improving safety and quality of care essay

Improving Patient Safety and Quality of Medical Care Expository Essay

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Introduction

Use of technology, evidence-based medicine, health literacy.

Patient safety is an important aspect of risk management in health care. Improvement of patient safety entails assessment of possible ways that could harm patients, prevention and management of medical risks, and analysis of incidents that harm patients (Leape et al, 2007). In addition, it involves reporting such incidents to management and consequently putting measures in place to ensure that they do not recur.

Improving patient safety is one of the methods used to improve the quality of medical care given to patients. In provision of medical care, patient safety is the most important aspect to consider. For example, during medication, surgery and other medical procedures, health care givers should ensure that the safety of the patient is guaranteed. Medical errors, poor quality medical care, inadequate patient monitoring, and uncoordinated patient care services compromise patient safety (Leape et al, 2007).

How to improve patient safety and quality of care

Several measures can be put in place to ensure patient safety during treatment and hence improve the quality of medical care. These measures include use of technology, use of evidence-based medicine, and improving health literacy for both patients and health care professionals. Improving patient safety and quality of patient care helps in management of risk involved in the health care sector because it minimizes harm and injuries to patients.

A study by RAND Health revealed that if health information technology (HIT) was adopted by the healthcare system of the United States, more than $81 billion would be saved every year (Wong, 2012). Adoption of HIT would help to minimize dangerous healthcare incidents that compromise patient safety and lower the quality of healthcare.

In addition, it would minimize the length of stay of patients in hospitals. Examples of technology advancements that can be used include Electronic Health Record (HER), Computerized Provider Order Entry (CPOE), complete safety medication system, and active RFID platform (Wong, 2012).

EHR is useful in reduction of errors related to drug prescription, laboratory tests, and several medical procedures. In many hospitals, medical errors are caused by failure to embrace technology. Illegible handwritten reports are a common cause of medical errors in areas such as drug prescription, medical tests, and treatment procedures (Wong, 2012).

Electronic patient records contribute highly in improving the safety of patients and quality of medical care because they facilitate efficient storage of patient information. Use of technology helps to improve patient safety by reducing diagnosis errors and improving patient monitoring (Wong, 2012).

Evidence-based medicine is an effective method of improving patient safety and quality of patient care. It combines research findings and results of a patient’s examination by a doctor. The doctor uses the results of research studies to make accurate diagnosis and prescription to minimize chances of harming patients (Leape et al, 2007).

In addition, this medical approach inculcates therapy, rehabilitation, and prevention measures that guarantee the safety of patients. It is effective because it offers healthcare practitioners a chance to use improved treatment methods and guidelines. In addition, it reduces cases of incorrect diagnosis and other medical errors such as overuse of certain medications used during surgeries and minor operations (Leape et al, 2007).

Moreover, it eliminates the risk presented by outdated treatment methods and procedures. These practices improve the safety of patients and the quality of medical care given. The field of evidence-based medicine needs further research in order to develop new treatment methods and procedures as well as tests for diagnosis of diseases.

Heath literacy is an important factor in the process of improving patient safety and quality of health care. Low levels of health literacy in patients compromise their safety and the quality of care given. After a doctor prescribes drugs to a patient, it then becomes the responsibility of the patient to take the drugs as prescribed.

However, many patients fail to adhere to directions due to poor comprehension of medication directions (AHRQ, 2012). Poor communication between a patient and a doctor leads to severe medication errors that harm the patient. Low levels of health literacy among patients result in negative healthcare outcomes that lower the quality of healthcare and cause harm to patients.

Patients with low health literacy levels are at a higher risk level of making medication mistakes and are more likely to be hospitalized compared to patients with high health literacy levels. This lengthens their stay at hospital and may be a source of health complications. It is necessary to educate patients on proper interpretation of prescription directions in order to avoid errors that harm them and compromise their safety.

Another dimension of health literacy is education of healthcare providers. To improve patient safety, it is important to ensure that all healthcare professionals possess the required qualifications for their jobs (AHRQ, 2012).

Health care professionals in all sites that provide patient care services such as nursing homes, hospitals, and beneficiary homes should possess the required qualifications for their jobs. Frequent training programs should be offered to health care professionals to ensure that they keep up with recent discoveries and research in their respective medical field (AHRQ, 2012).

This is necessary in order to ensure that they stop using outdated treatment procedures and tests to treat patients. In addition, it is a way of ensuring that they adopt improved medical guidelines that are geared towards improving patient safety and raising the quality of health care provided to patients.

Errors made during medical procedures arise from the actions of unqualified health care professionals who possess inadequate knowledge that does not enable them to offer quality services to patients (AHRQ, 2012). On the other hand, unqualified professionals make errors in drug prescription due to ignorance. Stringent measures should be put in place to ensure that all health care professionals are qualified and fit to provide medical services to patients.

Patient safety and quality of patient care is an important area in risk management in health care. Improvement of patient safety entails assessment of possible ways that could harm patients, prevention, and management of medical risks and analysis of incidents that cause harm to patients.

In addition, it involves reporting of such incidents to management and putting measures in place to ensure that they do not recur. Medical errors, prescription and medication errors, poor monitoring of patients, quack health care professionals, and low levels of heath literacy compromise patient safety and quality of health care.

Methods that could be used to improve patient safety and quality of health care include use of technology in the health care sector, use of evidence-based medicine, and improving health literacy for both patients and health care professionals. To manage risk in health care sector, it is important to put stringent measures that guarantee improved patient safety and high quality of patient care.

Agency for Healthcare Research and Quality (AHRQ). (2012). Tips to Help Prevent Medical Errors . Web.

Leape, L., Berwick, D., and Bates, D. (2007). What Practices Will Most Improve Safety? Evidence-Based Medicine Meets Patient Safety . Web.

Wong, Michael. (2012). Tips on How to Improve Patient Safety With the Help of Technology . Web.

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IvyPanda. (2018, December 11). Improving Patient Safety and Quality of Medical Care. https://ivypanda.com/essays/improving-patient-safety-and-quality-of-medical-care/

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1. IvyPanda . "Improving Patient Safety and Quality of Medical Care." December 11, 2018. https://ivypanda.com/essays/improving-patient-safety-and-quality-of-medical-care/.

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IvyPanda . "Improving Patient Safety and Quality of Medical Care." December 11, 2018. https://ivypanda.com/essays/improving-patient-safety-and-quality-of-medical-care/.

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Quality improvement into practice

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• Adam Backhouse , quality improvement programme lead 1 ,
• Fatai Ogunlayi , public health specialty registrar 2
• 1 North London Partners in Health and Care, Islington CCG, London N1 1TH, UK
• 2 Institute of Applied Health Research, Public Health, University of Birmingham, B15 2TT, UK
• Correspondence to: A Backhouse adam.backhouse{at}nhs.net

What you need to know

Thinking of quality improvement (QI) as a principle-based approach to change provides greater clarity about ( a ) the contribution QI offers to staff and patients, ( b ) how to differentiate it from other approaches, ( c ) the benefits of using QI together with other change approaches

QI is not a silver bullet for all changes required in healthcare: it has great potential to be used together with other change approaches, either concurrently (using audit to inform iterative tests of change) or consecutively (using QI to adapt published research to local context)

As QI becomes established, opportunities for these collaborations will grow, to the benefit of patients.

The benefits to front line clinicians of participating in quality improvement (QI) activity are promoted in many health systems. QI can represent a valuable opportunity for individuals to be involved in leading and delivering change, from improving individual patient care to transforming services across complex health and care systems. 1

However, it is not clear that this promotion of QI has created greater understanding of QI or widespread adoption. QI largely remains an activity undertaken by experts and early adopters, often in isolation from their peers. 2 There is a danger of a widening gap between this group and the majority of healthcare professionals.

This article will make it easier for those new to QI to understand what it is, where it fits with other approaches to improving care (such as audit or research), when best to use a QI approach, making it easier to understand the relevance and usefulness of QI in delivering better outcomes for patients.

How this article was made

AB and FO are both specialist quality improvement practitioners and have developed their expertise working in QI roles for a variety of UK healthcare organisations. The analysis presented here arose from AB and FO’s observations of the challenges faced when introducing QI, with healthcare providers often unable to distinguish between QI and other change approaches, making it difficult to understand what QI can do for them.

How is quality improvement defined?

There are many definitions of QI ( box 1 ). The BMJ ’s Quality Improvement series uses the Academy of Medical Royal Colleges definition. 6 Rather than viewing QI as a single method or set of tools, it can be more helpful to think of QI as based on a set of principles common to many of these definitions: a systematic continuous approach that aims to solve problems in healthcare, improve service provision, and ultimately provide better outcomes for patients.

Definitions of quality improvement

Improvement in patient outcomes, system performance, and professional development that results from a combined, multidisciplinary approach in how change is delivered. 3

The delivery of healthcare with improved outcomes and lower cost through continuous redesigning of work processes and systems. 4

Using a systematic change method and strategies to improve patient experience and outcome. 5

To make a difference to patients by improving safety, effectiveness, and experience of care by using understanding of our complex healthcare environment, applying a systematic approach, and designing, testing, and implementing changes using real time measurement for improvement. 6

In this article we discuss QI as an approach to improving healthcare that follows the principles outlined in box 2 ; this may be a useful reference to consider how particular methods or tools could be used as part of a QI approach.

