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  • 1.
    Bachnick, Stefanie
    et al.
    University of Applied Sciences, Bochum, Germany, DE.
    Unbeck, Maria
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad. Danderyd Hospital, Karolinska Institutet, Stockholm.
    Ahmadi Shad, Maryam
    University of Basel, Basel, Switzerland, CH.
    Falta, Katja
    University of Applied Sciences, Bochum, Germany, DE.
    Grossmann, Nicole
    University of Basel, Basel, Switzerland, CH.
    Holle, Daniela
    University of Applied Sciences, Bochum, Germany, DE.
    Bartakova, Jana
    University of Basel, Basel, Switzerland, CH.
    Musy, Sarah N
    University of Basel, Basel, Switzerland, CH.
    Hellberg, Sarah
    Danderyd Hospital, Karolinska Institutet, Stockholm; Danderyd University Hospital, Stockholm.
    Dillner, Pernilla
    Karolinska Institutet, Stockholm; Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm.
    Atoof, Fatemeh
    Kashan University of Medical Sciences, Kashan, Iran, IR.
    Khorasanizadeh, Mohammadhossein
    Kashan University of Medical Sciences, Kashan, Iran, IR.
    Kelly-Pettersson, Paula
    Danderyd Hospital, Karolinska Institutet, Stockholm; Danderyd University Hospital, Stockholm.
    Simon, Michael
    University of Basel, Basel, Switzerland, CH.
    TAILR (Nursing-Sensitive Events and Their Association With Individual Nurse Staffing Levels) Project: Protocol for an International Longitudinal Multicenter Study2024Ingår i: JMIR Research Protocols, E-ISSN 1929-0748, Vol. 13, artikel-id e56262Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Nursing-sensitive events (NSEs) are common, accounting for up to 77% of adverse events in hospitalized patients (eg, fall-related harm, pressure ulcers, and health care-associated infections). NSEs lead to adverse patient outcomes and impose an economic burden on hospitals due to increased medical costs through a prolonged hospital stay and additional medical procedures. To reduce NSEs and ensure high-quality nursing care, appropriate nurse staffing levels are needed. Although the link between nurse staffing and NSEs has been described in many studies, appropriate nurse staffing levels are lacking. Existing studies describe constant staffing exposure at the unit or hospital level without assessing patient-level exposure to nurse staffing during the hospital stay. Few studies have assessed nurse staffing and patient outcomes using a single-center longitudinal design, with limited generalizability. There is a need for multicenter longitudinal studies with improved potential for generalizing the association between individual nurse staffing levels and NSEs.

    OBJECTIVE: This study aimed (1) to determine the prevalence, preventability, type, and severity of NSEs; (2) to describe individual patient-level nurse staffing exposure across hospitals; (3) to assess the effect of nurse staffing on NSEs in patients; and (4) to identify thresholds of safe nurse staffing levels and test them against NSEs in hospitalized patients.

    METHODS: This international multicenter study uses a longitudinal and observational research design; it involves 4 countries (Switzerland, Sweden, Germany, and Iran), with participation from 14 hospitals and 61 medical, surgery, and mixed units. The 16-week observation period will collect NSEs using systematic retrospective record reviews. A total of 3680 patient admissions will be reviewed, with 60 randomly selected admissions per unit. To be included, patients must have been hospitalized for at least 48 hours. Nurse staffing data (ie, the number of nurses and their education level) will be collected daily for each shift to assess the association between NSEs and individual nurse staffing levels. Additionally, hospital data (ie, type, teaching status, and ownership) and unit data (ie, service line and number of beds) will be collected.

    RESULTS: As of January 2024, the verification process for the plausibility and comprehensibility of patients' and nurse staffing data is underway across all 4 countries. Data analyses are planned to be completed by spring 2024, with the first results expected to be published in late 2024.

    CONCLUSIONS: This study will provide comprehensive information on NSEs, including their prevalence, preventability, type, and severity, across countries. Moreover, it seeks to enhance understanding of NSE mechanisms and the potential impact of nurse staffing on these events. We will evaluate within- and between-hospital variability to identify productive strategies to ensure safe nurse staffing levels, thereby reducing NSEs in hospitalized patients. The TAILR (Nursing-Sensitive Events and Their Association With Individual Nurse Staffing Levels) study will focus on the optimization of scarce staffing resources.

    INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/56262.

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  • 2.
    Nilsson, Lena
    et al.
    Linköping University, Linköping.
    Lindblad, Marléne
    Swedish Red Cross University, Stockholm.
    Johansson, Nathalie
    Högskolan Dalarna, Institutionen för hälsa och välfärd. Region Uppsala.
    Säfström, Lisa
    Högskolan Dalarna, Institutionen för hälsa och välfärd. Heby Home Health Care, Heby.
    Schildmeijer, Kristina
    Linnaeus University, Kalmar.
    Ekstedt, Mirjam
    Linnaeus University, Kalmar; Karolinska Institutet, Stockholm.
    Unbeck, Maria
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad. Karolinska Institutet, Stockholm.
    Exploring nursing-sensitive events in home healthcare: A national multicenter cohort study using a trigger tool2023Ingår i: International Journal of Nursing Studies, ISSN 0020-7489, E-ISSN 1873-491X, Vol. 138, artikel-id 104434Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: The provision of home healthcare is increasing in response to the growing aging population with the need for chronic disease management in their homes. Safety work differs from hospital care. The incidence of adverse events in home healthcare is sparsely studied but is estimated to occur in-one third of patients, and most are deemed preventable. Although nursing care is crucial for risk assessment and preventive work in the home environment, the role of registered nurses in the prevention of no-harm incidents and adverse events has not received sufficient scientific attention.

    OBJECTIVES: To explore nursing-sensitive events in patients receiving home healthcare.

    DESIGN, SETTING AND PARTICIPANTS: A Swedish national multicenter study based on a structured record review of 600 randomly chosen healthcare records from 10 organizations in different regions of the country.

    METHODS: Ten trained teams, each including physician(s) and registered nurses, undertook a review based on the Global Trigger Tool method. The review covered a maximum of 90 days from admission to home healthcare. First, each record was screened for the presence of 38 predefined triggers. In the second step, every potential event was assessed according to preventability, types of events, severity, time of occurrence, consequences of the event, and potential contributing causes.

    RESULTS: In total, 699 events were identified in the study. Of these, 495 (74.0%) were classified as nursing-sensitive (227 no-harm incidents and 268 adverse events) and affected 267 (44.5%) patients, with a mean of 1.9 events per patient. The majority (n = 367, 73.1%) were considered preventable. The most prominent types of nursing-sensitive event were falls (n = 138, 27.9%), pressure ulcers (n = 62, 12.5%), healthcare-associated infections (n = 58, 11.7%) and medication management (n = 50, 10.1%). Concerning severity, 45.9% were classified as no-harm incidents and another 36.6% resulted in temporary harm that required extra healthcare resources: 226 hospital days, 66 physician visits in outpatient care, and 99 in home healthcare. All severity types occurred from day 1, except death, which included only one patient. The most frequent contributing factors were deficiencies in nursing care, treatment & diagnosis, with the subgroups nursing care, observation, treatment & follow-up, followed by deficiencies in the organization.

    CONCLUSIONS: Nursing-sensitive events in home healthcare are common, often preventable, and occur from the start of the care period. This study contributes to increased knowledge of patient safety shortcomings and points to the important role that registered nurses play in patient safety work.

  • 3.
    Dillner, Pernilla
    et al.
    Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm; Karolinska Institutet, Stockholm.
    Unbeck, Maria
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad. Danderyd Hospital, Karolinska Institutet, Stockholm.
    Norman, Mikael
    Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm; Karolinska Institutet, Stockholm.
    Nydert, Per
    Karolinska University Hospital, Astrid Lindgren's Children's Hospital, Stockholm.
    Härenstam, Karin Pukk
    Karolinska Institutet, Stockholm; Karolinska University Hospital, Astrid Lindgren's Children's Hospital, Stockholm .
    Lindemalm, Synnöve
    Karolinska Institutet, Stockholm; Karolinska University Hospital, Astrid Lindgren's Children's Hospital, Stockholm .
    Wackernagel, Dirk
    Karolinska Institutet, Stockholm; University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany.
    Förberg, Ulrika
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad. Karolinska Institutet, Stockholm.
    Identifying neonatal adverse events in preterm and term infants using a Paediatric Trigger Tool2023Ingår i: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 112, nr 8, s. 1670-1682Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    AIM: To explore the incidence and characteristics of inpatient neonatal adverse events in a Swedish setting.

    METHODS: A retrospective record review, using a trigger tool, performed by registered nurses and a neonatologist, at a University Hospital. The identified adverse events were categorised by, for example, preventability, severity and time of occurrence.

    RESULTS: A random selection of 150 admissions representing 3531 patient days were reviewed (mean [SD] birthweight 2620 [1120]g). Three hundred sixty adverse events were identified in 78(52.0%) infants and 305(84.7%) of these were assessed as being preventable. The overall adverse event rate was 240 per 100 admissions and 102.0 per 1000 patient days. Preterm infants had a higher rate than term infants (353 versus 79 per 100 admissions, p=0.001), however with regard to the length of stay, the rates were similar. Most adverse events were temporary and less severe (n=338/360, 93.9%) and the most common type involved harm to skin, tissue or blood vessels (n=163/360, 45.3%). Forty percent (n=145) of adverse events occurred within the first week of admission.

    CONCLUSION: Adverse events were common in neonatal care and many occurred during the first days of treatment. Characterisation of adverse events may provide focus areas for improvements in patient safety.

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  • 4.
    Dillner, Pernilla
    et al.
    Karolinska Institutet, Stockholm; Karolinska University Hospital, Stockholm.
    Eggenschwiler, Luisa C
    University of Basel, Basel, Switzerland.
    Rutjes, Anne W S
    University of Modena and Reggio Emilia, Modena, Italy; University of Bern, Bern, Switzerland.
    Berg, Lena M
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad. Karolinska Institutet, Stockholm.
    Musy, Sarah N
    University of Basel, Basel, Switzerland.
    Simon, Michael
    University of Basel, Basel, Switzerland.
    Moffa, Giusi
    University of Basel, Basel, Switzerland.
    Förberg, Ulrika
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad. Karolinska Institutet, Stockholm.
    Unbeck, Maria
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad. Karolinska Institutet, Stockholm.
    Incidence and characteristics of adverse events in paediatric inpatient care: a systematic review and meta-analysis2023Ingår i: BMJ Quality and Safety, ISSN 2044-5415, E-ISSN 2044-5423, nr 3, s. 133-149Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Adverse events (AEs) cause suffering for hospitalised children, a fragile patient group where the delivery of adequate timely care is of great importance.

    OBJECTIVE: To report the incidence and characteristics of AEs, in paediatric inpatient care, as detected with the Global Trigger Tool (GTT), the Trigger Tool (TT) or the Harvard Medical Practice Study (HMPS) method.

