Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after ‘To Err is Human’

Automation to optimise physician treatment of individual patients: examples in psychiatry

There is widespread agreement by health-care providers, medical associations, industry, and governments that automation using digital technology could improve the delivery and quality of care in psychiatry, and reduce costs. Many benefits from technology have already been realised, along with the identification of many challenges. In this Review, we discuss some of the challenges to developing effective automation for psychiatry to optimise physician treatment of individual patients. Using the perspective of automation experts in other industries, three examples of automation in the delivery of routine care are reviewed: (1) effects of electronic medical records on the patient interview; (2) effects of complex systems integration on e-prescribing; and (3) use of clinical decision support to assist with clinical decision making. An increased understanding of the experience of automation from other sectors might allow for more effective deployment of technology in psychiatry.

Survey to identify depth of penetration of critical incident reporting systems in Austrian healthcare facilities

Incident reporting systems or so-called critical incident reporting systems (CIRS) were first recommended for use in health care more than 15 years ago. The uses of these CIRS are highly variable among countries, ranging from being used to report critical incidents, falls, or sentinel events resulting in death. In Austria, CIRS have only been introduced to the health care sector relatively recently. The goal of this work, therefore, was to determine whether and specifically how CIRS are used in Austria. A working group from the Austrian Society for Quality and Safety in Healthcare (ASQS) developed a survey on the topic of CIRS to collect information on penetration of CIRS in general and on how CIRS reports are used to increase patient safety. Three hundred seventy-one health care professionals from 274 health care facilities were contacted via e-mail. Seventy-eight respondents (21.0%) completed the online survey, thereof 66 from hospitals and 12 from other facilities (outpatient clinics, nursing homes). In all, 64.1% of the respondents indicated that CIRS were used in the entire health care facility; 20.6% had not yet introduced CIRS and 15.4% used CIRS only in particular areas. Most often, critical incidents without any harm to patients were reported (76.9%); however, some health care facilities also use their CIRS to report patient falls (16.7%), needle stick injuries (17.9%), technical problems (51.3%), or critical incidents involving health care professionals. CIRS are not yet extensively or homogeneously used in Austria. Inconsistencies exist with respect to which events are reported as well as how they are followed up and reported to health care professionals. Further recommendations for general use are needed to support the dissemination in Austrian health care environments.

Problems with incident reporting: Reports lead rarely to recommendations

AIM AND OBJECTIVE

To analyse trends in incident reporting over the last 5 years and determine how many reports led to recommendations?

BACKGROUND

Patient safety incident reporting systems have been used in health care for years. However, they have a significant weakness in that reports often do not lead to any visible action.

DESIGN

The study is a retrospective register study. STROBE checklist was applied in the preparation of the paper.

METHODS

Data were collected from a web-based incident reporting database (HaiPro) for a social- and healthcare organisation in Finland, covering the period from 2011-2015.

RESULTS

In total, 16,019 incident reports were analysed. In 2.7% (n = 426) of all reports, there was written recommendation to develop action that such incidents would not happen again. Those reports were classified into seven categories: education, introduction and information, introduction to work, patient care, guidelines, instruments and IT programmes, and the physical environment.

CONCLUSIONS

Managers get major amount incident reports. There should be (a) a definition what kind of events should be reported, (b) a definition for how serious events managers have to make a recommendation and (c) control that recommendations are implemented.

RELEVANCE TO CLINICAL PRACTICE

There is a need for more action to promote patient safety based on incident reports.

Exploring patient safety in Swedish specialised home healthcare: an interview study with multidisciplinary teams and clinical managers

OBJECTIVE

Home healthcare is the fastest growing arena in the healthcare system but patient safety research in this context is limited. The aim was to explore how patient safety in Swedish specialised home healthcare is described and adressed from multidisciplinary teams' and clinical managers' perspectives.

DESIGN

An explorative qualitative study.

SETTING

Multidisciplinary teams and clinical managers were recruited from three specialised home healthcare organisations in Sweden.

METHODS

Nine focus group interviews with multidisciplinary teams and six individual interviews with clinical managers were conducted, in total 51 participants. The data were transcribed verbatim and analysed using qualitative content analysis.

RESULTS

Patient safety was inherent in the well-established care ideology which shaped a common mindset between members in the multidisciplinary teams and clinical managers. This patient safety culture was challenged by the emerging complexity in which priority had to be given to standardised guidelines, quality assessments and management of information in maladapted communication systems and demands for required competence and skills. The multiple guidelines and quality assessments that aimed to promote patient safety from a macro-perspective, constrained the freedom, on a meso-level and micro-level, to adapt to challenges based on the care ideology.

CONCLUSION

Patient safety in home healthcare is dependent on adaptability at the management level; the team members' ability to adapt to the varying conditions and on patients being capable of adjusting their homes and behaviours to reduce safety risks. A strong culture related to a patient's value as a person where patients' and families' active participation and preferences guide the decisions, could be both a facilitator and a barrier to patient safety, depending on which value is given highest priority.

Using Patient Safety Reporting Systems to Understand the Clinical Learning Environment: A Content Analysis

OBJECTIVE

To examine patient safety event reporting behavior by trainees caring for surgical patients compared to other clinicians.

DESIGN

Qualitative analysis of a patient safety event reporting system comparing reports entered by trainees to those entered by attending physicians and nurses. Categorical data associated with reports were compared, and free-text event descriptions underwent content analysis focusing on themes related to report completeness and report focus.

