5^th World Congress on Patient Safety & Quality Healthcare June 22-23, 2020 Zurich, Switzerland

Biography:

Rebecca has a PhD in Engineering Science, a MSc in Medical Sciences and a MSc in Materials Engineering from Uppsala University, Sweden. Her scientific papers have been published in, among others, Analytical Chemistry, Annals of Pharmacotherapy, Biosensors and Bioelectronics, Biotechnology Journal and Langmuir. She is the co-founder and CTO of the Sweden based medical device company TADA Medical.

Abstract:

The most frequent invasive procedure in European healthcare is not safe. Around 80% of in-hospital patients receive intravenous (IV) therapy through a catheter and an average 10.1% of these are accidentally dislodged during treatment, leading to an annual 263 million interrupted treatments and €12 billion in unnecessary healthcare spending globally. The most affected patient groups are children and the elderly with a reported accident rate as high as 36%. This results in, e.g., patient injury, wasted medication, increased plastic waste and increased workload for healthcare staff. The level of severity associated with an incident depends on catheter type, i.e. peripheral venous catheters, central venous catheters, peripherally inserted central catheter and midline catheter, where the highest average costs of €480 per incident can be found for central venous catheters. An innovative safety device to address this problem is currently under development. The device is a two-part safety connector that is to be placed on the patient’s side of the catheter. When the catheter is accidentally pulled, the two parts acts as a weak link and separate, thus preventing dislodgement, patient injury and damage to medical equipment. A double vale system prevents spillage of blood and medication. The constitution of the device allows for rapid reinstatement of IV therapy after an accident and the protection of the catheter and associated consumables, which otherwise would be thrown away after an accident, heavily decreases the amount of plastic being 

Biography:

Dr Natalie Gallagher completed her MBChB with honors from the University of Liverpool and is currently Year 5 paediatric trainee in the Mersey Deanery in the UK.

Abstract:

Medication errors (MEs) are common in neonates and have the potential to cause significant harm in a vulnerable population. Previous studies have categorised the seriousness of MEs in purely subjective terms. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index is a validated standardised tool for categorising MEs according to the severity of the outcome but there are limited data on its use in neonates. We describe the use of the MERP Index to categorise MEs in neonates. MEs reported to an online system in a level 3 NICU over a 12-month period were reviewed. The severity of the error was assessed using the MERP Index containing 9 categories of severity. Information on patient demographics and the type of ME was also collected. 337 MEs were identified in 167 infants with a median (IQR) gestational age of 28 (25-33) weeks, birthweight of 1005 (745-2244) g and age 14 (2-37) days. The most common type of MEs were prescription (181) and administration errors (119). Categorisation of errors using the MERP Index showed that the majority of MEs did not reach the patient (222/337). 65 were errors that reached the patient but did not cause harm and 15 required further intervention to prevent harm. There were no errors that resulted in harm or death. In conclusion, although MEs are common in neonates, the vast majority are of no clinical significance. The MERP Index allows systematic, objective categorisation of errors and can be used effectively in a neonatal population.

Biography:

Experienced Consultant Obstetrician and Gynaecologist with a demonstrated history of working in the hospital & health care industry since 1995. Skilled in Obstetrics and Gynaecology, Change Management in healthcare, Clinical research and Social enterprise.Holds the fellowship of the Royal College of Obstetricians and Gynaecologists for contribution to the field (2015) .Also holds a leadership and management qualification from the NHS Leadership academy.Member of the Chartered Institute of Ergonomics and Human factors Interested in Innovation ,Human Factors and Patient safety. Senior clinical examiner for year 5, MBChB examinations, Birmingham University

Abstract:

Introduction: In UK, retained swabs after vaginal birth and perineal suturing are classed as “Never events.¹ Retained vaginal swabs have accounted for around 30% of retained foreign object -‘never events’ reported on an annual basis for a number of years.Retained vaginal swab post delivery could cause significant morbidity and patient may experience serious physical and psychological complications, including infection, secondary post-partum haemorrhage, sepsis, depression, lack of bonding with their baby and loss of trust in the healthcare system. As yet, the interventions developed to prevent this problem have focussed towards changing human behaviour. As per hazard control hierarchy,  a ‘human factors’ engineered solution is more likely to be effective than just modifying human behaviour⁴. We present a ‘human factors engineered system’ where a design solution and human behaviours complement each other, to prevent human error.