    METHOD: MEDLINE, Embase, Web of Science and Google Scholar were searched from inception to June 2021, without language restrictions. Studies using manual record review were included if paediatric data were reported separately. We excluded studies reporting: AEs for a specific disease/diagnosis/treatment/procedure, or deceased patients; study protocols with no AE outcomes; conference abstracts, editorials and systematic reviews; clinical incident reports as the primary data source; and studies focusing on specific AEs only. Methodological risk of bias was assessed using a tool based on the Quality Assessment Tool for Diagnostic Accuracy Studies 2. Primary outcome was the percentage of admissions with ≥1 AEs. All statistical analyses were stratified by record review methodology (GTT/TT or HMPS) and by type of population. Meta-analyses, applying random-effects models, were carried out. The variability of the pooled estimates was characterised by 95% prediction intervals (PIs).

    RESULTS: We included 32 studies from 44 publications, conducted in 15 countries totalling 33 873 paediatric admissions. The total number of AEs identified was 8577. The most common types of AEs were nosocomial infections (range, 6.8%-59.6%) for the general care population and pulmonary-related (10.5%-36.7%) for intensive care. The reported incidence rates were highly heterogeneous. The PIs for the primary outcome were 3.8%-53.8% and 6.9%-91.6% for GTT/TT studies (general and intensive care population). The equivalent PI was 0.3%-33.7% for HMPS studies (general care). The PIs for preventable AEs were 7.4%-96.2% and 4.5%-98.9% for GTT/TT studies (general and intensive care population) and 10.4%-91.8% for HMPS studies (general care). The quality assessment indicated several methodological concerns regarding the included studies.

    CONCLUSION: The reported incidence of AEs is highly variable in paediatric inpatient care research, and it is not possible to estimate a reliable single rate. Poor reporting standards and methodological differences hinder the comparison of study results.

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  • 5.
    Unbeck, Maria
    et al.
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad. Karolinska Institutet, Stockholm.
    Lidgren, Filippa
    Karolinska University Hospital, Stockholm.
    Tabbakh, Ella
    Karolinska University Hospital, Stockholm.
    Nymark, Carolin
    Karolinska Institutet, Stockholm; Karolinska University Hospital, Stockholm.
    The patient's experience of participation when admitted for elective surgical procedures: an interview study2023Ingår i: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 18, nr 1, artikel-id 2163958Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    PURPOSE: To describe the patient's experience of participation in their care when admitted for elective surgical procedures.

    MATERIALS AND METHODS: A purposive sample of 14 patients who had undergone elective surgery was included in semi-structured individual interviews at a university hospital. The data was analysed using qualitative content analysis.

    RESULTS: One theme was identified: Creating a meaningful relationship to enable participation in the care, based on three categories; Abilities, willingness, and a lack of experience affect participation, A professional approach with an open communication and individualized information, and The importance of structural factors.

    CONCLUSIONS: To meet the patient's individual needs and wishes regarding participation, meaningful relationships need to be created between patient and healthcare personnel. The results also indicate that the patients have insufficient knowledge about their role regarding participation. To improve patient participation, its meaning needs to be clarified individually to the patient, emphasizing the importance to be active involved in his or her own care.

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  • 6. Magnéli, M.
    et al.
    Kelly-Pettersson, P.
    Rogmark, C.
    Gordon, M.
    Sköldenberg, O.
    Unbeck, Maria
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad. Karolinska Institute, Stockholm.
    Timing of adverse events in patients undergoing acute and elective hip arthroplasty surgery: A multicentre cohort study using the Global Trigger Tool2023Ingår i: BMJ Open, E-ISSN 2044-6055, Vol. 13, nr 6, artikel-id e064794Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective To explore timing in relation to all types of adverse events (AEs), severity and preventability for patients undergoing acute and elective hip arthroplasty. Design A multicentre cohort study using retrospective record review with Global Trigger Tool methodology in combination with data from several registers. Setting 24 hospitals in 4 major regions of Sweden. Participants Patients ≥18 years, undergoing acute or elective total or hemiarthroplasty of the hip, were eligible for inclusion. Reviews of weighted samples of 1998 randomly selected patient records were carried out using Global Trigger Tool methodology. The patients were followed for readmissions up to 90 days postoperatively throughout the whole country. Results The cohort consisted of 667 acute and 1331 elective patients. Most AEs occurred perioperatively and postoperatively (n=2093, 99.1%) and after discharge (n=1142, 54.1%). The median time from the day of surgery to the occurrence of AE was 8 days. The median days for different AE types ranged from 0 to 24.5 for acute and 0 to 71 for elective patients and peaked during different time periods. 40.2% of the AEs, both major and minor, occurred within postoperative days 0-5 and 86.9% of the AEs occurred within 30 days. Most of the AEs were deemed to be of major severity (n=1370, 65.5%) or preventable (n=1591, 76%). Conclusions A wide variability was found regarding the timing of different AEs with the majority occurring within 30 days. The timing and preventability varied regarding the severity. Most of the AEs were deemed to be preventable and/or of major severity. To increase patient safety for patients undergoing hip arthroplasty surgery, a better understanding of the multifaceted nature of the timing of AEs in relation to the occurrence of differing AEs is needed. © Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

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  • 7.
    Tistad, Malin
    et al.
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Medicinsk vetenskap. Karolinska Institutet, Huddinge.
    Bergström, Anna
    Uppsala University, Akademiska sjukhuset, Uppsala.
    Elf, Marie
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad.
    Eriksson, Leif
    Uppsala University, Akademiska sjukhuset, Uppsala.
    Gustavsson, Catharina
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Medicinsk vetenskap. Center for Clinical Research Dalarna-Uppsala University, Falun; Uppsala University, Uppsala.
    Göras, Camilla
    Högskolan Dalarna, Institutionen för hälsa och välfärd.
    Harvey, Gill
    College of Nursing and Health Sciences, Flinders University, Adelaide, Australia.
    Källberg, Ann-Sofie
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad.
    Rudman, Ann
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad.
    Unbeck, Maria
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad. Karolinska Institutet, Huddinge.
    Wallin, Lars
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad.
    Training and support for the role of facilitator in implementation of innovations in health and community care: a scoping review protocol.2023Ingår i: Systematic Reviews, E-ISSN 2046-4053, Vol. 12, nr 1, artikel-id 15Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Implementing and sustaining innovations in clinical practice, such as evidence-based practices, programmes, and policies, is frequently described as challenging. Facilitation as a strategy for supporting implementation requires a facilitator, i.e. an individual with a designated role to support the implementation process. A growing number of studies report that facilitation can help tackle the challenges in implementation efforts. To optimise the potential contribution of facilitation as a strategy to improve the implementation of new practices, there is a need to enhance understanding about what training and support is required for individuals in the facilitator role. The objective of this scoping review is to map how facilitators have been trained for, and supported in, the facilitator role in implementation studies in health and community care. Specifically, the review aims to examine what is reported on training and support of facilitators in terms of learning outcomes, content, dose, mode of delivery, learning activities, and qualifications of the trainers and how the facilitators perceive training and support.

    METHODS: This scoping review will follow the guidance of the Joanna Briggs Institute and the PRISMA Extension for Scoping Review checklist. We will include articles in which (a) facilitation is deployed as an implementation strategy, with identified facilitator roles targeting staff and managers, to support the implementation of specified innovations in health or community care, and (b) training and/or support of facilitators is reported. We will exclude articles where facilitation is directed to education or training in specific clinical procedures or if facilitation supports the implementation of general quality improvement systems. All types of peer-reviewed studies and study protocols published in English will be included. A systematic search will be performed in MEDLINE (Ovid), Embase (embase.com), Web of Science Core Collection, and CINAHL (Ebsco).

    DISCUSSION: The proposed scoping review will provide a systematic mapping of the literature on the training and support of implementation facilitators and contribute useful knowledge within the field of implementation science to inform future facilitation initiatives.

    SYSTEMATIC REVIEW REGISTRATION: Registered at Open Science Framework (registration https://doi.org/10.17605/OSF.IO/M6NPQ ).

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  • 8.
    Olin, Karolina
    et al.
    Karolinska Institutet, Stockholm, Sweden; Tyks and Hospital District of Southwest Finland, Turku, Finland.
    Göras, Camilla
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad. Örebro University, Orebro, Sweden; Falu Hospital, Falun, Sweden.
    Nilsson, Ulrica
    Karolinska Institutet, Stockholm, Sweden.
    Unbeck, Maria
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad. Karolinska Institutet, Stockholm, Sweden .
    Ehrenberg, Anna
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad.
    Pukk-Härenstam, Karin
    Karolinska Institutet, Stockholm, Sweden; Karolinska Universitetssjukhuset, Stockholm, Sweden.
    Ekstedt, Mirjam
    Karolinska Institute, Stockholm, Sweden .
    Mapping registered nurse anaesthetists' intraoperative work: tasks, multitasking, interruptions and their causes, and interactions: a prospective observational study2022Ingår i: BMJ Open, E-ISSN 2044-6055, Vol. 12, nr 1, artikel-id e052283Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Safe anaesthesia care is a fundamental part of healthcare. In a previous study, registered nurse anaesthetists (RNAs) had the highest task frequency, with the largest amount of multitasking and interruptions among all professionals working in a surgical team. There is a lack of knowledge on how these factors are distributed during the intraoperative anaesthesia care process, and what implications they might have on safety and quality of care.

    OBJECTIVE: To map the RNAs' work as done in practice, including tasks, multitasking, interruptions and their causes, and interactions, during all phases of the intraoperative anaesthesia work process.

    METHODS: Structured observations of RNAs (n=8) conducted during 30 procedures lasting a total of 73 hours in an operating department at a county hospital in Sweden, using the Work Observation Method By Activity Timing tool.

    RESULTS: High task intensity and multitasking were revealed during preparation for anaesthesia induction (79 tasks/hour, 61.9% of task time spent multitasking), anaesthesia induction (98 tasks/hour, 50.7%) and preparation for anaesthesia maintenance (86 tasks/hour, 80.2%). Frequent interruptions took place during preoperative preparation (4.7 /hour), anaesthesia induction (6.2 /hour) and preparation for anaesthesia maintenance (4.3 /hour). The interruptions were most often related to medication care (n=54, 19.8%), equipment issues (n=40, 14.7%) or the procedure itself (n=39, 14.3%). RNAs' work was conducted mostly independently (58.4%), but RNAs interacted with multiple professionals in and outside the operating room during anaesthesia.

    CONCLUSION: The tasks, multitasking, interruptions and their causes, and interactions during different phases illustrated the RNAs' work as done, as part of a complex adaptive system. Management of safety in the most intense phases-preparing for anaesthesia induction, induction and preparing for anaesthesia maintenance-should be investigated further. The complexity and adaptivity of the nature of RNAs' work should be taken into consideration in future management, development, research and education.