Principles of QI

Primary intent— To bring about measurable improvement to a specific aspect of healthcare delivery, often with evidence or theory of what might work but requiring local iterative testing to find the best solution. 7

Employing an iterative process of testing change ideas— Adopting a theory of change which emphasises a continuous process of planning and testing changes, studying and learning from comparing the results to a predicted outcome, and adapting hypotheses in response to results of previous tests. 8 9

Consistent use of an agreed methodology— Many different QI methodologies are available; commonly cited methodologies include the Model for Improvement, Lean, Six Sigma, and Experience-based Co-design. 4 Systematic review shows that the choice of tools or methodologies has little impact on the success of QI provided that the chosen methodology is followed consistently. 10 Though there is no formal agreement on what constitutes a QI tool, it would include activities such as process mapping that can be used within a range of QI methodological approaches. NHS Scotland’s Quality Improvement Hub has a glossary of commonly used tools in QI. 11

Empowerment of front line staff and service users— QI work should engage staff and patients by providing them with the opportunity and skills to contribute to improvement work. Recognition of this need often manifests in drives from senior leadership or management to build QI capability in healthcare organisations, but it also requires that frontline staff and service users feel able to make use of these skills and take ownership of improvement work. 12

Using data to drive improvement— To drive decision making by measuring the impact of tests of change over time and understanding variation in processes and outcomes. Measurement for improvement typically prioritises this narrative approach over concerns around exactness and completeness of data. 13 14

Scale-up and spread, with adaptation to context— As interventions tested using a QI approach are scaled up and the degree of belief in their efficacy increases, it is desirable that they spread outward and be adopted by others. Key to successful diffusion of improvement is the adaption of interventions to new environments, patient and staff groups, available resources, and even personal preferences of healthcare providers in surrounding areas, again using an iterative testing approach. 15 16

What other approaches to improving healthcare are there?

Taking considered action to change healthcare for the better is not new, but QI as a distinct approach to improving healthcare is a relatively recent development. There are many well established approaches to evaluating and making changes to healthcare services in use, and QI will only be adopted more widely if it offers a new perspective or an advantage over other approaches in certain situations.

A non-systematic literature scan identified the following other approaches for making change in healthcare: research, clinical audit, service evaluation, and clinical transformation. We also identified innovation as an important catalyst for change, but we did not consider it an approach to evaluating and changing healthcare services so much as a catch-all term for describing the development and introduction of new ideas into the system. A summary of the different approaches and their definition is shown in box 3 . Many have elements in common with QI, but there are important difference in both intent and application. To be useful to clinicians and managers, QI must find a role within healthcare that complements research, audit, service evaluation, and clinical transformation while retaining the core principles that differentiate it from these approaches.

Alternatives to QI

Research— The attempt to derive generalisable new knowledge by addressing clearly defined questions with systematic and rigorous methods. 17

Clinical audit— A way to find out if healthcare is being provided in line with standards and to let care providers and patients know where their service is doing well, and where there could be improvements. 18

Service evaluation— A process of investigating the effectiveness or efficiency of a service with the purpose of generating information for local decision making about the service. 19

Clinical transformation— An umbrella term for more radical approaches to change; a deliberate, planned process to make dramatic and irreversible changes to how care is delivered. 20

Innovation— To develop and deliver new or improved health policies, systems, products and technologies, and services and delivery methods that improve people’s health. Health innovation responds to unmet needs by employing new ways of thinking and working. 21

Why do we need to make this distinction for QI to succeed?

Improvement in healthcare is 20% technical and 80% human. 22 Essential to that 80% is clear communication, clarity of approach, and a common language. Without this shared understanding of QI as a distinct approach to change, QI work risks straying from the core principles outlined above, making it less likely to succeed. If practitioners cannot communicate clearly with their colleagues about the key principles and differences of a QI approach, there will be mismatched expectations about what QI is and how it is used, lowering the chance that QI work will be effective in improving outcomes for patients. 23

There is also a risk that the language of QI is adopted to describe change efforts regardless of their fidelity to a QI approach, either due to a lack of understanding of QI or a lack of intention to carry it out consistently. 9 Poor fidelity to the core principles of QI reduces its effectiveness and makes its desired outcome less likely, leading to wasted effort by participants and decreasing its credibility. 2 8 24 This in turn further widens the gap between advocates of QI and those inclined to scepticism, and may lead to missed opportunities to use QI more widely, consequently leading to variation in the quality of patient care.

Without articulating the differences between QI and other approaches, there is a risk of not being able to identify where a QI approach can best add value. Conversely, we might be tempted to see QI as a “silver bullet” for every healthcare challenge when a different approach may be more effective. In reality it is not clear that QI will be fit for purpose in tackling all of the wicked problems of healthcare delivery and we must be able to identify the right tool for the job in each situation. 25 Finally, while different approaches will be better suited to different types of challenge, not having a clear understanding of how approaches differ and complement each other may mean missed opportunities for multi-pronged approaches to improving care.

What is the relationship between QI and other approaches such as audit?

Academic journals, healthcare providers, and “arms-length bodies” have made various attempts to distinguish between the different approaches to improving healthcare. 19 26 27 28 However, most comparisons do not include QI or compare QI to only one or two of the other approaches. 7 29 30 31 To make it easier for people to use QI approaches effectively and appropriately, we summarise the similarities, differences, and crossover between QI and other approaches to tackling healthcare challenges ( fig 1 ).

How quality improvement interacts with other approaches to improving healthcare

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QI and research

Research aims to generate new generalisable knowledge, while QI typically involves a combination of generating new knowledge or implementing existing knowledge within a specific setting. 32 Unlike research, including pragmatic research designed to test effectiveness of interventions in real life, QI does not aim to provide generalisable knowledge. In common with QI, research requires a consistent methodology. This method is typically used, however, to prove or disprove a fixed hypothesis rather than the adaptive hypotheses developed through the iterative testing of ideas typical of QI. Both research and QI are interested in the environment where work is conducted, though with different intentions: research aims to eliminate or at least reduce the impact of many variables to create generalisable knowledge, whereas QI seeks to understand what works best in a given context. The rigour of data collection and analysis required for research is much higher; in QI a criterion of “good enough” is often applied.

Relationship with QI

Though the goal of clinical research is to develop new knowledge that will lead to changes in practice, much has been written on the lag time between publication of research evidence and system-wide adoption, leading to delays in patients benefitting from new treatments or interventions. 33 QI offers a way to iteratively test the conditions required to adapt published research findings to the local context of individual healthcare providers, generating new knowledge in the process. Areas with little existing knowledge requiring further research may be identified during improvement activities, which in turn can form research questions for further study. QI and research also intersect in the field of improvement science, the academic study of QI methods which seeks to ensure QI is carried out as effectively as possible. 34

Scenario: QI for translational research

Newly published research shows that a particular physiotherapy intervention is more clinically effective when delivered in short, twice-daily bursts rather than longer, less frequent sessions. A team of hospital physiotherapists wish to implement the change but are unclear how they will manage the shift in workload and how they should introduce this potentially disruptive change to staff and to patients.

Before continuing reading think about your own practice— How would you approach this situation, and how would you use the QI principles described in this article?

Adopting a QI approach, the team realise that, although the change they want to make is already determined, the way in which it is introduced and adapted to their wards is for them to decide. They take time to explain the benefits of the change to colleagues and their current patients, and ask patients how they would best like to receive their extra physiotherapy sessions.

The change is planned and tested for two weeks with one physiotherapist working with a small number of patients. Data are collected each day, including reasons why sessions were missed or refused. The team review the data each day and make iterative changes to the physiotherapist’s schedule, and to the times of day the sessions are offered to patients. Once an improvement is seen, this new way of working is scaled up to all of the patients on the ward.

The findings of the work are fed into a service evaluation of physiotherapy provision across the hospital, which uses the findings of the QI work to make recommendations about how physiotherapy provision should be structured in the future. People feel more positive about the change because they know colleagues who have already made it work in practice.

QI and clinical audit

Clinical audit is closely related to QI: it is often used with the intention of iteratively improving the standard of healthcare, albeit in relation to a pre-determined standard of best practice. 35 When used iteratively, interspersed with improvement action, the clinical audit cycle adheres to many of the principles of QI. However, in practice clinical audit is often used by healthcare organisations as an assurance function, making it less likely to be carried out with a focus on empowering staff and service users to make changes to practice. 36 Furthermore, academic reviews of audit programmes have shown audit to be an ineffective approach to improving quality due to a focus on data collection and analysis without a well developed approach to the action section of the audit cycle. 37 Clinical audits, such as the National Clinical Audit Programme in the UK (NCAPOP), often focus on the management of specific clinical conditions. QI can focus on any part of service delivery and can take a more cross-cutting view which may identify issues and solutions that benefit multiple patient groups and pathways. 30

Audit is often the first step in a QI process and is used to identify improvement opportunities, particularly where compliance with known standards for high quality patient care needs to be improved. Audit can be used to establish a baseline and to analyse the impact of tests of change against the baseline. Also, once an improvement project is under way, audit may form part of rapid cycle evaluation, during the iterative testing phase, to understand the impact of the idea being tested. Regular clinical audit may be a useful assurance tool to help track whether improvements have been sustained over time.

Scenario: Audit and QI

A foundation year 2 (FY2) doctor is asked to complete an audit of a pre-surgical pathway by looking retrospectively through patient documentation. She concludes that adherence to best practice is mixed and recommends: “Remind the team of the importance of being thorough in this respect and re-audit in 6 months.” The results are presented at an audit meeting, but a re-audit a year later by a new FY2 doctor shows similar results.

Before continuing reading think about your own practice— How would you approach this situation, and how would you use the QI principles described in this paper?

Contrast the above with a team-led, rapid cycle audit in which everyone contributes to collecting and reviewing data from the previous week, discussed at a regular team meeting. Though surgical patients are often transient, their experience of care and ideas for improvement are captured during discharge conversations. The team identify and test several iterative changes to care processes. They document and test these changes between audits, leading to sustainable change. Some of the surgeons involved work across multiple hospitals, and spread some of the improvements, with the audit tool, as they go.

