PMID- 38212131
OWN - NLM
STAT- MEDLINE
DCOM- 20240115
LR  - 20240304
IS  - 2399-6641 (Electronic)
IS  - 2399-6641 (Linking)
VI  - 13
IP  - 1
DP  - 2024 Jan 11
TI  - Evaluation of a new patient safety educational programme to reduce adverse events 
      by encouraging staff to speak up: application of the trigger tool methodology.
LID - 10.1136/bmjoq-2022-002162 [doi]
LID - e002162
AB  - BACKGROUND: Poor communication contributes to adverse events (AEs). In our 
      hospital, following an experience of a fatal incident in 2014, we developed an 
      educational programme aimed at improving communication for better teamwork that 
      led to a reduction in AEs. METHODS: We developed and implemented an intervention 
      bundle comprising external investigation committee reviews, the establishment of 
      a working group (WG), standards and emergency response guidelines, as well as 
      educational programmes and tools. To determine the effectiveness of the 
      educational programmes, we measured communication abilities among doctors and 
      nurses by administering psychological scales focused on their confidence in 
      speaking up. Furthermore, we applied the trigger tool methodology in a 
      retrospective study to determine if our interventions had reduced AEs. RESULTS: 
      The nurses' scores for 'perceived barriers to speaking up' and 'negative attitude 
      toward voicing opinions in the healthcare team' decreased significantly after the 
      training from 3.20 to 3.00 and from 2.47 to 2.29 points, respectively. The junior 
      doctors' scores for the same items also decreased significantly after the 
      training from 3.34 to 2.51 and from 2.42 to 2.11 points, respectively. The number 
      of AEs was 32.1 (median) before the WG, 39.9 (median) before the general 
      training, 22.2 (median) after the general training and 18.4 (median) after 
      implementing the leadership educational programmes. During the intervention 
      period the hospital's incident reports per employee kept increasing. CONCLUSION: 
      Our new educational programmes improved junior doctors and nurses' perceptions of 
      speaking up. We speculated that our intervention may have improved staff 
      communication, which in turn may have led to a reduction in AEs and a sustained 
      increase in incident reports per employee.
CI  - (c) Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No 
      commercial re-use. See rights and permissions. Published by BMJ.
FAU - Nakatani, Kaoru
AU  - Nakatani K
AUID- ORCID: 0000-0003-4612-2399
AD  - Medical Quality and Safety Science, Osaka City University Graduate School of 
      Medicine, Osaka, Japan.
FAU - Nakagami-Yamaguchi, Etsuko
AU  - Nakagami-Yamaguchi E
AUID- ORCID: 0000-0001-6718-4658
AD  - Medical Quality and Safety Science, Osaka Metropolitan University Graduate School 
      of Medicine, Osaka, Japan nyamaguchi.e@omu.ac.jp.
AD  - Quality and Safety Management, Osaka Metropolitan University Hospital, Osaka, 
      Japan.
FAU - Hagawa, Naohiro
AU  - Hagawa N
AD  - Traumatology and Critical Care Medicine, Osaka Metropolitan University Graduate 
      School of Medicine, Osaka, Japan.
FAU - Tokuwame, Atsushi
AU  - Tokuwame A
AD  - Medical Quality and Safety Science, Osaka Metropolitan University Graduate School 
      of Medicine, Osaka, Japan.
AD  - Quality and Safety Management, Osaka Metropolitan University Hospital, Osaka, 
      Japan.
FAU - Ehara, Shoichi
AU  - Ehara S
AD  - Intensive Care Medicine, Osaka Metropolitan University Graduate School of 
      Medicine, Osaka, Japan.
FAU - Nishimura, Tetsuro
AU  - Nishimura T
AD  - Traumatology and Critical Care Medicine, Osaka Metropolitan University Graduate 
      School of Medicine, Osaka, Japan.
FAU - Mizobata, Yasumitsu
AU  - Mizobata Y
AD  - Traumatology and Critical Care Medicine, Osaka Metropolitan University Graduate 
      School of Medicine, Osaka, Japan.
LA  - eng
PT  - Journal Article
PT  - Research Support, Non-U.S. Gov't
DEP - 20240111
PL  - England
TA  - BMJ Open Qual
JT  - BMJ open quality
JID - 101710381
SB  - IM
MH  - Humans
MH  - *Patient Safety
MH  - Retrospective Studies
MH  - *Physicians
MH  - Medical Staff, Hospital
MH  - Leadership
PMC - PMC10806700
OTO - NOTNLM
OT  - Communication
OT  - Quality improvement
OT  - Safety culture
OT  - Team training
OT  - Trigger tools
COIS- Competing interests: None declared.
EDAT- 2024/01/12 00:42
MHDA- 2024/01/15 12:43
PMCR- 2024/01/12
CRDT- 2024/01/11 21:23
PHST- 2022/10/18 00:00 [received]
PHST- 2023/12/19 00:00 [accepted]
PHST- 2024/01/15 12:43 [medline]
PHST- 2024/01/12 00:42 [pubmed]
PHST- 2024/01/11 21:23 [entrez]
PHST- 2024/01/12 00:00 [pmc-release]
AID - bmjoq-2022-002162 [pii]
AID - 10.1136/bmjoq-2022-002162 [doi]
PST - epublish
SO  - BMJ Open Qual. 2024 Jan 11;13(1):e002162. doi: 10.1136/bmjoq-2022-002162.