SETTING

The Hospital of the University of Pennsylvania, an academic tertiary care hospital in Philadelphia, Pennsylvania.

PARTICIPANTS

All patient safety event reports related to surgical patients from a 6-month period (July-December 2016).

RESULTS

One thousand four hundred twenty-three reports were entered by trainees (T), attendings (A), and nurses (N). Trainees had a lower number of reports entered per reporter compared to nurses (T median [IQR]: 1 [1-2], N: 2 [1-3]), and the highest percentage of reports entered anonymously for any group (T: 28.7%, N: 9.9%, A: 4.6%). The overall distribution of event location and event type differed significantly between groups (p < 0.001). Trainee reports were found to have a broader range of focus, more elements associated with completeness of reports, and more frequent use of blame language.

CONCLUSIONS

Surgical trainees report a wide variety of issues in the perioperative, floor, and ICU settings. Their reports often include more details than those entered by other clinicians, but feature higher rates of anonymous reporting and use of blame language. Analysis of patient safety event reports by trainees compared with other healthcare professionals can reveal important insights into the clinical learning environment and areas for safety improvement.

Development of an Adverse Event Surveillance Model for Outpatient Surgery in the Veterans Health Administration

OBJECTIVE

Develop and validate a surveillance model to identify outpatient surgical adverse events (AEs) based on previously developed electronic triggers.

DATA SOURCES

Veterans Health Administration's Corporate Data Warehouse.

STUDY DESIGN

Six surgical AE triggers, including postoperative emergency room visits and hospitalizations, were applied to FY2012-2014 outpatient surgeries (n = 744,355). We randomly sampled trigger-flagged and unflagged cases for nurse chart review to document AEs and measured positive predictive value (PPV) for triggers. Next, we used chart review data to iteratively estimate multilevel logistic regression models to predict the probability of an AE, starting with the six triggers and adding in patient, procedure, and facility characteristics to improve model fit. We validated the final model by applying the coefficients to FY2015 outpatient surgery data (n = 256,690) and reviewing charts for cases at high and moderate probability of an AE.

PRINCIPAL FINDINGS

Of 1,730 FY2012-2014 reviewed surgeries, 350 had an AE (20 percent). The final surveillance model c-statistic was 0.81. In FY2015 surgeries with >0.8 predicted probability of an AE (n = 405, 0.15 percent), PPV was 85 percent; in surgeries with a 0.4-0.5 predicted probability of an AE, PPV was 38 percent.

CONCLUSIONS

The surveillance model performed well, accurately identifying outpatient surgeries with a high probability of an AE.

How Well Do Incident Reporting Systems Work on Inpatient Psychiatric Units?

BACKGROUND

Adverse events and medical errors have been shown to be a persistent issue in health care. However, little research has been conducted regarding the efficacy of incident reporting systems, particularly within an inpatient psychiatry setting.

METHODS

The medical records from a random sample of 40 psychiatric units within Veterans Health Administration (VHA) medical centers were screened and evaluated by physicians for 9 types of safety events. The abstracted safety events were then evaluated to assess if they were caused by an error and if they caused harm to the patient. These safety events were then matched to incidents that were reported to the VHA Adverse Event Reporting System (AERS), which includes all reported adverse events, close calls, and root cause analyses that occur within the VHA health system.

RESULTS

Overall, 37.4% (95% confidence interval [CI] = 33.5%-41.5%) of safety events detected in the medical record were reported to the AERS. Among the patient safety events identified, the most commonly reported to the AERS were patient falls (52.3%), assaults (46.2%), and elopements (42.3%). Reporting rates increased when the patient safety event resulted in harm to the patient (48.2%; CI = 41.6%-55.0%).

CONCLUSION

The majority of patient safety events that occur on VHA inpatient psychiatric units do not get reported to the VHA's Adverse Event Reporting System. These findings suggest that self-reporting is not a reliable method of tracking patient safety events. Future efforts should target the barriers to inpatient psychiatric reporting and develop mechanisms to overcome these barriers.

Record of the circumstances of falls in the community: perspective in the Iberian Peninsula

Objective:

to determine the diagnosis of the situation regarding documentation of falls and risk of falls in people older than 75 years in basic health units in Spain and Portugal.

Method:

mixed exploratory study in two stages: (i) quantitative descriptive of randomly selected fall records produced in one year (597 records; 197 Spanish and 400 Portuguese); and (ii) qualitative, with the purpose of knowing the perception of health professionals employing semi-structured interviews (72 professionals, 16 Spanish and 56 Portuguese). The study areas were two basic health units in southern Spain and northern Portugal.

Results:

in the fall records, the number of women was higher. The presence of fall was associated with the variables age, presence of dementia, osteoarticular disease, previous falls and consumption of antivertiginous medication. Health professionals perceived an absence of risk assessment instruments, as well as lack of prevention programs and lack of awareness of this event.

Conclusion:

falls are perceived as an area of ​​priority attention for health professionals. Nonetheless, there is a lack of adherence to the registration of falls and risk assessment, due to organizational, logistical and motivational problems.