QI and service evaluation

In practice, service evaluation is not subject to the same rigorous definition or governance as research or clinical audit, meaning that there are inconsistencies in the methodology for carrying it out. While the primary intent for QI is to make change that will drive improvement, the primary intent for evaluation is to assess the performance of current patient care. 38 Service evaluation may be carried out proactively to assess a service against its stated aims or to review the quality of patient care, or may be commissioned in response to serious patient harm or red flags about service performance. The purpose of service evaluation is to help local decision makers determine whether a service is fit for purpose and, if necessary, identify areas for improvement.

Service evaluation may be used to initiate QI activity by identifying opportunities for change that would benefit from a QI approach. It may also evaluate the impact of changes made using QI, either during the work or after completion to assess sustainability of improvements made. Though likely planned as separate activities, service evaluation and QI may overlap and inform each other as they both develop. Service evaluation may also make a judgment about a service’s readiness for change and identify any barriers to, or prerequisites for, carrying out QI.

QI and clinical transformation

Clinical transformation involves radical, dramatic, and irreversible change—the sort of change that cannot be achieved through continuous improvement alone. As with service evaluation, there is no consensus on what clinical transformation entails, and it may be best thought of as an umbrella term for the large scale reform or redesign of clinical services and the non-clinical services that support them. 20 39 While it is possible to carry out transformation activity that uses elements of QI approach, such as effective engagement of the staff and patients involved, QI which rests on iterative test of change cannot have a transformational approach—that is, one-off, irreversible change.

There is opportunity to use QI to identify and test ideas before full scale clinical transformation is implemented. This has the benefit of engaging staff and patients in the clinical transformation process and increasing the degree of belief that clinical transformation will be effective or beneficial. Transformation activity, once completed, could be followed up with QI activity to drive continuous improvement of the new process or allow adaption of new ways of working. As interventions made using QI are scaled up and spread, the line between QI and transformation may seem to blur. The shift from QI to transformation occurs when the intention of the work shifts away from continuous testing and adaptation into the wholesale implementation of an agreed solution.

Scenario: QI and clinical transformation

An NHS trust’s human resources (HR) team is struggling to manage its junior doctor placements, rotas, and on-call duties, which is causing tension and has led to concern about medical cover and patient safety out of hours. A neighbouring trust has launched a smartphone app that supports clinicians and HR colleagues to manage these processes with the great success.

This problem feels ripe for a transformation approach—to launch the app across the trust, confident that it will solve the trust’s problems.

Before continuing reading think about your own organisation— What do you think will happen, and how would you use the QI principles described in this article for this situation?

Outcome without QI

Unfortunately, the HR team haven’t taken the time to understand the underlying problems with their current system, which revolve around poor communication and clarity from the HR team, based on not knowing who to contact and being unable to answer questions. HR assume that because the app has been a success elsewhere, it will work here as well.

People get excited about the new app and the benefits it will bring, but no consideration is given to the processes and relationships that need to be in place to make it work. The app is launched with a high profile campaign and adoption is high, but the same issues continue. The HR team are confused as to why things didn’t work.

Outcome with QI

Although the app has worked elsewhere, rolling it out without adapting it to local context is a risk – one which application of QI principles can mitigate.

HR pilot the app in a volunteer specialty after spending time speaking to clinicians to better understand their needs. They carry out several tests of change, ironing out issues with the process as they go, using issues logged and clinician feedback as a source of data. When they are confident the app works for them, they expand out to a directorate, a division, and finally the transformational step of an organisation-wide rollout can be taken.

Education into practice

Next time when faced with what looks like a quality improvement (QI) opportunity, consider asking:

How do you know that QI is the best approach to this situation? What else might be appropriate?

Have you considered how to ensure you implement QI according to the principles described above?

Is there opportunity to use other approaches in tandem with QI for a more effective result?

How patients were involved in the creation of this article

This article was conceived and developed in response to conversations with clinicians and patients working together on co-produced quality improvement and research projects in a large UK hospital. The first iteration of the article was reviewed by an expert patient, and, in response to their feedback, we have sought to make clearer the link between understanding the issues raised and better patient care.

Contributors: This work was initially conceived by AB. AB and FO were responsible for the research and drafting of the article. AB is the guarantor of the article.

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Provenance and peer review: This article is part of a series commissioned by The BMJ based on ideas generated by a joint editorial group with members from the Health Foundation and The BMJ , including a patient/carer. The BMJ retained full editorial control over external peer review, editing, and publication. Open access fees and The BMJ ’s quality improvement editor post are funded by the Health Foundation.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

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Quality Improvement and Safety in Nursing

Ensuring a safe environment for patients is among the primary concerns for nurses. It could be difficult, as many factors impact safety within the health care setting. One of them is connected with medicine administration, which is an essential part of a nurse’s job. While it may feel routine, the action also involves risks that may threaten the patient’s life. The Evidence-based practice offers several up-to-date solutions to the issue to enhance safety. This paper will discuss the factors surrounding medication administration errors that lead to a patient-safety risk and suggest quality improvement measures.

The factors that affect medication administration are numerous, and some are more prevalent and dangerous than others, but the general picture is homogeneous. A major reason for errors is medicine being out of its packaging with instructions (Hammoudi, Ismaile, & Abu Yahya, 2017). It might or might not be related to another factor: poor communication with doctors, caused either by its quality or shortness (Hammoudi et al., 2017). Increased workload and various interruptions, including unfinished work with another patient, may also cause errors, such as slips and leaps (Thomas, Donohue-Porter, & Stein-Fishbein, 2017). It appears that using barcode technology is also potentially risky due to malfunctions, although its original intent is to improve safety (van der Veen et al., 2018). A nurse’s past experience is also a significant factor that can enhance or reduce safety; in the latter case, if a medication that requires new approaches is introduced (Parry, Barriball, & While, 2015). Considering that such errors are not subject to reimbursement, the nursing staff should avoid them and focus on decreasing the risk factors. Overall, many variables lead to medication administration errors, and they should be tackled.

Some guidelines and practices can assist in mitigating safety risks, including those that occur in medication administration. A system of labeling should be introduced to resolve the issues with packaging, which would remove confusion for the nurses and consequences for the patients (Hammoudi et al., 2017). While the effectiveness of double-checking does not have enough evidence support, it might also be beneficial (Koyama, Maddox, Li, Bucknall, & Westbrook, 2020). Improving the nurses’ work environment and facilitating collaboration between all participants in the system responsible for medication within the hospital setting is essential (Härkänen, Saano, & Vehviläinen-Julkunen, 2017). Diversion strategies and checklists can be used to decrease interruptions, as well as special clothes that signify that a nurse is busy, although their impact requires further studies (Lapkin, Levett-Jones, Chenoweth, & Johnson, 2016). Error reporting also appears to be a contributing factor in lowering safety risks, as they can be further analyzed and avoided, especially if it is something that the administration can resolve (Kavanagh, 2017). Altogether, most of the risk factors can be addressed by applying respective measures that will not burden the budget and adopting a safety culture.

A nurse, regardless of their position, a novice or a leader, can contribute significantly to safety. However, the current strategy is for nurses to unite in teams to support each other and help less experienced colleagues (Choete, 2015). Such assistance can be instrumental in resolving poor communication and the fear of reporting medication administration errors (Choete, 2015). It is also important for a nurse to recognize patients as equal partners worthy of respect, which may enhance the attention and meticulousness with which care is provided (Sherwood & Nickel, 2017). Nurses should also constantly evaluate their performance and use technologies and information to update their knowledge and mitigate safety risks while remembering that some, such as barcode usage, have issues (Sherwood & Nickel, 2017). In conclusion, an individual nurse can do much to enhance safety, although it remains a collective effort of the staff and the system in place.

Sometimes nurses can feel restricted in their actions to tackle safety risks, so they have to cooperate with stakeholders to implement changes. The relevant groups would be the employers and the firms that provide medication. The former’s importance is that they are responsible for systematic improvements and staffing, and the nurses might negotiate their shifts and workload in a way that would decrease distractions and other oversights. Pharmaceutical firms can be instrumental in resolving the issues with packaging and instructions, making the former more distinct and the latter more detailed. The patients can also be considered an important stakeholder group in relation to medication administration, as most issues manifest in nurse-patient situations. Such cooperation allows a nurse to be aware of their opinion and vision of the ways a certain safety risk can be tackled because those directly affect them. Overall, by communicating with such stakeholders as the employers, the pharmaceutical firms, and the patients, a nurse may achieve improved safety results.

In conclusion, the paper described such a safety risk as medication administration errors, the factors that lead to them, and the measures that can enhance safety. Those can be roughly divided into the systematic and individual ones, but they should still apply together. A nurse can contribute considerably to maintaining safety as a team or a single unit, although cooperation with stakeholders is necessary to ensure a safe environment in the health care setting.

Cloete, L. (2015). Reducing medication errors in nursing practice. Cancer Nursing Practice, 14 (1), 29–36. Web.

Hammoudi, B. M., Ismaile, S., & Abu Yahya, O. (2017). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian Journal of Caring Sciences, 32 (3), 1038–1046. Web.

Härkänen, M., Saano, S., & Vehviläinen-Julkunen, K. (2017). Using incident reports to inform the prevention of medication administration errors . Journal of Clinical Nursing, 26 (21-22), 3486–3499.

Kavanagh, C. (2017). Medication governance: Preventing errors and promoting patient safety . British Journal of Nursing, 26 (3), 159–165.

Koyama, A. K., Maddox, C. S., Li, L., Bucknall, T., & Westbrook, J. I. (2020). Effectiveness of double checking to reduce medication administration errors: a systematic review. BMJ Quality & Safety, 29 , 595–603. Web.

