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Studies suggest that the majority of hospital errors go unreported. Equally disturbing is that data surrounding near miss events that could have harmed patients has been found to be even sparser. At the core of any medical error reporting effort is a desire to obtain data that can be used to reduce the frequency of errors, reveal the cause of errors, and empower those involved in the healthcare delivery system with the insight required to design methods to prevent the flaws that allow mistakes to occur. Aligned with the adage that “we can’t fix what we don’t know is broke”, the question is raised why does underreporting exist? The likelihood of reporting medical errors is explored as a manifestation of culture. Factors studied include communication and feedback, teamwork, fear of retribution, and leadership support (top management and supervisor). Data is presented using a nationally recognized instrument—the Agency for Healthcare Research and Quality (AHRQ) Culture of Safety survey. Findings from the research are mixed with little positive relationship between the model and number of events reported although each factor is found to be positively associated with an employee’s perceived frequency by which near miss and no harm events are reported. While advances in patient safety have materialized, the act of employees’ actually reporting events still pales in comparison to the number of errors that have likely occurred, regardless of efforts to advance culture. To explore influencers beyond those found in the AHRQ Culture of Safety survey, an overlapping model is presented. This includes studying various underlying factors, such as understanding what constitutes a reportable event, ease of reporting, and knowledge of the processes supporting data submission, along with attempting to better assess the impact of the direct supervisor and incentives in influencing behavior. Findings suggest that these additional factors do contribute, albeit modestly, to the act of reporting errors. When adding tenure and patient interaction to the model, a higher percentage of the variance is explained. In terms of perceived frequency of reporting near misses and no harm events, this model yields similar results to the first, explaining approximately 28% of the variance. The two factors most positively associated with perceived frequency of reporting near miss and no harm events are communication and feedback and infrastructure —suggesting that some unexplored relationship may exist between the overlapping models. / Business Administration/Interdisciplinary

Objectives: The objective of this thesis is to explore the association between delayed rapid response team activation and patient mortality and morbidity in adult in-patients. Methods: Study 1 presents a protocol for a systematic review of literature regarding the association of delayed activation of rapid response teams and patient outcomes. Study 2 contains the results of the conducted systematic review, performing a search of the literature to critically appraise, aggregate, and present a narrative synthesis of included studies. The final study examines the association between delayed rapid response team activation and hospital mortality, ICU transfer, and cardiopulmonary arrest risk in a retrospective observational cohort study conducted as part of the “Hospital without Code Blues” initiative at Hamilton Health Sciences. Results: Studies included in the systematic review report an association between delayed activation and patient mortality and ICU transfer odds. Results of study three find that these delays may not be associated with patient mortality, but are significantly associated with ICU transfer events and a composite outcome of patient in-hospital mortality, ICU transfer, and cardiopulmonary arrest. Overall, patients experiencing a delayed rapid response team activation were at greater odds of experiencing a negative event during their course of stay in hospital. Conclusions: This thesis presents findings that suggest delayed activation of rapid response teams is associated with an increase in patient mortality and ICU transfers. Increased durations of delay are associated with increased odds of experiencing the above events. / Thesis / Master of Science (MSc)

Bakgrund: Sjuksköterskan på en akutmottagning arbetar under ständig tidspress med en bristande arbetsmiljö. Genom en ökad förståelse för sjuksköterskors upplevelser avseende arbetsrelaterad stress, kan medvetenheten öka kring problematiken och eventuellt leda till potentiella framtida lösningar.  Syfte: Syftet med denna litteraturstudien var att undersöka samt belysa sjuksköterskors upplevelser av arbetsrelaterad stress på akutmottagningar. Metod: Denna litteraturstudie bestod av 10 vetenskapliga artiklar med kvalitativ ansats. Databassökningen genomfördes i Pubmed och Cinahl. Resultat: Studiens resultat baserades på 10 vetenskapliga studier och delades in i två kategorier och fem subkategorier. Organisatorisk arbetsmiljö, belyste arbetsbördor samt resursbrister som råder på akutmottagningar. Sjuksköterskorna upplevde en bristande arbetsmiljö i form av överbelastning som bidrog till stress i arbetet. I den andra kategorin, konsekvenser av stress, belystes konsekvenser av arbetsrelaterad stress på akutmottagningar som visade sig ha en negativ påverkan på sjuksköterskornas psykiska hälsa, privatliv samt patientsäkerheten . Sjuksköterskorna upplevde att stress till följd av resursbrist medförde en ökad risk för vårdskador. Slutsats: Den upplevda arbetsrelaterade stressen hos sjuksköterskor på Akutmottagningar har en negativ påverkan på sjuksköterskors hälsa, bidrar till en bristande omvårdnad, samt hotad patientsäkerhet. Förbättring av arbetsmiljön är av ytterst vikt för att uppnå en säkrare och effektivare vård samt för att främja sjuksköterskors hälsa.