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  • 9.
    Nowak, Bartosch
    et al.
    Department Head Organs, Spine- and Neuromedicine, University Hospital Basel, Basel, Switzerland.
    Schwendimann, René
    Patient Safety Office, University Hospital Basel, Basel, Switzerland; Institute of Nursing Science, University of Basel, Basel, Switzerland.
    Lyrer, Philippe
    Department of Neurology and Stroke Center, University Hospital and University of Basel, Basel, Switzerland.
    Bonati, Leo H.
    Department of Neurology and Stroke Center, University Hospital and University of Basel, Basel, Switzerland.
    De Marchis, Gian Marco
    Department of Neurology and Stroke Center, University Hospital and University of Basel, Basel, Switzerland.
    Peters, Nils
    Department of Neurology and Stroke Center, University Hospital and University of Basel, Basel, Switzerland.
    Zúñiga, Franziska
    Institute of Nursing Science, University of Basel, Basel, Switzerland..
    Saar, Lili
    Department of Neurology, Universitätsklinik Freiburg, Freiburg im Breisgau, Germany.
    Unbeck, Maria
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad. Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden..
    Simon, Michael
    Institute of Nursing Science, University of Basel, Basel, Switzerland.
    Occurrence of No-Harm Incidents and Adverse Events in Hospitalized Patients with Ischemic Stroke or TIA: A Cohort Study Using Trigger Tool Methodology2022Ingår i: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 19, nr 5, artikel-id 2796Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Adverse events (AEs)-healthcare caused events leading to patient harm or even death-are common in healthcare. Although it is a frequently investigated topic, systematic knowledge on this phenomenon in stroke patients is limited. To determine cumulative incidence of no-harm incidents and AEs, including their severity and preventability, a cohort study using trigger tool methodology for retrospective record review was designed. The study was carried out in a stroke center at a university hospital in the German speaking part of Switzerland. Electronic records from 150 randomly selected patient admissions for transient ischemic attack (TIA) or ischemic stroke, with or without acute recanalization therapy, were used. In total, 170 events (108 AEs and 62 no-harm incidents) were identified, affecting 83 patients (55.3%; 95% CI 47 to 63.4), corresponding to an event rate of 113 events/100 admissions or 142 events/1000 patient days. The three most frequent AEs were ischemic strokes (n = 12, 7.1%), urinary tract infections (n = 11, 6.5%) and phlebitis (n = 10, 5.9%). The most frequent no-harm incidents were medication events (n = 37, 21.8%). Preventability ranged from 12.5% for allergic reactions to 100% for medication events and pressure ulcers. Most of the events found (142; 83.5%; 95% CI 76.9 to 88.6) occurred throughout the whole stroke care. The remaining 28 events (16.5%; 95% CI 11.4 to 23.1) were detected during stroke care but were related to care outside the stroke pathway. Trigger tool methodology allows detection of AEs and no-harm incidents, showing a frequent occurrence of both event types in stroke and TIA patients. Further investigations into events' relationships with organizational systems and processes will be needed, first to achieve a better understanding of these events' underlying mechanisms and risk factors, then to determine efforts needed to improve patient safety.

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  • 10.
    Eggenschwiler, Luisa C
    et al.
    University of Basel, Basel, Switzerland.
    Rutjes, Anne W S
    University of Bern, Bern, Switzerland.
    Musy, Sarah N
    University of Basel, Basel, Switzerland.
    Ausserhofer, Dietmar
    University of Basel, Basel, Switzerland; College of Health Care-Professions Claudiana, Bozen-Bolzano, Italy.
    Nielen, Natascha M
    University of Basel, Basel, Switzerland.
    Schwendimann, René
    University of Basel, Basel, Switzerland; University Hospital Basel, Basel, Switzerland.
    Unbeck, Maria
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad. Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
    Simon, Michael
    University of Basel, Basel, Switzerland.
    Variation in detected adverse events using trigger tools: A systematic review and meta-analysis2022Ingår i: PLOS ONE, E-ISSN 1932-6203, Vol. 17, nr 9, artikel-id e0273800Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Adverse event (AE) detection is a major patient safety priority. However, despite extensive research on AEs, reported incidence rates vary widely.

    OBJECTIVE: This study aimed: (1) to synthesize available evidence on AE incidence in acute care inpatient settings using Trigger Tool methodology; and (2) to explore whether study characteristics and study quality explain variations in reported AE incidence.

    DESIGN: Systematic review and meta-analysis.

    METHODS: To identify relevant studies, we queried PubMed, EMBASE, CINAHL, Cochrane Library and three journals in the patient safety field (last update search 25.05.2022). Eligible publications fulfilled the following criteria: adult inpatient samples; acute care hospital settings; Trigger Tool methodology; focus on specialty of internal medicine, surgery or oncology; published in English, French, German, Italian or Spanish. Systematic reviews and studies addressing adverse drug events or exclusively deceased patients were excluded. Risk of bias was assessed using an adapted version of the Quality Assessment Tool for Diagnostic Accuracy Studies 2. Our main outcome of interest was AEs per 100 admissions. We assessed nine study characteristics plus study quality as potential sources of variation using random regression models. We received no funding and did not register this review.

    RESULTS: Screening 6,685 publications yielded 54 eligible studies covering 194,470 admissions. The cumulative AE incidence was 30.0 per 100 admissions (95% CI 23.9-37.5; I2 = 99.7%) and between study heterogeneity was high with a prediction interval of 5.4-164.7. Overall studies' risk of bias and applicability-related concerns were rated as low. Eight out of nine methodological study characteristics did explain some variation of reported AE rates, such as patient age and type of hospital. Also, study quality did explain variation.

    CONCLUSION: Estimates of AE studies using trigger tool methodology vary while explaining variation is seriously hampered by the low standards of reporting such as the timeframe of AE detection. Specific reporting guidelines for studies using retrospective medical record review methodology are necessary to strengthen the current evidence base and to help explain between study variation.

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  • 11. Saar, Lili
    et al.
    Unbeck, Maria
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad. Karolinska Institutet.
    Bachnick, Stefanie
    Gehri, Beatrice
    Simon, Michael
    Exploring omissions in nursing care using retrospective chart review: An observational study.2021Ingår i: International Journal of Nursing Studies, ISSN 0020-7489, E-ISSN 1873-491X, Vol. 122, artikel-id 104009Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Omissions in nursing care can compromise patient safety. To date, this phenomenon has been investigated almost exclusively via nurse surveys. However, such surveys restrict the range of activities which can be assessed for omissions, and patient level analysis. As an alternative, retrospective chart review methodology has been used successfully in other research fields, but not yet for omitted nursing care.

    OBJECTIVES: To describe characteristics and frequency of omitted nursing care using a retrospective chart review methodology.

    DESIGN, SETTING AND PARTICIPANTS: Observational single center study in two German neurological inpatient units. A random sample of 100 patient admissions was used.

    METHODS: A structured chart review protocol to detect nursing omissions was developed and applied. The full range of expected nursing care activities were assessed regarding the importance of documenting them and whether they had been fully or partially omitted. Vital sign measurements were assessed regarding both the measurement target number and the number of measurements recorded.

    RESULTS: In total, 1885 activities-a mean of 19 per patient-were identified. Of the reviewed activities, 52% (n = 971) were fully or partially omitted. Patients experienced between one and 22 omitted nursing care activities during their hospital stay (8-84% of expected care activities). Ranging from 6% to 100% some activities were more commonly omitted than others during admission. The most frequently omitted nursing activity was giving emotional care (88%, n = 66); the least frequently omitted was teaching (10%, n = 29). Vital signs were recorded only 50% (n = 141) of the targeted number of times.

    CONCLUSIONS: Using a retrospective chart review protocol to identify omissions in nursing care allows the assessment of a broad range of nursing activities. Additionally, this is the first-time patient-level data on a broad range of activities have been analyzed. The newly developed chart review methodology can complement established survey methods and provide a new perspective on the phenomenon of omitted nursing care.

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  • 12. Krakau, K.
    et al.
    Andersson, H.
    Dahlin, ÅF.
    Egberg, L.
    Sterner, E.
    Unbeck, Maria
    Högskolan Dalarna, Institutionen för hälsa och välfärd, Omvårdnad. Karolinska Institutet.
    Validation of nursing documentation regarding in-hospital falls: a cohort study2021Ingår i: BMC Nursing, ISSN 1472-6955, E-ISSN 1472-6955, Vol. 20, nr 1, artikel-id 58Artikel i tidskrift (Refereegranskat)
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  • 13. Nydert, Per
    et al.
    Unbeck, Maria
    Karolinska Institutet.
    Pukk Härenstam, Karin
    Norman, Mikael
    Lindemalm, Synnöve
    Drug Use and Type of Adverse Drug Events-Identified by a Trigger Tool in Different Units in a Swedish Pediatric Hospital.2020Ingår i: Drug, Healthcare and Patient Safety, E-ISSN 1179-1365, Vol. 12, s. 31-40Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Purpose: The objectives of our study were to determine drug use, type and incidence of all adverse event associated with drug or drug-related processes (Adverse Drug Events, ADE) among pediatric inpatients in relation to hospital unit and length of stay.

    Patients and Methods: 600 pediatric (0-18 years) admissions at a Swedish university hospital during one year were included and stratified in blocks to 150 neonatal, surgical/orthopedic, medicine and emergency-medicine unit admissions, respectively. Adverse events were identified from medical records using a pediatric trigger tool. All triggers identifying an adverse event related to drugs and drug-related devices were included. Data on drug use were extracted from the hospital drug-data warehouse.

    Results: In total, 17794 daily drug orders were administrated to 486 (81.0% exposed) admissions. Parental nutrition, potassium salts and morphine constituted half of all high-risk drugs prescribed. Two-thirds of intravenous irritating drug doses consisted of vancomycin, esomeprazole and meropenem. In 129 (21.5%) admissions, at least one ADE was identified, out of which 21 ADE were classified as more severe (National Coordinating Council Medication Error Reporting Prevention-Index, NCCMERP≥F). The ADE incidence was 47.4 (95% confidence interval: 39.4-57.3) per 1000 admission days and varied by unit category. In neonatal units, 56.9 (49.5-65.4) ADEs/1000 admission days were detected, in surgery/orthopedic 54.2 (40.3-72.8), in medicine 44.1 (33.1-58.7), and in emergency-medicine 14.3 (7.7-26.7) ADEs/1000 admission days were found. The most common types of ADEs were identified by triggers that were not directly aiming at drugs including insufficiently treated pain (incidence peaking already in the first days), skin, tissue or vascular harm (peaking at the end of the first week) and hospital-acquired infections (peaking in later admission days).

    Conclusion: Adverse drug events are common in pediatric patients. The incidence of ADEs and type of ADE varies by hospital unit and length of hospital stay.

  • 14. Hommel, Ami
    et al.
    Magnéli, Martin
    Samuelsson, Bodil
    Schildmeijer, Kristina
    Sjöstrand, Desirée
    Göransson, Katarina
    Karolinska institutet, Stockholm.
    Unbeck, Maria
    Karolinska Institutet.
    Exploring the incidence and nature of nursing-sensitive orthopaedic adverse events: A multicenter cohort study using Global Trigger Tool.2020Ingår i: International Journal of Nursing Studies, ISSN 0020-7489, E-ISSN 1873-491X, Vol. 102, artikel-id 103473Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: For decades, patient safety has been recognized as a critical global healthcare issue. However, there is a gap of knowledge of all types of adverse events sensitive to nursing care within hospitals in general and within orthopaedic care specifically.