Lapkin, S., Levett-Jones, T., Chenoweth, L., & Johnson, M. (2016). The effectiveness of interventions designed to reduce medication administration errors: A synthesis of findings from systematic reviews . Journal of Nursing Management, 24 (7), 845–858.

Parry, A. M., Barriball, K. L., & While, A. E. (2015). Factors contributing to Registered Nurse medication administration error: A narrative review . International Journal of Nursing Studies, 52 (1), 403–420.

Sherwood, G., & Nickel, B. (2017). Integrating quality and safety competencies to improve outcomes. Journal of Infusion Nursing, 40 (2), 116–122. Web.

Thomas, L., Donohue-Porter, P., & Stein-Fishbein, J. (2017). Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration errors. Journal of Nursing Care Quality, 32 (4), 309–317. Web.

van der Veen, W., van den Bemt, P. M., Wouters, H., Bates, D. W., Twisk, J. W., de Gier, J. J., & Taxis, K. (2017). Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals. Journal of the American Medical Informatics Association, 25 (4), 385–392. Web.

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• Peter McCulloch
• Nuffield Department of Surgical Science , Oxford University , Oxford , UK
• Correspondence to Peter McCulloch, Nuffield Department of Surgery, Oxford University, Oxford OX3 9DU, UK; peter.mcculloch{at}nds.ox.ac.uk

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• Implementation science
• Patient safety
• Safety culture
• Healthcare quality improvement
• Human factors

Reducing harm in hospital care using Human Factors and Quality Improvement approaches has proved harder than expected: better evaluation of our efforts, a more realistic understanding of the challenges we face and an intense focus on engaging staff are the key elements needed for progress.

Patient safety was not a recognised term in medical research parlance until the 1990s. Prior to this, avoidable harm from treatment was assumed to be rare, and failure was commonly attributed to the incompetence or lack of diligence of individuals. The emergence of convincing evidence that around 10% of hospital inpatients suffered serious harm from their treatment stimulated alarm, and a search for a rapid solution to this huge, previously unnoticed problem. 1 Analyses of adverse events showed that their causes were usually complex, system-based and to some extent stochastic, echoing the typical findings of professional accident investigations in the transport and energy sectors. It seemed likely that systematic analysis of the underlying problems would result in effective solutions which could drastically reduce harm from treatment, and the concept of the high reliability organisation became hugely popular. 2 Following the lead of civil aviation, healthcare professionals became enthusiastic about using ergonomics (Human Factors science) to solve the safety problem. Decades on, progress has been incremental, and studies of harm show results not dissimilar to those from the 1990s. 3 4

So why are we not there yet?

There are several answers to this question. I focus here on the ones I think are most important, respectfully recognising the subjectivity in my position. First, there is a difference in the commitment of management and policymakers at the most senior level in healthcare when compared with leaders in airline companies and fossil fuel producers, for whom the massive financial consequences of a major accident were ever-present in safety decision-making. Second, the Human Factors approaches we tried to adopt from other industries had developed organically over time to fit particular contexts, and over-literal translation to healthcare environments was often a poor fit. 5 Third, our evaluation of our own efforts has been consistently weak, making it hard to learn the right lessons. Finally and importantly, the modern healthcare industry, by its very nature, poses underlying wicked problems of interaction between structure and culture, which make change very hard. I describe each of these in turn below. Some points in this viewpoint are well-evidenced, while others are based on experience and perceptions, but I hope that the arguments provide a helpful and potentially creative opportunity for readers to react and reflect.

Management and relentless organisational pressures

Human factors: the can of worms.

Innovators cannot be held accountable for not finding the perfect solution immediately—this is rare in any context. Human Factors researchers started by standardising processes, adopting checklists and modifying a team training philosophy from civil aviation to improve team communication and co-operation. 7 8 They were immediately faced with questions to which only trial and error could provide answers. What is the correct dose and duration for team training? Should we try to standardise everything across the system or focus on key events? How do we measure success? How do we ensure compliance? Is there data to show change? Is it better to fix the system by standardising or to improve team relationships and effectiveness? We found that if we tried to fix every problem, the complexity of the solution and the resource requirements defeated us. If we focused too narrowly, our impact on patient outcome was small. Team training approaches designed for aviation produced measurable effects on internal team process and function, but the impact on patient outcomes remains hard to demonstrate. 9 A striking and repeated finding was that staff engagement with the intended changes was highly variable and often weak. 10

Some lessons learnt from other fields were applicable and helpful. The importance of codesign of changes with frontline staff and the value of short iterative cycles of experimentation were products of the ‘lean’ Quality Improvement philosophy, which had some remarkable successes and underpins the work of several successful healthcare quality and safety organisations. Not surprisingly, combining attempts to improve teamwork with systems redesign seemed to do better than either alone. 11 The research community gradually realised that we were dealing more with a sociocultural challenge than with a technical problem in process design. This refocused interest in the patient safety field onto culture and how to change it—but no reliably effective, evidence-based, generalisable solutions to this age-old question have yet emerged from our work.

(Not) doing the science right

Measuring the effects of complex interventions on human work processes is challenging by its nature, and we have not helped ourselves by doing it much less well than we could have. Changes to complex processes need first to be trialled and iteratively improved, then tested in a wide range of settings before they can undergo a definitive evaluation of their benefit, and we have rarely followed this kind of stepwise evaluation pathway in patient safety work. 12 The impact of some of the most important major initiatives has been blunted by study designs which have left the validity of their claims uncertain. The pivotal study on the WHO surgical checklist was a short term, open label, non-randomised before–after comparison with evaluation performed by the team carrying out the study. 7 , 12 13 A subsequent observational whole-system study in Canada showed no benefit, and a later, better designed study showed no significant mortality reduction. 13 14 The largest ever study of teamwork training compared trained and untrained units halfway through a multihospital programme, but selected units for training priority on the basis of ‘readiness’, thus introducing major bias. 15 Randomised studies have been dismissed as impossible by leading figures in this field, but several have been done—and like randomised studies in other fields have tended to disappoint their authors. This often reflects the lack of support for adequate stepwise preparatory studies to ensure that the RCT is feasible. 12 Even having an independent control group is uncommon—and in the rare cases, where it has been done has demonstrated its value in reducing overoptimistic interpretation of results. 16 The value of parallel qualitative process evaluation was initially ignored, but where it has been done, the insights into why things worked or did not have often been compelling. 17 Clearly, we need to do better science to make better progress. It may be more expensive, but if it yields more reliable answers, we may end up getting there faster in the long run.

The wicked problems: complexity, pressure and culture

This brings us to the wicked problems, which are interlinked. Healthcare staff attitudes, organisational structures and the stress of constant high demand can interact to produce a culture of fear, risk aversion, denial and arrogance, as reported in numerous investigations of systemic failures in hospital care. How does this happen? The rigid hierarchical management structure noted above is an understandable response to the need to maintain activity constantly near the theoretical maximum, and severely limits capacity for and interest in systems change. The cultural aspects of professional formation for clinical staff, however, may also have paradoxical negative effects on clinical engagement with systems change. Both medical and nursing training are steeped in an idealistic but very person-centred set of values including diligence, duty, perfectionism and selfless beneficence. 18

This has served the NHS enormously well, by inducing countless talented people to work far harder for far less reward than they would otherwise have done. But the implied converse side of this "heroic" model is the ‘shame and blame’ mindset in which adverse outcomes are attributed to individual failure, making staff fearful, defensive and judgemental, and inhibiting their acceptance of systems-based solutions. 19 20 Frontline clinical staff working in this kind of organisation learn that attempts to change the system encounter great difficulties, are disruptive to their normal work patterns and usually fail. Because of the risks to leaders who take on change management directly, projects are usually driven by external academics, experts or consultants, who are seen by staff (sometimes correctly) as remote and unfamiliar with the realities of work in their environment, and are clearly not acting under the direction of senior management. It is easy to see how apathy and cynicism can flourish in these circumstances. This symbiotic relationship between a defensive tribal culture and a change-resistant bureaucracy is incapable of delivering high-quality care but is very hard to change, and, therefore can be highly durable over long periods of time.

So what can be done?

The wicked problems are embedded in the system and culture so deeply that only radical reform of both will lead to sustainable major change. This may be necessary at an institutional or whole system level. Some examples of how this can be done, and can be transformative, exist but to experiment with and implement this kind of change across a large health system would take considerable boldness and change management skills. 21 22

If we cannot tackle the wicked problems, we should downgrade our expectations, but we can still achieve a good deal. We have learnt from our mistakes over the last 30 years, and we can incorporate the lessons into our work. Enabling organisational improvements needs to start with a thorough understanding of ‘work as done’ and the gap between this and ‘work as imagined’. 23 Systematic use of analytical tools to understand work processes is helpful in redesigning them. All changes need to be codesigned with frontline staff, whose implicit knowledge of the system is impossible for outsiders to reproduce. 24 Expecting a single intervention to transform performance is fantasy, but trying to change everything is a recipe for exhausted failure. In a complex interconnected system, the limits of intervention are difficult to define, and too narrow a focus may predestine failure. Hence, projects which concentrate efforts on the staff in a particular specialty area may need to widen their scope and include, for example, both their patients and the other departments whose help they need as partners. Finally, staff engagement will remain the greatest challenge. The importance of careful thought and detailed planning in enhancing engagement cannot be overemphasised. Much can be done by using professional approaches to communication and having well-liked and respected ambassadors. 25 Efforts to improve a sense of belonging and common purpose in the clinical team are logical as part of a strategy. The long-established principles of diffusion of innovations, and of social influence generally, need to be taken seriously as essential components of any project which intends to bring about change. 26 This is a key area for future research.

