Original Research: What Health Care Staff Who Experienced Assisted Patient Falls Can Teach Us: Implications for Fall and Fall Injury Risk.

Purpose: This quality improvement project had three aims: to identify common assisted falls scenarios, describe staff members' experiences with and risk perceptions of such falls, and explore factors that influenced their perceptions. The overarching goal was to gain useful insight for the development of assisted fall-related strategies and policies.

Methods: In the fall of 2020, 16 staff members from 13 health care facilities were purposively recruited and interviewed.

A Review of Adverse Event Reports From Emergency Departments in the Veterans Health Administration.

Background: Previous work assessing the frequency of adverse events in emergency medicine has been limited. The emergency department (ED) provides an initial point of care for millions of patients. Given the volume of patient encounters and the complexity of medical conditions treated in the ED, it is necessary to determine the system-based issues and associated contributing factors impacting patient safety.

What's the Evidence: A Review of the One-Minute Preceptor Model of Clinical Teaching and Implications for Teaching in the Emergency Department.

Background: The 2012 Academic Emergency Medicine Consensus Conference, "Education Research in Emergency Medicine: Opportunities, Challenges, and Strategies for Success" noted that emergency medicine (EM) educators often rely on theory and tradition in molding their approaches to teaching and learning, and called on the EM education community to advance the teaching of our specialty through the performance and application of research in teaching and assessment methods, cognitive function, and the effects of education interventions.

Objective: The purpose of this article is to review the research-based evidence for the effectiveness of the one-minute preceptor (OMP) teaching method, and to provide suggestions for its use in clinical teaching and learning in EM.

Discussion: This article reviews hypothesis-testing education research related to the use of the OMP as a pedagogical method applicable to clinical teaching.

Wrong-side thoracentesis: lessons learned from root cause analysis.

Importance: Despite the recognized value of the Joint Commission's Universal Protocol and the implementation of time-outs, incorrect surgical procedures are still among the most common types of sentinel events and can have fatal consequences.

Objectives: To examine a root cause analysis database for reported wrong-side thoracenteses and to determine the contributing factors associated with their occurrence.

Design, Setting, And Participants: We searched the National Center for Patient Safety database for wrong-side thoracenteses performed in ambulatory clinics and hospital units other than the operating room reported from January 1, 2004, through December 31, 2011.

Institutional disclosure: promise and problems.

This study explores rationale for and barriers to the prompt and honest disclosure by healthcare organizations of care-related un-intended harm to patients. Although fear of legal action is frequently put forward as the reason that disclosure programs have been slow to be adopted by the medical community, social and nonjurisprudential explanations also pose challenges. This study identifies multiple facilitators and obstacles that transcend concerns about litigation and limit disclosure of adverse events that result in serious injury or death.

Review of the effectiveness of transcranial magnetic stimulation for post-traumatic stress disorder.

Background: Post-traumatic stress disorder (PTSD) is a psychiatric condition with significant morbidity and limited treatment options. Transcranial magnetic stimulation (TMS) has been shown to be an effective treatment for mental illnesses including major depressive disorder.

Objective: Review effectiveness of TMS for PTSD.

Nursing crew resource management: a follow-up report from the Veterans Health Administration.

In response to low scores on a patient safety culture survey, the Veterans Health Administration National Center for Patient Safety implemented a comprehensive nursing-focused crew resource management program for frontline nursing staff. This article highlights significant cultural and clinical outcomes from the program.

Using root cause analysis to reduce falls with injury in community settings.

Background: Falls are a common occurrence for older adults living in the community that may lead to physical injury and psychological harm. The US Department of Veterans Affairs National Center for Patient Safety (NCPS) database contains root cause analysis (RCA) reviews that identify falls resulting in injury in the community and subsequent action plans that may be helpful to prevent future falls.

Methods: A search of the NCPS-database identified RCA reviews where the patient (community-dwelling and long term care elders) fell in the community resulting in moderate to severe injury.

Using root cause analysis to reduce falls with injury in the psychiatric unit.

Objective: The objective was to identify how falls on psychiatric units occur, the underlying root causes and effective action plans to reduce falls and injuries.

Methods: A search of the Veterans Health Administration National Center for Patient Safety database was conducted to identify root cause analysis (RCA) reviews where a fall was sustained by a patient on a psychiatric unit. Seventy-five RCAs from January 2000 to March 2010 were included.