    OBJECTIVES: The aim of this study is to explore the incidence and nature of nursing-sensitive adverse events following elective or acute hip arthroplasty at a national level.

    DESIGN: A retrospective multicenter cohort study.

    OUTCOME VARIABLES: Nursing-sensitive adverse events, preventability, severity and length of stay.

    METHODS: All patients, 18 years or older, who had undergone an elective (degenerative joint disease) or acute (fractures) hemi or total hip arthroplasty surgery at 24 hospitals were eligible for inclusion. Retrospective reviews of weighted samples of 1998 randomly selected patient records were carried out using the Swedish version of the Global Trigger Tool. The patients were followed for readmissions up to 90 days postoperatively throughout the whole country regardless of index hospital.

    RESULTS: A total of 1150 nursing-sensitive adverse events were identified in 728 (36.4%) of patient records, and 943 (82.0%) of the adverse events were judged preventable in the study cohort. The adjusted cumulative incidence regarding nursing-sensitive adverse events for the study population was 18.8%. The most common nursing-sensitive adverse event types were different kinds of healthcare-associated infections (40.9%) and pressure ulcers (16.5%). Significantly higher proportions of nursing-sensitive adverse events were found among female patients compared to male, p < 0.001, and patients with acute admissions compared to elective patients, p < 0.001. Almost half (48.5%) of the adverse events were temporary and of a less severe nature. On the other hand, 592 adverse events were estimated to have contributed to 3351 extra hospital days.

    CONCLUSIONS: This study shows the magnitude of nursing-sensitive adverse events. We found that nursing-sensitive adverse events were common, in most cases deemed preventable and were associated with different kinds of adverse events and levels of severity in orthopaedic care. Registered nurses play a vital role within the interdisciplinary team as they are the largest group of healthcare professionals, work 24/7 and spend much time at the bedside with patients. Therefore, nursing leadership at all hospital levels must assume responsibility for patient safety and authorize bedside registered nurses to deliver high-quality and sustainable care to patients.

  • 15. Lindblad, Marléne
    et al.
    Unbeck, Maria
    Karolinska Institutet.
    Nilsson, Lena
    Schildmeijer, Kristina
    Ekstedt, Mirjam
    Identifying no-harm incidents in home healthcare: a cohort study using trigger tool methodology.2020Ingår i: BMC Health Services Research, E-ISSN 1472-6963, Vol. 20, nr 1, artikel-id 289Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Patient safety in home healthcare is largely unexplored. No-harm incidents may give valuable information about risk areas and system failures as a source for proactive patient safety work. We hypothesized that it would be feasible to retrospectively identify no-harm incidents and thus aimed to explore the cumulative incidence, preventability, types, and potential contributing causes of no-harm incidents that affected adult patients admitted to home healthcare.

    METHODS: A structured retrospective record review using a trigger tool designed for home healthcare. A random sample of 600 home healthcare records from ten different organizations across Sweden was reviewed.

    RESULTS: In the study, 40,735 days were reviewed. In all, 313 no-harm incidents affected 177 (29.5%) patients; of these, 198 (63.2%) no-harm incidents, in 127 (21.2%) patients, were considered preventable. The most common no-harm incident types were "fall without harm," "deficiencies in medication management," and "moderate pain." The type "deficiencies in medication management" was deemed to have a preventability rate twice as high as those of "fall without harm" and "moderate pain." The most common potential contributing cause was "deficiencies in nursing care and treatment, i.e., delayed, erroneous, omitted or incomplete treatment or care."

    CONCLUSION: This study suggests that it is feasible to identify no-harm incidents and potential contributing causes such as omission of care using record review with a trigger tool adapted to the context. No-harm incidents and potential contributing causes are valuable sources of knowledge for improving patient safety, as they highlight system failures and indicate risks before an adverse event reach the patient.

  • 16.
    Göras, Camilla
    et al.
    Falu Hospital; Center for Clinical Research, Falun.
    Nilsson, Ulrica
    Ekstedt, Mirjam
    Unbeck, Maria
    Karolinska Institutet.
    Ehrenberg, Anna
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Managing complexity in the operating room: a group interview study.2020Ingår i: BMC Health Services Research, E-ISSN 1472-6963, Vol. 20, nr 1, artikel-id 440Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Clinical work in the operating room (OR) is considered challenging as it is complex, dynamic, and often time- and resource-constrained. Important characteristics for successful management of complexity include adaptations and adaptive coordination when managing expected and unexpected events. However, there is a lack of explorative research addressing what makes things go well and how OR staff describe they do when responding to challenges and compensating for constraints. The aim of this study was therefore to explore how complexity is managed as expressed by operating room nurses, registered nurse anesthetists, and surgeons, and how these professionals adapt to create safe care in the OR.

    METHOD: Data for this qualitative explorative study were collected via group interviews with three professional groups of the OR-team, including operating room nurses, registered nurse anesthetists and operating and assisting surgeons in four group interview sessions, one for each profession except for ORNs for which two separate interviews were performed. The audio-taped transcripts were transcribed verbatim and analyzed by inductive qualitative content analysis.

    RESULTS: The findings revealed three generic categories covering ways of creating safe care in the OR: preconditions and resources, planning and preparing for the expected and unexpected, and adapting to the unexpected. In each generic category, one sub-category emerged that was common to all three professions: coordinating and reaffirming information, creating a plan for the patient and undergoing mental preparation, and prioritizing and solving upcoming problems, respectively.

    CONCLUSION: Creating safe care in the OR should be understood as a process of planning and preparing in order to manage challenging and complex work processes. OR staff need preconditions and resources such as having experience and coordinating and reaffirming information, to make sense of different situations. This requires a mental model, which is created through planning and preparing in different ways. Some situations are repetitive and easier to plan for but planning for the unexpected requires anticipation from experience. The main results strengthen that abilities described in the theory of resilience are used by OR staff as a strategy to manage complexity in the OR.

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  • 17. Magnéli, Martin
    et al.
    Unbeck, Maria
    Rogmark, Cecilia
    Sköldenberg, Olof
    Gordon, Max
    Measuring adverse events following hip arthroplasty surgery using administrative data without relying on ICD-codes.2020Ingår i: PLOS ONE, E-ISSN 1932-6203, Vol. 15, nr 11, artikel-id e0242008Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Measure and monitor adverse events (AEs) following hip arthroplasty is challenging. The aim of this study was to create a model for measuring AEs after hip arthroplasty using administrative data, such as length of stay and readmissions, with equal or better precision than an ICD-code based model.

    MATERIALS AND METHODS: This study included 1 998 patients operated with an acute or elective hip arthroplasty in a national multi-centre study. We collected AEs within 90 days following surgery with retrospective record review. Additional data came from the Swedish Hip Arthroplasty Register, the Swedish National Patient Register and the Swedish National Board of Health and Welfare. We made a 2:1 split of the data into a training and a holdout set. We used the training set to train different machine learning models to predict if a patient had sustained an AE or not. After training and cross-validation we tested the best performing model on the holdout-set. We compared the results with an established ICD-code based measure for AEs.

    RESULTS: The best performing model was a logistic regression model with four natural age splines. The variables included in the model were as follows: length of stay at the orthopaedic department, discharge to acute care, age, number of readmissions and ED visits. The sensitivity and specificity for the new model was 23 and 90% for AE within 30 days, compared with 5 and 94% for the ICD-code based model. For AEs within 90 days the sensitivity and specificity were 31% and 89% compared with 16% and 92% for the ICD-code based model.

    CONCLUSION: We conclude that a prediction model for AEs following hip arthroplasty surgery, relying on administrative data without ICD-codes is more accurate than a model based on ICD-codes.

  • 18. Magnéli, Martin
    et al.
    Unbeck, Maria
    Karolinska Institutet.
    Samuelsson, Bodil
    Rogmark, Cecilia
    Rolfson, Ola
    Gordon, Max
    Sköldenberg, Olof
    Only 8% of major preventable adverse events after hip arthroplasty are filed as claims: a Swedish multi-center cohort study on 1,998 patients.2020Ingår i: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 91, nr 1, s. 20-25Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background and purpose - Hip arthroplasty is one of the most performed surgeries in Sweden, and the rate of adverse events (AEs) is fairly high. All patients in publicly financed healthcare in Sweden are insured by the Mutual Insurance Company of Swedish County Councils (Löf). We assessed the proportion of patients that sustained a major preventable AE and filed an AE claim to Löf.Patients and methods - We performed retrospective record review using the Global Trigger Tool to identify AEs in a Swedish multi-center cohort consisting of 1,998 patients with a total or hemi hip arthroplasty. We compared the major preventable AEs with all patient-reported claims to Löf from the same cohort and calculated the proportion of filed claims.Results - We found 1,066 major preventable AEs in 744 patients. Löf received 62 claims for these AEs, resulting in a claim proportion of 8%. 58 of the 62 claims were accepted by Löf and received compensation. The claim proportion was 13% for the elective patients and 0.3% for the acute patients. The most common AE for filing a claim was periprosthetic joint infection; of the 150 infections found 37 were claimed.Interpretation - The proportion of filed claims for major preventable AEs is very low, even for obvious and serious AEs such as periprosthetic joint infection.

  • 19. Pettersson, Paula Kelly
    et al.
    Sköldenberg, Olof
    Samuelsson, Bodil
    Stark, Andreas
    Muren, Olav
    Unbeck, Maria
    Karolinska Institutet.
    The identification of adverse events in hip fracture patients using the Global Trigger Tool: A prospective observational cohort study.2020Ingår i: International Journal of Orthopaedic and Trauma Nursing, ISSN 1878-1241, E-ISSN 1878-1292, artikel-id 100779Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Hip fracture is common in the elderly and is associated with high comorbidity, mortality and complication rates. There has been an increase in the investigation of healthcare-related adverse events (AEs) in some patient groups but there is limited knowledge about hip fracture patients. The aim was to explore the incidence, preventability and nature of AEs in hip fracture patients.

    METHODS: One hundred and sixty three hip fracture patients participated. A record review was conducted of prospectively collected data using Global Trigger Tool methodology to identify AEs up to 90 days after surgery.

    RESULTS: Sixty two (38.0%) of 163 patients had at least one AE (range 1-7). One hundred and two AEs were identified and 62 (60.8%) were deemed preventable. Healthcare-associated infections e.g. pneumonia, urinary tract infections and pressure ulcers were common. AEs were more common in older patients and those with pre-existing health conditions. Fifty eight (56.9%) AEs caused temporary harm and 4 (3.9%) contributed to patient death.