Aim of the project: To prevent the accidental retention of vaginal swab with a simple device so as to ‘design out’ the human error. We present findings from a formative usability study done in a high fidelity simulation environment, which looked at the user experience, safety and acceptability of the novel device system. Description of the device- the device has a seatbelt plug in system where by each swab tail has a plastic clip at the end which plugs into the device displaying a green indicator when all are plugged in and a red indicator when one or more are disconnected. The aim is to ensure that all swabs are returned and not retained in the patient. Its major benefit is its simplicity and cost effectiveness.

Methods: Seven healthcare professionals who work in that particular clinical area participated in the usability study done by NIHR Medtech, University hospitals, Birmingham. Each user session lasted for approximately 40 minutes and it involved audio video content, hands-on session using the device in a high fidelity theatre simulation set up and feedback in the form of a semistructured interview

Usability study findings : All the participants have a positive attitude towards the device being supportive of the concept but made some valuable design recommendations based on their clinical practice and personal preferences. The device is external to the patient and is mechanical and therefore poses no risk to the user or the patient as observed in the simulated environment.  The feedback suggested improving the design of the clips in order to make them finer and to make the device compact and easy to handle. This valuable feedback led to further prototype iterations in the device development journey. A simulation study and a pilot study in childbirth clinical environment is being planned to develop further understanding.

Conclusion: The users found the design solution acceptable and felt positive about the concept. Further evaluation studies are required to establish the reliability of the system in preventing the accidental retention. Further evaluation studies should be planned to establish the reliability of the system in preventing accidental retention and to design a ‘human factors engineered system’ where a design solution and human behaviours complement each other, to prevent human error.

Biography:

Alison Kay is an Occupational Psychologist based at the Centre for Innovative Human Systems. Her core focus is on the human aspects of safety critical systems. She has worked on human factors research projects in aviation, healthcare, the process industries, maritime industry and manufacturing. Her research has addressed decision making, competence, process modelling and resource management for training, procedure writing and accident investigation. In 2008, Alison was one of the Human Factors Integration Defence Technology Centre team awarded the UK Ergonomics Society President's Medal 'for significant contributions to original research, the development of methodology and the application of knowledge within the field of ergonomics'

Abstract:

Statement of the Problem: Retained Foreign Objects (RFO) are rare events but can be devastating for patient and practitioners alike. Research has diverged from a blame culture and acknowledges the impact that communication and collective team responsibility could have on reducing RFOs . This research designed and evaluated a pilot implementation of foreign object management in two Irish Hospitals sites, one surgical, one midwifery & obstetrics. It recommends further steps to ensure we move towards a team responsibility for proactive patient safety management of RFOs. Methodology: A multi-phase socio-technical systems approach was adopted  focussing heavily on co-design, actively engaging and collaborating with clinical and other healthcare staff through each phase of research. The evaluation was multi-modal and both qualitative and quantitative in nature.

Findings: Team Communication – Communication surrounding the count must be clear. Silence for the count must be preserved (where possible) and cultural support must be in place to raise the profile and integrity of the count to a higher level.

Context - It is vitally important to obtain a rich and accurate systems picture of RFO ‘how?’ & ‘why?’ & ‘when?’, objects are retained needs to be understood, not just the “who?”.

Education & Training – Specific training on RFO prevention should be given to all staff on a recurrent basis to promote a culture of encouragement to speak up and a culture of being listened to.

Reporting - The cultural interpretation of “near miss” in clinical settings needs to be revised. Learning from other safety critical industries re smart data handling is prudent if effective implementation is to be achieved.

Conclusion & Significance- This research was novel in its approach to multi-modal evaluation and is significant as the research included much needed exploration of complex cultural, social and political challenges surrounding the count and RFO prevention.

Biography:

Hoi-Ting Wong is junior doctors based at the Royal United Hospital, Bath in the UK.

