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1.  Application of a trigger tool in near real time to inform quality improvement activities: a prospective study in a general medicine ward 
BMJ Quality & Safety  2015;24(4):272-281.
Retrospective record review using trigger tools remains the most widely used method for measuring adverse events (AEs) to identify targets for improvement and measure temporal trends. However, medical records often contain limited information about factors contributing to AEs. We implemented an augmented trigger tool that supplemented record review with debriefing front-line staff to obtain details not included in the medical record. We hypothesised that this would foster the identification of factors contributing to AEs that could inform improvement initiatives.
A trained observer prospectively identified events in consecutive patients admitted to a general medical ward in a tertiary care academic medical centre (November 2010 to February 2011 inclusive), gathering information from record review and debriefing front-line staff in near real time. An interprofessional team reviewed events to identify preventable and potential AEs and characterised contributing factors using a previously published taxonomy.
Among 141 patients, 14 (10%; 95% CI 5% to 15%) experienced at least one preventable AE; 32 patients (23%; 95% CI 16% to 30%) experienced at least one potential AE. The most common contributing factors included policy and procedural problems (eg, routine protocol violations, conflicting policies; 37%), communication and teamwork problems (34%), and medication process problems (23%). However, these broad categories each included distinct subcategories that seemed to require different interventions. For instance, the 32 identified communication and teamwork problems comprised 7 distinct subcategories (eg, ineffective intraprofessional handovers, poor interprofessional communication, lacking a shared patient care, paging problems). Thus, even the major categories of contributing factors consisted of subcategories that individually related to a much smaller subset of AEs.
Prospective application of an augmented trigger tool identified a wide range of factors contributing to AEs. However, the majority of contributing factors accounted for a small number of AEs, and more general categories were too heterogeneous to inform specific interventions. Successfully using trigger tools to stimulate quality improvement activities may require development of a framework that better classifies events that share contributing factors amenable to the same intervention.
PMCID: PMC4387453  PMID: 25749028
Trigger tools; Adverse events, epidemiology and detection; Hospital medicine
2.  Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial 
Shorter resident duty periods are increasingly mandated to improve patient safety and physician well-being. However, increases in continuity-related errors may counteract the purported benefits of reducing fatigue. We evaluated the effects of 3 resident schedules in the intensive care unit (ICU) on patient safety, resident well-being and continuity of care.
Residents in 2 university-affiliated ICUs were randomly assigned (in 2-month rotation-blocks from January to June 2009) to in-house overnight schedules of 24, 16 or 12 hours. The primary patient outcome was adverse events. The primary resident outcome was sleepiness, measured by the 7-point Stanford Sleepiness Scale. Secondary outcomes were patient deaths, preventable adverse events, and residents’ physical symptoms and burnout. Continuity of care and perceptions of ICU staff were also assessed.
We evaluated 47 (96%) of 49 residents, all 971 admissions, 5894 patient-days and 452 staff surveys. We found no effect of schedule (24-, 16- or 12-h shifts) on adverse events (81.3, 76.3 and 78.2 events per 1000 patient-days, respectively; p = 0.7) or on residents’ sleepiness in the daytime (mean rating 2.33, 2.61 and 2.30, respectively; p = 0.3) or at night (mean rating 3.06, 2.73 and 2.42, respectively; p = 0.2). Seven of 8 preventable adverse events occurred with the 12-hour schedule (p = 0.1). Mortality rates were similar for the 3 schedules. Residents’ somatic symptoms were more severe and more frequent with the 24-hour schedule (p = 0.04); however, burnout was similar across the groups. ICU staff rated residents’ knowledge and decision-making worst with the 16-hour schedule.
Our findings do not support the purported advantages of shorter duty schedules. They also highlight the trade-offs between residents’ symptoms and multiple secondary measures of patient safety. Further delineation of this emerging signal is required before widespread system change. Trial registration:, no. NCT00679809.