    CONCLUSION: AEs are common in hip fracture patients and most are preventable. If the focus is on improving healthcare for these patients, we should be concentrating our efforts on reducing the number of these preventable AEs, with a particular emphasis on improving the care of older patients with pre-existing health conditions.

  • 20. Kelly-Pettersson, Paula
    et al.
    Samuelsson, Bodil
    Unbeck, Maria
    Karolinska Institutet.
    Muren, Olav
    Magnéli, Martin
    Gordon, Max
    Stark, André
    Sköldenberg, Olof
    The influence of depression on patient-reported outcomes for hip-fracture patients 1 year after surgery: a prospective cohort study.2020Ingår i: Aging Clinical and Experimental Research, ISSN 1594-0667, E-ISSN 1720-8319, Vol. 32, nr 2, s. 247-255Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Depression is common in elderly hip-fracture patients and together with cognitive impairment is associated with increased risk of mortality.

    AIM: We aimed to examine the influence depression has on patient-reported outcome up to 1 year after acute hip fracture.

    METHODS: 162 hip-fracture patients participated in the prospective observational cohort study and were followed up at baseline, and 3 and 12 months using patient-reported outcome scores. Patients with cognitive impairment were excluded. Depression was defined as a score ≥ 8 on the depression subscale of the Hospital Anxiety Depression Scale (HADS D), having a diagnosis of depression or being treated with anti-depressant medication. Hip function was assessed using Harris Hip Score (HHS), EQ-5D was used to assess health status and Quality of life, and the Pain Numerical Rating Scale (PRNS) was used to assess pain levels. A linear regression model adjusted for group, age, sex, and ASA class was used to identify risk factors for functional outcome 12 months after fracture.

    RESULTS: 35 patients were included in the depression group versus 127 in the control group. No statistical differences were found in the demographic data (age, sex, ASA class, fracture type, operation method, living situation, activities of daily living ADL and clinical pathway) between the groups. In the regression model, we found no correlation between depression and the patient-reported outcome.

    CONCLUSION: In young elderly hip fracture patients without cognitive dysfunction, depression may not be of major importance for the rehabilitation of hip function in the short term.

  • 21. Göras, Camilla
    et al.
    Olin, Karolina
    Unbeck, Maria
    Karolinska Institutet.
    Pukk-Härenstam, Karin
    Ehrenberg, Anna
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Tessma, Mesfin Kassaye
    Nilsson, Ulrica
    Ekstedt, Mirjam
    Tasks, multitasking and interruptions among the surgical team in an operating room: a prospective observational study.2019Ingår i: BMJ Open, E-ISSN 2044-6055, Vol. 9, nr 5, artikel-id e026410Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: The work context of the operating room (OR) is considered complex and dynamic with high cognitive demands. A multidimensional view of the complete preoperative and intraoperative work process of the surgical team in the OR has been sparsely described. The aim of this study was to describe the type and frequency of tasks, multitasking, interruptions and their causes during surgical procedures from a multidimensional perspective on the surgical team in the OR.

    DESIGN: Prospective observational study using the Work Observation Method By Activity Timing tool.

    SETTING: An OR department at a county hospital in Sweden.

    PARTICIPANTS: OR nurses (ORNs) (n=10), registered nurse anaesthetists (RNAs) (n=8) and surgeons (n=9).

    RESULTS: The type, frequency and time spent on specific tasks, multitasking and interruptions were measured. From a multidimensional view, the surgical team performed 64 tasks per hour. Communication represented almost half (45.7%) of all observed tasks. Concerning task time, direct care dominated the surgeons' and ORNs' intraoperative time, while in RNAs' work, it was intra-indirect care. In total, 48.2% of time was spent in multitasking and was most often observed in ORNs' and surgeons' work during communication. Interruptions occurred 3.0 per hour, and the largest proportion, 26.7%, was related to equipment. Interruptions were most commonly followed by professional communication.

    CONCLUSIONS: The surgical team constantly dealt with multitasking and interruptions, both with potential impact on workflow and patient safety. Interruptions were commonly followed by professional communication, which may reflect the interactions and constant adaptations in a complex adaptive system. Future research should focus on understanding the complexity within the system, on the design of different work processes and on how teams meet the challenges of a complex adaptive system.

    TRIAL REGISTRATION NUMBER: 2016/264.

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  • 22. Magnéli, Martin
    et al.
    Unbeck, Maria
    Karolinska Institutet.
    Rogmark, Cecilia
    Rolfson, Ola
    Hommel, Ami
    Samuelsson, Bodil
    Schildmeijer, Kristina
    Sjöstrand, Desirée
    Gordon, Max
    Sköldenberg, Olof
    Validation of adverse events after hip arthroplasty: a Swedish multi-centre cohort study.2019Ingår i: BMJ Open, E-ISSN 2044-6055, Vol. 9, nr 3, artikel-id e023773Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: Preventing adverse events (AEs) after orthopaedic surgery is a field with great room for improvement. A Swedish instrument for measuring AEs after hip arthroplasty based on administrative data from the national patient register is used by both the Swedish Hip Arthroplasty Register and the Swedish Association of Local Authorities and Regions. It has never been validated and its accuracy is unknown. The aim of this study was to validate the instrument's ability to detect AEs, and to calculate the incidence of AEs following primary hip arthroplasties.

    DESIGN: Retrospective cohort study using retrospective record review with Global Trigger Tool methodology in combination with register data.

    SETTING: 24 different hospitals in four major regions of Sweden.

    PARTICIPANTS: 2000 patients with either total or hemi-hip arthroplasty were recruited from the SHAR. We included both acute and elective patients.

    PRIMARY AND SECONDARY OUTCOME MEASURES: The sensitivity and specificity of the instrument. Adjusted cumulative incidence and incidence rate.

    RESULTS: The sensitivity for all identified AEs was 5.7% (95% CI: 4.9% to 6.7%) for 30 days and 14.8% (95% CI: 8.2 to 24.3) for 90 days, and the specificity was 95.2% (95% CI: 93.5% to 96.6%) for 30 days and 92.1% (95% CI: 89.9% to 93.8%) for 90 days. The adjusted cumulative incidence for all AEs was 28.4% (95% CI: 25.0% to 32.3%) for 30 days and 29.5% (95% CI: 26.0% to 33.8%) for 90 days. The incidence rate was 0.43 AEs per person-month (95% CI: 0.39 to 0.47).

    CONCLUSIONS: The AE incidence was high, and most AEs occurred within the first 30 days. The instrument sensitivity for AEs was very low for both 30 and 90 days, but the specificity was high for both 30 and 90 days. The studied instrument is insufficient for valid measurements of AEs after hip arthroplasty.

  • 23. Schildmeijer, Kristina Görel Ingegerd
    et al.
    Unbeck, Maria
    Karolinska Institutet.
    Ekstedt, Mirjam
    Lindblad, Marléne
    Nilsson, Lena
    Adverse events in patients in home healthcare: a retrospective record review using trigger tool methodology.2018Ingår i: BMJ Open, E-ISSN 2044-6055, Vol. 8, nr 1, artikel-id e019267Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: Home healthcare is an increasingly common part of healthcare. The patients are often aged, frail and have multiple diseases, and multiple caregivers are involved in their treatment. This study explores the origin, incidence, types and preventability of adverse events (AEs) that occur in patients receiving home healthcare.

    DESIGN: A study using retrospective record review and trigger tool methodology.

    SETTING AND METHODS: Ten teams with experience of home healthcare from nine regions across Sweden reviewed home healthcare records in a two-stage procedure using 38 predefined triggers in four modules. A random sample of records from 600 patients (aged 18 years or older) receiving home healthcare during 2015 were reviewed.

    PRIMARY AND SECONDARY OUTCOME MEASURES: The cumulative incidence of AEs found in patients receiving home healthcare; secondary measures were origin, types, severity of harm and preventability of the AEs.

    RESULTS: The patients were aged 20-79 years, 280 men and 320 women. The review teams identified 356 AEs in 226 (37.7%; 95% CI 33.0 to 42.8) of the home healthcare records. Of these, 255 (71.6%; 95% CI 63.2 to 80.8) were assessed as being preventable, and most (246, 69.1%; 95% CI 60.9 to 78.2) required extra healthcare visits or led to a prolonged period of healthcare. Most of the AEs (271, 76.1%; 95% CI 67.5 to 85.6) originated in home healthcare; the rest were detected during home healthcare but were related to care outside home healthcare. The most common AEs were healthcare-associated infections, falls and pressure ulcers.

    CONCLUSIONS: AEs in patients receiving home healthcare are common, mostly preventable and often cause temporary harm requiring extra healthcare resources. The most frequent types of AEs must be addressed and reduced through improvements in interprofessional collaboration. This is an important area for future studies.

  • 24. Lindblad, Marléne
    et al.
    Schildmeijer, Kristina
    Nilsson, Lena
    Ekstedt, Mirjam
    Unbeck, Maria
    Karolinska Institutet.
    Development of a trigger tool to identify adverse events and no-harm incidents that affect patients admitted to home healthcare.2018Ingår i: BMJ Quality and Safety, ISSN 2044-5415, E-ISSN 2044-5423, Vol. 27, nr 7, s. 502-511Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Adverse events (AEs) and no-harm incidents are common and of great concern in healthcare. A common method for identification of AEs is retrospective record review (RRR) using predefined triggers. This method has been used frequently in inpatient care, but AEs in home healthcare have not been explored to the same extent. The aim of this study was to develop a trigger tool (TT) for the identification of both AEs and no-harm incidents affecting adult patients admitted to home healthcare in Sweden, and to describe the methodology used for this development.

    METHODS: The TT was developed and validated in a stepwise manner, in collaboration with experts with different skills, using (1) literature review and interviews, (2) a five-round modified Delphi process, and (3) two-stage RRRs. Ten trained teams from different sites in Sweden reviewed 600 randomly selected records.

    RESULTS: In all, triggers were found 4031 times in 518 (86.3%) records, with a mean of 6.7 (median 4, range 1-54) triggers per record with triggers. The positive predictive values (PPVs) for AEs and no-harm incidents were 25.4% and 16.3%, respectively, resulting in a PPV of 41.7% (range 0.0%-96.1% per trigger) for the total TT when using 38 triggers. The most common triggers were unplanned contact with physician and/or registered nurse, moderate/severe pain, moderate/severe worry, anxiety, suffering, existential pain and/or psychological pain. AEs were identified in 37.7% of the patients and no-harm incidents in 29.5%.

    CONCLUSION: This study shows that adapted triggers with definitions and decision support, developed to identify AEs and no-harm incidents that affect patients admitted to home healthcare, may be a valid method for safety and quality improvement work in home healthcare.

  • 25. Nilsson, U.
    et al.
    Göras, C.
    Wallentin, F. Y.
    Ehrenberg, Anna
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Örebro University.
    Unbeck, Maria
    Karolinska Institutet.
    The Swedish Safety Attitudes Questionnaire - Operating Room Version: Psychometric Properties in the Surgical Team2018Ingår i: Journal of Perianesthesia Nursing, ISSN 1089-9472, E-ISSN 1532-8473, Vol. 33, nr 6, s. 935-945Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Purpose: To validate the Swedish Safety Attitudes Questionnaire-operating room (SAQ-OR) version by re-evaluating its psychometric properties for the surgical team.