The Psychiatry Morbidity and Mortality Incident Reporting Tool Increases Psychiatrist Participation in Reporting Adverse Events

OBJECTIVES

Although the reporting of adverse events (AEs) is widely thought to be a key first step to improving patient safety in hospital systems, underreporting remains a common problem, particularly among physicians. We aimed to increase the number of safety reports filed by psychiatrists in our hospital system.

METHODS

We piloted an online survey for psychiatry-specific AE reporting, the Psychiatry Morbidity and Mortality Incident Reporting Tool (PMIRT) for a 1-year period. An e-mail prompt containing a link to the survey was sent on a weekly basis to all psychiatry department clinical staff. The primary outcome was the total number of events reported by psychiatrists through PMIRT; secondary outcomes were the total number of AEs and the number of serious harm events filed by psychiatrists in our hospital's formal event reporting system before and after implementation of the new protocol.

RESULTS

Psychiatrists filed 65 reports in PMIRT during the study period. The average number of AEs reported by psychiatrists in the hospital's formal event reporting system significantly increased after the intervention (P = 0.0251), and the average number of serious harm events reported by psychiatrists increased nonsignificantly (P = 0.1394).

CONCLUSIONS

The combination of an increase in awareness of event reporting with a psychiatry-specific AE reporting tool resulted in a significant improvement in the number of reports by psychiatrists.

Introduction of a Mobile Adverse Event Reporting System Is Associated With Participation in Adverse Event Reporting

Physicians underutilize adverse event reporting systems. Web-based platforms have increased participation; thus, it was hypothesized that a mobile application would increase adverse event reporting. The authors developed a mobile reporting application for iOS and Android operating systems and performed a retrospective review on reporting rates by clinicians in the Department of Anesthesia and Critical Care. Monthly reporting rates were calculated for the intervention year and for the 2 prior years (2013-2016). The Wilcoxon rank sum test and χ² test were used to evaluate significance. Overall monthly reporting rates for all clinicians were 15.3 ± 7 for the first time period, 17.3 ± 6 for the second time period, and 27.9 ± 7 for the third time period ( P = .0035). The majority of reports in the third time period were submitted using the mobile application (193/337, 57%, P = .026). Deployment of a mobile application reduced barriers to adverse event reporting and increased monthly reporting rates for all clinicians.

Barriers to the success of an electronic pharmacovigilance reporting system in Kenya: an evaluation three years post implementation

Objective

Electronic pharmacovigilance reporting systems are being implemented in many developing countries in an effort to improve reporting rates. This study sought to establish the factors that acted as barriers to the success of an electronic pharmacovigilance reporting system in Kenya 3 years after its implementation.

Materials and Methods

Factors that could act as barriers to using electronic reporting systems were identified in a review of literature and then used to develop a survey questionnaire that was administered to pharmacists working in government hospitals in 6 counties in Kenya.

Results

The survey was completed by 103 out of the 115 targeted pharmacists (89.5%) and included free-text comments. The key factors identified as barriers were: unavailable, unreliable, or expensive Internet access; challenges associated with a hybrid system of paper and electronic reporting tools; and system usability issues. Coordination challenges at the national pharmacovigilance center and changes in the structure of health management in the country also had an impact on the success of the electronic reporting system.

Discussion

Different personal, organizational, infrastructural, and reporting system factors affect the success of electronic reporting systems in different ways, depending on the context. Context-specific formative evaluations are useful in establishing the performance of electronic reporting systems to identify problems and ensure that they achieve the desired objectives.

Conclusion

While several factors hindered the optimal use of the electronic pharmacovigilance reporting system in Kenya, all were considered modifiable. Effort should be directed toward tackling the identified issues in order to facilitate use and improve pharmacovigilance reporting rates.

Risk factors for near-miss events and safety incidents in pediatric radiation therapy

BACKGROUND AND PURPOSE

Factors contributing to safety- or quality-related incidents (e.g. variances) in children are unknown. We identified clinical and RT treatment variables associated with risk for variances in a pediatric cohort.

MATERIALS AND METHODS

Using our institution's incident learning system, 81 patients age ≤21 years old who experienced variances were compared to 191 pediatric patients without variances. Clinical and RT treatment variables were evaluated as potential predictors for variances using univariate and multivariate analyses.

RESULTS

Variances were primarily documentation errors (n = 46, 57%) and were most commonly detected during treatment planning (n = 14, 21%). Treatment planning errors constituted the majority (n = 16 out of 29, 55%) of near-misses and safety incidents (NMSI), which excludes workflow incidents. Therapists reported the majority of variances (n = 50, 62%). Physician cross-coverage (OR = 2.1, 95% CI = 1.04-4.38) and 3D conformal RT (OR = 2.3, 95% CI = 1.11-4.69) increased variance risk. Conversely, age >14 years (OR = 0.5, 95% CI = 0.28-0.88) and diagnosis of abdominal tumor (OR = 0.2, 95% CI = 0.04-0.59) decreased variance risk.

CONCLUSIONS

Variances in children occurred in early treatment phases, but were detected at later workflow stages. Quality measures should be implemented during early treatment phases with a focus on younger children and those cared for by cross-covering physicians.

10,000 Good Catches: Increasing Safety Event Reporting In A Pediatric Health Care System

Background:

In 2014, Children’s National Health System’s executive leadership team challenged the organization to double the number of voluntary safety event reports submitted over a 3-year period; the intent was to increase reliability and promote our safety culture by hardwiring employee event reporting.

