Reporting of adverse events

Clinical factors associated with the non-utilization of an anaesthesia incident reporting system

BACKGROUND

Incident reporting is a widely recommended method to measure undesirable events in anaesthesia. Under-utilization is a major weakness of voluntary incident reporting systems. Little is known about factors influencing reporting practices, particularly the clinical environment, anaesthesia team composition, severity of the incident, and perceived risk of litigation. The purpose of this study was to assess each of these, using an existing anaesthesia database.

METHODS

We performed a retrospective cohort study and analysed 46 207 surgical patients. We used multivariate analysis to identify factors associated with the non-utilization of the reporting system.

RESULTS

We found that in 7022 (15.1%) of the procedures performed, the incident reporting system was not used. Factors associated with the non-use of the system were regional anaesthesia/local anaesthesia, odds ratio (OR) 1.64 [95% confidence interval (CI) 1.03-2.62], emergency procedures OR 1.15 (95% CI: 1.05-1.27), and a consultant anaesthetist working without a trainee, OR 1.71 (95% CI: 1.03-2.82). In contrast, factors such as longer duration of surgery, OR 0.85 (95% CI: 0.76-0.94), the presence of a senior anaesthesia trainee, OR 0.86 (95% CI: 0.81-0.92), and the occurrence of severe complications with a high risk of litigation (i.e. death, nerve injuries) were less associated with a non-use of the reporting system, OR 0.65 (95% CI: 0.44-0.97). Team composition and time of day had no measurable impact on reporting practices.

CONCLUSIONS

Clinical factors play a significant role in the utilization of an anaesthesia incident reporting system and more particularly, severity of complications and higher liability risks which appear more as incentives than barriers to incident reporting.

Texas pharmacists' knowledge of reporting serious adverse drug events to the Food and Drug Administration

OBJECTIVES

To assess Texas pharmacists' knowledge of adverse drug event (ADE) reporting to the Food and Drug Administration (FDA) and to determine demographic and practice characteristics associated with this knowledge.

DESIGN

Cross-sectional descriptive study.

SETTING

Austin, TX, in June and July 2009.

PARTICIPANTS

377 pharmacists practicing in hospital and community settings.

INTERVENTION

Survey instrument mailed to participants.

MAIN OUTCOME MEASURES

Scores on an eight-item test were used to assess pharmacists' knowledge about ADE reporting to FDA. Pharmacists' demographic and practice characteristics, as well as past reporting, were also measured.

RESULTS

1,500 surveys were mailed and 377 usable responses were obtained (26.4% response rate). Most (67.9%) pharmacists had never reported ADEs to FDA. A majority of pharmacists (65.7%) reported having inadequate knowledge about ADE reporting. Pharmacists had low knowledge scores on ADE reporting, and the pass rate for all items ranged from 56.7% to 96.0%. Pharmacists' age (r = -0.106, P = 0.042) and years of experience (-0.134, P = 0.010) were negatively correlated with knowledge levels, whereas hours worked by pharmacists was positively correlated with knowledge levels (0.130, P = 0.012). Mean knowledge levels differed by practice setting, job title, and area/setting of primary place of employment (P < 0.001).

CONCLUSION

Texas pharmacists have knowledge gaps concerning ADE reporting to FDA. Pharmacists need more education, awareness, and training on ADE reporting, especially regarding reportable ADEs, how to report, and what constitutes a good report.

Communicating pathology and laboratory errors: anatomic pathologists' and laboratory medical directors' attitudes and experiences

Physicians are urged to communicate more openly following medical errors, but little is known about pathologists' attitudes about reporting errors to their institution and disclosing them to patients. We undertook a survey to characterize pathologists' and laboratory medical directors' attitudes and experience regarding the communication of errors with hospitals, treating physicians, and affected patients. We invited 260 practicing pathologists and 81 academic hospital laboratory medical directors to participate in a self-administered survey. This survey included questions regarding estimated error rates and barriers to and experience with error disclosure. The majority of respondents (~95%) reported having been involved with an error, and respondents expressed near unanimous belief that errors should be disclosed to hospitals, colleagues, and patients; however, only about 48% thought that current error reporting systems were adequate. In addition, pathologists expressed discomfort with their communication skills in regard to error disclosure. Improving error reporting systems and developing robust disclosure training could help prevent future errors, improving patient safety and trust.

Medical errors and patient safety in palliative care: a review of current literature

BACKGROUND

Recently, the discussion about medical errors and patient safety has gained scientific as well as public attention. Errors in medicine have been proven to be frequent and to carry enormous financial costs and moral consequences. We aimed to review the research on medical errors in palliative care and to screen relevant literature to appreciate the relevance of safety studies to the field.

METHODS

We performed a literature search using the database PubMed that cross-matched terms for palliative care with the words "errors" and "patient safety." Publications were classified according to type of study and kind of error, and empiric research results were extracted and critically assessed.

RESULTS

We found 44 articles concerning medical errors in palliative care, most of which were case studies. Of these 44 articles, 16 deal with palliative care errors as a key issue, referring mostly to symptom control (n = 13). Other examples are errors in communication, prognostication, and advance care planning. There are very few empirical studies, which are mostly retrospective observational studies.

DISCUSSION

Although patients in palliative care are more vulnerable to errors and their consequences, there is little theoretical or empirical research on the subject. We propose a specific definition for errors in palliative care and analyze the challenges of delineating, identifying and preventing errors in such key areas as prognostication, advance care planning and end-of-life decision-making.

Introduction of a prehospital critical incident monitoring system--final results

BACKGROUND

Incident monitoring has been shown to improve patient care and has been adopted widely in the hospital care setting. There are limited data on incident monitoring in the prehospital setting.

HYPOTHESIS

A high-yield, systems-oriented, incident monitoring process can be implemented successfully in a prehospital setting.

METHODS

This prospective, descriptive study outlines the implementation of an incident monitoring process in a regional prehospital setting. Both trauma care and non-trauma care were monitored by a system of anonymous reporting and chart review with debriefing for trauma cases that met major trauma criteria. A committee reviewed all identified cases and coded and logged all incidents and provider recommendations.