PMCID: PMC4361104  PMID: 25667258
3.  The contribution of case study research to knowledge of how to improve quality of care 
BMJ quality & safety  2011;20(Suppl_1):i30-i35.
Efforts to improve the implementation of effective practice and to speed up improvements in quality and patient safety continue to pose challenges for researchers and policy makers. Organisational research, and, in particular, case studies of quality improvement, offer methods to improve understanding of the role of organisational and microsystem contexts for improving care and the development of theories which might guide improvement strategies.
This paper reviews examples of such research and details the methodological issues in constructing and analysing case studies. Case study research typically collects a wide array of data from interviews, documents and other sources.
Advances in methods for coding and analysing these data are improving the quality of reports from these studies.
PMCID: PMC3066793  PMID: 21450767
Quality improvement; case study; qualitative research; healthcare quality improvement; research
4.  One size does not fit all: a qualitative content analysis of the importance of existing quality improvement capacity in the implementation of Releasing Time to Care: the Productive Ward™ in Saskatchewan, Canada 
Releasing Time to Care: The Productive Ward™ (RTC) is a method for conducting continuous quality improvement (QI). The Saskatchewan Ministry of Health mandated its implementation in Saskatchewan, Canada between 2008 and 2012. Subsequently, a research team was developed to evaluate its impact on the nursing unit environment. We sought to explore the influence of the unit’s existing QI capacity on their ability to engage with RTC as a program for continuous QI.
We conducted interviews with staff from 8 nursing units and asked them to speak about their experience doing RTC. Using qualitative content analysis, and guided by the Organizing for Quality framework, we describe the existing QI capacity and impact of RTC on the unit environment.
The results focus on 2 units chosen to highlight extreme variation in existing QI capacity. Unit B was characterized by a strong existing environment. RTC was implemented in an environment with a motivated manager and collaborative culture. Aided by the structural support provided by the organization, the QI capacity on this unit was strengthened through RTC. Staff recognized the potential of using the RTC processes to support QI work. Staff on unit E did not have the same experience with RTC. Like unit B, they had similar structural supports provided by their organization but they did not have the same existing cultural or political environment to facilitate the implementation of RTC. They did not have internal motivation and felt they were only doing RTC because they had to. Though they had some success with RTC activities, the staff did not have the same understanding of the methods that RTC could provide for continuous QI work.
RTC has the potential to be a strong tool for engaging units to do QI. This occurs best when RTC is implemented in a supporting environment. One size does not fit all and administrative bodies must consider the unique context of each environment prior to implementing large-scale QI projects. Use of an established framework, like Organizing for Quality, could highlight the distinctive supports needed in particular care environments to increase the likelihood of successful engagement.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-014-0642-x) contains supplementary material, which is available to authorized users.
PMCID: PMC4279911  PMID: 25547227
Productive ward; Releasing time to care; Organizing for quality; Nursing; Qualitative methodology; Quality improvement capacity; Change mechanisms
5.  Organizational interventions in response to duty hour reforms 
BMC Medical Education  2014;14(Suppl 1):S4.
Changes in resident duty hours in Europe and North America have had a major impact on the internal organizational dynamics of health care organizations. This paper examines, and assesses the impact of, organizational interventions that were a direct response to these duty hour reforms.
The academic literature was searched through the SCOPUS database using the search terms “resident duty hours” and “European Working Time Directive,” together with terms related to organizational factors. The search was limited to English-language literature published between January 2003 and January 2012. Studies were included if they reported an organizational intervention and measured an organizational outcome.
Twenty-five articles were included from the United States (n = 18), the United Kingdom (n = 5), Hong Kong (n = 1), and Australia (n = 1). They all described single-site projects; the majority used post-intervention surveys (n = 15) and audit techniques (n = 4). The studies assessed organizational measures, including relationships among staff, work satisfaction, continuity of care, workflow, compliance, workload, and cost. Interventions included using new technologies to improve handovers and communications, changing staff mixes, and introducing new shift structures, all of which had varying effects on the organizational measures listed previously.