Abstract:

Learning from mistakes is vital for providing safe patient care. Serious untoward incidents are reviewed by several groups within the Royal United Hospial (RUH) and the wider NHS, but communicating the learning gained from this can be difficult.‘Cautionary Tales’ is a newsletter designed to share learning from incidents reviewed by the Division of Medicine Clinical Governance Group with junior doctors at the Royal United Hospital, UK. ‘Cautionary Tales’ is written by junior doctors, which strives to disseminate key messages and highlight common themes.Serious Untoward Incidents (SUIs) are shared in a concise manner using the SBAR format. The Assessment includes analysis of notable practice, contributory factors and the root cause. Recommendations are tailored to the hospital – often this part is also used to highlight new and existing guidelines and services. In addition, related topics are explained and consolidated (for example hyperkalaemia guidelines and how to diagnose postural hypotension). Previous newsletters have included learning points from SUIs such as falls and prescribing errors, shared Central Alerting System (CAS) alerts as well as results from a survey amongst RUH staff on complaints.‘Cautionary Tales’ has been sharing learning points from incident reviews for two years, and has been well received by junior doctors. In a recent survey all respondents stated they enjoyed reading the newsletter and had learned from it. 96% of respondents stated they would alter their practice after reading it. In future editions, we are also hoping to include “Exemplary Tales”, where learning from excellence is promoted.

Biography:

In her years of professional nursing experience, Dr. Wilson developed the skills to deliver impeccable health care services towards patients; thus, making the same exemplary effort to deliver exquisite services to nursing students, nurses, and patients.  Dr. Wilson likes to express her level of resilience, keen attention to detail, flexibility, and adaptability.  Dr. Wilson’s knowledge in research and education fosters a learning environment for nurses.  She is also competent in her current role as an educator.  She is prepared to critically analyze policy/laws/ethics to develop, evaluate, and advocate for, regulation, and delivery of nursing and health care services

Abstract:

The problem:There is an increase in antibiotic prescribing on patients in the long-term care unit without adherence to specimen collection of culture prior to antibiotic prescribing. There is an increase of misuse of antibiotics in the case of viral infections, minor infections, and ineffective dosing of antibiotics

The purpose: Education and teaching of nurses and physicians about proper adherence to specimen collection of culture prior to antibiotic prescription And Optimal use of antibiotic prescription

Collection of data from the pre-intervention phase shows significant trend indicating patients are often prescribed antibiotics without any specimen collection, resulting in inappropriate treatment to bacterial infections.  The trend places patients at risks for superinfections. The purpose of the project is to implement the antibiotic stewardship program in a long-term care unit and promote a steadfast resolution to optimize use of antibiotics and adhere to specimen collection of culture prior to antibiotic prescribing.

For the antibiotic stewardship project, the PICOT states: For nursing staff in a long-term care unit, does the implementation of an evidence-based antibiotic stewardship program, versus current practice of improper adherence of collection of cultures prior to antibiotic prescribing, improve the adherence of specimen collection for culture prior to antibiotic prescribing, in an 8-10-week timeframe?

Two-way percentage table was used to cross-tabulate the adherence of specimen collection for culture prior to antibiotic prescribing before and after implementation.  Kai-square test of independence was used to determine if there was a relationship between adherence of specimen collection for culture prior to antibiotic prescribing. The percentage of YES to collection of specimen of culture for pre-intervention is 30.3%.  The percentage of YES to collection of specimen of culture for post-intervention is 67.6%.  The adherence to specimen collection of culture has shown significant improvement from pre-intervention to post intervention.

Biography:

Sumariah Mehwish has completed his MSHCM at the age of 26 years from Riphah International University, Islamabad. Pakistan. and she is the Executive Research Associate at Riphah Institute of Healthcare Improvement & Safety (RIHIS), a Healthcare organization. She has been serving as a Research Associate from the last 4 years in the field of healthcare quality & Patient Safety. She has also presented her poster in the 4th International Conference on Patient Safety (ICPS). And winning the poster competition among all the healthcare professionals from across the Pakistan.