So when it comes to patient safety we are not nearly there yet, but we have travelled through the territory and learnt a lot on the journey. It is harder than we thought, but the lessons learnt do point to what success requires. The focus of our efforts needs to be directed far more towards finding out how to engage frontline staff actively in change management, since without their support, nothing works. Radical transformation will require fundamental reform of the system, but better science, which directly involves management in studies at a whole-institution scale can take us further, and perhaps provide the impetus to stimulate the necessary policy change.

Key messages

Harm and suboptimal outcomes due to imperfections in care remain stubbornly frequent in modern hospital care, despite three decades of study and attempts at intervention.

Efforts to improve safety using a Human Factors approach remain rational but have been impeded by over-reliance on modification of strategies from very different contexts, poor evaluation, lack of genuine management support and interdependent aspects of hospital staff culture and decision-making processes.

Frontline staff engagement is the key ingredient for success and is often difficult to generate. Understanding how to achieve it should be the main focus of our efforts.

Radical improvement may require radical reform of management structure and process in order to change staff culture.

Ethics statements

Patient consent for publication.

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Ethics approval

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X @McCullochP

Contributors This article draws on experience of the challenges of implementing quality and safety changes in healthcare organisations in England and the US. Professor PM is a surgeon by background and has led multiple research groups focused on improving the safety of surgical care and quality of surgical research. He would like to acknowledge the assistance of Ms Olivia Lounsbury, a US quality and safety practitioner and researcher focused on removing barriers to implementation of safety changes in healthcare organisations. The piece was first conceptualised from discussions between PM and Ms Lounsbury, and both consulted a variety of international healthcare journals for evidence on the topic. Ms Lounsbury commented on and edited drafts, but declined to be an author. Professor PM is the article’s guarantor, and declares that the opinions expressed in it are his alone.

Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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• Open access
• Published: 28 May 2024

The influence of hospital accreditation on nurses’ perceptions of patient safety culture

• Islam Ali Oweidat   ORCID: orcid.org/0000-0003-2344-4299 1 ,
• Huda Atiyeh 1 ,
• Mohammed Alosta 1 ,
• Khalid Al-Mugheed 2 ,
• Amany Anwar Saeed Alabdullah 3 ,
• Majdi M. Alzoubi 4 &
• Sally Mohammed Farghaly Abdelaliem 5  

Human Resources for Health volume  22 , Article number:  36 ( 2024 ) Cite this article

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Hospitals’ accreditation process is carried out to enhance the quality of hospitals’ care and patient safety practices as well. The current study aimed to investigate the influence of hospitals’ accreditation on patient safety culture as perceived by Jordanian hospitals among nurses.

A descriptive cross-sectional correlational survey was used for the current study, where the data were obtained from 395 nurses by convenient sampling technique who were working in 3 accredited hospitals with 254 nurses, and 3 non-accredited hospitals with 141 nurses, with a response rate of 89%.

The overall patient safety culture was (71.9%). Moreover, the results of the current study revealed that there were no statistically significant differences between the perceptions of nurses in accredited and non-accredited hospitals in terms of perceptions of patient safety culture.

The current study will add new knowledge about nurses’ perceptions of patient safety culture in both accredited and non-accredited hospitals in Jordan which in turn will provide valid evidence to healthcare stakeholders if the accreditation status positively affects the nurses’ perceptions of patient safety culture or not. Continuous evaluation of the accreditation application needs to be carried out to improve healthcare services as well as quality and patient safety.

Peer Review reports

Introduction

Patient safety culture is considered an essential principle and crucial priority for healthcare institutions [ 1 ]. The Institute of Medicine (IOM) in 1999, “To Err is Human: Building a Safer Health System” highlighted the need for creating a safety culture in healthcare facilities to manage preventable medical errors [ 2 ]. According to the concept of “First, do no harm,” a concept embedded in basic ethical principles and human rights, the primary focus in the delivery of healthcare is to keep patients’ safety [ 3 ].

According to WHO, most of patients’ harms or injuries come from surgical procedure, medical errors, hospital-acquired infection, pressure ulcer, and patient fall [ 4 ]. Around 50% of these harms and injuries can be prevented while the patient receives care in healthcare facilities [ 5 ]. In the UK, the incidence of patients’ harm is reported around 35 incidents every second [ 6 ]. In the United States, medical errors become the third cause of death with incidences were 6.3 million patients [ 5 , 7 ]. In the low- and middle-income countries are not better than developed countries. In Eastern Mediterranean countries, the annual events of patients’ harms or injuries are around 4.4 million and associated with high lifelong disability and rate of death [ 8 ]. In Jordan, the annual report of harm or injuries is estimated around 28% [ 9 ]. In Palestinian hospitals, found that 59.3% of medical errors were preventable [ 10 ]. The consequences of these harms and injuries increase length of stay, increase cost for patient care (around 6 to 29 billion per year), and loss of trust in the delivered healthcare service [ 6 ]. For this reason, WHO provided objectives to improve patient safety culture in worldwide healthcare facilities. These objectives are mainly designed to support collaboration among the healthcare teams, improve leadership and working environment to ensure non-punitive response, enhance adequate reporting of any error, and develop policies to enhance the patient safety culture in the healthcare facilities [ 11 ].

The Institute of Medicine stressed the need to create a safety culture in all health services [ 2 ]. Patient safety culture is a complex principle that needs interdisciplinary teamwork rather than personal performance to improve the quality of care [ 12 ]. It depends on the individual and group values, attitudes, and perceptions of providing safe care for their patients [ 13 , 14 ]. Thus, assessing the perceptions of healthcare providers about patient safety culture can guide the administration of healthcare facilities and the policymakers toward building patient safety culture in their healthcare facilities [ 15 , 16 ].

Hospital accreditation is a thorough process & management concept and method that is carried out for various healthcare institutions to improve the quality of hospitals’ services as well as patient safety aspects [ 17 ]. Moreover, the accreditation process is considered a key component and prioritizes patient safety aspects and the quality of rendered services as well [ 18 ]. According to the World Health Organization (WHO), this concept could be the single most substantial process to boost healthcare institutions’ quality [ 19 ]. It has been confirmed as the driving process for development and enhancement and includes all of the service delivery components such as processes, structures, and outcomes [ 20 ]. The accredited hospitals showed significant improvements in performance compared with non-accredited hospitals, the improvements were shown in creating patient safety systems, disaster planning, staff development and training, and reducing incidence reports [ 21 ].

Among the searched literature, there were many research studies that support the fact that the accreditation status of the hospital positively affects the perceptions of nurses toward patient safety culture. For example, a study conducted in Turkey among nurses that revealed hospital accreditation has a positive impact on quality outcomes, especially on the quality of care provided to patients and patient safety perceptions as well [ 22 ]. A cross-sectional study found that the nursing accreditation level was positive with patient safety indicators [ 23 ]. In a recent study conducted in South Korea, the nurses showed high significance in terms of safety climate with accreditation [ 24 ]. Shaw et al. found evidence for positive effects between accreditation, and patient safety [ 25 ]. Although numerous hospitals endeavor to obtain the accreditation, several factors affect progress and contribute to reducing healthcare performance-related patient safety, such as staff experience, adverse events, workload, and hospital budgets [ 26 ].

Among the searched literature in Jordan, in a recent study, the average positive response rate to the 6 domains of safety culture ranged from 58.54 to 75.63% [ 27 ]. In a cross-sectional, descriptive design study among 658 Jordanian nurses, the results provide insight into how nurses perceive patient safety culture [ 4 ]. A self-reported questionnaire about patient safety was distributed to the Jordanian nurses, the results obtained that 59% of participants reported good knowledge about patient safety [ 28 ]. Up to the researchers’ knowledge; limited literature especially in Jordan was found addressing the influence of hospitals' accreditation on nurses’ perceptions of patient safety culture. Therefore, understanding the influence of accreditation on Jordanian’s nurses’ perceptions of patient safety culture and its dimensions may lead to maintaining the commitment, support, and compliance of healthcare workers and even nurses towards quality principles and patient safety issues inside their hospitals. The study’s primary aim was to investigate patient safety culture among nurses. The secondary aim was to explore associations between patient safety culture and hospital accreditation.

Research design

A descriptive correlational cross-sectional design was used in this study.

The study was conducted in different hospitals in Jordan. The target population of this study is nurses working in hospitals with different departments. According to Cohen J [ 29 ], the sample size was based on conventional power analysis of medium effect size, a power of 0.80, and a level of significance at 0.05; the estimated sample size was 164 participants for each group (accredited hospitals, and non-accredited hospitals). The hospitals were selected via a simple random sampling technique from accredited hospitals and non-accredited hospitals in Jordan. Hospitals with a capacity of fewer than 60 beds were excluded because of the small number of registered nurses on their duty schedules, and they tended to be peripheral hospitals as well. Convenience sampling enrolls the availability and agreed of nurses to participate in this study with a total of 450 nurses. The final sample was 395 registered nurses who completed the study, in 3 accredited hospitals with 254 nurses, and 3 non-accredited hospitals with 141 nurses, with a response rate of 89%.

The inclusion criteria were nurses who provide direct patient care, have a minimum experience of two years in the hospital where the study is conducted, and have a minimum educational level of bachelor’s degree. The nurses who handle administrative, and managerial roles or clerical work and trainees were exulted from the study.

Instruments

The hospital survey on patient safety culture (HSPSC) was used to assess the perception of patient safety culture among healthcare providers. The instrument was included in two parts; the first part was demographic and background data such as age, gender, working experience, and accreditation status of the hospital. The second part was an HSPSC instrument composed of three main domains, with 12 sub-domains with a total of 42 items. The first main domain was dimensions of patient safety culture relating to the work area or unit and included seven sub-domains namely teamwork within hospital units (4 items); supervisor/manager expectations and promotion of safety (4 items); organizational action for learning and continuous improvement (3 items); feedback and communication in relation to error (3 items); communication openness (3 items); staffing (4 items); non-punitive response towards error (3 items).