Little research has assessed the organizational impact of duty hour reforms; however, the literature reviewed demonstrates that many organizations are using new technologies, new personnel, and revised and innovative shift structures to compensate for reduced resident coverage and to decrease the risk of limited continuity of care. Future research in this area should focus on both micro (e.g., use of technology, shift changes, staff mix) and macro (e.g., culture, leadership support) organizational aspects to aid in our understanding of how best to respond to these duty hour reforms.
PMCID: PMC4304281  PMID: 25558915
6.  Adverse Events Associated with Hospitalization or Detected through the RAI-HC Assessment among Canadian Home Care Clients 
Healthcare Policy  2013;9(1):76-88.
The occurrence of adverse events (AEs) in care settings is a patient safety concern that has significant consequences across healthcare systems. Patient safety problems have been well documented in acute care settings; however, similar data for clients in home care (HC) settings in Canada are limited. The purpose of this Canadian study was to investigate AEs in HC, specifically those associated with hospitalization or detected through the Resident Assessment Instrument for Home Care (RAI-HC).
A retrospective cohort design was used. The cohort consisted of HC clients from the provinces of Nova Scotia, Ontario, British Columbia and the Winnipeg Regional Health Authority.
The overall incidence rate of AEs associated with hospitalization ranged from 6% to 9%. The incidence rate of AEs determined from the RAI-HC was 4%. Injurious falls, injuries from other than fall and medication-related events were the most frequent AEs associated with hospitalization, whereas new caregiver distress was the most frequent AE identified through the RAI-HC.
The incidence of AEs from all sources of data ranged from 4% to 9%. More resources are needed to target strategies for addressing safety risks in HC in a broader context. Tools such as the RAI-HC and its Clinical Assessment Protocols, already available in Canada, could be very useful in the assessment and management of HC clients who are at safety risk.
PMCID: PMC3999553  PMID: 23968676
7.  Knowledge Translation and Patient Safety: The Canadian Adverse Events Study 
Healthcare Policy  2006;1(3):45-50.
The Canadian Adverse Events Study was the first national study of adverse events in Canadian hospitals. Learning from the controversy surrounding similar studies in other countries, the team engaged in extensive knowledge translation activities throughout the life of the project. Using meetings, Web-based communication and other tools, the team successfully prepared most Canadian stakeholders for the study’s release, allowing them to develop anticipatory patient safety initiatives. However, upon publication of the study, the policy spotlight quickly shifted to other issues, and the long-term commitment needed to create safer healthcare is still uncertain.
PMCID: PMC2585339  PMID: 19305669
8.  A cognitive perspective on health systems integration: results of a Canadian Delphi study 
Ongoing challenges to healthcare integration point toward the need to move beyond structural and process issues. While we know what needs to be done to achieve integrated care, there is little that informs us as to how. We need to understand how diverse organizations and professionals develop shared knowledge and beliefs – that is, we need to generate knowledge about normative integration. We present a cognitive perspective on integration, based on shared mental model theory, that may enhance our understanding and ability to measure and influence normative integration. The aim of this paper is to validate and improve the Mental Models of Integrated Care (MMIC) Framework, which outlines important knowledge and beliefs whose convergence or divergence across stakeholder groups may influence inter-professional and inter-organizational relations.
We used a two-stage web-based modified Delphi process to test the MMIC Framework against expert opinion using a random sample of participants from Canada’s National Symposium on Integrated Care. Respondents were asked to rate the framework’s clarity, comprehensiveness, usefulness, and importance using seven-point ordinal scales. Spaces for open comments were provided. Descriptive statistics were used to describe the structured responses, while open comments were coded and categorized using thematic analysis. The Kruskall-Wallis test was used to examine cross-group agreement by level of integration experience, current workplace, and current role.