The case for training Veterans Administration frontline nurses in crew resource management.

Using cultural analysis, the authors present a rationale for a nursing-focused crew resource management (CRM) program in the Veterans Health Administration. Although the value of CRM in aviation is well documented and CRM has been successfully applied in healthcare settings to improve communication and teamwork, there is little evidence outlining the implementation of CRM on nursing units with nursing as the primary focus. This article describes the preproject data supporting a nursing-focused CRM program called nursing CRM.

Using human factors engineering to improve the effectiveness of infection prevention and control.

Human factors engineering is a discipline that studies the capabilities and limitations of humans and the design of devices and systems for improved performance. The principles of human factors engineering can be applied to infection prevention and control to study the interaction between the healthcare worker and the system that he or she is working with, including the use of devices, the built environment, and the demands and complexities of patient care. Some key challenges in infection prevention, such as delayed feedback to healthcare workers, high cognitive workload, and poor ergonomic design, are explained, as is how human factors engineering can be used for improvement and increased compliance with practices to prevent hospital-acquired infections.

Teamwork and communication in surgical teams: implications for patient safety.

Background: As part of a national program in the Department of Veterans Affairs to improve communication within the health-care environment, the Medical Team Training questionnaire was developed to assess organizational culture, communication, teamwork, and awareness of human factors engineering principles.

Study Design: The Medical Team Training questionnaire was pilot tested with 300 health-care clinicians. The final version of the Medical Team Training questionnaire was administered to an interdisciplinary group of 384 surgical staff members in 6 facilities as part of the Medical Team Training pilot project in the Department of Veterans Affairs.

Medical team training: applying crew resource management in the Veterans Health Administration.

Background: Communication failure, a leading source of adverse events in health care, was involved in approximately 75% of more than 7,000 root cause analysis reports to the Department of Veterans Affairs (VA) National Center for Patient Safety (NCPS).

Methods: The VA NCPS Medical Team Training (MTT) program, which is based on aviation principles of crew resource management (CRM), is intended to improve outcomes of patient care by enhancing communication between health care professionals. Unique features of MTT include a full-day interactive learning session (facilitated entirely by clinical peers in a health care context), administration of pre-and postintervention safety attitudes questionnaires, and follow-up semistructured interviews with reports of program activities and lessons learned.

Conclusion: You need human factors engineering expertise to see design hazards that are hiding in "plain sight!".

Background: The Human Factors Engineering (HFE) series was launched to share the ideas and methods to aid deeper analyses of adverse events and provide tools to ensure more effective and lasting therapies. Articles in the series showed how human limitations and capabilities were important design issues in a variety of areas, ranging from labels and warnings to work place design and complex decision support systems.

Remaining Questions: After reading all the articles, one might ask a number of questions, such as who made all our "puzzle rooms?" How did it happen that so many device components "masquerade" as each other yet perform very distinct functions? What are the procurement systems that gave us medication containers, tubing, and connectors that are hard to see and easy to misconnect? Behind all those questions remains a key query: what stands in the way of developing or hiring the expertise to see and fix these catastrophic design hazards "hiding in plain sight?"

Summary And Conclusion: HFE has already found its way into health care organizations and industry.

How to make the most of failure mode and effect analysis.

Current accreditation standards issued by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) require hospitals to carry out a proactive risk assessment on at least 1 high-risk activity each year for each accredited program. Because hospital risk managers and patient safety managers generally do not have the knowledge or level of comfort for conducting a proactive risk assessment, they will appreciate the expertise offered by biomedical equipment technicians (BMETs), occupational safety and health professionals, and others. The skills that have been developed by BMETs and others while conducting job safety analyses or failure mode effect analysis can now be applied to a health care proactive analysis.

A multihospital safety improvement effort and the dissemination of new knowledge.

Background: Research on the transfer of medical technology and guidelines suggests that this transfer is driven more by interpersonal relationships than by new research or available information and that it is inconsistent, largely unsuccessful, and strongly influenced by local factors. Yet studies of collaborative, multiple-hospital improvement efforts have shown these transfers to be effective for the specific microsystems participating in the project. The diffusion of medical innovations beyond the participating teams was studied during a 2000-2001 national collaborative safety improvement effort.