RESULTS

There were 454 incidents identified from 230 cases (mean=2.0; 95% CI 1.8-2.1 per case). Anonymous reporting resulted in the identification of 113 incidents from 69 cases (1.6l per case 95% CI=1.4-1.9 per case) Major trauma cases generated 266 incidents from 134 cases (mean=2.0; 95% CI=1.8-2.2 per case), and there were 74 incidents from 26 combined cases (mean=2.9; 95% CI=2.2-3.5 per case). One incident was uncategorized. There were 315 (69.4%) incidents categorized as management problems and 123 (27.1%) were system problems. Prolonged scene time was the most common incident in both management and system categories; 56 (17.8%) and 18 (14.6%) respectively. Mitigating circumstances were found in 111 (24.4%) incidents. The most common incident-related patient outcome was none/near miss (127 (28%)). Incident monitoring most commonly led to generalized feedback (105 (23.1%)) or specific trend analysis (140 (30.8%)). Reports to higher or external bodies occurred in 18 incidents (4.0%).

CONCLUSIONS

The project has been implemented successfully in a regional prehospital settling. The methodology, utilizing a number of incident detection techniques, results in a high yield of incidents over a broad range of error types. The large proportion of "near miss" type incidents allows for incident assessment without demonstrable patient harm. Many incidents were mitigated and the majority represented management-type issues.

Using prospective clinical surveillance to identify adverse events in hospital

Background

To improve patient safety, organisations must systematically measure avoidable harms. Clinical surveillance—consisting of prospective case finding and peer review—could improve identification of adverse events (AEs), preventable AEs and potential AEs. The authors sought to describe and compare findings of clinical surveillance on four clinical services in an academic hospital.

Methods

Clinical surveillance was performed by a nurse observer who monitored patients for prespecified clinical events and collected standard information about each event. A multidisciplinary, peer-review committee rated causation for each event. Events were subsequently classified in terms of severity and type.

Results

The authors monitored 1406 patients during their admission to four hospital services: Cardiac Surgery Intensive Care (n=226), Intensive Care (n=211), General Internal Medicine (n=453) and Obstetrics (n=516). The authors detected 245 AEs during 9300 patient days of observation (2.6 AEs per 100 patient days). 88 AEs (33%) were preventable. The proportion of patients experiencing at least one AE, preventable AE or potential AE was 13.7%, 6.1% and 5.3%, respectively. AE risk varied between services, ranging from 1.4% of Obstetrics to 11% of Internal Medicine and Intensive Care patients experiencing at least one preventable AE. The proportion of patients experiencing AEs resulting in permanent disability or death varied between services: ranging from 0.2% on Obstetrics to 4.9% on Cardiac Surgery Intensive Care. No services shared the most frequent AE type.

Conclusions

Using clinical surveillance, the authors identified a high risk of AE and significant variation in AE risks and subtypes between services. These findings suggest that institutions will need to evaluate service-specific safety problems to set priorities and design improvement strategies.

To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints, claims and incident reports?

Background

Patient record review is believed to be the most useful method for estimating the rate of adverse events among hospitalised patients. However, the method has some practical and financial disadvantages. Some of these disadvantages might be overcome by using existing reporting systems in which patient safety issues are already reported, such as incidents reported by healthcare professionals and complaints and medico-legal claims filled by patients or their relatives. The aim of the study is to examine to what extent the hospital reporting systems cover the adverse events identified by patient record review.

Methods

We conducted a retrospective study using a database from a record review study of 5375 patient records in 14 hospitals in the Netherlands. Trained nurses and physicians using a method based on the protocol of The Harvard Medical Practice Study previously reviewed the records. Four reporting systems were linked with the database of reviewed records: 1) informal and 2) formal complaints by patients/relatives, 3) medico-legal claims by patients/relatives and 4) incident reports by healthcare professionals. For each adverse event identified in patient records the equivalent was sought in these reporting systems by comparing dates and descriptions of the events. The study focussed on the number of adverse event matches, overlap of adverse events detected by different sources, preventability and severity of consequences of reported and non-reported events and sensitivity and specificity of reports.

Results

In the sample of 5375 patient records, 498 adverse events were identified. Only 18 of the 498 (3.6%) adverse events identified by record review were found in one or more of the four reporting systems. There was some overlap: one adverse event had an equivalent in both a complaint and incident report and in three cases a patient/relative used two or three systems to complain about an adverse event. Healthcare professionals reported relatively more preventable adverse events than patients.

Reports are not sensitive for adverse events nor do reports have a positive predictive value.

Conclusions

In order to detect the same adverse events as identified by patient record review, one cannot rely on the existing reporting systems within hospitals.

[An adverse event continuous surveillance system in surgical services of the autonomous region of Cantabria (Spain)]

OBJECTIVE

To design a continuous surveillance system for adverse events (AEs) in surgical services in the Autonomous Community of Cantabria. Through homogeneous methodology, this system will provide the information needed to prevent and control AEs and avoid their recurrence.

MATERIAL AND METHODS

We performed a prospective study of the population undergoing inpatient surgery in our service. The methodology used was an adapted version of the IDEA (Identification of Adverse Events) project. Surgeons had access to an intranet website and introduced the data by using a personal login. A web application allowed feedback through report-generation.

RESULTS

During the pilot phase, limited collection of variables requiring calculations and of those related to location and causality was observed. Assessment of the system indicated the need for simplification to obtain valid and useful information, as well as the need to provide help windows. The system was redesigned with two data input screens and currently allows for automatic report generation of registered AEs. Information was gathered on 70% of the patients and an incidence of 11.2 AEs/100 admissions was found. Of these, 47% were defined as surgical complications.

CONCLUSIONS

Establishing a continuous surveillance system for AEs is feasible if professionals participate in the process, data input is easy and feedback from the system is rapid and useful for implementing corrective measures. This system can be considered highly useful for obtaining information on AEs and consequently on the potential areas of improvement in surgical activity in Spanish hospitals.

Effect of emergency medicine pharmacists on medication-error reporting in an emergency department

PURPOSE

The effect of an emergency medicine (EM) clinical pharmacist on medication-error reporting in an emergency department (ED) was studied.

METHODS

The medication-error reports for patients seen at a university's ED between September 1, 2005, and February 28, 2009, were retrospectively reviewed. Errors reported before the addition of an EM pharmacist (from September 1, 2005, through February 28, 2006) were compared with those reported after the addition of two EM pharmacists (from September 1, 2008, through February 28, 2009). The severity of errors and the provider who reported the errors were characterized.

RESULTS

A total of 402 medication errors were reported over the two time periods. Pharmacy personnel captured significantly more errors than did other health care personnel (94.5% versus 5.7%, p < 0.001). The addition of two EM pharmacists resulted in 14.8 times as many medication-error reports as were made when no EM pharmacist was in the ED. More errors that actually occurred were captured with two pharmacists providing care (95.7% versus 4.3%, p < 0.001). A majority of the errors documented were ordering errors (79.8%). Of these, 73.7% were captured after the addition of two EM pharmacists. Performance (40.0%) and knowledge (27.9%) deficits were the most common contributing factors to medication errors.