In the first round, 90 individuals responded (52% response rate), representing a wide range of professional roles and organization types from across the continuum of care. In the second round, 68 individuals responded (75.6% response rate). The quantitative and qualitative feedback from experts was used to revise the framework. The re-named “Integration Mindsets Framework” consists of a Strategy Mental Model and a Relationships Mental Model, comprising a total of nineteen content areas.
The Integration Mindsets Framework draws the attention of researchers and practitioners to how various stakeholders think about and conceptualize integration. A cognitive approach to understanding and measuring normative integration complements dominant cultural approaches and allows for more fine-grained analyses. The framework can be used by managers and leaders to facilitate the interpretation, planning, implementation, management and evaluation of integration initiatives.
PMCID: PMC4066828  PMID: 24885659
Health systems integration; Integrated care; Shared mental models; Group cognition; Organizational culture; Change management
11.  Silence, power and communication in the operating room 
Journal of Advanced Nursing  2009;65(7):1390-1399.
Title. Silence, power and communication in the operating room
This paper is a report of a study conducted to explore whether a 1- to 3-minute preoperative interprofessional team briefing with a structured checklist was an effective way to support communication in the operating room.
Previous research suggests that nurses often feel constrained in their ability to communicate with physicians. Previous research on silence and power suggests that silence is not only a reflection of powerlessness or passivity, and that silence and speech are not opposites, but closely interrelated.
We conducted a retrospective study of silences observed in communication between nurses and surgeons in a multi-site observational study of interprofessional communication in the operating room. Over 700 surgical procedures were observed from 2005–2007. Instances of communication characterized by unresolved or unarticulated issues were identified in field notes and analysed from a critical ethnography perspective.
We identified three forms of recurring ‘silences’: absence of communication; not responding to queries or requests; and speaking quietly. These silences may be defensive or strategic, and they may be influenced by larger institutional and structural power dynamics as well as by the immediate situational context.
There is no single answer to the question of why ‘nobody said anything’. Exploring silences in relation to power suggests that there are multiple and complex ways that constrained communication is produced in the operating room, which are essential to understand in order to improve interprofessional communication and collaboration.
PMCID: PMC3001035
communicating; ethnography; nurse–physician relationships; operating room; power; silence; theatre nursing
12.  Adverse events among Ontario home care clients associated with emergency room visit or hospitalization: a retrospective cohort study 
Home care (HC) is a critical component of the ongoing restructuring of healthcare in Canada. It impacts three dimensions of healthcare delivery: primary healthcare, chronic disease management, and aging at home strategies. The purpose of our study is to investigate a significant safety dimension of HC, the occurrence of adverse events and their related outcomes. The study reports on the incidence of HC adverse events, the magnitude of the events, the types of events that occur, and the consequences experienced by HC clients in the province of Ontario.
A retrospective cohort design was used, utilizing comprehensive secondary databases available for Ontario HC clients from the years 2008 and 2009. The data were derived from the Canadian Home Care Reporting System, the Hospital Discharge Abstract Database, the National Ambulatory Care Reporting System, the Ontario Mental Health Reporting System, and the Continuing Care Reporting System. Descriptive analysis was used to identify the type and frequency of the adverse events recorded and the consequences of the events. Logistic regression analysis was used to examine the association between the events and their consequences.
The study found that the incident rate for adverse events for the HC clients included in the cohort was 13%. The most frequent adverse events identified in the databases were injurious falls, injuries from other than a fall, and medication-related incidents. With respect to outcomes, we determined that an injurious fall was associated with a significant increase in the odds of a client requiring long-term-care facility admission and of client death. We further determined that three types of events, delirium, sepsis, and medication-related incidents were associated directly with an increase in the odds of client death.
Our study concludes that 13% of clients in homecare experience an adverse event annually. We also determined that an injurious fall was the most frequent of the adverse events and was associated with increased admission to long-term care or death. We recommend the use of tools that are presently available in Canada, such as the Resident Assessment Instrument and its Clinical Assessment Protocols, for assessing and mitigating the risk of an adverse event occurring.