Bakgrund: Ett av de mest kritiska momenten inom vården, där risken för hotadpatientsäkerhet är som störst, är vid överrapportering av kritiskt sjuka patienter. SBAR är enstandardiserad överrapporteringsmodell som rekommenderas att användas inom all hälso- ochsjukvård och anses stärka patientsäkerheten. Aktuell forskningen går dock isär om SBAR ären bra överrapporteringsmodell. Den fungerar bra vid övningar men sämre i praktiken. Akutatidskritiska situationer anses ha en tydlig påverkan på användandet av SBAR. Komplexiteten idessa situationer anses inte tillräckligt utforskad och det behövs mer forskning om vad sompåverkar ambulanssjuksköterskors användande av SBAR. Syfte: Syftet är att beskriva vad som påverkar användandet av SBAR vid överrapportering avkritiskt sjuka patienter till vårdpersonal på akutrummet. Metod: Kvalitativ deltagande observationsstudie med efterföljande intervju med induktivansats. 20 stycken observationer utfördes på ett akutrum med intervjuer som utfördes direktefteråt. Den insamlade datan analyserades manifest med Graneheim och Lundmans (2004)kvalitativa innehållsanalys. Resultat: I intervjuernas resultat framkom två kategorier: Inre och Yttre faktorer och iobservationernas resultat framkom en kategori: Yttre faktorer. Inre faktorer beskriverambulanspersonalens egna påverkan på SBAR där förberedelser och justeringar av SBARhade störst påverkan. Yttre faktorer beskriver hur vårdpersonalens mottagande av rapport påakutrummet och arbetsmiljön påverkade ambulanspersonalens användande av SBAR. Slutsats: Resultatet visar på inre och yttre faktorer som både underlättar och försvårarambulanspersonalens överrapporteringar. Denna förståelse kan leda till förbättrat användandeav SBAR och därför en ökad patientsäkerhet. / Bakground: A critical moment where the risk to patient safety is high is during handover ofcritically ill patients. SBAR is recommended for use across all healthcare settings and isbelieved to increase patient safety. However, current research diverges on whether SBAR is agood model. It performs well in exercises but not as good in practice. Acute time-criticalsituations are considered to influence the use of SBAR. The complexity of these situations isdeemed insufficiently explored and further research about factors influencing ambulancenurses use of SBAR is needed. Aim: The aim of this study is to describe the factors influencing the use of SBAR duringhandover of critically ill patients to healthcare personnel in the emergency room. Method: Qualitative participatory observational study followed by interviews using aninductive approach. Twenty observations were conducted in an emergency room followed byinterviews. The collected data was analyzed manifest and by using Graneheim and Lundmans(2004) qualitative content analysis method. Results: The interviews revealed two categories: Internal factors and external factors. Theobservations revealed one category: External factors. Internal factors describes theambulance personnel´s own influence on SBAR, where preparations and adjustments toSBAR had the greatest impact. External factors describes how the reception of the patienthandover and the work environment affected the ambulance personnel´s use of SBAR. Conclusion: The result indicates that internal and external factors both facilitates and hinderambulance personnel´s handovers. This understanding can lead to improved use of SBAR andthus increase patient safety.

Bakgrund: Dagsljuset är en stor del av vår vardag, då det ger oss ljus och energi. Forskning visar att för lite tillgång till dagsljus kan påverka individen negativt. Studien har för avsikt att undersöka om det kan påverka operationssjuksköterskorna och patientsäkerheten.Syfte: Operationssjuksköterskors upplevelser av tillgång till dagsljus under arbetstid och hur det kan påverka patientsäkerheten.Metod: Kvalitativa semistrukturerade intervjuer användes, där sex intervjuer hölls, som kunde generera svar gentemot syftet. Intervjuerna analyserades genom en kvalitativ manifest innehållsanalys.Resultat: Operationssjuksköterskorna upplevde att tillgången till dagsljus var minimal och att det gjorde dem tröttare. De upplevde inte att det påverkade patientsäkerheten negativt, då de samlade krafter och såg till att god kvalitet av patientsäkerheten hölls. Detta dock på bekostnad av operationssjuksköterskornas psykiska och fysiska hälsa. Slutsats: Operationssjuksköterskorna upplevde att tillgången till dagsljus på arbetsplatsen var mycket begränsad. Trots begränsad åtkomst av dagsljus upplevde operationssjuksköterskorna inte att det påverkade patientsäkerheten negativt. Däremot påverkade det operationssjuksköterskornas välmående och deras energi efter arbetspassen. / Background: Daylight is a big part of our everyday lives because it gives us light and energy. Decreased exposure to this light source has been proven to impact individuals negatively. This study wants to examine whether lowered exposure impacts scrub nurses and patient safety.Aim: The aim is to describe scrub nurses’ experiences with access to daylight during working hours and how it might affect patient safety.Method: This study used qualitative semi-structured interviews, where six interviews were conducted that could answer the aim. The interviews were analyzed through qualitative manifest content analysis.Result: The scrub nurses experienced that the exposure to daylight was minimal, which made them more fatigued. They did not experience that it impacted patient safety negatively because they gathered their strength and made sure that the quality of patient safety was good. The scrub nurses' thought it was at the cost of their health.Conclusion: Scrub nurses experienced that the access to daylight at the workplace was very limited. Even though access to daylight was limited, the scrub nurses did not experience it negatively impacting patient safety. Though, it affected the scrub nurses’ well-being and their energy after their shift was over.

