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Scott J, Sykes K, Waring J, Spencer M, Young-Murphy L, Mason C, Newman C, Brittain K, Dawson P. Systematic review of types of safety incidents and the processes and systems used for safety incident reporting in care homes. J Adv Nurs 2024. [PMID: 38895931 DOI: 10.1111/jan.16264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/15/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024]
Abstract
AIMS To identify the safety incident reporting systems and processes used within care homes to capture staff reports of safety incidents, and the types and characteristics of safety incidents captured by safety incident reporting systems. DESIGN Systematic review following PRISMA reporting guidelines. METHODS Databases were searched January 2023 for studies published after year 2000, written in English, focus on care homes and incident reporting systems. Data were extracted using a bespoke data extraction tool, and quality was assessed. Data were analysed descriptively and using narrative synthesis, with types and characteristics of incidents analysed using the International Classification for Patient Safety. DATA SOURCES Databases were CINAHL, MEDLINE, PsycINFO, EMBASE, HMIC, ASSISA, Nursing and Allied Health Database, MedNar and OpenGrey. RESULTS We identified 8150 papers with 106 studies eligible for inclusion, all conducted in high-income countries. Numerous incident reporting processes and systems were identified. Using modalities, typical incident reporting systems captured all types of incidents via electronic computerized reporting, with reports made by nursing staff and captured information about patient demographics, the incident and post-incident actions, whilst some reporting systems included medication- and falls-specific information. Reports were most often used to summarize data and identify trends. Incidents categories most often were patient behaviour, clinical process/procedure, documentation, medication/intravenous fluids and falls. Various contributing and mitigating factors and actions to reduce risk were identified. The most reported action to reduce risk was to improve safety culture. Individual outcomes were often reported, but social/economic impact of incidents and organizational outcomes were rarely reported. CONCLUSIONS This review has demonstrated a complex picture of incident reporting in care homes with evidence limited to high-income countries, highlighting a significant knowledge gap. The findings emphasize the central role of nursing staff in reporting safety incidents and the lack of standardized reporting systems and processes. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE The findings from this study can inform the development or adaptation of safety incident reporting systems in care home settings, which is of relevance for nurses, care home managers, commissioners and regulators. This can help to improve patient care by identifying common safety issues across various types of care home and inform learning responses, which require further research. IMPACT This study addresses a gap in the literature on the systems and processes used to report safety incidents in care homes across many countries, and provides a comprehensive overview of safety issues identified via incident reporting. REPORTING METHOD PRISMA. PATIENT OR PUBLIC CONTRIBUTION A member of the research team is a patient and public representative, involved from study conception.
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Affiliation(s)
- Jason Scott
- Northumbria University, Newcastle upon Tyne, UK
| | - Kate Sykes
- Northumbria University, Newcastle upon Tyne, UK
| | | | - Michele Spencer
- North Tyneside Community and Health Care Forum, North Shields, UK
| | | | - Celia Mason
- Northumbria University, Newcastle upon Tyne, UK
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Tchijevitch O, Birkeland SF, Bogh SB, Hallas J. Identifying high-risk medications and error types in Danish patient safety database using disproportionality analysis. Pharmacoepidemiol Drug Saf 2024; 33:e5735. [PMID: 38357842 DOI: 10.1002/pds.5735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/25/2023] [Accepted: 11/10/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND Medication error (ME) surveillance in Danish healthcare relies on the mandatory national incident reporting system, the Danish Patient Safety Database (DPSD). Individual case reviews and descriptive statistics with frequency counts are the most often used approaches when analyzing MEs in incident reporting systems, including the DPSD. However, incident reporting systems often generate a large number of reports and may suffer from underreporting; consequently, additional approaches are needed to overcome these challenges. Disproportionality analysis (DPA) is a statistical tool used for signal detection of adverse drug reactions in pharmacovigilance reports, but the evidence for using DPA on ME analysis in safety reporting systems is limited. OBJECTIVES We aimed to test the feasibility of DPA by analysing harmful MEs reported to DPSD 2014-2018. METHODS We utilized proportional reporting ratios (PRR) to identify signals of diproportionality. RESULTS We identified well-known high-risk medicines, including anticoagulants, opioids, insulins, antiepileptic, and antipsychotic drugs, and their association with several ME types and stages in a medication process. CONCLUSION DPA might be suggested as an additional tool for screening MEs and identifying priority areas for further investigation in safety reporting systems.