    Design: Cross-sectional questionnaire study.

    Methods: 541 surgical team members including perioperative nurses, physicians, and licensed practical nurses at three Swedish hospitals were included.

    Findings: For the total sample, the Cronbach's α for the six factors ranged from 0.51 to 0.76. Goodness-of-fit analyses indicated that the six-factor model was acceptable and the factor loadings were statistically significant. The test of the hypothesized relationships among the factors showed a correlation from 0.936 to 0.042.

    Conclusions: The refined Swedish version of the SAQ-OR is a reasonably reliable and acceptably valid instrument for the measurement of patient safety climate in the surgical team. However, the results related to the different analyses varied among the different professionals and further research, using larger samples, is needed to explore these differences, especially among the physicians.

  • 26. Göras, Camilla
    et al.
    Unbeck, Maria
    Karolinska Institutet.
    Nilsson, Ulrica
    Ehrenberg, Anna
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Örebro universitet.
    Interprofessional team assessments of the patient safety climate in Swedish operating rooms: a cross-sectional survey2017Ingår i: BMJ Open, E-ISSN 2044-6055, Vol. 7, nr 9, artikel-id e015607Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: A positive patient safety climate within teams has been associated with higher safety performance. The aim of this study was to describe and compare attitudes to patient safety among the various professionals in surgical teams in Swedish operating room (OR) departments. A further aim was to study nurse managers in the OR and medical directors' estimations of their staffs' attitudes to patient safety.

    METHODS: A cross-sectional survey with the Safety Attitudes Questionnaire (SAQ) was used to elicit estimations from surgical teams. To evoke estimations from nurse managers and medical directors about staff attitudes to patient safety, a short questionnaire, based on SAQ, was used. Three OR departments at three different hospitals in Sweden participated. All licensed practical nurses (n=124), perioperative nurses (n=233), physicians (n=184) and their respective manager (n=22) were invited to participate.

    RESULTS: Mean percentage positive scores for the six SAQ factors and the three professional groups varied, and most factors (safety climate, teamwork climate, stress recognition, working conditions and perceptions of management), except job satisfaction, were below 60%. Significantly lower mean values were found for perioperative nurses compared with physicians for perceptions of management (56.4 vs 61.4, p=0.013) and working conditions (63.7 vs 69.8, p=0.007). Nurse managers and medical directors' estimations of their staffs' ratings of the safety climate cohered fairly well.

    CONCLUSIONS: This study shows variations and some weak areas for patient safety climate in the studied ORs as reported by front-line staff and acknowledged by nurse managers and medical directors. This finding is a concern because a weak patient safety climate has been associated with poor patient outcomes. To raise awareness, managers need to support patient safety work in the OR.

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  • 27.
    Göransson, Katarina
    et al.
    Karolinska institutet, Stockholm.
    Förberg, Ulrika
    Karolinska University Hospital; Karolinska Institutet, Stockholm.
    Johansson, Eva
    Unbeck, Maria
    Danderyd Hospital, Karolinska Institutet, Stockholm.
    Measurement of peripheral venous catheter-related phlebitis: a cross-sectional study.2017Ingår i: The Lancet Haematology, E-ISSN 2352-3026, Vol. 4, nr 9, s. e424-e430, artikel-id S2352-3026(17)30122-9Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Many instruments for measurement of peripheral venous catheter (PVC)-related phlebitis are available, but no consensus exists on their applicability in clinical practice. This absence of consensus affects the ability to identify and compare proportions of PVCs causing phlebitis within and across hospitals as the range varies between 2% and 62% in previous studies. We hypothesised that the instruments' ability to identify phlebitis varies. The aim of this study is to illustrate the complexity of application of phlebitis instruments to a clinical dataset.

    METHODS: In this cross-sectional study, we applied 17 instruments for phlebitis identification (divided into three groups [instruments using definitions, severity rating systems, and scoring systems]) to PVCs in adult patients admitted to 12 inpatient units at Karolinska University Hospital in Sweden. We calculated the proportion of PVCs causing phlebitis on the basis of each instrument's minimum criterion for phlebitis. We also analysed each instrument's face validity. We compared proportions using the Z test.

    FINDINGS: On the basis of data collected between Feb 2, 2009, and Feb 20, 2009, May 18, 2009, and June 5, 2009, and Feb 8, 2010, and Feb 26, 2010, we applied 17 instruments for phlebitis identification (eight instruments using definitions, seven severity rating systems, and two scoring systems) to 1175 observed PVCs in 1032 patients. The highest number of PVCs causing phlebitis generated by definitions was 137 (11·7%), by severity rating systems was 395 (33·6%), and by scoring systems was 363 (30·9%). The proportion generated by instruments using definitions was significantly different to that of both the severity rating (difference 21·9% [95% CI 18·6-25·2]; p<0·0001) and scoring (19·2% [12·0-26·4]; p<0·0001) systems. Proportions did not differ significantly between severity rating systems and scoring system (difference 2·7% [95% CI -1·1 to 6·6]; p=0·16). The proportion within instruments ranged from less than 1% to 28%. We identified face validity issues, such as use of indistinct or complex measurements and inconsistent measurements or definitions.

    INTERPRETATION: Our study highlights several concerns regarding instruments to measure phlebitis published in the scientific community. From a work environment and patient safety perspective, clinical staff engaged in PVC management should be aware of the absence of adequately validated instruments for phlebitis assessment. We suggest that researchers within the field of PVC come together in a joint research programme aiming to develop valid and reliable methods that accurately identify PVC-related adverse events that also includes decision support for clinical staff concerning clinical indications for PVC removal. Such actions could lead to a revised view on what is best practice for management of PVCs.

    FUNDING: None.

  • 28. Persson, Marie
    et al.
    Hvitfeldt-Forsberg, Helena
    Unbeck, Maria
    Karolinska Institutet.
    Sköldenberg, Olof Gustaf
    Stark, Andreas
    Kelly-Pettersson, Paula
    Mazzocato, Pamela
    Operational strategies to manage non-elective orthopaedic surgical flows: a simulation modelling study.2017Ingår i: BMJ Open, E-ISSN 2044-6055, Vol. 7, nr 4, artikel-id e013303Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVES: To explore the value of simulation modelling in evaluating the effects of strategies to plan and schedule operating room (OR) resources aimed at reducing time to surgery for non-elective orthopaedic inpatients at a Swedish hospital.

    METHODS: We applied discrete-event simulation modelling. The model was populated with real world data from a university hospital with a strong focus on reducing waiting time to surgery for patients with hip fracture. The system modelled concerned two patient groups that share the same OR resources: hip-fracture and other non-elective orthopaedic patients in need of surgical treatment. We simulated three scenarios based on the literature and interaction with staff and managers: (1) baseline; (2) reduced turnover time between surgeries by 20 min and (3) one extra OR during the day, Monday to Friday. The outcome variables were waiting time to surgery and the percentage of patients who waited longer than 24 hours for surgery.

    RESULTS: The mean waiting time in hours was significantly reduced from 16.2 hours in scenario 1 (baseline) to 13.3 hours in scenario 2 and 13.6 hours in scenario 3 for hip-fracture surgery and from 26.0 hours in baseline to 18.9 hours in scenario 2 and 18.5 hours in scenario 3 for other non-elective patients. The percentage of patients who were treated within 24 hours significantly increased from 86.4% (baseline) to 96.1% (scenario 2) and 95.1% (scenario 3) for hip-fracture patients and from 60.2% (baseline) to 79.8% (scenario 2) and 79.8% (scenario 3) for patients with other non-elective patients.

    CONCLUSIONS: Healthcare managers who strive to improve the timelines of non-elective orthopaedic surgeries may benefit from using simulation modelling to analyse different strategies to support their decisions. In this specific case, the simulation results showed that the reduction of surgery turnover times could yield the same results as an extra OR.

  • 29. Hvitfeldt-Forsberg, Helena
    et al.
    Mazzocato, Pamela
    Glaser, Daniel
    Keller, Christina
    Unbeck, Maria
    Karolinska Institutet.
    Staffs' and managers' perceptions of how and when discrete event simulation modelling can be used as a decision support in quality improvement: a focus group discussion study at two hospital settings in Sweden.2017Ingår i: BMJ Open, E-ISSN 2044-6055, Vol. 7, nr 5, artikel-id e013869Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: To explore healthcare staffs' and managers' perceptions of how and when discrete event simulation modelling can be used as a decision support in improvement efforts.

    DESIGN: Two focus group discussions were performed.

    SETTING: Two settings were included: a rheumatology department and an orthopaedic section both situated in Sweden.

    PARTICIPANTS: Healthcare staff and managers (n=13) from the two settings.

    INTERVENTIONS: Two workshops were performed, one at each setting. Workshops were initiated by a short introduction to simulation modelling. Results from the respective simulation model were then presented and discussed in the following focus group discussion.

    RESULTS: Categories from the content analysis are presented according to the following research questions: how and when simulation modelling can assist healthcare improvement? Regarding how, the participants mentioned that simulation modelling could act as a tool for support and a way to visualise problems, potential solutions and their effects. Regarding when, simulation modelling could be used both locally and by management, as well as a pedagogical tool to develop and test innovative ideas and to involve everyone in the improvement work.

    CONCLUSIONS: Its potential as an information and communication tool and as an instrument for pedagogic work within healthcare improvement render a broader application and value of simulation modelling than previously reported.

  • 30. Kelly-Pettersson, Paula
    et al.
    Samuelsson, Bodil
    Muren, Olle
    Unbeck, Maria
    Karolinska Institutet.
    Gordon, Max
    Stark, André
    Sköldenberg, Olof
    Waiting time to surgery is correlated with an increased risk of serious adverse events during hospital stay in patients with hip-fracture: A cohort study.2017Ingår i: International Journal of Nursing Studies, ISSN 0020-7489, E-ISSN 1873-491X, Vol. 69, s. 91-97, artikel-id S0020-7489(17)30031-7Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Hip fractures are common in the elderly and are associated with a high adverse event and mortality rate. Time to surgery is one of the major modifiable risk factors influencing adverse outcomes in hip-fracture patients. National guidelines and recommendations have been introduced which advocate specific time frames in which surgery should be performed i.e. within 24-48h. These time constraints have been arbitrarily set without being modelled on the linear assumption i.e. that risk increases continually over time and not within specific cut-off times.

    OBJECTIVES: To investigate how waiting time to surgery influenced the risk of serious adverse events in hip-fracture patients during the hospital stay and to examine how the risk increased over time.

    DESIGN: An observational single cohort study Participants 576 patients (72.4% females, mean [SD] age 82 [10]) years, with a hip fracture were included in the cohort study.