CONCLUSION

During the study period after the addition of two EM pharmacists in the ED, 371 medication-error reports were completed, compared with 31 reports during the study period before the addition of the pharmacists. Pharmacy personnel reported the majority of medication errors during both study periods.

Variability in the definition and reporting of adverse events in suicide prevention trials: an examination of the issues and a proposed solution

Adverse events (AEs) and serious adverse events (SAEs) are important outcomes of any intervention study yet are under-researched. Vague and variable definitions and substantial underreporting make comparisons of risk between studies difficult and evaluation of the safety of a particular intervention almost impossible. These realities may deter researchers from studying at-risk populations. Suicidal behavior is an adverse event in any study, and potentially a very serious one. Thus the issues of reporting and definition are particularly salient for researchers who work with populations at risk for suicidal behavior, especially when the suicidal behavior is the outcome of interest. We conducted a qualitative study with experienced suicide researchers and intervention experts to delineate the issues related to reporting serious adverse events faced by investigators conducting trials in suicide prevention. Participants from multiple sites were interviewed by phone, interviews transcribed and coded for definition and reporting issues and suggested solutions. A narrative synthesis was prepared and validated by all participants. Participants highlighted the difficulties in defining AEs and SAEs and stressed the importance and complexity of ensuring the AE was related to the study and reported properly, and were in agreement about the consequences of AEs to both institutions and individuals. Participants identified the need for the development of clear and consistent AE definitions and reporting requirements. Clear and consistently applied definitions of adverse and serious adverse events and reporting requirements would enhance the comparability of intervention studies in suicidal populations.

Assessing hospitals' clinical risk management: Development of a monitoring instrument

BACKGROUND

Clinical risk management (CRM) plays a crucial role in enabling hospitals to identify, contain, and manage risks related to patient safety. So far, no instruments are available to measure and monitor the level of implementation of CRM. Therefore, our objective was to develop an instrument for assessing CRM in hospitals.

METHODS

The instrument was developed based on a literature review, which identified key elements of CRM. These elements were then discussed with a panel of patient safety experts. A theoretical model was used to describe the level to which CRM elements have been implemented within the organization. Interviews with CRM practitioners and a pilot evaluation were conducted to revise the instrument. The first nationwide application of the instrument (138 participating Swiss hospitals) was complemented by in-depth interviews with 25 CRM practitioners in selected hospitals, for validation purposes.

RESULTS

The monitoring instrument consists of 28 main questions organized in three sections: 1) Implementation and organizational integration of CRM, 2) Strategic objectives and operational implementation of CRM at hospital level, and 3) Overview of CRM in different services. The instrument is available in four languages (English, German, French, and Italian). It allows hospitals to gather comprehensive and systematic data on their CRM practice and to identify areas for further improvement.

CONCLUSIONS

We have developed an instrument for assessing development stages of CRM in hospitals that should be feasible for a continuous monitoring of developments in this important area of patient safety.

Increasing patient safety event reporting in 2 intensive care units: a prospective interventional study

PURPOSE

The aims of this study were to increase the reporting of patient safety events and to enhance report analysis and responsive action.

MATERIALS AND METHODS

A prospective, interventional study in 2 adult intensive care units (ICUs) in an academic center was used. A paper-based reporting system, adapted from a previously reported intervention, was introduced. A multifaceted approach, including education, reminders, regular updates, personal and group feedback, and weekly leadership rounds, was led by a patient safety committee. Committee members reviewed the reports and initiated solutions as required.

RESULTS

During the first year, a total of 332 safety events were reported using the new system, reflecting a significant increase in total reporting (10.3/1000 patient days preintervention to 34.5/1000 patient days postintervention; rate ratio, 3.35; 95% confidence interval, 2.23-5.04). Most reports were submitted by nurses (nurses, 75.3%; physicians, 10.5%; other workers, 7.8%). Overall reported events per 1000 patient days differed by unit (level 3 ICU, 44.1; level 2 ICU, 24.9; P < .001). Several system-based interventions were initiated in the ICUs to address reported safety hazards.

CONCLUSIONS

After the introduction of this new approach, reporting rates have increased significantly throughout the first year. Differences in reporting rates among workers and units may reveal priorities and barriers to reporting. The integrated approach facilitated prompt response to selected reports.

Radiation Oncology Safety Information System (ROSIS)--profiles of participants and the first 1074 incident reports

BACKGROUND AND PURPOSE

The Radiation Oncology Safety Information System (ROSIS) was established in 2001. The aim of ROSIS is to collate and share information on incidents and near-incidents in radiotherapy, and to learn from these incidents in the context of departmental infrastructure and procedures.

MATERIALS AND METHODS

A voluntary web-based cross-organisational and international reporting and learning system was developed (cf. the www.rosis.info website). Data is collected via online Department Description and Incident Report Forms. A total of 101 departments, and 1074 incident reports are reviewed.

RESULTS

The ROSIS departments represent about 150,000 patients, 343 megavoltage (MV) units, and 114 brachytherapy units. On average, there are 437 patients per MV unit, 281 per radiation oncologist, 387 per physicist and 353 per radiation therapy technologist (RT/RTT). Only 14 departments have a completely networked system of electronic data transfer, while 10 departments have no electronic data transfer. On average seven quality assurance (QA) or quality control (QC) methods are used at each department. A total of 1074 ROSIS reports are analysed; 97.7% relate to external beam radiation treatment and 50% resulted in incorrect irradiation. Many incidents arise during pre-treatment but are not detected until later in the treatment process. Where an incident is not detected prior to treatment, an average of 22% of the prescribed treatment fractions were delivered incorrectly. The most commonly reported detection methods were "found at time of patient treatment" and during "chart-check".

CONCLUSION

While the majority of the incidents that reported to this international cross-organisational reporting system are of minor dosimetric consequence, they affect on average more than 20% of the patient's treatment fractions. Nonetheless, defence-in-depth is apparent in departments registered with ROSIS. This indicates a need for further evaluation of the effectiveness of quality controls.

Risk management systems for health care and safety development on transplantation: a review and a proposal

Starting from the report on medical errors published in 1999 by the US Institute of Medicine, a number of different approaches to risk management have been developed for maximum risk reduction in health care activities. The health care authorities in many countries have focused attention on patient safety, employing action research programs that are based on quite different principles.