Methods:

Following a Donabedian quality improvement framework of structure, process, and outcomes, a multidisciplinary team was formed and areas for improvement were identified. The multidisciplinary team focused on 3 major areas: the perceived ease of reporting (ie, how difficult is it to report an event?); the perceived safety of reporting (ie, will I get in trouble for reporting?); and the perceived impact of reporting (ie, does my report make a difference?) technology, making it safe to report, and how reporting makes a difference. The team developed a key driver diagram and implemented interventions designed to impact the key drivers and to increase reporting.

Results:

Children’s National increased the number of safety event reports from 4,668 in fiscal year 2014 to 10,971 safety event reports in fiscal year 2017. Median event report submission time was decreased by nearly 30%, anonymous reporting decreased by 69%, the number of submitting departments increased by 94%, and the number of reports submitted as “other” decreased from a baseline of 6% to 2%.

Conclusions:

Children’s National Health System’s focus on increasing safety event reporting resulted in increased organizational engagement and attention. This initiative served as a tangible step to improve organizational reliability and the culture of safety and is readily generalizable to other hospitals.

Assessing the Health-Care Risk: The Clinical-VaR, a Key Indicator for Sound Management

Clinical risk includes any undesirable situation or operational factor that may have negative consequences for patient safety or capable of causing an adverse event (AE). The AE, intentional or unintentionally, may be related to the human factor, that is, medical errors (MEs). Therefore, the importance of the health-care risk management is a current and relevant issue on the agenda of many public and private institutions. The objective of the management has been evolving from the identification of AE to the assessment of cost-effective and efficient measures that improve the quality control through monitoring. Consequently, the goal of this paper is to propose a Key Risk Indicator (KRI) that enhances the advancement of the health-care management system. Thus, the application of the Value at Risk (VaR) concept in combination to the Loss Distribution Approach (LDA) is proved to be a proactive tool, within the frame of balanced scorecard (BSC), in health organizations. For this purpose, the historical events recorded in the Algo-OpData^® database (Algorithmics Inc., Toronto, ON, Canada, IBM, Armonk, NY, USA) have been used. The analysis highlights the importance of risk in the financials outcomes of the sector. The results of paper show the usefulness of the Clinical-VaR to identify and monitor the risk and sustainability of the implemented controls.

Experiences from ten years of incident reporting in health care: a qualitative study among department managers and coordinators

Background

Incident reporting (IR) in health care has been advocated as a means to improve patient safety. The purpose of IR is to identify safety hazards and develop interventions to mitigate these hazards in order to reduce harm in health care. Using qualitative methods is a way to reveal how IR is used and perceived in health care practice. The aim of the present study was to explore the experiences of IR from two different perspectives, including heads of departments and IR coordinators, to better understand how they value the practice and their thoughts regarding future application.

Methods

Data collection was performed in Östergötland County, Sweden, where an electronic IR system was implemented in 2004, and the authorities explicitly have advocated IR from that date. A purposive sample of nine heads of departments from three hospitals were interviewed, and two focus group discussions with IR coordinators took place. Data were analysed using qualitative content analysis.

Results

Two main themes emerged from the data: “Incident reporting has come to stay” building on the categories entitled perceived advantages, observed changes and value of the IR system, and “Remaining challenges in incident reporting” including the categories entitled need for action, encouraged learning, continuous culture improvement, IR system development and proper use of IR.

Conclusions

After 10 years, the practice of IR is widely accepted in the selected setting. IR has helped to put patient safety on the agenda, and a cultural change towards no blame has been observed. The informants suggest an increased focus on action, and further development of the tools for reporting and handling incidents.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2876-5) contains supplementary material, which is available to authorized users.

What have we learned from reporting safety incidents in the Surgical Block?: Cross-sectional descriptive study of two-years of activity of a multidisciplinary analytical group

BACKGROUND AND OBJECTIVES

Incident Reporting Systems (IRS) are considered a tool that facilitates learning and safety culture. Using the experience gained with SENSAR, we evaluated the feasibility and the activity of a multidisciplinary group analyzing incidents in the surgical patient notified to a general community system, that of the Observatory for Patient Safety (OPS).

MATERIAL AND METHOD

Cross-sectional observational study planned for two years. After training in the analysis, a multidisciplinary group was created in terms of specialties and professional categories, which would analyze the incidents in the surgical patient notified to the OPS. Incidents are classified and their circumstances analyzed.

RESULTS

Between March 2015 and 2017, 95 incidents were reported (4 by non-professionals). Doctors reported more than nurses, at 54 (56.84%) vs. 37 (38.94%). The anaesthesia unit reported most at 46 (48.42%) (P=.025). The types of incidents mainly related to the care procedure (30.52%); to the preoperative period (42.10%); and to the place, the surgical area (48.42%). Significant differences were detected according to the origin of the notifier (P=.03). No harm, or minor morbidity, constituted 88% of the incidents. Errors were identified in 79%. The analysis of the incidents directed the measures to be taken.

CONCLUSIONS

The activity undertaken by the multidisciplinary analytical group during the period of study facilitated knowledge of the system among the professionals and enabled the identification of areas for improvement in the Surgical Block at different levels.