    METHODS: The outcomes of the study were the occurrence of serious adverse events during hospital stay, length of stay and one-year mortality. A structured medical record review was carried out to identify outcomes and mortality data was obtained from the Swedish National Death Registry. Waiting time to surgery was used as the exposure variable and age, sex, type of fracture, comorbidities using the American Society of Anaesthesiologists classification score and the presence of cognitive dysfunction were identified as confounders. A logistic regression analysis was performed to identify risk factors influencing outcomes.

    RESULTS: A total of 119 patients (20.6%) suffered 397 (range 1-5) serious adverse events during hospital stay. Every 10h of waiting time to surgery increased the risk of serious adverse events by 12% (odds ratio 1.12 [95% confidence interval 1.02-1.23]). We found no optimal cut-off times for waiting time to surgery. For every 24h of waiting time, the length of stay from surgery was increased by 0.6days (95% CI 0.1-1.1). We found no correlation between waiting time to surgery and one-year mortality.

    CONCLUSIONS: A large proportion of patients suffered from at least one serious adverse event after hip-fracture surgery and there are no safe limits for waiting time to surgery for hip-fracture patients. As the risk increases with every hour of waiting time, patients with higher American Society of Anesthesiologists classification scores, males and those with subtrochanteric fractures should be prioritized for surgery.

  • 31. Rutberg, Hans
    et al.
    Borgstedt-Risberg, Madeleine
    Gustafson, Pelle
    Unbeck, Maria
    Karolinska Institutet.
    Adverse events in orthopedic care identified via the Global Trigger Tool in Sweden - implications on preventable prolonged hospitalizations.2016Ingår i: Patient Safety in Surgery, E-ISSN 1754-9493, Vol. 10, artikel-id 23Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: The national incidence of adverse events (AEs) in Swedish orthopedic care has never been described. A new national database has made it possible to describe incidence, nature, preventability and consequences of AEs in Swedish orthopedic care.

    METHODS: We used national data from a structured two-stage record review with a Swedish modification of the Global Trigger Tool. The sample was 4,994 randomly selected orthopedic admissions in 56 hospitals during 2013 and 2014. The AEs were classified according to the Swedish Patient Safety Act into preventable or non-preventable.

    RESULTS: At least one AE occurred in 733 (15 %, 95 % CI 13.7-15.7) admissions. Of 950 identified AEs, 697 (73 %) were judged preventable. More than half of the AEs (54 %) were of temporary nature. The most common types of AE were healthcare-associated infections and distended urinary bladder. Patients ≥65 years had more AEs (p < 0.001), and were more often affected by pressure ulcer (p < 0.001) and urinary tract infections (p < 0.01). Distended urinary bladder was seen more frequently in patients aged 18-64 years (p = 0.01). Length of stay was twice as long for patients with AEs (p < 0.001). We estimate 232,000 extra hospital days due to AEs during these 2 years. The pattern of AEs in orthopedic care was different compared to other hospital specialties.

    CONCLUSIONS: Using a national database, we found AEs in 15 % of orthopedic admissions. The majority of the AEs was of temporary nature and judged preventable. Our results can be used to guide focused patient safety work.

  • 32.
    Förberg, Ulrika
    et al.
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Karolinska institutet.
    Unbeck, Maria
    Karolinska institutet.
    Wallin, Lars
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Karolinska institutet.
    Johansson, Eva
    Petzold, Max
    Ygge, Britt-Marie
    Karolinska institutet.
    Ehrenberg, Anna
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Effects of computer reminders on complications of peripheral venous catheters and nurses' adherence to a guideline in paediatric care: a cluster randomised study2016Ingår i: Implementation Science, E-ISSN 1748-5908, Vol. 11, nr 1Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Reminder systems in electronic patient records (EPR) have proven to affect both health care professionals' behaviour and patient outcomes. The aim of this cluster randomised trial was to investigate the effects of implementing a clinical practice guideline (CPG) for peripheral venous catheters (PVCs) in paediatric care in the format of reminders integrated in the EPRs, on PVC-related complications, and on registered nurses' (RNs') self-reported adherence to the guideline. An additional aim was to study the relationship between contextual factors and the outcomes of the intervention.

    METHODS: The study involved 12 inpatient units at a paediatric university hospital. The reminders included choice of PVC, hygiene, maintenance, and daily inspection of PVC site. Primary outcome was documented signs and symptoms of PVC-related complications at removal, retrieved from the EPR. Secondary outcome was RNs' adherence to a PVC guideline, collected through a questionnaire that also included RNs' perceived work context, as measured by the Alberta Context Tool. Units were allocated into two strata, based on occurrence of PVCs. A blinded simple draw of lots from each stratum randomised six units to the control and intervention groups, respectively. Units were not blinded. The intervention group included 626 PVCs at baseline and 618 post-intervention and the control group 724 PVCs at baseline and 674 post-intervention. RNs included at baseline were 212 (65.4 %) and 208 (71.5 %) post-intervention.

    RESULTS: No significant effect was found for the computer reminders on PVC-related complications nor on RNs' adherence to the guideline recommendations. The complication rate at baseline and post-intervention was 40.6 % (95 % confidence interval (CI) 36.7-44.5) and 41.9 % (95 % CI 38.0-45.8), for the intervention group and 40.3 % (95 % CI 36.8-44.0) and 46.9 % (95 % CI 43.1-50.7) for the control. In general, RNs' self-rated work context varied from moderately low to moderately high, indicating that conditions for a successful implementation to occur were less optimal.

    CONCLUSIONS: The reminders might have benefitted from being accompanied by a tailored intervention that targeted specific barriers, such as the low frequency of recorded reasons for removal, the low adherence to daily inspection of PVC sites, and the lack of regular feedback to the RNs.

    TRIAL REGISTRATION: Current Controlled Trials ISRCTN44819426.

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  • 33.
    Unbeck, Maria
    et al.
    Karolinska Institutet.
    Sterner, Eila
    Elg, Mattias
    Fossum, Bjöörn
    Thor, Johan
    PukkHärenstam, Karin
    Authors' response (Unbeck and colleagues).2015Ingår i: International Journal of Nursing Studies, ISSN 0020-7489, E-ISSN 1873-491X, Vol. 52, nr 1, s. 484-5; discussion 485Artikel i tidskrift (Refereegranskat)
  • 34.
    Unbeck, Maria
    et al.
    Karolinska Institutet.
    Förberg, Ulrika
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Karolinska Institutet.
    Ygge, Britt-Marie
    Ehrenberg, Anna
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Petzold, Max
    Johansson, Eva
    Peripheral venous catheter related complications are common among peadiatric and neonatal patients2015Ingår i: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 104, nr 6, s. 566-574Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Aim: The aims of this study were to describe the characteristics of peripheral venous catheters (PVCs), including dwell time and reasons for removal, and explore predictors for PVC-related complications. 

    Methods: We included PVCs in 2032 children - 484 neonatal and 1548 paediatric - from 12 inpatient units. Data were retrieved from the patient record system, and predictors for complications were explored using logistic regression analyses. 

    Results: Just over one-third (35.4%) of the PVCs were removed due to complications, in particular infiltration and occlusion (51.9 and 48.4/1000 PVC days, respectively). PVC survival time was shorter in neonatal than paediatric patients (4 versus 5days), and infiltration was more frequent in neonatal patients (92.8 versus 38.7/1000 PVC days). Infiltration was associated with younger age (odds ratio 0.97) for neonatal patients and with younger age (OR 0.96), insertion in the bend of the arm (OR 1.48) or ankle (OR2.81) for paediatric patients. Occlusion was, both for neonatal and paediatric patients, associated with longer dwell time (OR 1.32 and 1.22 respectively), insertion in the ankle (OR 5.00 and 3.51) or foot (OR 3.47 and 1.99). 

    Conclusion: PVC-related complications, particularly infiltration and occlusion, were more common in hospitalised children but decreased with the child's age.

  • 35. Mazzocato, Pamela
    et al.
    Unbeck, Maria
    Karolinska Institutet.
    Elg, Mattias
    Sköldenberg, Olof Gustaf
    Thor, Johan
    Unpacking the key components of a programme to improve the timeliness of hip-fracture care: a mixed-methods case study.2015Ingår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 23, artikel-id 93Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Delay to surgery for patients with hip fracture is associated with higher incidence of post-operative complications, prolonged recovery and length of stay, and increased mortality. Therefore, many health care organisations launch improvement programmes to reduce the wait for surgery. The heterogeneous application of similar methods, and the multifaceted nature of the interventions, constrain the understanding of which method works, when, and how. In complex acute care settings, another concern is how changes for one patient group influence the care for other groups. We therefore set out to analyse how multiple components of hip-fracture improvement efforts aimed to reduce the time to surgery influenced that time both for hip-fracture patients and for other acute surgical orthopaedic inpatients.

    METHODS: This study is an observational mixed-methods single case study of improvement efforts at a Swedish acute care hospital, which triangulates control chart analysis of process performance data over a five year period with interview, document, and non-participant observation data.

    RESULTS: The improvement efforts led to an increase in the monthly percentage of hip-fracture patients operated within 24 h of admission from an average of 47% to 83%, with performance predictably ranging between 67% and 98% if the process continues unchanged. Meanwhile, no significant changes in lead time to surgery for other acute surgical orthopaedic inpatients were observed. Interview data indicated that multiple intervention components contributed to making the process more reliable. The triangulation of qualitative and quantitative data, however, indicated that key changes that improved performance were the creation of a process improvement team and having an experienced clinician coordinate demand and supply of surgical services daily and enhance pre-operative patient preparation.

    CONCLUSIONS: Timeliness of surgery for patients with hip fracture in a complex hospital setting can be substantially improved without displacing other patient groups, by involving staff in improvement efforts and actively managing acute surgical procedures.

  • 36.
    Unbeck, Maria
    et al.
    Karolinska Institutet.
    Lindemalm, Synnöve
    Nydert, Per
    Ygge, Britt-Marie
    Nylén, Urban
    Berglund, Carina
    Härenstam, Karin Pukk
    Validation of triggers and development of a pediatric trigger tool to identify adverse events.2014Ingår i: BMC Health Services Research, E-ISSN 1472-6963, Vol. 14, artikel-id 655Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Little is known about adverse events (AEs) in pediatric patients. Record review is a common methodology for identifying AEs, but in pediatrics the record review tools generally have limited focus. The aim of the present study was to develop a broadly applicable record review tool to identify AEs in pediatric inpatients.

    METHODS: Using a broad literature review and expert opinion with a modified Delphi process, a pediatric trigger tool with 88 triggers, definitions, and descriptions including AE preventability decision support was developed and tested in a random sample of 600 hospitalized pediatric patients admitted in 2010 to a single university children's hospital. Four registered nurse-physician teams performed complete two-stage retrospective reviews of 150 records each from either neonatal, surgical/orthopedic, medicine, or emergency medicine units.

