement, but as a relational and person-centred practice for patients and families. PATIENT OR PUBLIC CONTRIBUTION: Healthcare consumer representatives were part of the research team, assisting with the study design, data analysis, and article writing.
Journal of evaluation in clinical practiceJéssica Santos Oliveira Targino, Antônio Alves da Silva Neto, Wanderley de Lima Pereira, Marlon Natan Baracho de Oliveira, Rodrigo Guimarães Dos Santos Almeida…
AIM: To understand healthcare professionals' perceptions regarding the application of the Debriefing TALK method in clinical practice, with emphasis on interprofessional communication and patient safety. METHOD: A qualitative action research study conducted with 12 healthcare professionals from secondary care in the Northeast region of Brazil. The educational intervention included dialogic lectures, communication skills training, clinical simulation, and structured debriefing sessions using the TALK method. Qualitative data were analyzed using the Collective Subject Discourse method, while quantitative data were analyzed using descriptive statistics. The study followed COREQ recommendations. RESULTS: The TALK method functioned as a structuring device for reflective practice, promoting the reorganization of interprofessional interactions and reframing communication failures as opportunities for learning. Participants reported improvements in communication, team integration, and care planning, as well as the promotion of a psychologically safe and non-punitive environment. Reported barriers included time constraints, workload burden, variable engagement, and limited institutional support. CONCLUSION: The TALK Debriefing method proved feasible and well accepted, showing potential to enhance clinical practice through structured reflection, meaningful learning, and strengthened interprofessional communication, contributing to patient safety in real-world care contexts. IMPLICATIONS FOR PRACTICE: The findings suggest that the TALK method may support reflective and communication-centered practices in healthcare services, strengthening interprofessional collaboration and patient safety culture. IMPACT: This study advances knowledge on structured debriefing in real clinical settings, highlighting the TALK method as a pedagogical and organizational strategy capable of transforming communication failures into opportunities for collective learning and practice improvement. REPORTING METHOD: Reported according to COREQ. Patient or Public Contribution: No patient or public contribution was involved in this study.
Journal of medical Internet researchJae Hyun Lee, Boram Choi, Kwunho Jeong, Sang Won Suh, Ju Han Kim, Dae-Soon Son
Medical AI is often evaluated using aggregate measures of discrimination, calibration, and accuracy. However, these measures can obscure clinically important variation across patient groups, institutions, devices, and workflows. This viewpoint defines refined exclusion as a governance condition in which an AI system appears successful in aggregate, while uncertainty, error, or reduced clinical reliability is concentrated in populations that are insufficiently represented, measured, validated, or monitored. The concept does not replace algorithmic fairness, hidden stratification, dataset shift, or subgroup performance analysis. It connects these mechanisms to a distinct consequence: an unequal distribution of safety that remains inadequately detected or corrected. Drawing on purposively selected, illustrative evidence from population health management, chest radiography, dermatology, computational pathology, medical foundation models, and clinical measurement, we distinguish model-level disparity, patient safety signals, and documented patient harm. We then frame data justice as a complementary governance approach with distributional, procedural, and substantive dimensions. The proposed lifecycle decision gates address intended use, subgroup learnability, data provenance, validation, procurement, local deployment, monitoring, updates, and patient feedback. Each gate links minimum evidence to decision authority and 1 of 4 actions: proceed, enrich or validate, restrict use, or pause or retire. Governance intensity should be proportionate to clinical risk and evidentiary uncertainty. By linking subgroup evidence gaps to institutional decisions and corrective action, the framework shifts attention from whether a model performs well on average to whether its safety is demonstrable for the populations and settings in which it will be used.
Critical care nurseAbigail Weilbacher, Marilyn A Prasun, Heather Cook
BACKGROUND: No standardized process for determining intensive care unit discharge readiness is available. Intensive care unit readmission is associated with adverse patient outcomes. OBJECTIVE: To evaluate whether implementation of an intensive care unit discharge protocol based on the National Early Warning Score impacts intensive care unit readmission rates, intensive care unit length of stay, and rapid response team activations. METHODS: This quality improvement initiative was implemented in the medical intensive care unit at a 671-bed urban, academic medical center. De-identified electronic medical record data (vital signs, length of intensive care unit stay, and readmission risk factors) were obtained before and during the intervention. RESULTS: Two hundred ten patients during the preintervention phase and 211 patients during the intervention phase met inclusion criteria. A nonsignificant 1.5% reduction in intensive care unit readmission rate was found (P = .54). Mean National Early Warning Score at intensive care unit discharge for patients who required readmission was significantly higher in the preintervention group (P = .004), and significantly more patients in the preintervention group were discharged with a National Early Warning Score indicating high risk (P = .04). Length of stay and rapid response team activations did not significantly differ between groups. All readmitted patients had readmission risk factors, most commonly respiratory reasons and vital sign abnormalities. CONCLUSION: An intensive care unit discharge protocol provides standardization to the discharge process and promotes collaboration between nurses and physicians. Future research on a National Early Warning Score-driven intensive care unit discharge protocol is needed.