MATERIALS AND METHODS

We performed a systematic Medline research of the literature since 1999. The following key words were used, also combining boolean operators and medical subheading terms: "adverse event," "risk management," "error," and "governance." Studies published in the last 5 years were particularly classified in various groups: risk management in health care systems; safety in specific hospital activities; and health care institutions' official documents. Methods of action researches have been analysed and their characteristics compared. Their suitability for safety development in donation, retrieval, and transplantation processes were discussed in the reality of the Italian transplant network.

DISCUSSION

Some action researches and studies were dedicated to entire national healthcare systems, whereas others focused on specific risks. Many research programs have undergone critical review in the literature. Retrospective analysis has centered on so-called sentinel events to particularly analyze only a minor portion of the organizational phenomena, which can be the origin of an adverse event, an incident, or an error. Sentinel events give useful information if they are studied in highly engineered and standardized organizations like laboratories or tissue establishments, but they show several limits in the analysis of organ donation, retrieval, and transplantation processes, which are characterized by prevailing human factors, with high intrinsic risk and variability. Thus, they are poorly effective to deliver sure elements to base safety management improvement programs, especially regarding multidisciplinary systems with high complexity.

CONCLUSION

In organ transplantation, the possibility to increase safety seems greater using proactive research, mainly centred on organizational processes together with retrospective analyses but not limited to sentinel event reports.

Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant

BACKGROUND

A study was conducted to examine and compare information gleaned from five different reporting systems within one institution: incident reporting, patient complaints, risk management, medical malpractice claims, and executive walk rounds. These data sources vary in the timing of the reporting (retrospective or prospective), severity of the events, and profession of the reporters.

METHODS

A common methodology was developed for classifying incidents. Data specific to each incident were abstracted from each system and then categorized using the same framework into one of 23 categories.

RESULTS

Overall, there was little overlap, although each reporting system identified important safety issues. Communication problems were common among patient complaints and malpractice claims; malpractice claims' leading category was clinical judgement. Walk rounds identified issues with equipment and supplies. Adverse event reporting systems highlighted identification issues, especially mislabelled specimens. The frequency of contributions of reports by provider group varied substantially by system. Physicians accounted for 50% of risk management reports, but in adverse event reporting, where nurses were the main reporters, physicians accounted for only 2.5% of reports. Complaints and malpractice claims come primarily from patients.

CONCLUSIONS

The five reporting systems each identified different yet complementary patient safety issues. To obtain a comprehensive picture of their patient safety problems and to develop priorities for improving safety, hospitals should use a broad portfolio of approaches and then synthesize the messages from all individual approaches into a collated and cohesive whole.

Iatrogenic complications in the neonatal intensive care unit

With the introduction of novel technologies and approaches in neonatal care and the lack of appropriately designed and well-executed randomized clinical trials to investigate the impact of these interventions, iatrogenic complications have been increasingly seen in the neonatal intensive care unit. In addition, increased awareness and the introduction of more appropriate quality control measures have resulted in higher levels of suspicion about and increased recognition of complications associated with delivery of care. The incidence of complications also rises with the increased length of hospital stay and level of immaturity. Approximately half of the iatrogenic complications are related to medication errors. The other complications are due to nosocomial infections, insertion of invasive catheters, prolonged mechanical ventilation, administration of parenteral nutrition solution, skin damage and environmental complications. Adopting newer technologies and preventive measures might decrease these complications and improve outcomes. Quality improvement projects targeting areas for improvement are expected to build team spirit and further improve the outcomes. In addition, participation in national reporting systems will enhance education and provide an opportunity to compare outcomes with peer institutions.

Process of care events in transplantation: effects on the cost of hospitalization

Deviations in the processes of healthcare delivery that affect patient outcomes are recognized to have an impact on the cost of hospitalization. Whether deviations that do not affect patient outcome affects cost has not been studied. We have analyzed process of care (POC) events that were reported in a large transplantation service (n = 3,012) in 2005, delineating whether or not there was a health consequence of the event and assessing the impact on hospital resource utilization. Propensity score matching was used to adjust for patient differences. The rate of POC events varied by transplanted organ: from 10.8 per 1000 patient days (kidney) to 17.3 (liver). The probability of a POC event increased with severity of illness. The majority (81.5%) of the POC events had no apparent effect on patients' health (63.6% no effect and 17.9% unknown). POC events were associated with longer length of stay (LOS) and higher costs independent of whether there was a patient health impact. Multiple events during the same hospitalization were associated with the highest impact on LOS and cost. POC events in transplantation occur frequently, more often in sicker patients and, although the majority of POC events do not harm the patient, their effect on resource utilization is significant.

Clinical Risk Management in radiology. Part I: general background and types of error and their prevention

The present contribution, presented as an Editorial, addresses the issue of patient safety in Radiology: this topic, of great current National and Regional interest, has stimulated a strong focus on accidents and mistakes in medicine, together with the diffusion of procedures for Risk Management in all health facilities. The possible sources of incidents in the radiological process are exposed, due to human errors and to system errors connected both to the organization and to the dissemination of Information Technology in the Radiological world. It also describes the most common methods and tools for risk analysis in health systems, together with some application examples presented in Part II.

A Survey of Nurses Self-Reported Prospective Memory Tasks: What Must they Remember and What do they Forget?

Although a nurse's job is inundated with prospective memory (PM) demands, and studies show that PM failures are a key component of adverse medical events, only one study has examined prospective memory in nursing (Grundgeiger, Sanderson, MacDougall, & Venkatesh, 2009). The purpose of the current study was to complement existing research with self-reports from 25 nurses on the PM tasks they must remember and those they forget. Results revealed that nurses most frequently perform episodic tasks, and these tasks can be further classified to better explain when nursing PM demands arise and what the demands consist of. A more specific categorization of nursing PM tasks enables researchers to focus on specific design solutions. We provide examples of such re-design recommendations intended to alleviate PM demands.

Learning mechanisms to limit medication administration errors

AIM

This paper is a report of a study conducted to identify and test the effectiveness of learning mechanisms applied by the nursing staff of hospital wards as a means of limiting medication administration errors.

BACKGROUND

Since the influential report ;To Err Is Human', research has emphasized the role of team learning in reducing medication administration errors. Nevertheless, little is known about the mechanisms underlying team learning.

METHOD

Thirty-two hospital wards were randomly recruited. Data were collected during 2006 in Israel by a multi-method (observations, interviews and administrative data), multi-source (head nurses, bedside nurses) approach. Medication administration error was defined as any deviation from procedures, policies and/or best practices for medication administration, and was identified using semi-structured observations of nurses administering medication. Organizational learning was measured using semi-structured interviews with head nurses, and the previous year's reported medication administration errors were assessed using administrative data.