Identifying, Understanding, and Managing Patient Safety and Clinical Risks in the Clinical Research Environment

Meticulous study design, exacting scientific review, scrupulous data management, rigorous human subjects' protection, and effective recruitment strategies are essential components of all clinical research studies that must be in place prior to the conduct of the study. Equally important to the success of the study and to the well-being and protection of study participants is the assurance that safe clinical environments are provided for the care of research participants. This chapter describes approaches to managing patient care and clinical research quality, as well as the application of established health care-based clinical quality methods and tools to the complex processes of clinical research. Techniques for identifying clinical risks, tools for collecting data about the quality of clinical care processes, strategies for mitigating risk and patient harm, and techniques for measuring the participants' perceptions of the research process are discussed in detail.

Nurses' perspectives on how an e-message system supports cross-sectoral communication in relation to medication administration: A qualitative study

AIMS AND OBJECTIVES

To describe nurses' perspectives on how an e-message system supports communication between hospital and home care nurses in relation to medication administration.

BACKGROUND

Medication administration is a complex process involving a high risk of error. Unclear communication and lack of updated information about medication have been identified as the leading cause of medication errors during care transitions. E-message systems are progressively being used to improve information exchange across sectors, yet little is known about their usage for exchange of medication information between nurses.

DESIGN

A qualitative design using content analysis.

METHODS

Focus group interviews were conducted with nurses from eight hospital wards and six municipalities (n = 79). Participant observations were conducted in three hospital wards and in three municipalities (165 hr).

RESULTS

The e-message system did not provide the information needed by the home care nurses to ensure safe medication administration after discharge due to (1) limitations of the system, (2) hospital nurses' lack of knowledge about home care nurses' information needs and (3) hospital nurses' lack of access to medication information. Due the home care nurses' perception of responsibility, they bypassed the e-message system to get the information.

CONCLUSIONS

The home care nurses perceived themselves as the last link in the safety chain. As such, access to adequate information was essential for the nurses to ensure safe medication administration; however, the e-message system did not support exchange of the information needed.

RELEVANCE TO CLINICAL PRACTICE

E-message systems must meet home care nurses' need for information to ensure that safe medication administration does not depend on the knowledge of the individual nurse. Moreover, other system factors that influence interprofessional collaboration and nurses' cross-sectoral communication must be addressed.

Trends and Progress in Human Factors and Organizational Issues in 2016: Learning from Experience

Objective: To summarize significant research contributions on human factors and organizational issues in medical informatics published in 2016. Methods: An extensive search using PubMed/Medline and Web of Science® was conducted to identify the scientific contributions published in 2016 that address human factors and organizational issues in medical informatics. The selection process comprised three steps: (i) 15 candidate best papers were first selected by the two section editors, (ii) external reviewers from internationally renowned research teams reviewed each candidate best paper, and (iii) the final selection of five best papers was conducted by the editorial board of the Yearbook. Results: The five selected best papers present studies with rigorous methods, properly designed and described and are, therefore, efficiently reusable for other researches. Conclusion: Human factors and ergonomics- based interventions must be tailored to the context, but meaningful ways must be simultaneously found to generate a stronger evidence base for research and to provide efficient, easy to implement, and useful methods.

Medical students' perceptions of a novel institutional incident reporting system : A thematic analysis

BACKGROUND

Errors in healthcare are a major patient safety issue, with incident reporting a key solution. The incident reporting system has been integrated within a new medical curriculum, encouraging medical students to take part in this key safety process. The aim of this study was to describe the system and assess how students perceived the reporting system with regards to its role in enhancing safety.

METHODS

Employing a thematic analysis, this study used interviews with medical students at the end of the first year. Thematic indices were developed according to the information emerging from the data. Through open, axial and then selective stages of coding, an understanding of how the system was perceived was established.

RESULTS

Analysis of the interview specified five core themes: (1) Aims of the incident reporting system; (2) internalized cognition of the system; (3) the impact of the reporting system; (4) threshold for reporting; (5) feedback on the systems operation. Selective analysis revealed three overriding findings: lack of error awareness and error wisdom as underpinned by key theoretical constructs, student support of the principle of safety, and perceptions of a blame culture.

CONCLUSIONS

Students did not interpret reporting as a manner to support institutional learning and safety, rather many perceived it as a tool for a blame culture. The impact reporting had on students was unexpected and may give insight into how other undergraduates and early graduates interpret such a system. Future studies should aim to produce interventions that can support a reporting culture.

Implementing the Comprehensive Unit-Based Safety Program (CUSP) to Improve Patient Safety in an Academic Primary Care Practice

BACKGROUND

While there is growing awareness of the risk of harm in ambulatory health care, most patient safety efforts have focused on the inpatient setting. The Comprehensive Unit-based Safety Program (CUSP) has been an integral part of highly successful safety efforts in inpatient settings. In 2014 CUSP was implemented in an academic primary care practice.

METHODS

As part of CUSP implementation, staff and clinicians underwent training on the science of safety and completed a two-question safety assessment survey to identify safety concerns in the practice. The concerns identified by team members were used to select two initial safety priorities. The impact of CUSP on safety climate and teamwork was assessed through a pre-post comparison of results on the validated Safety Attitudes Questionnaire.