No / Objectives: To empirically compare 2 different commonly used failure mode and effects analysis (FMEA) scoring procedures with respect to their resultant failure mode scores and prioritization: a mathematical procedure, where scores are assigned independently by FMEA team members and averaged, and a consensus procedure, where scores are agreed on by the FMEA team via discussion. Methods: A multidisciplinary team undertook a Healthcare FMEA of chemotherapy administration. This included mapping the chemotherapy process, identifying and scoring failure modes (potential errors) for each process step, and generating remedial strategies to counteract them. Failure modes were scored using both an independent mathematical procedure and a team consensus procedure. Results: Almost three-fifths of the 30 failure modes generated were scored differently by the 2 procedures, and for just more than one-third of cases, the score discrepancy was substantial. Using the Healthcare FMEA prioritization cutoff score, almost twice as many failure modes were prioritized by the consensus procedure than by the mathematical procedure. Conclusions: This is the first study to empirically demonstrate that different FMEA scoring procedures can score and prioritize failure modes differently. It found considerable variability in individual team members' opinions on scores, which highlights the subjective and qualitative nature of failure mode scoring. A consensus scoring procedure may be most appropriate for FMEA as it allows variability in individuals' scores and rationales to become apparent and to be discussed and resolved by the team. It may also yield team learning and communication benefits unlikely to result from a mathematical procedure.

No / Patients are increasingly being thought of as central to patient safety. A small but growing body of work suggests that patients may have a role in reporting patient safety problems within a hospital setting. This review considers this disparate body of work, aiming to establish a collective view on hospital-based patient reporting. STUDY OBJECTIVES: This review asks: (a) What can patients report? (b) In what settings can they report? (c) At what times have patients been asked to report? (d) How have patients been asked to report? METHOD: 5 databases (MEDLINE, EMBASE, CINAHL, (Kings Fund) HMIC and PsycINFO) were searched for published literature on patient reporting of patient safety 'problems' (a number of search terms were utilised) within a hospital setting. In addition, reference lists of all included papers were checked for relevant literature. RESULTS: 13 papers were included within this review. All included papers were quality assessed using a framework for comparing both qualitative and quantitative designs, and reviewed in line with the study objectives. DISCUSSION: Patients are clearly in a position to report on patient safety, but included papers varied considerably in focus, design and analysis, with all papers lacking a theoretical underpinning. In all papers, reports were actively solicited from patients, with no evidence currently supporting spontaneous reporting. The impact of timing upon accuracy of information has yet to be established, and many vulnerable patients are not currently being included in patient reporting studies, potentially introducing bias and underestimating the scale of patient reporting. The future of patient reporting may well be as part of an 'error detection jigsaw' used alongside other methods as part of a quality improvement toolkit.

No / The involvement of two nurses to dispense and administer controlled drugs is routine practice in most clinical areas despite there being no legal or evidence-based rationale. Indeed, evidence suggests this practice enhances neither safety nor care. Registered nurses at two hospices agreed to change practice to single nurse dispensing and administration of controlled drugs (SNAD). Participants’ views on SNAD were evaluated before and after implementation. The aim of this study was to explore the views and experiences of nurses who had implemented SNAD and to identify the views and concerns of those who had not yet experienced SNAD. Method: Data was obtained through semi-structured interviews. Results: Qualitative thematic analysis of interview transcripts identified three key themes: practice to enhance patient benefit and care; practice to enhance nursing care and satisfaction; and practice to enhance organisational safety. Conclusion: The findings have implications for the understanding of influences on medicines safety in clinical practice and for hospice policy makers.