Abstract:

The aim of this study was to investigate the medication adherence and health literacy and level of education among diabetic patients. The moderating role of disease knowledge in the relationship between medication adherence and level of education along with health literacy was also examined. Data collection was processes through adopted and adapted questionnaire in cross sectional study from diabetic patients working at junior, middle and senior level of organization and out-door patients of almost all the hospitals of Rawalpindi and Islamabad. Out of 400 distributed questionnaires 271 were completely responded. SPSS software were used to analyze the respondents’ feedback. Two of the hypothesis are positively correlated with one another while rest of the other hypothesis are not significant while regression results showed that health literacy both are positively associated with medication adherence. Subsequently, disease knowledge moderates the significant relationship between health literacy and medication adherence and level of education and medication adherence also significant relationship with the disease knowledge according to our expectations. Therefore, according to results implications were made for diabetic patients to obtain the best of their knowledge to get good life style and improve their behavior towards learning and understanding about their health.

Biography:

Maryam Husain is a nurse at Trinity College, Dublin

Abstract:

High profile N.H.S. inquiries into declining care standards and unsafe patient care, highlight many contributing factors including organizational, cultural, staffing and resources, with recommendations for improvement based around addressing these factors. While health care organisations are under pressure to maintain delivery of high quality care, the question of why standards of care continue to decline resulting in failures in modern healthcare settings is key. The focus has turned to gaining a deeper understanding of health care professionals’ behaviors as potential mitigating factors.Health care professionals generally hold strong value in delivering high quality care; however due to factors mentioned previously, these values are compromised, resulting in discomfort (dissonance). Humans are motivated to achieve consistency between values and behavior and discomfort can be reduced by “challenging outside forces”, “reporting discomfort”, and “denial and justification”. When the discomfort is resolved consistency between values and behaviours is achieved. Alternatively when justification, compromise and denial are used to reduce discomfort, substandard care delivery and poor quality ensues. The Cognitive Dissonance Theory by Leon Festinger (1950) provides an understanding of the process of declining levels of care, reiterating the importance of achieving consistency between values and behaviours Conclusion: Substandard care is often the result of efforts to reduce discomfort by ignoring, justifying, and denying, rather than finding practical approaches to restoring good care standards 

Biography:

Hayk Saakian has been developing apps and building businesses from an early age. He designed and developed the Pacific Middle School’s website as a 6th-grader and in high school, developed a series of Android apps that accumulated over 300,000 downloads on the Google Play Store

Abstract:

This sessions goal is to demonstrate successful & reproducible tactics that will increase search traffic, conversions, & improve your rankings in Google. Looking at our campaigns & experiments in 2019, we'll review examples of SEO tactics that have increased rankings, how much traffic improvement was seeing over 3, 6, and 12 month timelines. I will present the processes and documentation we used so that attendees can replicate and perform the work independently with their teams as they are able. This session will be targeted to those with mid-tier knowledge of SEO who want to increase results

Biography:

Ferdous Arfina Osman has completed her PhD at the age of 31 years from the University of Manchester, UK and postdoctoral studies from Johns Hopkins University, USA. She is a Professor  of the Department of Public Administration at the University of Dhaka, a premier university of Bangladesh. She has published one book and more than 25 papers in reputed national and internationaljournals. 

Abstract:

Despite the fact that Bangladesh has witnessed substantial success with respect to health but the health of the poor people living in urban areas is still under numerous challenges.  While public sector has a strong Primary Health Care (PHC) infrastructure in rural areas, provision of PHC services in urban areas is pluralistic, fragmented and predominantly delivered by NGOs and the private sector.  Since last two decades, government has been providing the PHC services to the urban poor through contracting out to the NGOs. Urban Primary Health Care Service Development Program (UPHCSDP) is such an initiative. This is one of the first large-scale attempts in Asia to contract out primary care services to NGOs.  Various studies have reported the efficacy of the contracting out initiative in terms of service coverage and various pro-poor strategies but no in- depth study on the “quality” of these services has yet been available.  Addressing this gap, the current study has investigated the quality of service provided under the UPHCSDP.  Drawing on Carlson and Schwarz (1995), the study assessed the quality of services across four dimensions: access, equity, responsiveness and opportunity of citizens to influence the service. The study was carried out in eight slums of Dhaka city.  It relied on qualitative data collected through 40 key in-depth interviews of both service providers (8) and service recipients (32).  Findings demonstrate that the services are accessible to the urban poor both in financial and physical terms but in terms of other indicators services are yet to reach the expected level.