Journal of evaluation in clinical practiceAntonio Ragusa
RATIONALE, AIMS, AND OBJECTIVES: Rare catastrophic obstetric outcomes are uncommon in high-income settings but may exert an influence on clinical practice that is disproportionate to their epidemiological frequency. This paper proposes the one-per-thousand effect, a conceptual framework describing how exceptional adverse events may progressively influence clinical judgement, organisational behaviour, and intervention thresholds. Although developed in obstetrics, the framework addresses broader questions of clinical decision-making under uncertainty, patient safety, and healthcare evaluation. METHODS: A conceptual analysis was undertaken by integrating evidence and theory from obstetrics, cognitive psychology, patient safety, human factors, and defensive medicine. The framework examines how organisational memory, availability effects, hindsight and outcome bias, asymmetric accountability, and anticipation of blame may interact to shape clinical behaviour following rare catastrophic events. RESULTS: The proposed model suggests that severe but infrequent adverse outcomes may produce organisational effects that extend beyond the individual case. Through reinforcing cognitive and organisational mechanisms, isolated catastrophes may progressively lower intervention thresholds, increase intervention rates and expose a much larger population to intervention-related harms. The framework distinguishes targeted learning from identifiable failures and broader behavioural adaptation driven primarily by exceptional events rather than by proportionate evidence. CONCLUSIONS: The one-per-thousand effect offers a conceptual explanation for how rare catastrophic events may reshape routine clinical practice through organisational learning processes operating under uncertainty. By distinguishing proportionate learning from defensive adaptation, the framework provides a basis for strengthening clinical governance through prospective sequential review, just culture, structured professional support, and no-fault compensation. Although illustrated in obstetrics, the proposed model may be applicable to other high-risk healthcare settings in which rare adverse outcomes exert disproportionate organisational influence.
BACKGROUND: Centralizing pacemaker implantations delays care for geriatric populations in remote regions, particularly in post-Soviet healthcare systems like Latvia. We hypothesized that a regional hospital could safely establish a high-volume pacing program to overcome geographical barriers, utilizing structured mentorship from a national tertiary center. METHODS: This 2-year prospective observational study evaluated 173 consecutive patients (mean age 78.1 years) undergoing permanent pacemaker implantation at Daugavpils Regional Hospital. Procedures were performed by two regional interventional cardiologists transitioning to independent practice, supported by Latvian Cardiology Centre mentors. Endpoints included 30-day major complications, procedural efficiency, surgical learning curve evaluation using Cumulative Sum (CUSUM) analysis, and patient-reported quality of life (AQUAREL, SF-36). RESULTS: Across 173 procedures (66.5% dual-chamber, 33.5% single-chamber), the overall complication rate was 5.7%. CUSUM analysis demonstrated a complication rate reduction from 8.7% during the initial acquisition phase to a 3.4% expertise plateau. Procedural efficiency stabilized with a mean fluoroscopy time of 3.9 min. Specific complications included lead dislodgement (2.3%), pocket hematoma (1.7%), pneumothorax (1.1%), and wound infection (0.6%), managed successfully without mortality or device abandonment. At 6-month follow-up, patients reported significant quality of life improvements and high trust in the regional team. CONCLUSIONS: Regional high-volume cardiac pacing programs are safe and vital for equitable geriatric care. With structured mentorship, regional hospitals can overcome historical centralization, safely transitioning to independent high-volume centers and achieving an expert-level safety profile non-inferior to tertiary standards.