RESULTS

The interview data revealed four learning mechanism patterns employed in an attempt to learn from medication administration errors: integrated, non-integrated, supervisory and patchy learning. Regression analysis results demonstrated that whereas the integrated pattern of learning mechanisms was associated with decreased errors, the non-integrated pattern was associated with increased errors. Supervisory and patchy learning mechanisms were not associated with errors.

CONCLUSION

Superior learning mechanisms are those that represent the whole cycle of team learning, are enacted by nurses who administer medications to patients, and emphasize a system approach to data analysis instead of analysis of individual cases.

Texas pharmacists' opinions on reporting serious adverse drug events to the Food and Drug Administration: a qualitative study

OBJECTIVE

Pharmacists in the United States (U.S.) are encouraged to report serious adverse drug events (ADEs) to the Food and Drug Administration (FDA) through MedWatch. The aim of this study is to investigate the beliefs and opinions of Texas pharmacists toward reporting ADEs to the FDA.

METHODS

The comments made by pharmacists in state-wide mail survey about reporting serious ADEs to the FDA were independently content analyzed and categorized into themes by two raters. Some comments contained more than one idea and these were categorized into different themes.

MAIN OUTCOME

Beliefs and opinions of Texas pharmacists toward ADE reporting.

RESULTS

A total of 86 pharmacists provided comments on ADE reporting. Texas pharmacists had positive opinions about reporting ADEs to the FDA (e.g., important, valuable and positive). Respondents cited many constraints that impeded the reporting of ADEs: lack of time, failure to know which ADEs to report, difficulty in linking ADEs to a specific drug, lack of patient history, lack of compensation, fear of malpractice suits, limited support from employers and mistrust of the FDA. Pharmacists recommended continuing education and training to raise awareness on ADE reporting and streamlining the reporting process to enhance pharmacists' reporting behavior.

CONCLUSIONS

Despite pharmacists having positive opinions about reporting ADEs to the FDA, actual reporting may be impeded by a myriad of challenges involved in reporting ADEs. ADE reporting can be improved through addressing these challenges. Continuing education and on-the-job training on ADE reporting are imperative.

Incidence and type of complications in non-operated patients at a surgical ward

BACKGROUND

This study was designed to analyze a group of non-operated patients admitted to our surgical ward for incidence and type of documented complication. We classified and categorised these complications according to the definition of the Association of Surgeons of the Netherlands (ASN). Our main interest was to identify adverse events for non-operated patients that are caused by medical management and thus preventable.

METHODS

Complications were prospectively collected in our registry, which is part of an electronic medical patient file, and in retrospective analysed. All non-operated patients admitted to our surgical ward between January 2003 and January 2006 have been analysed for type and incidence of complications.

RESULTS

We recorded 437 complications in 364 (8%) of 4602 non-operated patients and we categorised 196 (45%) of these events in the Hospital - Provider group. In this last category 161 (82%) events were related to medical management and appeared to be preventable. Numerous different types of complications were recorded (n = 69) among the 437 events. Of all the complications, 75 (17%) were found to be a negative effect/failure of therapy.

CONCLUSION

The incidence of complications in non-operated patients at our surgical ward was 8%, with a great variety in types of events documented. Almost half of all complications (45%) were recorded in the Hospital-Provider category and appeared to be preventable, which needs further investigation.

Critical incident reporting and learning

The success of incident reporting in improving safety, although obvious in aviation and other high-risk industries, is yet to be seen in health-care systems. An incident reporting system which would improve patient safety would allow front-end clinicians to have easy access for reporting an incident with an understanding that their report will be handled in a non-punitive manner, and that it will lead to enhanced learning regarding the causation of the incident and systemic changes which will prevent it from recurring. At present, significant problems remain with local and national incident reporting systems. These include fear of punitive action, poor safety culture in an organization, lack of understanding among clinicians about what should be reported, lack of awareness of how the reported incidents will be analysed, and how will the reports ultimately lead to changes which will improve patient safety. In particular, lack of systematic analysis of the reports and feedback directly to the clinicians are seen as major barriers to clinical engagement. In this review, robust systematic methodology of analysing incidents is discussed. This methodology is based on human factors model, and the learning paradigm which emphasizes significant shift from traditional judicial approach to understanding how 'latent errors' may play a role in a chain of events which can set up an 'active error' to occur. Feedback directly to the clinicians is extremely important for keeping them 'in the loop' for their continued engagement, and it should target different levels of analyses. In addition to high-level information on the types of incidents, the feedback should incorporate results of the analyses of active and latent factors. Finally, it should inform what actions, and at what level/stage, have been taken in response to the reported incidents. For this, local and national systems will be required to work in close cooperation, so that the lessons can be learnt and actions taken within an organization, and across organizations. In the UK, a recently introduced speciality-specific incident reporting system for anaesthesia aims to incorporate the elements of successful reporting system, as presented in this review, to achieve enhanced clinical engagement and improved patient safety.

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit

OBJECTIVE

To identify a risk profile for harmful medication errors in the neonatal intensive care unit (NICU).

STUDY DESIGN

A retrospective cross-sectional study on NICU medication error reports submitted to MEDMARX between 1 January 1999, and 31 December 2005. The Rao-Scott modified chi(2) test was used for analysis.

RESULT

6749 NICU medication error reports were submitted by 163 health-care facilities. Administering errors accounted for approximately one half of errors, and human factors were the most frequently cited cause of error. Patient age was not associated with an increased likelihood of an error being harmful (P=0.11). Error reports involving Institute for Safe Medication Practices (ISMP) High-Alert Medications, occurring in the prescribing phase of medication processing, or involving equipment/delivery device failures were more likely to be harmful (P< or =0.05).

CONCLUSION

Risk factors for harmful medication error reports include use of ISMP High-Alert Medications, the prescribing phase of the medication use process, and failure of equipment/delivery devices.

Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs

BACKGROUND

External reporting of medical errors a adverse events enables learning from the errors of others in the pursuit of systems-level improvements that can prevent future errors. It is logical to presume that medication errors involving the use of anticoagulants, among the most frequently cited product classes involved in harmful medication errors, would be captured in a variety of patient safety reporting programs.

METHODS

Data on reported errors involving the anticoagulant heparin were reviewed, compared, and aggregated from the databases of three large patient safety reporting programs-MEDMARX, the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, and the University Health System Consortium, together representing more than 1,000 reporting organizations for 2005

RESULTS

Approximately 300,000 medication errors and near misses were reported to the programs, and 10,359-a mean of 3.6% (range, 3.1%-5.5%)-involved heparin products. The proportion of heparin-related reports that involved patient harm ranged from 1.4% to 4.9%. The phase of the medication use process cited most frequently in harmful events was the administration phase (56% of errors leading to harm), followed by the prescribing phase (19% of errors leading to harm).