PMCID: PMC3751652  PMID: 23800280
13.  Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study 
Limited data are available on adverse events among children admitted to hospital. The Canadian Paediatric Adverse Events Study was done to describe the epidemiology of adverse events among children in hospital in Canada.
We performed a 2-stage medical record review at 8 academic pediatric centres and 14 community hospitals in Canada. We reviewed charts from patients admitted from April 2008 through March 2009, evenly distributed across 4 age groups (0 to 28 d; 29 to 365 d; > 1 to 5 yr and > 5 to 18 yr). In stage 1, nurses and health records personnel who had received training in the use of the Canadian Paediatric Trigger Tool reviewed medical records to detect triggers for possible adverse events. In stage 2, physicians reviewed the charts identified as having triggers and described the adverse events.
A total of 3669 children were admitted to hospital during the study period. The weighted rate of adverse events was 9.2%. Adverse events were more frequent in academic pediatric centres than in community hospitals (adjusted odds ratio [OR] 2.98, 95% confidence interval [CI] 1.65–5.39). The incidence of preventable adverse events was not significantly different between types of hospital, but nonpreventable adverse events were more common in academic pediatric centres (adjusted OR 4.39, 95% CI 2.08–9.27). Surgical events predominated overall and occurred more frequently in academic pediatric centres than in community hospitals (37.2% v. 21.5%, relative risk [RR] 1.7, 95% CI 1.0–3.1), whereas events associated with diagnostic errors were significantly less frequent (11.1% v. 23.1%, RR 0.5, 95% CI 0.2–0.9).
More children have adverse events in academic pediatric centres than in community hospitals; however, adverse events in the former are less likely to be preventable. There are many opportunities to reduce harm affecting children in hospital in Canada, particularly related to surgery, intensive care and diagnostic error.
PMCID: PMC3447037  PMID: 22847964
14.  Description of the development and validation of the Canadian Paediatric Trigger Tool 
BMJ quality & safety  2011;20(5):416-423.
To describe the process of developing and validating the Canadian Association of Paediatric Health Centres Trigger Tool (CPTT).
Five existing trigger tools were consolidated with duplicate triggers eliminated. After a risk analysis and modified Delphi process, the tool was reduced from 94 to 47 triggers. Feasibility of use was tested, reviewing 40 charts in three hospitals. For validation, charts were randomly selected across four age groups, half medical/half surgical diagnoses, from six paediatric academic health sciences centres. 591 charts were reviewed by six nurses (for triggers and adverse events (AEs)) and three physicians (for AEs only). The incidence of trigger- and AE-positive charts was documented, and the sensitivity and specificity of the tool to identify charts with AEs were determined. Identification of AEs by nurses and physicians was compared. The positive predictive value (PPV) of each trigger was calculated and the ratio of false- to true-positive AE predictors analysed for each trigger.
Nurses rated the CPTT easy to use and identified triggers in 61.1% (361/591; 95% CI 57.2 to 65.0) of patient charts; physicians identified AEs in 15.1% (89/ 591, 95% CI 0.23 to 0.43). Over a third of patients with AEs were neonates. The sensitivity and specificity were 0.88 and 0.44, respectively. Nurse and physician AE assessments correlated poorly. The PPV for each trigger ranged from 0 to 88.3%. Triggers with a false/true-positive ratio of >0.7 were eliminated, resulting in the final 35-trigger CPTT.
The CPTT is the first validated, comprehensive trigger tool available to detect AEs in children hospitalised in acute care facilities.
PMCID: PMC3088437  PMID: 21242527
Trigger; adverse event; harm; patient safety; research
15.  Adverse Event Reporting for Herbal Medicines: A Result of Market Forces 
Healthcare Policy  2009;4(4):77-90.