Biography:

Faiza Aljarameez is a newly graduated doctoral student in 2019 with a deep passion towards improving health and medical education. Regardless her decent years of experience as advanced practice clinician and researcher, she has a great potential is to improve the image of nursing and healthy empowering working conditions.

Abstract:

Statement of the Problem: Organizational commitment is a critical element of nurse retention and highly associated with intent to leave and actual turnover. Nurses' commitment is influenced greatly by nurses’ perceived empowerment in the workplace. In Saudi Arabia, currently there is a gap in the literature regarding staff nurses’ perception of empowerment and organizational commitment. Therefore, it was imperative to conduct a research to acquire better understanding of nurses’ perceptions and attitudes regarding empowerment and organizational commitment.

The primary purpose of this study was to examine and compare the relationships among structural empowerment, psychological empowerment, and organizational commitment in Saudi and non-Saudi  nurses working in Saudi Arabia. Additionally, the study determined the factors that predict organizational commitment among the two study populations.

Methodology & Theoretical Orientation: The theoretical framework was based on Kanter’s (1977,1993) Theory of Structural Empowerment and Spreitzer’s (1995) Theory of Psychological Empowerment. The study used a descriptive comparative multivariate correlational research design and a self-administered, paper and pencil survey to collect data from a convenience sample of full-time nurses (N = 398) working in inpatient units in three governmental hospitals in Saudi Arabia.

Findings: Statistically significant positive partial correlations were found among structural empowerment, psychological empowerment and organizational commitment. Non-Saudi nurses perceived higher levels of empowerment and commitment compared to Saudi nurses. Psychological empowerment was found to have a small moderation effect on the relationship between structural empowerment and continuance commitment.

Conclusion & Significance: Findings of this study may assist nursing authority understand the relationships between nurses’ empowerment and organizational commitment and facilitate the necessary changes to improve the current working conditions. The findings may provide evidence for recommendations to use empowerment and organizational commitment as new concepts to investigate and measure commitment and improve future retention and anticipated turnover among staff nurses working in Saudi Arabia.

Biography:

Fatemeh Bakhshi is a PhD cotutelle student. She is PhD candidate in Nursing education and Research Management. Her area of interest during PhD is hospital management with emphasize on patient safety and medical errors. She tries to create new pathways for improving medication safety and continuity of care. She has conducted several qualitative methods with focus of action research to better address these issues.

Abstract:

Medication Errors are among the most common medical errors in the healthcare system. There are many factors related to ME incidence in hospitals that affect healthcare professionals involved in medication therapy. Failure to Medication Management (MM) might be the leading factor for medication error incidents especially in the emergency department. The objective of this explanatory sequential mixed-method study was to perform situation analysis of MM deficiencies and uncover promotion strategies in the emergency ward with focus on interprofessional collaboration. First, a descriptive cross-sectional survey was performed. In this quantitative phase the developed MM Comprehensive Instrument was completed. Then three Focus Group Discussions (FGD) with informants of medical, nursing and pharmacy professionals were conducted to explain observed deficiencies and develop strategies. Interviews were analysed by directed qualitative content analysis. Quantitative findings mainly showed that participants were insufficiently informed about medication policies and reporting medication errors. The focus of discussions in FGDs was regarding the revealed deficiencies in quantitative phase. Six themes with two categories of deficiencies and promotion approaches were extracted: Monitoring, preventing, reporting, reaction, evaluation and feedback, inter-professional collaborations. Informants stated inadequate training and supervision, and failure to develop inter-professional collaborations in medication therapy as the most important causes of the current deficiencies in MM. Informants emphasized that enhancing Inter-professional education in medication therapy with emphasize on medication error scenarios, interprofessional audit with feedback meetings for analysing reported medication errors, interprofessional teamwork policies, computerization of the whole medication documentation process, and online reporting applications for medication errors to effectively improve MM in the emergency department. A combination of offered promotion strategies with support of the hospital managers and faculty members are the most likely means to improve MM in the emergency department.