DISCUSSION

This study represents the first attempt by these three large reporting systems to combine data on a single clinical process. The consistent patterns evident in the reports, such as the percentage of all medication errors that involved heparin, suggests that reporting programs, at least for common events such as medication errors, may reach a point of diminishing returns in which aggregating more reports of a certain type yields no additional insight once a large volume of similar events is captured and analyzed.

Medication errors involving oral chemotherapy

BACKGROUND

Given the expanding use of oral chemotherapies, the authors set out to examine errors in the prescribing, dispensing, administration, and monitoring of these drugs.

METHODS

Reports were collected of oral chemotherapy-associated medication errors from a medical literature and Internet search and review of reports to the Medication Errors Reporting Program and MEDMARX. The authors solicited incident reports from 14 comprehensive cancer centers, and also collected incident reports, pharmacy interventions, and prompted clinician reports from their own center. They classified the type of incident, severity, stage in the medication use process, and type of medication error. They examined the yield of the various reporting methods to identify oral chemotherapy-related medication errors.

RESULTS

The authors identified 99 adverse drug events, 322 near misses, and 87 medical errors with low risk of harm. Of the 99 adverse drug events, 20 were serious or life-threatening, 52 were significant, and 25 were minor. The most common medication errors involved wrong dose (38.8%), wrong drug (13.6%), wrong number of days supplied (11.0%), and missed dose (10.0%). The majority of errors resulted in a near miss; however, 39.3% of reports involving the wrong number of days supplied resulted in adverse drug events. Incidents derived from the literature search and hospital incident reporting system included a larger percentage of adverse drug events (73.1% and 58.8%, respectively) compared with other sources.

CONCLUSIONS

Ensuring oral chemotherapy safety requires improvements in the way these drugs are ordered, dispensed, administered, and monitored.

[Reporting of patient injuries--the supervisory authority's use of sanctions]

BACKGROUND

When health care leads to serious adverse events that result in (or could have resulted in) injuries to patients, hospitals are obliged to report this to The Norwegian Board of Health Supervision in the Counties. The purpose of this study was to quantify how many cases were instigated on the basis of reports sent to the supervisory authority and to what extent health personnel were sanctioned because of them.

MATERIAL AND METHODS

Reports received by The Norwegian Board of Health Supervision in the Counties (in the period 1.07.2002- 30.06.2007) and cases instigated by the National Board of Health (on basis of the reports) in the period 1.01.2003-31.12.2007.

RESULTS

The supervisory authority received 9268 reports in the period. 443 (4.7 %) of them led to instigation of cases and 19 of these (2 of the reports) resulted in formal sanctioning of health personnel (13 of the sanctions were to physicians; 12 received a warning and one lost her specialist license). The Board of Health Supervision seems to have quite different thresholds for instigating report-based cases in the various counties.

INTERPRETATION

Health personnel seem to have little reason to fear that reports on (potential) adverse events will lead to sanctions from the supervisory authority. However, the Board of Health Supervision in the Counties should have a more predictable practice concerning instigation of report-based cases.

Survey of dispensing error practices in community pharmacies in Finland: a nationwide study

OBJECTIVES

To assess the actions taken to manage dispensing errors, to investigate pharmacists' perceptions of ideal methods for managing dispensing errors, and to evaluate the reliability of in-house dispensing error reporting systems.

DESIGN

National cross-sectional survey.

SETTING

Main outlets of all privately owned Finnish community pharmacies (n = 599) in March 2005.

PARTICIPANTS

Owners and operational managers of Finnish community pharmacies.

INTERVENTION

Mail survey containing structured and open-ended questions.

MAIN OUTCOME MEASURES

Current actions taken in the dispensing error managing process, pharmacist perceptions on the ideal ways of action to manage dispensing errors, and reported dispensing error rates.

RESULTS

340 participants responded to the survey (response rate 57%). Almost 90% of the responding outlets documented dispensing errors at least occasionally, 47% always documented, and 29% almost always documented. Discussion about dispensing errors was considered the most ideal method for managing dispensing errors in the pharmacy (76% of the respondents), followed by documenting them (45%). The error rate collected from in-house error reporting systems was 14 per 100,000 prescriptions dispensed in 2004.

CONCLUSION

Most Finnish community pharmacies have an in-house dispensing error reporting system, but reporting has not been fully implemented in all pharmacies. The actual error reporting in most Finnish community pharmacies is not reliable and needs further development and coordination. Discussing dispensing errors and documenting dispensing errors were reported as the most ideal methods for managing errors. Respondents indicated a hope that dispensing errors would be discussed more frequently with the whole staff. These findings demonstrate that Finnish community pharmacists are aware of some of the principles of managing dispensing errors based on the system approach and the benefits of error reporting systems in managing dispensing errors.

The detection and prevention of errors in laboratory medicine

The last few decades have seen a significant decrease in the rates of analytical errors in clinical laboratories. Evidence demonstrates that pre- and post-analytical steps of the total testing process (TTP) are more error-prone than the analytical phase. Most errors are identified in pre-pre-analytic and post-post-analytic steps outside of the laboratory. In a patient-centred approach to the delivery of health-care services, there is the need to investigate, in the TTP, any possible defect that may have a negative impact on the patient. In the interests of patients, any direct or indirect negative consequence related to a laboratory test must be considered, irrespective of which step is involved and whether the error depends on a laboratory professional (e.g. calibration/testing error) or non-laboratory operator (e.g. inappropriate test request, error in patient identification and/or blood collection). Patient misidentification and problems communicating results, which affect the delivery of diagnostic services, are recognized as the main goals for quality improvement. International initiatives aim at improving these aspects. Grading laboratory errors on the basis of their seriousness should help identify priorities for quality improvement and encourage a focus on corrective/preventive actions. It is important to consider not only the actual patient harm sustained but also the potential worst-case outcome if such an error were to reoccur. The most important lessons we have learned are that system theory also applies to laboratory testing and that errors and injuries can be prevented by redesigning systems that render it difficult for all health-care professionals to make mistakes.

