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Lin M, Chen B, Xiao L, Zhang L. Publication Trends of Research on Adverse Event and Patient Safety in Nursing Research: A 8-Year Bibliometric Analysis. J Patient Saf 2024; 20:288-298. [PMID: 38314796 DOI: 10.1097/pts.0000000000001207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND Adverse events (AEs), which are associated with medical system instability, poor clinical outcomes, and increasing socioeconomic burden, represent a negative outcome of the healthcare system and profoundly influence patient safety. However, research into AEs remains at a developmental stage according to the existing literature, and no previous studies have systematically reviewed the current state of research in the field of AEs. Therefore, the aims of this study were to interpret the results of published research in the field of AEs through bibliometric analysis and to analyze the trends and patterns in the data, which will be important for subsequent innovations in the field. METHODS A statistical and retrospective visualization bibliometric analysis was performed on July 28, 2022. The research data were extracted from the Web of Science Core Collection, and bibliometric citation analysis was performed using Microsoft Excel, VOSviewer 1.6.18, CiteSpace 6.1.R2, and the Online Analysis Platform of Literature Metrology ( http://bibliometric.com/ ). RESULTS A total of 1035 publications on AEs were included in the analysis. The number of articles increased annually from 2014 to 2022. Among them, the United States (n = 318) made the largest contribution, and Chung-Ang University (n = 20) was the affiliation with the greatest influence in this field. Despite notable international cooperation, a regional concentration of research literature production was observed in economically more developed countries. In terms of authors, Stone ND (n = 9) was the most productive author in the research of AEs. Most of the publications concerning AEs were cited from internationally influential nursing journals, and the Journal of Nursing Management (n = 62) was the most highly published journal. Regarding referencing, the article titled "Medical error-the third leading cause of death in the US" received the greatest attention on this topic (51 citations). CONCLUSIONS After systematically reviewed the current state of research in the field of AEs through bibliometric analysis, and AEs highlighted medication errors, patient safety, according reporting, and quality improvement as essential developments and research hotspots in this field. Furthermore, thematic analysis identified 2 new directions in research, concerned with psychological safety, nurse burnout, and with important research value and broad application prospects in the future.
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Affiliation(s)
| | - Bei Chen
- From the Department of Orthopaedic Surgery, The Affiliated Hospital of Zunyi Medical University
| | - Leyao Xiao
- School of Nursing, ZunyiMedical University
| | - Li Zhang
- The Affiliated Hospital of Zunyi Medical University, Zunyi
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Chen Y, He Y, Wang P, Jiang F, Du Y, Cheung MY, Liu H, Liu Y, Liu T, Tang YL, Zhu J. The association between the adverse event reporting system and burnout and job satisfaction of nurses: Workplace violence as a mediator. Int Nurs Rev 2024. [PMID: 38650586 DOI: 10.1111/inr.12962] [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: 09/08/2023] [Accepted: 02/25/2024] [Indexed: 04/25/2024]
Abstract
AIMS This study aims to explore the association between the implementation of the adverse event reporting system (AERS), burnout, and job satisfaction among psychiatric nurses, with a focus on examining the mediating effect of workplace violence from patients. BACKGROUND Many organizational and personal factors contribute to burnout and job satisfaction experienced by nurses. AERS, serving as a key component of organizational-level quality improvement system, impacts the overall workplace wellness of nurses. METHODS A national sample of 9,744 psychiatric nurses from 41 psychiatric hospitals across 29 provinces in China participated. Burnout was measured by the Maslach Burnout Inventory. Job satisfaction was measured using the Minnesota Satisfaction Questionnaire. Workplace violence was assessed by nurses' experience of verbal and physical violence. Multilevel linear regression analyses were carried out to examine if AERS impacts burnout and job satisfaction and to identify the mediating role of workplace violence. RESULTS AERS was positively associated with job satisfaction, but negatively with burnout and workplace violence. Workplace violence exhibited a positive association with burnout and a negative association with job satisfaction. Mediation analyses indicated that the associations between AERS, burnout, and job satisfaction were mediated by workplace violence. CONCLUSIONS The application of AERS is associated with a reduction in workplace violence in hospitals, which contributes to the diminished burnout and heightened job satisfaction among psychiatric nurses. IMPLICATIONS FOR NURSING PRACTICE AND HEALTH POLICY The study highlights the importance of organizational efforts and mechanisms in promoting nurses' well-being. It is necessary for hospital management to create a safe workplace through the implementation of AERS.