The second main domain was dimensions that explore aspects of safety culture in a hospital and included three sub-domains namely management support about patient safety (3 items); teamwork across units (4 items); hands-off and transitions (3 items).

The third main domain was dimensions of outcome measurements and included two sub-domains was overall perceptions of safety (4 items); frequency of reporting events (3 items). In this study, the Cronbach’s α , was 0.84.

Data collection

The researcher started data collection between April to June 2021, by sending a link in Google Form and sharing it between the nurses, which included the aim of the study and contact information. By clicking on the “Agree and Proceed” button it was considered agreed to participate. Also, participants were informed that data would be kept at a high level of confidentiality and would not affect their job.

Data analysis

Data analysis was done using the Statistical Package for the Social Sciences version 23 (SPSS 23). Descriptive analysis was utilized to describe the demographic characteristics of the participants. Scores from the HSPSC were obtained to describe the status of patient safety culture in hospitals. Each item is rated by a five-point Likert scale with scores ranging from 1 = strongly disagree to 5 = strongly agree. Independent sample t test was used to detect if there is a statistically significant difference between accredited and non-accredited hospitals toward patient safety culture.

Table 1 shows the demographics of participants with mean age were (29.1 ± 6.7). The majority of participants were female in both groups accredited (82.1%, non-accredited 86.7%). Half of the participants had experiences of more than 11 years (66.1%) in non-accredited. Most participants work in accredited hospitals (67.4%).

In regard to the dimensions of patient safety culture, the overall patient safety culture was (71.9%). The highest positive response of patient safety was teamwork within hospital units (83.3%), hands-off and transitions (81.5%), Communication openness (79.1%), and feedback and communication in relation to error (77.5%). The lowest positive response was supervisor/manager expectations and promotion of safety (58.1%), followed by frequency of reporting events (59.7%) Table 2 .

In regard to the other research question which was about whether there is a statistically significant difference between accredited and non-accredited hospitals in terms of perceptions of patient safety culture; the results of the current study revealed that there were statistically significant differences between the perceptions in accredited and non-accredited hospitals in terms of patient safety culture Table 3 .

The study found no significant predictors for accredited hospitals and non-accredited hospitals based on participants’ demographics. Nurses who were working in accredited hospitals showed more positive related to patient safety culture than nurses who were working in non-accredited hospitals in terms of gender and years of experience Table 4 .

Patient safety and accreditation concepts are global concerns, so, further research studies should be conducted to explore the reasons behind the accreditation process does not guarantee patient safety culture and reporting culture [ 26 ]. A positive patient safety culture is crucial for every healthcare institution in Jordan and even in the world to provide safe care and to avoid any harm to patients.

Up to the best knowledge of the researchers; this is the first research study that investigates the influence of accreditation on the perceptions of patient safety culture among nurses. Actually, the results of the current study showed that the highest composite frequency of patient safety reflected nurses’ positive perception of teamwork within hospital units, while the lowest composite reflected positive opinion were the frequency of reporting errors. These results are considered consistent with the results of Khater and colleagues which they found that the highest dimension that was perceived positively by nurses in Jordan was “team work within units” [ 4 ]. Additionally, the results of the current study are considered consistent with the results of Al-Mugheed and colleagues which they found that the highest domain that was perceived positively by the surveyed participants was teamwork within units [ 12 ]. On the other hand, the current results are inconsistent with the results of Rao and colleagues [ 30 ]. In other words, the participants of the current study viewed their environment as supportive of each other; there is mutual respect between staff.

One of the alarming results of the current study was related to the frequency of reporting errors among Jordanian nurses which was the lowest dimension in terms of perceptions of patient safety culture; it may be due to the complexity of the healthcare system in the world and in Jordanian context (high technical equipment and inadequate communication; continuous evolutions in healthcare); patients are more prone to be harmed or injured while receiving care in the healthcare facilities [ 31 , 32 ]. Some healthcare providers also feared that their mistakes would have been held against them, Patient safety issues could be improved in Jordanian hospitals if JUST culture was fostered, which means recognizing the errors as flaws in the system, rather than a single individual’s failure, as well as they could be learned lessons [ 33 ]. There is a need to have an adequate understanding about patient safety culture to be implemented in healthcare facilities [ 34 ]. This can be achieved by assessing the current patient safety culture in the healthcare facilities [ 35 , 36 ].

The results of the current study revealed that there is no statistically significant difference was found between healthcare providers in accredited versus non-accredited hospitals in terms of perceptions toward patient safety culture. These results were considered consistent with the results of Shaikh study, in which he had investigated the impact of accreditation on safety practices perspectives of healthcare workers in India and it was revealed that there is a significant increase in the number of incidents reporting practices after the accreditation process of the hospitals [ 19 ]. In fact, the researcher does believe that this issue is debatable since some research studies support the idea that the accreditation status of any healthcare institution is highly correlated with safety culture perceptions [ 37 , 38 ], however, other research studies revealed that there is no significant correlation between accreditation status of the healthcare setting and incidents reporting practices. For example, the study that was conducted in the Jordanian context (2015) by AbuAlRub and colleagues revealed that healthcare providers in accredited and non-accredited hospitals did not differ statistically either in their incident reporting practices or their awareness of the reporting system [ 39 ]. However, nursing managers in accredited hospitals are required to maintain patient safety culture aspects such as incident reporting and communication among health workers after the accreditation process which needs actual commitment and support from all staff in hospitals.

Limitations of the study

Although the current study has many strength points; the results of the current study were subjected to several limitations. One limitation of this study resulted from its convenience sampling method; a method based on the selection of participants who were accessible electronically at the time of data collection. However, many nurses from different settings were selected to expand the generalizability of findings, also the represented sample was conducted in one country. Additionally, the current results revealed the perspectives of healthcare workers only; but actually, there is a need to assess the patient safety culture from the perspectives of clients and recipients of care being rendered.

To enhance the perceptions of patient safety culture among nurses, they need to be sensitized regarding patient safety issues, especially on standard treatment protocols, incident reporting practices, and communication mechanisms through continuing professional development (CPDs) or job training. The current study will add new knowledge about nurses’ perceptions of patient safety culture in both accredited and non-accredited hospitals in Jordan which in turn will provide valid evidence to healthcare stakeholders if the accreditation status positively affects the nurses’ perceptions toward patient safety culture or not. As well as it clearly shows the areas of strength and areas that are in need of improvement for nurses to expand their practice toward patient safety culture.

Availability of data and materials

The data that support the findings of this study are available on request from the corresponding author.

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Acknowledgements

The authors extend their appreciation to Princess Nourah bint Abdulrahman University Researchers Supporting Project number (PNURSP2024R444), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.

The research was funded by Princess Nourah bint Abdulrahman University Researchers Supporting Project number (PNURSP2024R444), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.

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Al-Oweidat I and Atiyeh H: conceptualization and methodology; Al-Mugheed K and Alosta M: validation and formal analysis; Amany A A and Sally M: writing and data curation; Alzoubi M and Amany A A: funding and data curation.

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Oweidat, I.A., Atiyeh, H., Alosta, M. et al. The influence of hospital accreditation on nurses’ perceptions of patient safety culture. Hum Resour Health 22 , 36 (2024). https://doi.org/10.1186/s12960-024-00920-1

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This document provides the Australian Government's response to the report on the Independent Capability Review of the Aged Care Quality and Safety Commission (ACQSC). The Government accepts all 32 recommendations.

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ASHRAE Issues Call for Papers for IEQ 2025

ASHRAE is accepting papers for the  IEQ (Indoor Environmental Quality) 2025 Conference , co-organized by ASHRAE and AIVC, to be held Sept. 24-26, 2025, in Montreal, Canada.

The conference expands upon the research and discussions of the former ASHRAE IAQ conference series that began in 1986. The theme of the conference is  “Rising to New Challenges: Connecting IEQ to a Sustainable Future”  and focuses on the increasing understanding of how occupants respond to various indoor environmental factors while enhancing resilience in the face of a changing climate.

"Incorporating sustainability into building design and operation is a key goal for ASHRAE and the broader buildings community,” said Iain Walker, conference co-chair. “This conference will focus on the relationships between IEQ and sustainability, offering a platform for industry leading researchers and practitioners to share their knowledge and solutions for address sustainability challenges."    

“One aspect of IEQ in the built environment is to raise awareness of resilience without incurring resource penalties in our dynamic world,” said Jennifer Isenbeck, co-chair. “This conference will provide a collaborative framework to showcase advanced technologies, materials selection and their integration into building designs and retrofits, all of which support sustainability and resilience in our communities.”

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 Authors have the option to submit a short abstract for either a conference paper (8-page manuscript) or an extended abstract (3-page manuscript). Short abstract submissions are due Nov. 11, 2024. If accepted, complete manuscript submissions are due March 10, 2025. For more information or to submit an abstract, visit ashrae.org/IEQ2025 .

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Health Information Technology in Healthcare Quality and Patient Safety: Literature Review

Sue s feldman.

1 Department of Health Services Administration, The University of Alabama at Birmingham, Birmingham, AL, United States

Scott Buchalter

2 Pulmonary and Critical Care, The University of Alabama at Birmingham Medical Center, Birmingham, AL, United States

Leslie W Hayes

3 Department of Pediatrics, The University of Alabama at Birmingham Medical Center, Birmingham, AL, United States

The area of healthcare quality and patient safety is starting to use health information technology to prevent reportable events, identify them before they become issues, and act on events that are thought to be unavoidable. As healthcare organizations begin to explore the use of health information technology in this realm, it is often unclear where fiscal and human efforts should be focused.

