Table 1 Teams and their clinical processes (H = hospital)

1. Obstetrics and maternity wards (H1): medication verification process

Covering the outpatient clinic, acute and planned admissions, or discharges, physicians, nurses and obstetricians on the wards work interdependently to monitor and verify prescribed medication with current treatment plans to prevent drug interactions and mis-dosages

The ward reported to struggle with the verification process, resulting from a mix of a generally young and healthy patient group and admission of acute cases in which professionals prioritized providing acute care over verifying medication

2. Neurology and neurosurgery ward (H1): Pressure ulcers

Nurses try to prevent pressure ulcers from arising by repositioning patients and being alert on emerging bedsores. When wounds do occur, the nurses make a treatment plan in consultation with the wound care nurse

The neurological and neurosurgical patients are especially prone to developing pressure ulcers due to old age, malnutrition, immobilization, prescribed bed rest or comorbidity

3. Operating rooms (H2): instrument counts

To prevent unintentional retention of instruments and sponges in surgical wounds, operating staff counts all pre-listed instruments before the start of procedure and recounts instruments and sponges again before/at the onset of wound closure

As part of safe surgery, the department installed a protocol for counting instruments following two incidents. Since then, the hospital merged with another local hospital. Both locations kept their surgical units and professionals worked at both locations. Due to different histories with incidents and cultures, uptake and adherence to the protocol by the other location was limited

4. Emergency department (H2): transfer to acute short stay unit

To decrease patient processing time at the ED, an acute short stay (ASS) unit was implemented. Incoming patients that were considered stable and low-complex, but had to await test results, would be transferred to a more comfortable ASS whilst creating space for new incoming patients

The ASS unit was built in a separate location in the hospital compared to the other ED units. Although not far in distance, nurses and physicians take the distance into account when considering a patient transfer. Other factors influence patient transfer too, such as physicians having limited trust in the capabilities of ASS nurses due to their lower educational status than ED nurses

5. Vascular surgery ward (H3): early warning scores and pain re-assessment

Early warning scores are used by nurses to quickly determine acute illness in patients according to routinely scored physiological measurements at the bedside. When a threshold score is reached, the nurse informs the physicians and takes further action. The score has to be reassessed within two hours

In pain assessment, the nurse asks a patient how much pain they experience on a scale of 0–10. If significant pain is present, i.e. a pain score of 4 or higher, pain medication is administered, followed by a re-assessment within the hour

Pain scores and revaluations have been introduced to prevent patients from experiencing pain needlessly. Early warning scores are tools to aid quick recognition of clinically deteriorating patients. The ward however struggled with full compliance in the digital pain reassessment form and the early warning score form

6. Gastroenterology ward (H3): Parenteral drug preparation and administration

In preparing and administering parenteral drugs, nurses use a four-eyes principle. By checking each other’s medication preparation before administration, errors may be prevented

Double checking with parenteral drugs is part of safe drug administration in nursing. The ward however remained to struggle with full compliance for all prepared and given parenteral drugs and dosages