RESULTS

Ninety-six percent of staff completed science of safety training as part of CUSP implementation, and 100% of staff completed the two-question safety assessment. The most frequently identified safety concerns were related to medications (n = 11, 28.2), diagnostic testing (n = 9, 25), and communication (n = 5, 14). The CUSP team initially prioritized communication and infection control, which led to standardization of work flows within the practice. Six months following CUSP implementation, large but nonstatistically significant increases were found for the percentage of survey respondents who reported knowledge of the proper channels for questions about patient safety, felt encouraged to report safety concerns, and believed that the work setting made it easy to learn from the errors of others.

CONCLUSION

CUSP is a promising tool to improve safety climate and to identify and address safety concerns within ambulatory health care.

Simulation-based Assessment of the Management of Critical Events by Board-certified Anesthesiologists

Background

We sought to determine whether mannequin-based simulation can reliably characterize how board-certified anesthesiologists manage simulated medical emergencies. Our primary focus was to identify gaps in performance and to establish psychometric properties of the assessment methods.

Methods

A total of 263 consenting board-certified anesthesiologists participating in existing simulation-based maintenance of certification courses at one of eight simulation centers were video recorded performing simulated emergency scenarios. Each participated in two 20-min, standardized, high-fidelity simulated medical crisis scenarios, once each as primary anesthesiologist and first responder. Via a Delphi technique, an independent panel of expert anesthesiologists identified critical performance elements for each scenario. Trained, blinded anesthesiologists rated video recordings using standardized rating tools. Measures included the percentage of critical performance elements observed and holistic (one to nine ordinal scale) ratings of participant’s technical and nontechnical performance. Raters also judged whether the performance was at a level expected of a board-certified anesthesiologist.

Results

Rater reliability for most measures was good. In 284 simulated emergencies, participants were rated as successfully completing 81% (interquartile range, 75 to 90%) of the critical performance elements. The median rating of both technical and nontechnical holistic performance was five, distributed across the nine-point scale. Approximately one-quarter of participants received low holistic ratings (i.e., three or less). Higher-rated performances were associated with younger age but not with previous simulation experience or other individual characteristics. Calling for help was associated with better individual and team performance.

Conclusions

Standardized simulation-based assessment identified performance gaps informing opportunities for improvement. If a substantial proportion of experienced anesthesiologists struggle with managing medical emergencies, continuing medical education activities should be reevaluated.

Effect of an electronic medication administration record application on patient safety

RATIONALE, AIMS, AND OBJECTIVES

To evaluate the effect of an electronic medication administration record (eMAR) application on the rate of medication errors in medication administration recording (ME-MAR).

METHODS

A before-and-after, quasiexperimental study was conducted in a university hospital that implemented the eMAR application in March 2014. Data collection was conducted in April 2012 (pre-) and June 2014 (post-) by two pharmacists. The ME-MARs were analysed by the staff involved to identify their cause. The two pharmacists independently classified the ME-MARs. In the case of disagreement, a research team examined the ME-MARs and categorized them by consensus. Three classifications were used: A classic medication error taxonomy and 2 technology-induced error taxonomies.

RESULTS

The pharmacists analysed 2835 (pre-) and 2621 (post-) medication administration records (MAR), respectively. Overall, the ME-MAR rate decreased from 48.0% (pre-) to 36.9% (post-) (P < .05). The same types of ME-MAR were observed in both phases except for "MAR with incomplete information," which was not observed in the postimplementation phase. In both phases, the most frequent ME-MAR was "MAR at the wrong time" (MAR before or after medication administration) (31.6% vs 30.2%). The main cause of ME-MARs in both phases was the failure to follow work procedures. The potential future risk of ME-MARs significantly decreased after the eMAR implementation (P < .05). All ME-MARs were "use errors" because of human factors. New ME-MARs (1.24%; n = 12) were observed in the postimplementation phase.

CONCLUSION

Use of the eMAR application significantly reduces the rate of ME-MAR and their potential risk. The main cause of ME-MAR was the failure to follow work procedures.

A Model for Incident Review Committees in Behavioral Health Settings

Despite the fact that incident review committees have been a key component of quality improvement in behavioral health settings for decades, specific models of how these committees are structured and operate are not well described. We present a model for an incident review committee that has been implemented in 2 large, academic acute care psychiatric hospitals. We believe the model not only permitted us to efficiently and effectively review untoward incidents, but that it also provided an approach to calibrating standards of care for the institution, engaging physicians in an interdisciplinary effort, promulgating a culture of quality review and improvement throughout the organization, promoting continuity and sustainability of the incident review process, and, most importantly, driving beneficial change in clinical practice. Demonstration of the effectiveness of this model requires formal investigation.

Using multiclass classification to automate the identification of patient safety incident reports by type and severity

BACKGROUND

Approximately 10% of admissions to acute-care hospitals are associated with an adverse event. Analysis of incident reports helps to understand how and why incidents occur and can inform policy and practice for safer care. Unfortunately our capacity to monitor and respond to incident reports in a timely manner is limited by the sheer volumes of data collected. In this study, we aim to evaluate the feasibility of using multiclass classification to automate the identification of patient safety incidents in hospitals.

METHODS

Text based classifiers were applied to identify 10 incident types and 4 severity levels. Using the one-versus-one (OvsO) and one-versus-all (OvsA) ensemble strategies, we evaluated regularized logistic regression, linear support vector machine (SVM) and SVM with a radial-basis function (RBF) kernel. Classifiers were trained and tested with "balanced" datasets (n_ _Type  = 2860, n_ _{SeverityLevel}  = 1160) from a state-wide incident reporting system. Testing was also undertaken with imbalanced "stratified" datasets (n_ _Type  = 6000, n_ _{SeverityLevel} =5950) from the state-wide system and an independent hospital reporting system. Classifier performance was evaluated using a confusion matrix, as well as F-score, precision and recall.