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Affiliation(s)
- Olga Tchijevitch
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Søren F Birkeland
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Forensic Mental Health Research Unit Middelfart (RFM), Department of Regional Health Research, Faculty of Health Science, University of Southern Denmark, Denmark
- Psychiatric Department Middelfart, Mental Health Services in the Region of Southern Denmark, Denmark
| | - Søren B Bogh
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jesper Hallas
- Department of Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, Odense, Denmark
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Bie Bogh S, Fryd Birkeland S, Maj-Britt Hansen S, Alexandrovna Tchijevitch O, Hallas J, Morsø L. Harnessing patient complaints to systematically monitoring healthcare concerns through disproportionality analysis. Int J Qual Health Care 2023; 35:mzad062. [PMID: 37556110 DOI: 10.1093/intqhc/mzad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/12/2023] [Accepted: 08/07/2023] [Indexed: 08/10/2023] Open
Abstract
Staff observations are the most common source of data for driving improvements in care. However, the patient perspective should also be considered, and healthcare complaints offer concrete details that health organizations might otherwise overlook and that can highlight areas for learning and improvement in the healthcare system. However, because of the diverse nature of patient complaints, systematic analyses can be challenging. This study aimed to identify and prioritize areas for improvement using a data-driven approach to analysing patient complaints. The Danish version of the Healthcare Complaints Analysis Tool was used to categorize the content of complaint letters. All complaints managed by the national complaints authority, compensation claims to the Patient Compensation Association, and locally managed complaints that were filed directly at Odense University Hospital from 2017 to 2021 were included. Proportional reporting ratios (PRRs) were used to measure and display the top five signals of disproportionality and rank them by excess complaints at the hospital level and when divided into department types. The study included 6366 complaints containing 13 156 problems (on average, 2.1 problems mentioned per complaint letter). Surgical departments had the highest number of complaints (3818), followed by medical (1059), service (439), and emergency departments (239). Signal 1 of disproportionality, relating to quality problems during ward procedures, had the highest excess reporting of 1043 complaints at the hospital level and a PRR of 1.61 and was present in all department types. Signal 2, relating to safety problems during the examination and diagnosis stage, had an excess reporting of 699 problems and a PRR of 1.86 and was also present in all department types. Signal 3, relating to institutional problems during admission, had the highest PRR of 3.54 and was found in most department types. Signals 4 and 5, relating to environmental problems during ward procedures and care on the ward, respectively, had PRRs of 1.5 and 1.84 and were present in most department types. The study found that analysing patient complaints can identify potential areas for hospital improvement. The study identified recurring issues in multiple departments, including quality problems during ward procedures, safety problems during the examination, institutional problems during admission, and environmental problems on the ward. The study highlights disproportionality analysis of complaints as a valuable tool to monitor patient concerns systematically.
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Affiliation(s)
- Søren Bie Bogh
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, Odense, Syddanmark 5000, Denmark
- Odense University Hospital, Region of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Denmark
| | - Søren Fryd Birkeland
- Odense University Hospital, Region of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Denmark
- Department of Regional Health Research, Faculty of Health Science, Forensic Mental Health Research Unit Middelfart (RFM), University of Southern Denmark, J.B. Winsløws Vej 19,3, Odense 5000, Denmark
- Psychiatric Department Middelfart, Mental Health Services in the Region of Southern Denmark, Østre Hougvej 70, Middelfart 5500, Denmark
| | - Sebrina Maj-Britt Hansen
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, Odense, Syddanmark 5000, Denmark
| | - Olga Alexandrovna Tchijevitch
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, Odense, Syddanmark 5000, Denmark
| | - Jesper Hallas
- Department of Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, J.B. Winsløws Vej 19,3, Odense, Denmark
| | - Lars Morsø
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, Odense, Syddanmark 5000, Denmark
- Odense University Hospital, Region of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Denmark
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Vinther S, Bøgevig S, Eriksen KR, Hansen NB, Petersen TS, Dalhoff KP, Christensen MB. A poison information centre can provide important assessment and guidance regarding medication errors in nursing homes: A prospective cohort study. Basic Clin Pharmacol Toxicol 2020; 128:542-549. [PMID: 33150720 DOI: 10.1111/bcpt.13529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/08/2020] [Accepted: 10/29/2020] [Indexed: 11/30/2022]
Abstract
The Danish Poison Information Centre (DPIC) regularly receives inquiries about nursing home residents who have been exposed to a medication error. The aim of this prospective cohort study was to describe and discuss the types and consequences of these errors. Data were collected from 1 March 2018 to 31 March 2019. Registered data included characteristics of caller and resident, data related to the suspected medication error, risk assessment and recommendation. Consequences and clinical outcomes were assessed by follow-up telephone calls. Over the study period, the DPIC was consulted about 145 medication errors occurring at Danish nursing homes. The median number of substances administered by error was two (interquartile range 1-5). Hospitalization was recommended in 21% of cases. In one-third of the cases where consultation with the DPIC was done with the resident either on his/her way to or in hospital, hospitalization was found unnecessary, and the resident could have stayed in accustomed surroundings for observation. Follow-up demonstrated that very few medication errors had a severe outcome. This prospective study illustrates that consulting with a poison information centre can qualify risk assessment and potentially reduce hospital admissions following medication errors in a nursing home setting.