Herbal products are readily available over the counter in health food stores and are often perceived to be without risk. The current Canadian adverse event reporting system suffers from severe underreporting, resulting in a scarcity of safety data on herbal products. Twelve health food store personnel in the Greater Toronto Area were interviewed about their responses to herbal product–related adverse reactions. They generally fostered customer loyalty by offering generous return policies, which included collecting contact information to be sent to the manufacturers with the returned product. Thus, despite the public's lack of knowledge about the formal reporting system, adverse reaction information was directed to manufacturers whenever it resulted in a product return. The relationship between health food stores, industry and Health Canada provides a new opportunity to facilitate adverse event reporting. Additional information could be collected during the return process, and educational initiatives could be implemented to augment current post-market surveillance procedures for herbal products.
PMCID: PMC2700706  PMID: 20436811
16.  Consumers of natural health products: natural-born pharmacovigilantes? 
Natural health products (NHPs), such as herbal medicines and vitamins, are widely available over-the-counter and are often purchased by consumers without advice from a healthcare provider. This study examined how consumers respond when they believe they have experienced NHP-related adverse drug reactions (ADRs) in order to determine how to improve current safety monitoring strategies.
Qualitative semi-structured interviews were conducted with twelve consumers who had experienced a self-identified NHP-related ADR. Key emergent themes were identified and coded using content analysis techniques.
Consumers were generally not comfortable enough with their conventional health care providers to discuss their NHP-related ADRs. Consumers reported being more comfortable discussing NHP-related ADRs with personnel from health food stores, friends or family with whom they had developed trusted relationships. No one reported their suspected ADR to Health Canada and most did not know this was possible.
Consumers generally did not report their suspected NHP-related ADRs to healthcare providers or to Health Canada. Passive reporting systems for collecting information on NHP-related ADRs cannot be effective if consumers who experience NHP-related ADRs do not report their experiences. Healthcare providers, health food store personnel, manufacturers and other stakeholders also need to take responsibility for reporting ADRs in order to improve current pharmacovigilance of NHPs.
PMCID: PMC2847952  PMID: 20184759
17.  Preserving professional credibility: grounded theory study of medical trainees’ requests for clinical support 
Objective To develop a conceptual framework of the influences on medical trainees’ decisions regarding requests for clinical support from a supervisor.
Design Phase 1: members of teaching teams in internal and emergency medicine were observed during regular clinical activities (216 hours) and subsequently completed brief interviews. Phase 2: 36 in depth interviews were conducted using videotaped vignettes to probe tacit influences on decisions to request support. Data collection and analysis used grounded theory methods.
Setting Three teaching hospitals in an urban setting in Canada.
Participants 124 members of teaching teams on general internal medicine wards and in the emergency department, comprising 31 attending physicians, 57 junior and senior residents, 28 medical students, and eight nurses. Purposeful sampling to saturation was conducted.
Results Trainees’ decisions about whether or not to seek clinical support were influenced by three issues: the clinical question (clinical importance, scope of practice), supervisor factors (availability, approachability), and trainee factors (skill, desire for independence, evaluation). Trainees perceived that requesting frequent/inappropriate support threatened their credibility and used rhetorical strategies to preserve credibility. These strategies included building a case for the importance of requests, saving requests for opportune moments, making a plan before requesting support, and targeting requests to specific team members.
Conclusions Trainees consider not only clinical implications but also professional credibility when requesting support from clinical supervisors. Exposing the complexity of this process provides the opportunity to make changes to training programmes to promote timely supervision and provides a framework for further exploration of the impact of clinical training on quality of care of patients.
PMCID: PMC2640114  PMID: 19204035
18.  Emergency Planning in Ontario's Acute Care Hospitals: A Survey of Board Chairs 
Healthcare Policy  2008;3(3):64-74.
Effective hospital governance depends on proactive board leadership to minimize risk.