Medication errors: prescribing faults and prescription errors

1. Medication errors are common in general practice and in hospitals. Both errors in the act of writing (prescription errors) and prescribing faults due to erroneous medical decisions can result in harm to patients. 2. Any step in the prescribing process can generate errors. Slips, lapses, or mistakes are sources of errors, as in unintended omissions in the transcription of drugs. Faults in dose selection, omitted transcription, and poor handwriting are common. 3. Inadequate knowledge or competence and incomplete information about clinical characteristics and previous treatment of individual patients can result in prescribing faults, including the use of potentially inappropriate medications. 4. An unsafe working environment, complex or undefined procedures, and inadequate communication among health-care personnel, particularly between doctors and nurses, have been identified as important underlying factors that contribute to prescription errors and prescribing faults. 5. Active interventions aimed at reducing prescription errors and prescribing faults are strongly recommended. These should be focused on the education and training of prescribers and the use of on-line aids. The complexity of the prescribing procedure should be reduced by introducing automated systems or uniform prescribing charts, in order to avoid transcription and omission errors. Feedback control systems and immediate review of prescriptions, which can be performed with the assistance of a hospital pharmacist, are also helpful. Audits should be performed periodically.

An introduction to adverse drug reaction reporting systems in different countries

Objective

To review adverse drug reaction (ADR) reporting schemes in selected developed countries, with emphasis on identifying community pharmacists' roles in ADR reporting.

Setting

International comparison between eight developed countries, with respect to ADR reporting systems and developments.

Method

Review of published articles on ADR reporting by pharmacists. Health and medical sciences databases including International Pharmaceutical Abstracts, MEDLINE and ProQuest were searched for relevant publications from 1993 to 2003. Websites specific to ADR reporting schemes in the selected countries were also searched.

Key findings

ADRs impact significantly on a nation's healthcare costs. Voluntary reporting by health professionals is currently considered the cornerstone to the detection and management of ADRs and makes a valuable contribution to the safe use of medicines. ADR reporting systems are managed by national ADR or pharmacovigilance reporting centres, and differ internationally. In general, medication-related problems are reported more commonly in hospitals than in the community. Physicians are the main contributors, except in the Netherlands and Canada, where community pharmacists play the major role in ADR reporting. Time pressure, no remuneration for reporting, and confusion about what to report were identified as some of the main deterrents for reporting by pharmacists.

Conclusion

Most international reporting systems for ADRs are either hospital based, or physician based. The opportunity therefore exists to further develop reporting systems that are accessible by community pharmacists, as they are in an ideal situation to detect and report ADRs through contact with patients.

Pediatric antidepressant medication errors in a national error reporting database

OBJECTIVE

To describe inpatient and outpatient pediatric antidepressant medication errors.

METHODS

We analyzed all error reports from the United States Pharmacopeia MEDMARX database, from 2003 to 2006, involving antidepressant medications and patients younger than 18 years.

RESULTS

Of the 451 error reports identified, 95% reached the patient, 6.4% reached the patient and necessitated increased monitoring and/or treatment, and 77% involved medications being used off label. Thirty-three percent of errors cited administering as the macrolevel cause of the error, 30% cited dispensing, 28% cited transcribing, and 7.9% cited prescribing. The most commonly cited medications were sertraline (20%), bupropion (19%), fluoxetine (15%), and trazodone (11%). We found no statistically significant association between medication and reported patient harm; harmful errors involved significantly more administering errors (59% vs 32%, p = .023), errors occurring in inpatient care (93% vs 68%, p = .012) and extra doses of medication (31% vs 10%, p = .025) compared with nonharmful errors. Outpatient errors involved significantly more dispensing errors (p < .001) and more errors due to inaccurate or omitted transcription (p < .001), compared with inpatient errors. Family notification of medication errors was reported in only 12% of errors.

CONCLUSIONS

Pediatric antidepressant errors often reach patients, frequently involve off-label use of medications, and occur with varying severity and type depending on location and type of medication prescribed. Education and research should be directed toward prompt medication error disclosure and targeted error reduction strategies for specific medication types and settings.

Medical managers in contemporary healthcare organisations: a consideration of the literature

Objectives. To consider the literature supporting the evolution of the roles of a Medical Manager within contemporary healthcare organisations. Design. Consideration of available literature. Results. Limited dedicated literature available. Consideration of available studies and expert opinion reveals benefit of doctors in management positions within healthcare organisations. The roles of Medical Managers arise from: organisational structure-theory of healthcare’s ‘professional bureaucracy’; clinical directorate models; clinical governance, legislative and public health requirements; and the duality of combining medical knowledge with business and healthcare management training. Roles identified are: (1) leadership and management of medical staff including appointments and credentialing, and mentoring of medical staff in Clinical Directorate roles; (2) strategy development including Medical Advisory Role to Executive; (3) clinical governance including quality and risk management and legislative requirements; and (4) operational areas that benefit from clinical and management skills. Discussion. Strengths of this review include considering contexts of Medical Managers in medical and healthcare management literature. Weaknesses include drawing inferences from theory. Future recommendations include formal studies and systematic reviews of available literature of the subject. Conclusions. In light of falling Medical Management trainee numbers, this study highlights the value to the health system of a dwindling Medical Management profession, the urgent need to encourage more medical practitioners into management and for organisations to further embrace Medical Managers in key leadership roles. What is known about the topic? Although there is general acknowledgement about the benefits of medical leaders within health services, the exact nature and evidence for the Medical Manager role in current health services has not been comprehensively explored and articulated. What does this paper add? The aim of this consideration of the literature is to explore the evidence-base supporting the roles for Medical Managers within contemporary healthcare organisations, and articulate the exact nature and scope of the role. A concordance of studies and expert opinion highlights the benefits of Medical Managers within contemporary healthcare organisations, illustrating a theoretical basis for the differing roles. The nature of the roles include: leadership and management of medical staff (from organisational structure theory); leadership of the organisation within the executive team; clinical governance oversight; and operational management of medical areas with a business focus. What are the implications for practitioners? In light of falling Medical Management trainee numbers, this study highlights the value to the health system of a dwindling Medical Management profession, the urgent need to encourage more medical practitioners into management and for organisations to further embrace Medical Managers in key leadership roles.

Rates of surgical site infection as a performance measure: Are we ready?

With the introduction of quality assurance in health care delivery, there has been a proliferation of research studies that compare patient outcomes for similar conditions among many health care delivery facilities. Since the 1990s, increasing interest has been placed in the incorporation of clinical adverse events as quality indicators in hospital quality assurance programs. Adverse post-operative events, and very especially surgical site infection (SSI) rates after specific procedures, gained popularity as hospital quality indicators in the 1980s. For a SSI rate to be considered a valid indicator of the quality of care, it is essential that a proper adjustment for patient case mix be performed, so that meaningful comparisons of SSI rates can be made among surgeons, institutions, or over time. So far, a significant impediment to developing meaningful hospital-acquired infection rates that can be used for intra- and inter-hospital comparisons has been the lack of an adequate means of adjusting for case mix. This paper discusses what we have learned in the last years regarding risk adjustment of SSI rates for provider performance assessment, and identifies areas in which significant improvement is still needed.