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Affiliation(s)
- Siri Vinther
- Department of Clinical Pharmacology, The Danish Poison Information Centre, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Søren Bøgevig
- Department of Clinical Pharmacology, The Danish Poison Information Centre, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Karen Reenberg Eriksen
- Department of Clinical Pharmacology, The Danish Poison Information Centre, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Anaesthesiology and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Nete Brandt Hansen
- Department of Clinical Pharmacology, The Danish Poison Information Centre, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Anaesthesiology and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Tonny Studsgaard Petersen
- Department of Clinical Pharmacology, The Danish Poison Information Centre, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Kim Peder Dalhoff
- Department of Clinical Pharmacology, The Danish Poison Information Centre, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel Bring Christensen
- Department of Clinical Pharmacology, The Danish Poison Information Centre, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
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Carnovale C, Mazhar F, Pozzi M, Gentili M, Clementi E, Radice S. A characterization and disproportionality analysis of medication error related adverse events reported to the FAERS database. Expert Opin Drug Saf 2018; 17:1161-1169. [DOI: 10.1080/14740338.2018.1550069] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Carla Carnovale
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, “Luigi Sacco” University Hospital, Università di Milano, Milan, Italy
| | - Faizan Mazhar
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, “Luigi Sacco” University Hospital, Università di Milano, Milan, Italy
| | - Marco Pozzi
- Scientific Institute IRCCS Eugenio Medea, Lecco, Italy
| | - Marta Gentili
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, “Luigi Sacco” University Hospital, Università di Milano, Milan, Italy
| | - Emilio Clementi
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, “Luigi Sacco” University Hospital, Università di Milano, Milan, Italy
- Scientific Institute IRCCS Eugenio Medea, Lecco, Italy
| | - Sonia Radice
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, “Luigi Sacco” University Hospital, Università di Milano, Milan, Italy
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Rishoej RM, Thybo Christesen H, Juel Kjeldsen L, Almarsdóttir AB, Hallas J. Disproportionality Analysis Used to Identify Patterns in Medication Error Reports Involving Hospitalized Children. Basic Clin Pharmacol Toxicol 2018; 122:531-533. [DOI: 10.1111/bcpt.12947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/06/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Rikke Mie Rishoej
- Clinical Pharmacology and Pharmacy; Department of Public Health; University of Southern Denmark; Odense Denmark
| | - Henrik Thybo Christesen
- Hans Christian Andersen Children's Hospital; Odense University Hospital; Odense Denmark
- Department of Clinical Research; University of Southern Denmark; Odense Denmark
| | | | - Anna Birna Almarsdóttir
- Social and Clinical Pharmacy; Department of Pharmacy; University of Copenhagen; Copenhagen Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy; Department of Public Health; University of Southern Denmark; Odense Denmark
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Desai RJ, Williams CE, Greene SB, Pierson S, Caprio AJ, Hansen RA. Exploratory Evaluation of Medication Classes Most Commonly Involved in Nursing Home Errors. J Am Med Dir Assoc 2013; 14:403-8. [DOI: 10.1016/j.jamda.2012.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 11/14/2012] [Accepted: 11/14/2012] [Indexed: 10/27/2022]
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Desai RJ, Williams CE, Greene SB, Pierson S, Hansen RA. Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm. J Healthc Risk Manag 2013; 33:33-43. [PMID: 23861122 DOI: 10.1002/jhrm.21116] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Appropriate and safe use of medications is an important aspect of quality of care in nursing home patients. Because of their complex medication use process, anticoagulants are prone to medication errors in the frail elderly. Therefore, we designed this study to characterize anticoagulant medication errors and to evaluate their association with patient harm using individual medication error incidents reported by all North Carolina nursing homes to the Medication Error Quality Initiative (MEQI) during fiscal years 2010-2011. Characteristics, causes, and specific outcomes of harmful anticoagulant medication errors were reported as frequencies and proportions and compared between anticoagulant errors and other medication errors using chi-square tests. A multivariate logistic regression model explored the relationship between anticoagulant medication errors and patient harm, controlling for patient- and error-related factors.