    RESULTS: Registered nurse review identified 296 of 600 records with triggers indicating potential AEs. Records (n = 121) with only false positive triggers not indicating any potential AEs were not forwarded to the next review stage. On subsequent physician review, 204 (34.0%) of patients were found to have had 563 AEs, range 1-27 AEs/patient. A total of 442 preventable AEs were found in 161 patients (26.8%), range 1-22. Overall, triggers were found 3,598 times in 417 (69.5%) records, with a mean of 6 (median 1, range 0-176) triggers per patient. The overall positive predictive value of the triggers was 22.9%, (range 0.0-100.0%). The final pediatric trigger tool, developed with a second Delphi round, required 29 triggers.

    CONCLUSIONS: AEs are common in pediatric patients and most are preventable. The main contributions of this study are to further develop and adapt trigger definitions, including AE preventability decision support, to introduce new triggers in pediatric care, as well as to apply pediatric triggers in different clinical specialties. Our findings resulted in a national pediatric trigger tool, and might also be adapted internationally. The pediatric trigger tool can help healthcare organizations to measure and analyze the AEs occurring in hospitalized children in order to improve patient safety.

  • 37.
    Unbeck, Maria
    et al.
    Karolinska Institutet.
    Sterner, Eila
    Elg, Mattias
    Fossum, Bjöörn
    Thor, Johan
    Pukk Härenstam, Karin
    Design, application and impact of quality improvement 'theme months' in orthopaedic nursing: a mixed method case study on pressure ulcer prevention.2013Ingår i: International Journal of Nursing Studies, ISSN 0020-7489, E-ISSN 1873-491X, Vol. 50, nr 4, s. 527-35, artikel-id S0020-7489(13)00041-2Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: While there is growing awareness of quality problems in healthcare systems, it remains uncertain how best to accomplish and sustain improvement over time.

    OBJECTIVE: To report on the design and application of quality improvement theme months in orthopaedic nursing, and evaluate the impact on pressure ulcer as an example.

    DESIGN: Retrospective mixed method case study with time series diagrams.

    SETTING: An orthopaedic department at a Swedish university hospital.

    METHOD: The interventions were led by nursing teams and focused on one improvement theme at a time in two-month cycles, hence the term 'improvement theme months'. These included defined objectives, easy-to-use follow-up measurement, education, changes to daily routines, "reminder months" and data feedback. The study draws on retrospective record data regarding one of the theme topics, pressure ulcer risk assessment and prevalence, in 2281 orthopaedic admissions during January 2007-October 2010 through point prevalence measurement one-day per month. Data were analysed in time series diagrams and through comparison to annual point prevalence data from mandatory county council-wide measurements prior to, during and after interventions from 2003 to 2010. By using document analysis we reviewed concurrent initiatives at different levels in the healthcare organisation and related them to the improvement theme months and their impact.

    RESULTS: The 46 monthly point prevalence samples ranged from 28 to 66 admissions. Substantial improvements were found in risk assessment rates for pressure ulcers both in the longitudinal follow-up (p<0.001) and in the annual county council-wide measurements. A reduction in pressure ulcer rate was observed in the annual county council-wide measurements. In the longitudinal data, wider variation in the pressure ulcer rate was seen (p<0.067); however, there was a significant decrease in pressure ulcer rates during the final ten-month period in 2010, compared to the baseline period in 2007 (p=0.004). Improvements were moderate the first years and needed reinforcement to be maintained.

    CONCLUSIONS: The theme month design and the way it was applied in this case showed potential, contributing to reduced pressure ulcer prevalence, as a way to conduct quality improvement initiatives in nursing. For sustainable improvement, multi component interventions are needed with regular monitoring and reminder efforts.

  • 38.
    Unbeck, Maria
    et al.
    Karolinska Institutet.
    Schildmeijer, Kristina
    Henriksson, Peter
    Jürgensen, Urban
    Muren, Olav
    Nilsson, Lena
    Pukk Härenstam, Karin
    Is detection of adverse events affected by record review methodology? an evaluation of the "Harvard Medical Practice Study" method and the "Global Trigger Tool".2013Ingår i: Patient Safety in Surgery, E-ISSN 1754-9493, Vol. 7, nr 1, artikel-id 10Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: There has been a theoretical debate as to which retrospective record review method is the most valid, reliable, cost efficient and feasible for detecting adverse events. The aim of the present study was to evaluate the feasibility and capability of two common retrospective record review methods, the "Harvard Medical Practice Study" method and the "Global Trigger Tool" in detecting adverse events in adult orthopaedic inpatients.

    METHODS: We performed a three-stage structured retrospective record review process in a random sample of 350 orthopaedic admissions during 2009 at a Swedish university hospital. Two teams comprised each of a registered nurse and two physicians were assigned, one to each method. All records were primarily reviewed by registered nurses. Records containing a potential adverse event were forwarded to physicians for review in stage 2. Physicians made an independent review regarding, for example, healthcare causation, preventability and severity. In the third review stage all adverse events that were found with the two methods together were compared and all discrepancies after review stage 2 were analysed. Events that had not been identified by one of the methods in the first two review stages were reviewed by the respective physicians.

    RESULTS: Altogether, 160 different adverse events were identified in 105 (30.0%) of the 350 records with both methods combined. The "Harvard Medical Practice Study" method identified 155 of the 160 (96.9%, 95% CI: 92.9-99.0) adverse events in 104 (29.7%) records compared with 137 (85.6%, 95% CI: 79.2-90.7) adverse events in 98 (28.0%) records using the "Global Trigger Tool". Adverse events "causing harm without permanent disability" accounted for most of the observed difference. The overall positive predictive value for criteria and triggers using the "Harvard Medical Practice Study" method and the "Global Trigger Tool" was 40.3% and 30.4%, respectively.

    CONCLUSIONS: More adverse events were identified using the "Harvard Medical Practice Study" method than using the "Global Trigger Tool". Differences in review methodology, perception of less severe adverse events and context knowledge may explain the observed difference between two expert review teams in the detection of adverse events.

  • 39. Schildmeijer, Kristina
    et al.
    Unbeck, Maria
    Karolinska Institutet.
    Muren, Olav
    Perk, Joep
    Pukk Härenstam, Karin
    Nilsson, Lena
    Retrospective record review in proactive patient safety work - identification of no-harm incidents.2013Ingår i: BMC Health Services Research, E-ISSN 1472-6963, Vol. 13, artikel-id 282Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: In contrast to other safety critical industries, well-developed systems to monitor safety within the healthcare system remain limited. Retrospective record review is one way of identifying adverse events in healthcare. In proactive patient safety work, retrospective record review could be used to identify, analyze and gain information and knowledge about no-harm incidents and deficiencies in healthcare processes. The aim of the study was to evaluate retrospective record review for the detection and characterization of no-harm incidents, and compare findings with conventional incident-reporting systems.

    METHODS: A two-stage structured retrospective record review of no-harm incidents was performed on a random sample of 350 admissions at a Swedish orthopedic department. Results were compared with those found in one local, and four national incident-reporting systems.

    RESULTS: We identified 118 no-harm incidents in 91 (26.0%) of the 350 records by retrospective record review. Ninety-four (79.7%) no-harm incidents were classified as preventable. The five incident-reporting systems identified 16 no-harm incidents, of which ten were also found by retrospective record review. The most common no-harm incidents were related to drug therapy (n = 66), of which 87.9% were regarded as preventable.

    CONCLUSIONS: No-harm incidents are common and often preventable. Retrospective record review seems to be a valuable tool for identifying and characterizing no-harm incidents. Both harm and no-harm incidents can be identified in parallel during the same record review. By adding a retrospective record review of randomly selected records to conventional incident-reporting, health care providers can gain a clearer and broader picture of commonly occurring, no-harm incidents in order to improve patient safety.

  • 40.
    Unbeck, Maria
    et al.
    Karolinska Institutet.
    Dalen, Nils
    Muren, Olav
    Lillkrona, Ulf
    Härenstam, Karin Pukk
    Healthcare processes must be improved to reduce the occurrence of orthopaedic adverse events.2010Ingår i: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 24, nr 4, s. 671-7Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Many nonhealth industries have decades of experiences working with safety systems. Similar systems are also needed in healthcare to improve patient safety. Clinical incident reporting systems in healthcare identify adverse events but seriously underestimate the incidence of adverse events. A wide range of information sources and monitoring techniques are needed to understand and mitigate healthcare risks.

    AIM: The purpose of this study was to identify patient safety risk factors that can lead to adverse events in adult orthopaedic inpatients.

    DESIGN: A three-stage structured retrospective patient record review of consecutively admitted patients to the inpatient service of a large, urban Swedish hospital.

    METHOD: Records for all orthopaedic inpatients admitted during a 2-month period (n = 395) were screened using 12 criteria. Positive records were then reviewed in two stages by orthopaedic surgeons using a standardized protocol. Data were collected from the index admission and from subsequent visits or readmissions within 28 days of discharge.

    RESULTS: Sixty patients experienced 65 healthcare associated adverse events. Affected patients had a length of hospital stay double that of patients without adverse events. Adverse events were more common in patients undergoing surgical procedures and patients with risk factors for anaesthesia. Although 59 of the adverse events occurred in patients who underwent surgery, only nine of the adverse events were due to deficiencies in surgical/anaesthesia technique. The others were related to deficiencies in healthcare processes. The most common adverse events were hospital acquired infections (n = 20) and delayed detection of urinary retention (n = 13). Six adverse drug events involved elderly patients (≥65 years).

    CONCLUSION: Orthopaedic care is a high risk activity for its typically elderly, often debilitated patients. Reducing adverse events in orthopaedic patients will require more multidisciplinary, interdepartmental teamwork strategies that focus on healthcare processes outside the operating room.

  • 41.
    Unbeck, Maria
    et al.
    Karolinska Institutet.
    Muren, Olle
    Lillkrona, Ulf
    Identification of adverse events at an orthopedics department in Sweden.2008Ingår i: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 79, nr 3, s. 396-403Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND AND PURPOSE: Adverse events (AEs) are common in acute care hospitals, but there have been few data concerning AEs in orthopedic patients. We tested and evaluated a patient safety model (the Wimmera clinical risk management model) and performed a three-stage retrospective review of records to determine the occurrence of AEs in adult orthopedic inpatients.

    METHODS: The computerized medical and nursing records of 395 patients were included and screened for AEs using 12 criteria. Positive records were then reviewed by two senior orthopedic surgeons using a standardized protocol. An AE had to have occurred during the index admission or within the first 28 days of discharge from the Orthopedics Department. Screening of additional systems for reporting of AEs was also carried out for the same period. The number of patients suffering an AE and the number of AEs were recorded.

    RESULTS: Altogether, 60 (15 %) of 395 patients checked in the screening of records experienced 65 AEs (16%) due to healthcare management. Of the 65 AEs, 34 were estimated to have a high degree of preventability. 47 of the 65 AEs occurred during the index admission and 18 within 28 days of discharge. In screening of local and nationwide reporting systems for the same patients, 4 additional AEs were identified-2 of which were previously unknown. 67 different AEs were detected by using the Wimmera model (17%)

    INTERPRETATION: Using the Wimmera model with manual screening and review of records, many more AEs were detected than in all other traditional local and nationwide reporting systems used in Sweden when screening was done for the same period.

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