Healthcare safety committee in Japan: mandatory accountability reporting system and punishment

PURPOSE OF REVIEW

The publication of To Err is Human by the Institute of Medicine highlighted the increased international concern about patient safety. Each country has developed its own medical adverse event reporting system. In 2007, the Japanese government attempted to establish a new accountability system in medicine, after an obstetrician was arrested for manslaughter. This paper reviews how this accountability system affected Japanese physicians' behavior, and describes different types of medical adverse event reporting systems.

RECENT FINDINGS

In general, reporting of adverse event systems can be either mandatory or voluntary, with the purpose being either for learning or for accountability. The goal of a newly proposed mandatory accountability system from the Japanese government was to investigate the cause of death in medical cases in order to clarify liability. Reports generated by this system could potentially be cited in civil law suits, administrative sanctions, and criminal prosecutions. After announcement of this new system, Japanese physicians began to act defensively, fearing criminal prosecution. Refusing to see high-risk patients and 'bouncing' (sometimes referred to as 'turfing' or 'dumping') to other hospitals became national phenomena. In addition, medical school graduates began avoiding highly legally vulnerable specialties. Even though this new system is not yet legalized in Japan, at least 153 obstetrics hospitals and 3320 clinics have closed.

SUMMARY

The new system of investigating medical adverse events in Japan allows for incident reports to be utilized in court. This has led to widespread fear of prosecution and defensive medicine. The lessons from Japan should be considered when other countries implement nationwide accountability systems.

[How to identify adverse events in emergency services? A guide agreed for the screening]

OBJECTIVE

Since a third of adverse events (AE) occur outside hospital, the Emergency Services are a suitable place to look at their incidence. We considered designing a screening guide, adapted to the conditions of the emergency services, to identify AE.

MATERIAL AND METHODS

A qualitative technique was applied (nominal group) in which 14 professionals participated. They analysed which factors of intrinsic risk, extrinsic risk, and alert conditions, were suitable for a screening guide of AE in emergency services. The session was chaired by a specialist in these types of techniques.

RESULTS

Consensus was high in that the most frequent AE in emergencies were those related to medicines, diagnostic tests and with the correct identification of the reason for emergency. With respect to screening guide, the group proposed adding alcohol abuse, patient social problems, cognitive deterioration, basal autonomy and disability. In relation to extrinsic risk factors, they pointed to the need of including defibrillation, spinal tap or drainage implantation. With respect to the alert conditions form, the professionals agreed in that all the criteria seemed correct and suitable, except for that related to damage relation childbirth or amniocentesis.

CONCLUSIONS

By using this technique we have managed to validate materials already recognized, and widely used in our country. The screening guide was considered useful, with slight modifications in some risk factors and alert conditions. The professionals agreed that the MRF2 modular questionnaire is appropriate for the characterisation of AE in emergencies.

Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II

RATIONALE

Although intensive care units (ICUs) were created for patients with life-threatening illnesses, the ICU environment generates a high risk of iatrogenic events. Identifying medical errors (MEs) that serve as indicators for iatrogenic risk is crucial for purposes of reporting and prevention.

OBJECTIVES

We describe the selection of indicator MEs, the incidence of such MEs, and their relationship with mortality.

METHODS

We selected indicator MEs using Delphi techniques. An observational prospective multicenter cohort study of these MEs was conducted from March 27 to April 3, 2006, in 70 ICUs; 16 (23%) centers were audited. Harm from MEs was collected using specific scales.

MEASUREMENTS AND MAIN RESULTS

Fourteen types of MEs were selected as indicators; 1,192 MEs were reported for 1,369 patients, and 367 (26.8%) patients experienced at least 1 ME (2.1/1,000 patient-days). The most common MEs were insulin administration errors (185.9/1,000 d of insulin treatment). Of the 1,192 medical errors, 183 (15.4%) in 128 (9.3%) patients were adverse events that were followed by one or more clinical consequences (n = 163) or that required one or more procedures or treatments (n = 58). By multivariable analysis, having two or more adverse events was an independent risk factor for ICU mortality (odds ratio, 3.09; 95% confidence interval, 1.30-7.36; P = 0.039).

CONCLUSIONS

The impact of medical errors on mortality indicates an urgent need to develop prevention programs. We have planned a study to assess a program based on our results.

Safety as a criterion for quality: the critical nursing situation index in paediatric critical care, an observational study

INTRODUCTION

The Critical Nursing Situation Index (CNSI) identifies deviations from safe practice as laid down in guidelines, using an observational approach. The CNSI contains a list of predefined items that stem from nursing protocols and guidelines. Deviation from these may lead to adverse events and compromise the safety of the patient.

OBJECTIVE

To prevent and reduce nursing error we applied the "Critical Nursing Situation Index" in the Paediatric Intensive Care Unit (PICU).

DESIGN

Prospective observational study.

SETTING

A 12-bed PICU of an academic university teaching hospital in the Netherlands.

RESULTS

Out of 7147 items at risk we observed 1285 critical situations. The overall incidence of critical situations resulted in 18 per 100 items at risk. No correlation was found with effective time of direct patient care. Workload showed a significant correlation (Pearson's r .278; p=.001).

CONCLUSION

In every day PICU practice an unknown set of nursing situations exist, carrying the potential for the occurrence of an adverse event. The CNSI may be a valuable tool in analysing the incidence of these situations. The CNSI is a practical instrument used to quantify and analyse the frequency of potential nursing errors. It focuses on identifying events that could reduce patient's safety, before harm occurs.

[Safety and quality in intensive care medicine]

The safety and quality care are two attributes of the health care that are closely intertwined. Quality is a feature of the system that delivers health care, thereby improving it, we need a proper reorganization teamwork. Measurements of quality are intended to assess whether the process of health care reaches the desired objectives, while avoiding the processes that predispose to harm the patient. The critically ill patients are vulnerable to medical errors, and may experience side effects preventable, often associated with: medications, mechanical ventilation, and intravascular devices. The evidence currently available suggest that the safety and quality of care can be improved. In this article presents some of the strategies and interventions developed to optimize the processes of care in critically ill patients, and improve the safety culture in the ICU.