RESULTS

The most effective combination was a OvsO ensemble of binary SVM RBF classifiers with binary count feature extraction. For incident type, classifiers performed well on balanced and stratified datasets (F-score: 78.3, 73.9%), but were worse on independent datasets (68.5%). Reports about falls, medications, pressure injury, aggression and blood products were identified with high recall and precision. "Documentation" was the hardest type to identify. For severity level, F-score for severity assessment code (SAC) 1 (extreme risk) was 87.3 and 64% for SAC4 (low risk) on balanced data. With stratified data, high recall was achieved for SAC1 (82.8-84%) but precision was poor (6.8-11.2%). High risk incidents (SAC2) were confused with medium risk incidents (SAC3).

CONCLUSIONS

Binary classifier ensembles appear to be a feasible method for identifying incidents by type and severity level. Automated identification should enable safety problems to be detected and addressed in a more timely manner. Multi-label classifiers may be necessary for reports that relate to more than one incident type.

Innovative Use of the Electronic Health Record to Support Harm Reduction Efforts

BACKGROUND AND OBJECTIVES

Awareness of the impact of preventable harm on patients and families has resulted in extensive efforts to make our health care systems safer. We determined that, in our hospital, patients experienced 1 of 9 types of preventable harm approximately every other day. In an effort to expedite early identification of patients at risk and provide timely intervention, we used the electronic health record's (EHR) documentation to enable decision support, data capture, and auditing and implemented reporting tools to reduce rates of harm.

METHODS

Harm reduction strategies included aggregating data to generate a risk profile for hospital-acquired conditions (HACs) for all inpatients. The profile includes links to prevention bundles and available care guidelines. Additionally, lists of patients at risk for HACs autopopulate electronic audit tools contained within Research Electronic Data Capture, and data from observational audits and EHR documentation populate real-time dashboards of bundle compliance. Patient population summary reports promote the discussion of relevant HAC prevention measures during patient care and unit leadership rounds.

RESULTS

The hospital has sustained a >30% reduction in harm for 9 types of HAC since 2012. In 2014, the number of HACs with >80% bundle adherence doubled coincident with the progressive rollout of these EHR-based interventions.

CONCLUSIONS

Existing EHR documentation and reporting tools may be effective adjuncts to harm reduction initiatives. Additional study should include an evaluation of scalability across organizations, ongoing bundle adherence, and individual tests of change to isolate interventions with the highest impact on our results.

Translating concerns into action: a detailed qualitative evaluation of an interdisciplinary intervention on medical wards

OBJECTIVES

To understand how frontline reports of day-to-day care failings might be better translated into improvement.

DESIGN

Qualitative evaluation of an interdisciplinary team intervention capitalising on the frontline experience of care delivery. Prospective clinical team surveillance (PCTS) involved structured interdisciplinary briefings to capture challenges in care delivery, facilitated organisational escalation of the issues they identified, and feedback. Eighteen months of ethnography and two focus groups were conducted with staff taking part in a trial of PCTS.

RESULTS

PCTS fostered psychological safety-a confidence that the team would not embarrass or punish those who speak up. This was complemented by a hard edge of accountability, whereby team members would regulate their own behaviour in anticipation of future briefings. Frontline concerns were triaged to managers, or resolved autonomously by ward teams, reversing what had been well-established normalisations of deviance. Junior clinicians found a degree of catharsis in airing their concerns, and their teams became more proactive in addressing improvement opportunities. PCTS generated tangible organisational changes, and enabled managers to make a convincing case for investment. However, briefings were constrained by the need to preserve professional credibility, and staff found some comfort in avoiding accountability . At higher organisational levels, frontline concerns were subject to competition with other priorities, and their resolution was limited by the scale of the challenges they described.

CONCLUSIONS

Prospective safety strategies relying on staff-volunteered data produce acceptable, negotiated accounts, subject to the many interdisciplinary tensions that characterise ward work. Nonetheless, these strategies give managers access to the realities of frontline cares, and support frontline staff to make incremental changes in their daily work. These are goals for learning healthcare organisations.

TRIAL REGISTRATION

ISRCTN 34806867.

Evaluating the Effectiveness of an Educational Intervention to Improve the Patient Safety Attitudes of Intern Pharmacists

Objective. To evaluate the effectiveness of a face-to-face educational intervention in improving the patient safety attitudes of intern pharmacists. Methods. A patient safety education program was delivered to intern pharmacists undertaking The University of Sydney Intern Training Program in 2014. Their patient safety attitudes were evaluated immediately prior to, immediately after, and three-months post-intervention. Underlying attitudinal factors were identified using exploratory factor analysis. Changes in factor scores were examined using analysis of variance. Results. Of the 120 interns enrolled, 95 (78.7%) completed all three surveys. Four underlying attitudinal factors were identified: attitudes towards addressing errors, questioning behaviors, blaming individuals, and reporting errors. Improvements in all attitudinal factors were evident immediately after the intervention. However, only improvements in attitudes towards blaming individuals involved in errors were sustained at three months post-intervention. Conclusion. The educational intervention was associated with short-term improvements in pharmacist interns' patient safety attitudes. However, other factors likely influenced their attitudes in the longer term.