Study Aim:
To survey hospital board chairs about governance practices, particularly with respect to approval processes for oversight of management preparedness for unforeseen emergencies.
A 2004 survey of hospital managers initially suggested greater board leadership in risk management as a desired strategic priority for Ontario's acute care hospitals. Our literature review and panel process defined 34 best practices in board governance, including two practices explicitly addressing the board's role in preparing for risk.
Our findings revealed that some boards may not be actively engaged in ensuring that adequate processes are in place to protect against risk. More than one-quarter (n=28, 26.9%) of board chairs reported that they had not approved a management plan to address emergencies. Thirty respondents (28.8%) said they had not approved a process to identify, manage and minimize risks to the hospital's sustainability. Forty-seven respondents (45.2%) said they had not approved both of these two processes. A significant association emerged between boards that had approved both risk preparation strategies and boards that had implemented six key governance practices relating to accountability for leadership and stakeholder communication.
PMCID: PMC2645143  PMID: 19305769
19.  Clinical Oversight: Conceptualizing the Relationship Between Supervision and Safety 
Journal of General Internal Medicine  2007;22(8):1080-1085.
Concern about the link between clinical supervision and safe, quality health care has led to widespread increases in the supervision of medical trainees. The effects of increased supervision on patient care and trainee education are not known, primarily because the current multifacted and poorly operationalized concept of clinical supervision limits the potential for evaluation.
To develop a conceptual model of clinical supervision to inform and guide policy and research.
Design, Setting, and Participants
Observational fieldwork and interviews were conducted in the Emergency Department and General Internal Medicine in-patient teaching wards of two academic health sciences centers associated with an urban Canadian medical school. Members of 12 Internal Medicine and Emergency Medicine teaching teams (n = 88) were observed during regular clinical activities (216 hours). Sixty-five participants (12 physicians, 28 residents, 17 medical students, 8 nurses) also completed interviews about supervision. Field notes and interview transcripts were analyzed for emergent themes using grounded theory methodology.
The term “clinical oversight” was developed to describe patient care activities performed by supervisors to ensure quality of care. “Routine oversight” (preplanned monitoring of trainees’ clinical work) can expose supervisors to concerns that trigger “responsive oversight” (a double-check or elaboration of trainees’ clinical work). Supervisors sometimes engage in “backstage oversight” (oversight of which the trainee is not directly aware). When supervisors encounter a situation that exceeds a trainee’s competence, they move beyond clinical oversight to “direct patient care”.
This study elaborates a typology of clinical oversight activities including routine, responsive, and backstage oversight. This new typology provides a framework for clinical supervision policy and for research to evaluate the relationship between supervision and safety.
PMCID: PMC2305735  PMID: 17557190
qualitative research; grounded theory methodology; medical education; professionalism; patient safety
20.  The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada 
Research into adverse events (AEs) has highlighted the need to improve patient safety. AEs are unintended injuries or complications resulting in death, disability or prolonged hospital stay that arise from health care management. We estimated the incidence of AEs among patients in Canadian acute care hospitals.
We randomly selected 1 teaching, 1 large community and 2 small community hospitals in each of 5 provinces (British Columbia, Alberta, Ontario, Quebec and Nova Scotia) and reviewed a random sample of charts for nonpsychiatric, nonobstetric adult patients in each hospital for the fiscal year 2000. Trained reviewers screened all eligible charts, and physicians reviewed the positively screened charts to identify AEs and determine their preventability.
At least 1 screening criterion was identified in 1527 (40.8%) of 3745 charts. The physician reviewers identified AEs in 255 of the charts. After adjustment for the sampling strategy, the AE rate was 7.5 per 100 hospital admissions (95% confidence interval [CI] 5.7– 9.3). Among the patients with AEs, events judged to be preventable occurred in 36.9% (95% CI 32.0%–41.8%) and death in 20.8% (95% CI 7.8%–33.8%). Physician reviewers estimated that 1521 additional hospital days were associated with AEs. Although men and women experienced equal rates of AEs, patients who had AEs were significantly older than those who did not (mean age [and standard deviation] 64.9 [16.7] v. 62.0 [18.4] years; p = 0.016).