The purpose of this study was to provide a foundation for understanding where to focus health information technology fiscal and human resources as well as expectations for the use of health information technology in healthcare quality and patient safety.

A literature review was conducted to identify peer-reviewed publications reporting on the actual use of health information technology in healthcare quality and patient safety. Inductive thematic analysis with open coding was used to categorize a total of 41 studies. Three pre-set categories were used: prevention, identification, and action. Three additional categories were formed through coding: challenges, outcomes, and location.

This study identifies five main categories across seven study settings. A majority of the studies used health IT for identification and prevention of healthcare quality and patient safety issues. In this realm, alerts, clinical decision support, and customized health IT solutions were most often implemented. Implementation, interface design, and culture were most often noted as challenges.

Conclusions

This study provides valuable information as organizations determine where they stand to get the most “bang for their buck” relative to health IT for quality and patient safety. Knowing what implementations are being effectivity used by other organizations helps with fiscal and human resource planning as well as managing expectations relative to cost, scope, and outcomes. The findings from this scan of the literature suggest that having organizational champion leaders that can shepherd implementation, impact culture, and bridge knowledge with developers would be a valuable resource allocation to consider.

Introduction

It has long been known and accepted that healthcare in the US is too expensive and the outcomes are less than predictable [ 1 ]. The turn of the century brought with it a realization that healthcare, like other industries, could use data to increase our awareness of seemingly uncontrollable costs and unpredictable outcomes. With almost two decades of compiling, analyzing, mashing up data, and trying to make sense of how the data inform multiple layers of healthcare, it is time to look beyond the awareness that the data provide, and instead develop an understanding of how to use the data for predictable and actionable purposes, especially with regard to healthcare quality and patient safety. The literature is mixed on the degree to which health information technology (IT) as a valuable suite of tools, applications, and systems that have contributed to actual savings and efficiencies [ 1 - 4 ]. However, the area of healthcare quality and patient safety lends itself to many of the same business intelligence and predictability advantages that are seen in the credit card industry [ 5 - 7 ].

Much like the Triple Aim of Healthcare, the credit card industry is working toward decreased costs (fraud), increased quality (better transactions), and increased satisfaction (happier merchants and happier cardholders). The credit card industry began using business intelligence to predict behavior that suggested fraud, developed process maps for transaction processing, and offered perks to merchants and cardholders. Just as the credit card industry learned from healthcare, healthcare can borrow from the credit card industry to use healthcare intelligence for prevention, identification, and action related to healthcare quality and patient safety events.

The Institute for Healthcare Improvement (IHI) suggests that reliability around healthcare is a three-part cycle of failure prevention, failure identification, and process redesign and defines reliability as “failure-free operation over time.” [ 8 ]. Other areas of healthcare have used information systems to provide continuous monitoring with real-time, or near real-time reporting as a means of achieving reliability [ 9 ]. As such, it makes sense to think about the role of health IT in reliability as it relates to healthcare quality and patient safety. A review of the literature suggests that healthcare organizations are using health IT for healthcare quality and patient safety and that they have replaced redesign in Figure 1 with action as shown in Figure 2 [ 10 - 12 ]. Action, in this case, allows for health IT to be implemented after a potential healthcare quality or patient safety event has occurred and does not necessarily require a redesign. Ordering alerts in the electronic health record are an example of action; the event has occurred (the order has been entered) and health IT in the form of an alert is initiated to stop the potentially unsafe order from being filled by the pharmacy.

Improving the reliability of healthcare.

Improving the reliability of healthcare quality and patient safety.

Having an understanding of this cycle helps to create awareness around where various applications of health IT find their “best fit” in improving the reliability of healthcare quality and patient safety. A distinct advantage of this being a “cycle” is that there is no defined beginning and ending point, but rather an insertion point. This is all to say that the cycle should not be interpreted as starting with prevention and ending with action.

Health Information Technology for Prevention of Quality and Safety Events

Health IT for prevention of quality and safety events involves the use of health IT to prevent a quality and safety event from even happening . Automated reminders and alerts are useful in providing essential information that supports safe and effective clinical decisions [ 13 ]. Such alerts in the electronic health record (EHR) are a standard mechanism for the use of health IT for prevention of potential missed quality and patient safety events. For example, immunization alerts have led to a 12% increase in well-child and a 22% increase in sick child immunization administration [ 14 ] and drug alerts have been associated with a 22% decrease in medication prescription errors [ 15 ]. Soft-stops can provide key information about a potential quality or patient safety issue. They may offer choices but usually, require only that the user acknowledge the alert to proceed.

A hard-stop, on the other hand, prevents the user from moving forward with an order or intervention that would be potentially dangerous to a patient. Hard-stops may allow continuation of the process, but only if significant required action is taken by the user, such as a call to or consultation with an expert (such as a pharmacist or a medical specialist). In some cases, soft-stops might be ignored or overridden because of such issues as alert fatigue, poor implementation, or poor interface design [ 16 , 17 ]. Hard-stops, when appropriately designed, have been shown to be more successful in changing an unsafe plan or preventing a potentially dangerous intervention [ 18 , 19 ].

Health Information Technology for Identification of Quality and Safety Events

Health IT for identification of quality and safety events involves health IT that is used to identify a quality and safety event when it is about to occur . Health insurance providers increasingly place pressure on healthcare systems to reduce the cost of care delivery and improve patient outcomes. This pressure may exist through tiered reimbursement structures, benefitting those systems which meet or exceed specific benchmarks of performance. Growing pressure from these payers takes the form of non-reimbursement for care determined by the payer to be unnecessary or in excess of “standard care.” Health IT can be used to find the EHR populations of patients for whom reimbursement might be lower than expected. One such example to consider is the length of stay for a particular procedure. While the use of health IT can produce reports and dashboards that are helpful for decision-making relative to reimbursement trends and practices for lengths of stay for that diagnosis, it is crucial that thoughtful consideration be given for appreciating any unintended consequences. For example, when reducing the length of stay, unintended readmissions are an important metric to follow.

Health Information Technology for Action in Quality and Safety Events

Health IT for action of quality and safety events involves health IT that is used to a ct on a quality and safety event once it has already occurred. That is to say that these are actions that were reported in the literature that were taken as a result of an event. Health IT for action differs from health IT for prevention in that the former is a reaction directly correlated to an event reported in the article, whereas the latter is reported in the article as a preemptive measure, in advance of an event.

Because of their standardization, there are several clinical care pathways that lend themselves to clinical decision support. One such clinical care pathway is sepsis. Despite nearly two decades of advances in early sepsis care, sepsis outcomes persist to be poor, and sepsis remains a leading cause of death worldwide and accounts for significant morbidity and mortality [ 20 ]. In light of this, there is a growing national push to increase early identification and treatment of sepsis with a goal of improving outcomes. Patients with sepsis are some of the most critically ill patients admitted to hospitals, and survival depends heavily upon timely and early administration of key interventions followed quickly by assessing and acting on results of these interventions [ 21 ]. Some examples include administration of IV antibiotics and aggressive IV fluids within one hour [ 21 ]. Examples of assessments of interventions include measuring specific physical and laboratory values that provide crucial information about the patient response. All too often, clinicians are faced with an overabundance of data, that while all necessary, may not be relevant to the issue at hand. For example, lab results might be presented in their entirety, when in practice, there are only 3 or 4 tests that will drive decision-making. The difficulty is how to separate the noise (non-essential at that moment) from the signal (essential at that moment). Health IT solutions, such as dashboards and other solutions can be used to ensure that essential data are in a primary viewing position and non-essential data in a secondary viewing position (perhaps on drill down, for example).

This paper will provide foundational knowledge and understanding for organizations of where to focus health IT fiscal and human resources. It will also provide information relative to some of the challenges that can be expected in implementing health IT for quality and patient safety.

This review of the literature took a structured approach using PubMed and a combination of keywords. Since PubMed indexes peer-reviewed articles from biomedical information, it was felt that this was the most appropriate and inclusive source. A healthcare-focused librarian, under the direction of all authors, conducted the literature search. The articles for final selection were discussed and decided upon among the authors. The structured approach was guided by the model illustrated in Figure 3 .

Literature search process.

The process to article inclusion involved three passes to collect publications related to health IT in quality and patient safety for peer-reviewed studies published between 2012-2017, inclusive. The first pass, (shown as “1” in Figure 3 ), used high-level keywords and returned 86 full-text articles. From the articles gathered, additional keywords were added to the search. After deduplication and citation review, the second pass (shown as “2” in Figure 3 ) added 67 unique full-text articles. After deduplication and citation review, the third pass (shown as “3” in Figure 3 ) added 11 unique full-text articles, for a total of 164 unique full text articles. Each article was further analyzed to identify the degree to which the article discussed health IT in healthcare quality and patient safety. To be considered for inclusion, the study needed to report on the actual use of health IT in healthcare quality and patient safety. Forty-one studies met these criteria. Those studies with their contributions to the results are shown in the results section of this paper.

Qualitative data analysis software (Atlas.ti 8 for Windows) was used in directed content analysis as a method to categorize and code the 41 studies relative to how health IT was used in healthcare quality and patient safety. All 41 documents were uploaded into the document manager in Atlas.ti as Primary Documents (PD). During this process, the article title was used as the PD name. Inductive thematic analysis with open coding was used under the three pre-set categories of prevention, identification, and action [ 22 ]. This allowed for capturing descriptions of how health IT was used in each circumstance.