An Improvement Approach to Integrate Teaching Teams in the Reporting of Safety Events

BACKGROUND AND OBJECTIVE

Patient safety events are underreported by physicians. Baseline data demonstrated that physicians submitted 3% of event reports at Our Lady of the Lake Children's Hospital. Our aim was to increase the proportion of safety reports filed by residents and faculty to 6% of all reports within a 9-month period.

METHODS

We used the Model for Improvement and serial Plan, Do, Study, Act cycles to test interventions we hypothesized would improve physician recognition and reporting of patient safety events. We tracked the percentage of Our Lady of the Lake Children's Hospital event reports entered by residents or faculty over time as the primary outcome measure. Changes to teaching team processes included "patient safety rounds" prompted by text messages, an inpatient "superintendent" rotation with core patient safety responsibilities, and a "just-in-time" faculty development program called "QI on the Fly."

RESULTS

Physician-reported events increased to a monthly average of 24% of all events reported, an improvement that has been sustained over 17 months. Resident reporting accounted for most of the increase in physician reports. Increased physician reporting was temporally associated with implementation of the "superintendent" rotation. The total number of events reported increased as a result of increased physician reporting.

CONCLUSIONS

Incorporating patient safety responsibilities into a teaching team's workflow can increase physician safety event reporting. We plan additional Plan, Do, Study, Act cycles to spread this approach to other clinical settings and investigate the impact increased reporting might have on patient care.

International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process

BACKGROUND

Patient safety incident reporting systems (PSRS) have been established for over a decade, but uncertainty remains regarding the role that they can and ought to play in quantifying healthcare-related harm and improving care.

OBJECTIVE

To establish international, expert consensus on the purpose of PSRS regarding monitoring and learning from incidents and developing recommendations for their future role.

METHODS

After a scoping review of the literature, semi-structured interviews with experts in PSRS were conducted. Based on these findings, a survey-based questionnaire was developed and subsequently completed by a larger expert panel. Using a Delphi approach, consensus was reached regarding the ideal role of PSRSs. Recommendations for best practice were devised.

RESULTS

Forty recommendations emerged from the Delphi procedure on the role and use of PSRS. Experts agreed reporting system should not be used as an epidemiological tool to monitor the rate of harm over time or to appraise the relative safety of hospitals. They agreed reporting is a valuable mechanism for identifying organisational safety needs. The benefit of a national system was clear with respect to medication error, device failures, hospital-acquired infections and never events as these problems often require solutions at a national level. Experts recommended training for senior healthcare professionals in incident investigation. Consensus recommendation was for hospitals to take responsibility for creating safety solutions locally that could be shared nationally.

CONCLUSIONS

We obtained reasonable consensus among experts on aims and specifications of PSRS. This information can be used to reflect on existing and future PSRS, and their role within the wider patient safety landscape. The role of PSRS as instruments for learning needs to be elaborated and developed further internationally.

Two Cultures in Modern Science and Technology: For Safety and Validity Does Medicine Have to Update?

Two different scientific cultures go unreconciled in modern medicine. Each culture accepts that scientific knowledge and technologies are vulnerable to and easily invalidated by methods and conditions of acquisition, interpretation, and application. How these vulnerabilities are addressed separates the 2 cultures and potentially explains medicine's difficulties eradicating errors. A traditional culture, dominant in medicine, leaves error control in the hands of individual and group investigators and practitioners. A competing modern scientific culture accepts errors as inevitable, pernicious, and pervasive sources of adverse events throughout medical research and patient care too malignant for individuals or groups to control. Error risks to the validity of scientific knowledge and safety in patient care require systemwide programming able to support a culture in medicine grounded in tested, continually updated, widely promulgated, and uniformly implemented standards of practice for research and patient care. Experiences from successes in other sciences and industries strongly support the need for leadership from the Institute of Medicine's recommended Center for Patient Safely within the Federal Executive branch of government.

Patient safety problems from healthcare information technology in medical imaging

Health information technology (HIT) systems have been deployed extensively by healthcare organizations and promoted as a panacea to many of the challenges faced by medical imaging departments, particularly with respect to workflow, efficiency and diagnostic accuracy. This report describes how inadequate planning, integration, training and testing of HIT can impact on patient safety and result in patient harm.

The Role of Employee Whistleblowing and Raising Concerns in an Organizational Learning Culture - Elusive and Laudable?: Comment on "Cultures of Silence and Cultures of Voice: The Role of Whistleblowing in Healthcare Organisations"

It is inevitable that healthcare workers throughout their careers will witness actual or potential threats to patient safety in the course of their work. Some of these threats will result in serious harm occurring to others, whilst at other times such threats will result in minimal harm, or a 'near miss' where harm is avoided at the last minute. Despite organizations encouraging employees to 'speak up' about such threats, healthcare systems globally struggle to engage their staff to do so. Even when staff do raise concerns they are often ignored by those with a responsibility to listen and act. Learning how to create the conditions where employees continuously raise and respond to concerns is essential in creating a continuous and responsive learning culture that cherishes keeping patients and employees safe. Workplace culture is a real barrier to the creation of such a learning system but examples in healthcare exist from which we can learn.