The overall incidence rate of AEs of 7.5% in our study suggests that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about 185 000 are associated with an AE and close to 70 000 of these are potentially preventable.
PMCID: PMC408508  PMID: 15159366
21.  Assessing adverse events among home care clients in three Canadian provinces using chart review 
BMJ Quality & Safety  2013;22(12):989-997.
The objectives of this study were to document the incidence rate and types of adverse events (AEs) among home care (HC) clients in Canada; identify factors contributing to these AEs; and determine to what extent evidence of completion of incident reports were documented in charts where AEs were found.
This was a retrospective cohort study based on expert chart review of a random sample of 1200 charts of clients discharged in fiscal year 2009–2010 from publicly funded HC programmes in Manitoba, Quebec and Nova Scotia, Canada.
The results show that 4.2% (95% CI 3.0% to 5.4%) of HC patients discharged in a 12-month period experienced an AE. Adjusting to account for clients with lengths of stay in HC of less than 1 year, the AE incidence rate per client-year was 10.1% (95% CI 8.4% to 11.8%); 56% of AEs were judged preventable. The most frequent AEs were injuries from falls, wound infections, psychosocial, behavioural or mental health problems and adverse outcomes from medication errors. More comorbid conditions (OR 1.15; 95% CI 1.05 to 1.26) and a lower instrumental activities of daily living score (OR 1.54; 95% CI 1.16 to 2.04) were associated with a higher risk of experiencing an AE. Clients’ decisions or actions contributed to 48.4% of AEs, informal caregivers 20.4% of AEs, and healthcare personnel 46.2% of AEs. Only 17.3% of charts with an AE contained documentation that indicated an incident report was completed, while 4.8% of charts without an AE had such documentation.
Client safety is an important issue in HC, as it is in institutionalised care. HC includes the planned delivery of self-care by clients and care provision by family, friends and other individuals often described as ‘informal’ caregivers. As clients and these caregivers can contribute to the occurrence of AEs, their involvement in the delivery of healthcare interventions at home must be considered when planning strategies to improve HC safety.
PMCID: PMC3888609  PMID: 23828878
Adverse events, epidemiology and detection; Patient safety; Chart review methodologies
22.  Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study 
BMJ Quality & Safety  2014;23(12):974-980.
The Hawthorne effect, or behaviour change due to awareness of being observed, is assumed to inflate hand hygiene compliance rates as measured by direct observation but there are limited data to support this.
To determine whether the presence of hand hygiene auditors was associated with an increase in hand hygiene events as measured by a real-time location system (RTLS).
The RTLS recorded all uses of alcohol-based hand rub and soap for 8 months in two units in an academic acute care hospital. The RTLS also tracked the movement of hospital hand hygiene auditors. Rates of hand hygiene events per dispenser per hour as measured by the RTLS were compared for dispensers within sight of auditors and those not exposed to auditors.
The hand hygiene event rate in dispensers visible to auditors (3.75/dispenser/h) was significantly higher than in dispensers not visible to the auditors at the same time (1.48; p=0.001) and in the same dispensers during the week prior (1.07; p<0.001). The rate increased significantly when auditors were present compared with 1–5 min prior to the auditors’ arrival (1.50; p=0.009). There were no significant changes inside patient rooms.
Hand hygiene event rates were approximately threefold higher in hallways within eyesight of an auditor compared with when no auditor was visible and the increase occurred after the auditors’ arrival. This is consistent with the existence of a Hawthorne effect localised to areas where the auditor is visible and calls into question the accuracy of publicly reported hospital hand hygiene compliance rates.
PMCID: PMC4251174  PMID: 25002555
Infection control; Compliance; Nosocomial infections

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