For example, prevention included descriptions of any use of health IT to prevent quality issues or potential safety events, identification included any descriptions of the use of health IT to identify quality issues or safety events, and action included any descriptions of the use of health IT to act on quality issues or safety events that have occurred. When content was noted that did not fit into the three pre-set categories, an additional category was created. Additional categories were created to capture challenges relative to the use of health IT in quality and patient safety. Since some papers discussed how the use of health IT impacted health outcomes, an additional category was created for outcomes. Lastly, an additional category was created to capture the study settings or location.

The coding structure was agreed upon by all authors, and one author conducted the coding. After all of the studies were coded, two additional passes were made through the data. The first pass was to ensure that all information from the studies that should be coded was actually coded and coded to the correct code (ie, was a passage that described prevention actually coded to prevention?). The second pass was to consider sub-categories for consolidation. Six sub-categories were consolidated.

The purpose of examining co-occurrences is to understand what, if any, relation exists between concepts [ 22 , 23 ]. Within Atlas.ti, a co-occurrence table was run to find codes that co-occur across the literature, the purpose of which was to illuminate the areas most discussed. This table was then exported to Microsoft Excel for further analysis.

Network maps are a means by which analysis can be visualized in relationships to provide a different perspective on the codes, categories, etc., and with that visualization, provide a mechanism for moving codes around [ 22 ]. Those presented in the results do not differ from the final coding structure, but instead are used to provide a visual representation.

Literature reviews can be conducted using a qualitative approach [ 24 , 25 ] with the results displayed in a variety of ways to support models and show connections [ 22 ]. As such, this review presents qualitative findings to support the “improving the reliability of healthcare quality and patient safety” model introduced earlier in this paper and shows connections via network mappings in Figure 6 through Figure 7 and co-occurrences in Table 2 .

IDENTIFICATION Network Diagram (G=groundedness, D=density).

PREVENTION Network Diagram (G=groundedness, D=density).

a IT: information technology.

Table 1 provides a listing of the articles and their contribution in this results section to support the model ( Figure 2 ), network maps ( Figure 4 through Figure 7 ), and co-occurrences ( Table 2 ).

Article contribution to results (in alphabetical order). An “X” indicates the area of the results contribution and “—” indicates no contribution.

ACTION Network Diagram (G=groundedness, D=density).

From the 41 studies that fit the inclusion criteria, any element in which the authors discussed the use of health IT for healthcare quality and patient safety was identified, even if it did not fit into the three previously determined categories. This process yielded a total of 50 codes across five categories: action (7/41, 17.1%), challenges (12/41, 29.3%), identification (10/41, 24.4%), outcomes (5/41, 12.2%), and prevention (16/41, 39.0%) across seven study settings. Just under a quarter of the studies identified a study setting: anesthesia (2/41, 4.9%), behavioral health (1/41, 2.4%), emergency department (2/41, 4.9%), any intensive care unit (3/41, 7.3%), clinical diagnostic laboratory (1/41, 2.4%), pediatrics (2/41, 4.9), surgery (1/41, 2.4%).

Across all of the articles, there were 63 and 92 descriptions of the use of health IT for identification and prevention of healthcare quality and patient safety issues, respectively. Health IT for action and the challenges associated with health IT for healthcare quality and patient safety was described 41 and 43 times, respectively.

The findings from the literature review are presented by the categories outlined in the previously introduced model for improving the reliability of healthcare quality and patient safety.

The first exploration was across the literature that discussed health IT for prevention of quality and patient safety issues to see exactly how organizations were reporting health IT use to prevent a quality and safety event from even happening . The greatest areas of use were around alerts [ 30 , 31 , 44 , 56 , 58 ], clinical decision support [ 39 , 44 , 47 , 56 ], implementation [ 10 , 32 , 37 , 38 , 56 ], interface design [ 26 , 34 , 42 , 45 , 56 , 59 ], and customized health IT solutions [ 29 , 30 , 32 , 34 , 46 - 50 , 56 , 58 , 59 ]. Customized health IT solutions were anything that described the use of health IT but lacked any specificity beyond that described in this section. For example, this could be something as simple as checklists or as complex as algorithmic diagnostic trees. To clarify, alerts are a subset of clinical decision support. Since so many of the occurrences specified alerts and clinical decision support separately, these were coded separately. Clinical decision support, by definition, includes alerts, clinical care guidelines, condition-specific orders sets, clinical reports and/or summaries, documentation templates, diagnostic support, and clinical reference support. Implementation and interface design were each described in terms of having been poorly implemented or poorly designed and having implications on utility in healthcare quality and safety.

Identification

The next exploration was across the literature that discussed health IT for identification of quality and patient safety issues; in other words, how health IT was used to identify a quality and safety event when it is about to occur . In this regard, similar to prevention (but described differently in the included studies), alerts [ 26 , 30 , 31 , 44 , 56 , 58 ], clinical decision support [ 30 , 31 , 39 , 44 , 56 , 58 ], implementation [ 10 , 32 , 38 , 56 ], and customized health IT solutions [ 10 , 30 , 31 , 34 , 46 - 49 , 52 , 56 , 58 ] were most prominent. For example, alerts, clinical decision support, and customized health IT solutions were all described in the literature as having been implemented to identify a potential quality or patient safety issue, yet the literature also described how the implementation of these could have been better in terms of providing more training to those on the receiving end of the alerts, clinical decision support, or other customized health IT solutions.

OUTCOMES Network Diagram (G=groundedness, D=density).

The third exploration was across the literature that discussed health IT for action on a quality and safety event once it has already occurred. That is to say that these are actions that were reported in the literature that were taken as a result of an event. In regards to action, the major areas were documentation [ 10 , 32 , 37 , 41 , 46 , 56 , 58 ], implementation [ 10 , 32 , 37 , 58 ], and culture [ 10 , 29 , 41 , 53 , 58 ] relative to the use of health IT.

The findings from the review of the literature show that implementation appeared in prevention, identification, and action. Implementation in general has been demonstrated in the literature as a challenge, and that was revealed in this literature review also. Culture was most often referred to as needing to create a culture of quality and patient safety in order for health IT to be embraced. Organizations that started working on culture change before implementation of health IT solutions suggested that health IT for acting on quality and patient safety events was more favorable. Therefore, the analysis was run with challenges which suggests the major areas are: culture, implementation, and interface design.

Co-occurrences

Employing the Improving the reliability of healthcare quality and patient safety model introduced in Figure 2 and adding challenges, six critical co-occurrences emerged (see Table 2 ).

As described earlier, co-occurrences expose relationships exists between concepts [ 22 , 23 ]. The top co-occurring codes in Table 2 create a macro level view of how health IT was most commonly used for quality and patient safety relative to the “improving the reliability of healthcare quality and patient safety” model introduced in Figure 2 . However, it is also important to understand the universe of ways in which organizations used health IT for quality and patient safety; in other words, the art of the possible when using health IT for quality and patient safety. Network maps provide a mechanism by which to visualize the connectedness of all data coded across all 41 articles included in this analysis. These maps, along with some quantitative information increase understanding at this universe level (macro and micro views).

In the network diagrams that follow (which also represent the coded categories and sub-categories), G signifies the level of groundedness of the particular code. Groundedness, in this case, indicates the frequency of the code relative to the code category. D signifies the level of density or connectedness of the particular code. Density, in this case, indicates the number of other codes to which this code is connected. For example, under ACTION, Figure 4 , the code action: culture shows G6, D2. ACTION is the code category and action: culture is the code “culture” under the ACTION code category (this coding structure helps to maintain alpha order). This can be read as the following: “Culture was described six times across all 41 papers relative to ACTION and is connected to two code categories total.” Because it would make the network diagrams unwieldy, not shown in the exhibits is the specificity around the groundedness or the density. See Figures 4 through Figure 7 .

Principal Findings

This scan of the literature is intended to inform practice. The information from this study could be useful as organizations determine where they stand to get the most “bang for their buck” relative to health IT for quality and patient safety. Centered around the Improving the Reliability of Healthcare Quality and Safety model introduced in Figure 2 and the macro level uses of health IT for quality and patient safety outlined in Table 2 , organizations in the planning stages may want to begin with alerts and clinical decision support, understanding that alerts are a subset of clinical decision support. This information also helps with resource planning. For example, implementation appeared in all three categories of the Improving the Reliability of Healthcare Quality and Safety model. Additionally, culture was shown to be a challenge. Organizational leaders know that changing culture can be a long and intensive process. The findings from this scan of the literature suggest that having organizational champion leaders that can shepherd implementation, impact culture, and bridge knowledge with developers would be a valuable resource allocation to consider.

Health IT must meet quality improvement at the intersection with care delivery. From a clinical perspective, this is experienced on several levels, and the solution depends, in part, on the clinical problem to be addressed. Some typical examples of health IT interventions illuminated in the findings include: (1) reminders and alerts, (2) decision support tools, (3) checklists (including order sets and protocols), and (4) soft- and hard-stops.

As noted, this scan of the literature is provided as a means to inform practice. It does not consider further model modification, and this represents an area of future research in the application of health IT for quality and patient safety.

Limitations

This study is limited in that it used PubMed as a single source for the searching and one coder coded all studies. A more comprehensive and systematic review would include multiple databases and multiple coders. Although all authors reviewed the codes, multiple coders would ensure intercoder reliability, which cannot be assured in this study. Additionally, since all studies reviewed did not include locations, generalizability to all areas of clinical care cannot be certain.

A review of the literature for this study concluded that organizations in the planning stages of using health IT to improve quality and safety may want to begin with reminders and alerts, decision support tools, and checklists.

Acknowledgments

The authors acknowledge and appreciate the careful, detailed, and thoughtful comments by the reviewers whose suggestions strengthened this paper.

Abbreviations

Conflicts of Interest: None declared.