Critical care nurseNaomi Ragsdale, Wendy Simpson, W Frank Peacock
BACKGROUND: Central line [catheter]-associated bloodstream infections (CLABSIs) represent a significant mortality risk. LOCAL PROBLEM: Due to a significant increase in CLABSI rate, a new CLABSI prevention bundle strategy was evaluated to determine whether it changed the CLABSI rate. METHODS: A before and after quality improvement project was performed in an 18-bed intensive care unit from March 1, 2021, to March 1, 2025. A CLABSI prevention bundle was implemented; CLABSI rates were compared for 1 year before to 3 years after intervention implementation. Additionally, clinician satisfaction surveys were collected. INTERVENTIONS: The implemented bundle consisted of (1) replacement of disposable stethoscopes with touch-free, aseptic stethoscope diaphragm cover dispensers (DiskCover System, AseptiScope, Inc) in each intensive care unit room, and (2) requiring a chlorhexidine-impregnated dressing for all central catheters, with standardization and reeducation of bedside staff on central catheter dressing changes. RESULTS: Of 5226 intensive care unit patients, the mean CLABSI rate was 4.42 (95% CI, 2.93-5.91) infections per 1000 patient central catheter days during the year before implementation, which decreased to 0.70 (95% CI, -1.21 to 2.61) in the 3 years after implementation. Clinicians reported the new strategy was easy to use and superior to disposable stethoscopes. CONCLUSION: A CLABSI bundle that included touch-free, aseptic stethoscope hygiene barriers and chlorhexidine-impregnated dressings was highly effective at decreasing the CLABSI rate.
BMJ openYangxueqing Jiang, Yiyun Shou, Eryn J Newman, Bruce K Christensen, Megan Reid Hobbs, Susy Macqueen, Jane Desborough, Danielle Butler, Leanne Watts, Christine P…
INTRODUCTION: Internationally, routine telehealth consultations have been extensively implemented in primary care in telephone or video-based formats. Despite this widespread implementation, few studies have compared information exchange quality in telephone and video-based consultations from consumer and clinician perspectives, nor have they examined related indicators of safety.This protocol reports on a randomised controlled trial assessing safety and quality of telehealth consultations across telephone versus video-based modalities for simulated consultations about a fictional medication. The primary safety outcome is patient-centred delayed memory recall accuracy as a proxy for medication-information safety. Secondary outcomes include immediate recall accuracy and quality outcomes captured through patient-reported consultation experience and outcome measures. Findings can be used to develop guidance for clinicians and consumers in their selection of the most suitable telehealth modality for medication discussions, ultimately improving primary healthcare delivery. METHODS AND ANALYSIS: In this study, community participants aged 18-44 complete a simulated telehealth consultation with an actor-general practitioner (GP) through telephone or video, during which they learn about a fictional medication they are advised to take.Consultation safety will be reflected through participant memory of medication usage items including: frequency, timing, administration instructions, and side effects. Immediate memory will be assessed at the end of each consultation. After a 2-day delay, delayed memory will be assessed using structured recall questions. Consultation quality will be assessed at the end of each consultation through patient-reported outcome measures including: perceived therapeutic alliance with the GP, perceived empathy of the GP, behavioural intentions about medication usage, and risk perceptions regarding medication usage. ETHICS AND DISSEMINATION: This protocol (ID: H/2024/1249) received ethics approval from the Australian National University Human Research Ethics Committee (HREC) on 14 November 2025. Protocol amendments will be approved by The Australian National University HREC. Study findings will be disseminated through publication in peer-reviewed journals, presentations at academic conferences, and via the study website. TRIAL REGISTRATION AND DATA STATEMENT: The trial protocol including a full statistical analysis plan was prospectively registered to OSF (registration ID: osf.io/r6as3) prior to commencement of data collection. De-identified participant data, statistical code, and all materials used will also be uploaded to an online database.
BACKGROUND: Hospital-acquired pressure injuries (HAPIs) are recognized as potentially preventable adverse events and important indicators of patient safety and healthcare quality. However, evidence regarding their occurrence within hospital adverse event reporting systems remains limited. OBJECTIVE: To assess the occurrence of hospital-acquired pressure injuries recorded as adverse events and to identify factors associated with their occurrence. MATERIALS AND METHODS: This retrospective study was conducted at a hospital in Kraków, Poland. A total of 1,272 adverse event reports recorded between 2013 and 2020 were reviewed. Among these, 305 hospital-acquired pressure injuries (HAPIs) were identified. A comparison group of hospitalized patients without HAPIs was selected for comparative analyses. Clinical and demographic information was extracted from patients' medical records. RESULTS: Between 2013 and 2020, a total of 1,272 adverse events were recorded, representing 1.16% of all hospitalizations during the study period. Hospital-acquired pressure injuries (HAPIs) accounted for 24.0% (305/1,272) of all reported adverse events. Compared with the comparison group, patients with HAPIs had significantly longer hospital stays (18.64 ± 13.51 vs. 12.62 ± 7.81 days; p < 0.001) and were prescribed a significantly higher number of medications (18.14 ± 9.03 vs. 10.43 ± 7.90; p < 0.001). The highest number of adverse events was reported in the Internal Medicine and Allergology Ward. In multivariable analysis, older age, prolonged hospitalization, a higher number of prescribed medications, and greater comorbidity burden were independently associated with HAPI occurrence. CONCLUSIONS: Hospital-acquired pressure injuries are recognized as an important indicator of patient safety and healthcare quality. Their occurrence was significantly associated with prolonged hospitalization and greater pharmacological burden, suggesting an increased risk among patients with higher clinical complexity. Systematic monitoring of HAPIs within hospital adverse event reporting systems may facilitate the identification of high-risk patients, support targeted preventive interventions, and contribute to improvements in patient safety.