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Affiliation(s)
- Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School and Brigham & Women's Hospital, USA
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Tariq A, Georgiou A, Westbrook J. Medication incident reporting in residential aged care facilities: limitations and risks to residents' safety. BMC Geriatr 2012; 12:67. [PMID: 23122411 PMCID: PMC3547703 DOI: 10.1186/1471-2318-12-67] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 09/04/2012] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Medication incident reporting (MIR) is a key safety critical care process in residential aged care facilities (RACFs). Retrospective studies of medication incident reports in aged care have identified the inability of existing MIR processes to generate information that can be used to enhance residents' safety. However, there is little existing research that investigates the limitations of the existing information exchange process that underpins MIR, despite the considerable resources that RACFs' devote to the MIR process. The aim of this study was to undertake an in-depth exploration of the information exchange process involved in MIR and identify factors that inhibit the collection of meaningful information in RACFs. METHODS The study was undertaken in three RACFs (part of a large non-profit organisation) in NSW, Australia. A total of 23 semi-structured interviews and 62 hours of observation sessions were conducted between May to July 2011. The qualitative data was iteratively analysed using a grounded theory approach. RESULTS The findings highlight significant gaps in the design of the MIR artefacts as well as information exchange issues in MIR process execution. Study results emphasized the need to: a) design MIR artefacts that facilitate identification of the root causes of medication incidents, b) integrate the MIR process within existing information systems to overcome key gaps in information exchange execution, and c) support exchange of information that can facilitate a multi-disciplinary approach to medication incident management in RACFs. CONCLUSIONS This study highlights the advantages of viewing MIR process holistically rather than as segregated tasks, as a means to identify gaps in information exchange that need to be addressed in practice to improve safety critical processes.
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Affiliation(s)
- Amina Tariq
- Centre for Health Systems and Safety Research, University of New South Wales, Kensington, Sydney, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, University of New South Wales, Kensington, Sydney, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, University of New South Wales, Kensington, Sydney, Australia
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Tariq A, Georgiou A, Westbrook J. Medication errors in residential aged care facilities: a distributed cognition analysis of the information exchange process. Int J Med Inform 2012; 82:299-312. [PMID: 23026393 DOI: 10.1016/j.ijmedinf.2012.08.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Revised: 08/16/2012] [Accepted: 08/17/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Medication safety is a pressing concern for residential aged care facilities (RACFs). Retrospective studies in RACF settings identify inadequate communication between RACFs, doctors, hospitals and community pharmacies as the major cause of medication errors. Existing literature offers limited insight about the gaps in the existing information exchange process that may lead to medication errors. The aim of this research was to explicate the cognitive distribution that underlies RACF medication ordering and delivery to identify gaps in medication-related information exchange which lead to medication errors in RACFs. METHODS The study was undertaken in three RACFs in Sydney, Australia. Data were generated through ethnographic field work over a period of five months (May-September 2011). Triangulated analysis of data primarily focused on examining the transformation and exchange of information between different media across the process. RESULTS The findings of this study highlight the extensive scope and intense nature of information exchange in RACF medication ordering and delivery. Rather than attributing error to individual care providers, the explication of distributed cognition processes enabled the identification of gaps in three information exchange dimensions which potentially contribute to the occurrence of medication errors namely: (1) design of medication charts which complicates order processing and record keeping (2) lack of coordination mechanisms between participants which results in misalignment of local practices (3) reliance on restricted communication bandwidth channels mainly telephone and fax which complicates the information processing requirements. The study demonstrates how the identification of these gaps enhances understanding of medication errors in RACFs. CONCLUSIONS Application of the theoretical lens of distributed cognition can assist in enhancing our understanding of medication errors in RACFs through identification of gaps in information exchange. Understanding the dynamics of the cognitive process can inform the design of interventions to manage errors and improve residents' safety.
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Affiliation(s)
- Amina Tariq
- Centre for Health Systems and Safety Research, University of New South Wales, Sydney, Australia.
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