BMJ open qualityBereket Tesfaye, Birhanemeskel Damtew, Tizalegn Tesfaye, S Melaku, Surafuel Shewatatek, Nigatu Tilahun, Aberham Abeje
BACKGROUND: Immediate postpartum family planning (IPPFP) is a proven intervention to reduce unintended and closely spaced pregnancies, yet its utilisation remains low in Ethiopia. At Dilla University Teaching Hospital (DUTH), only 10.2% of postpartum mothers received contraception before discharge. This quality improvement (QI) project was implemented to address gaps in counselling, provider readiness and interdepartmental linkages affecting IPPFP uptake. METHODS: A QI initiative guided by the Model for Improvement and Plan-Do-Study-Act (PDSA) cycles was conducted from 8 July 2025 G.C. to 1 October 2025 G.C. Five sequential PDSA cycles were implemented, including staff orientation, assignment of a focal person, integration of IPPFP indicators into the hospital's daily system bottleneck focused reform (SBFR) monitoring dashboard, strengthening maternal, newborn and child health unit linkages and continuous monitoring with weekly feedback. Data were analysed using run charts and descriptive statistics following SQUIRE 2.0 guidelines. RESULTS: During the baseline period, 10.2% of eligible postpartum mothers received IPPFP. Major barriers included inadequate counselling, limited provider training and poor documentation systems. After implementing the QI interventions, IPPFP uptake increased to 45.8% among 786 postpartum mothers over 14 weeks. Implants were the most commonly chosen method (54.2%), followed by intrauterine devices (4.4%) and bilateral tubal ligation (1.1%). Although run charts demonstrated intermittent weekly improvements, the data did not meet criteria for a sustained performance shift, reflecting variable adherence to newly introduced processes. CONCLUSION: Implementation of the QI intervention was associated with increased IPPFP uptake at DUTH and may have been supported by strengthened counselling, improved accountability, enhanced provider readiness and better data-driven decision making.
BMJ open qualityChloe F C Yeo, Siting Goh, Renci Zeng, Jasper Goh, Wen Jia Tan, Jia Xuan Yeo, Sui An Lie
Excessive laboratory investigations in the intensive care units (ICUs) contribute to increased risk of line infections, iatrogenic anaemia, environmental burden and healthcare costs without clear mortality benefit. Despite Choosing Wisely recommendations advocating clinically indicated testing, overutilisation of laboratory tests in ICUs remains common. In our surgical ICU, ordering practices were driven by unclear consultant expectations, reassurance-seeking, junior doctor inexperience, ease conferred by order sets and limited awareness of value-based care.We conducted a two-phase quality improvement initiative between December 2023 and December 2025 to reduce laboratory utilisation. Root causes were identified via clinician surveys, visualised using an Ishikawa diagram and prioritised using Pareto charting. The primary outcome was the number of laboratory investigations ordered per patient-day. Counterbalance metrics included ICU mortality and length of stay (LOS).Interventions were mapped to a driver diagram. Phase 1 focused on education, visual reminders, encouraging shared decision-making, nursing empowerment to clarify orders and mid-phase audit and feedback. Phase 2 incorporated system-level strategies, including electronic prompts to reconcile investigation orders, frequent digital reminders and engagement of new junior doctors. Data were analysed using run charts according to standard healthcare improvement rules for special cause variation.During Phase 1, median laboratory investigations increased from 12.9 to 13.3 tests per patient-day despite comparable illness severity. ICU mortality was similar in the pre-intervention period (12.7%) and during our first study phase (12.9%), without a consistent temporal association with interventions. In Phase 2, laboratory utilisation returned to baseline levels with reduced ICU LOS and mortality. No sustained reduction was observed.In conclusion, educational and behavioural interventions alone were insufficient to de-implement entrenched ordering practices in a high-acuity ICU environment. Sustainable reduction likely requires stronger system redesign, including order-set modification and embedded decision support. Reporting null effects in de-implementation initiatives provides important insights into the structural and cultural barriers to reducing low-value care.