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Affiliation(s)
- Yanhua Chen
- Vanke School of Public Health, Tsinghua University, Beijing, China
- School of Medicine, Tsinghua University, Beijing, China
| | - Yanrong He
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Peicheng Wang
- Vanke School of Public Health, Tsinghua University, Beijing, China
- School of Medicine, Tsinghua University, Beijing, China
| | - Feng Jiang
- School of International and Public Affairs, Shanghai Jiao Tong University, Shanghai, China
- Institute of Healthy Yangtze River Delta, Shanghai Jiao Tong University, Shanghai, China
| | - Yanrong Du
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | | | - Huanzhong Liu
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, Hefei, China
- Anhui Psychiatric Center, Anhui Medical University, Hefei, China
| | - Yuanli Liu
- School of Health Policy and Management, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tingfang Liu
- Institute for Hospital Management, Tsinghua University, Beijing, China
| | - Yi-Lang Tang
- Mental Health Service Line, Atlanta VA Medical Center, Decatur, Georgia, USA
- Addiction Psychiatry Fellowship Program, Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA
| | - Jiming Zhu
- Vanke School of Public Health, Tsinghua University, Beijing, China
- Institute for Healthy China, Tsinghua University, Beijing, China
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Jacobs K, Jarrett P, Ballard E, Fox A. Accuracy of intra-arterial line transducer levelling practice in a general intensive care unit. Aust Crit Care 2024; 37:51-57. [PMID: 37798197 DOI: 10.1016/j.aucc.2023.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/23/2023] [Accepted: 07/24/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND The intra-arterial line is a common device intervention used in the intensive care environment to provide continuous blood pressure measurement. The transducer line is levelled to the patient's phlebostatic axis to provide accurate measurements. AIM The aim of this study was to investigate registered nurses' accuracy at levelling the transducer to the correct anatomical position using visual judgement, compared to one done using a laser level. METHODS Patient transducers were levelled by visual judgement and then by using a laser level. Time and mean arterial pressure (MAP) were recorded with each measurement along with any difference in transducer level between the two methods and subsequent changes in inotrope administration. RESULTS A total of 577 MAP measurements were recorded from 178 patients; 70% of observations had a difference in transducer level, 30% of the time the inotrope rate was increased and 18% of the time the inotrope rate was reduced. The prevalence of clinically significant observations with an absolute difference of 50 mm or more in transducer placement was 25%. The mean difference in MAP measurements when a cut-off of 64 mmHg or more for laser was applied to the data was 0.22 (95% confidence interval: -0.14, 0.58, n = 513, p = 0.23), and for a cut-off of less than 64 for laser, a larger mean difference of 4.36 (95% confidence interval: 3.75, 5.28], n = 64, p < 0.001) was observed. CONCLUSIONS Transducers were unable to be accurately levelled for haemodynamic monitoring using visual means alone. Over the range of patient MAP values examined, 25% of all observations had a clinically significant absolute difference of 50 mm or more in the transducer level position between the two methods. The visual method became increasingly inaccurate and unreliable at low MAP levels requiring medical intervention.
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Affiliation(s)
- Kylie Jacobs
- Redcliffe Hospital, Metro North Health Service, Queensland Health, Brisbane, Queensland, Australia.
| | - Paul Jarrett
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Emma Ballard
- QIMR Berghofer Medical Research Institute, Statistics Unit, Brisbane, Queensland, Australia; University of Queensland, School of Nursing, Midwifery and Social Work, Brisbane, Queensland, Australia
| | - Amanda Fox
- Redcliffe Hospital, Metro North Health Service, Queensland Health, Brisbane, Queensland, Australia; School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia; Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
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Morsø L, Birkeland SF, Walløe S, Grøn PS, Rexbye H, Bogh SBB. Does systematic analysis of patient complaints and compensation cases at hospitals provide useful information to guide quality improvement? Experience from Denmark. BMJ Open Qual 2023; 12:bmjoq-2022-002101. [PMID: 36796865 PMCID: PMC9936271 DOI: 10.1136/bmjoq-2022-002101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 02/08/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Patient complaints and compensation cases are analysed individually and do not allow for organisational learning. Systematic information on complaint patterns needs evidence-based measures. The Healthcare Complaints Analysis Tool (HCAT) can systematically code and analyse complaints and compensation claims, but whether this information is useful for quality improvement is underexplored. We aim to explore if and how HCAT information is perceived useful to inform healthcare quality gaps. METHODS To explore the HCAT's usefulness for quality improvement purposes, we used an iterative process. We accessed all complaints relating to a large university hospital. Trained HCAT raters systematically coded all cases, using the Danish version of HCAT. INTERVENTION The intervention had four phases: (1) coding of cases, (2) education, (3) selection of HCAT analyses for dissemination, (4) 'dashboard' development and delivery of targeted HCAT reports. To study the interventions and phases, we used quantitative and qualitative approaches. The coding patterns were descriptively displayed on department and hospital level. The educational programme was monitored using passing rates, coding reliability checks and rater feedback. Online interviews recorded dissemination feedback. We used a phenomenological approach with thematised quotations from the interviews to analyse the usefulness of the information from cases coded. RESULTS We coded 5217 complaint cases (11 056 complaint points). The average case coding time was 8.5 min (95% CI 8.2 to 8.7). All four raters passed the online test with >80% correct answers. Using rater feedback, we handled 25 cases of doubt. None affected the HCAT structure or categories. Interviews verified the usefulness of analyses after expert group dissemination. Three themes were important: 'overview of complaints', 'learning from complaints' and 'listening to the patients'. Stakeholders perceived the 'dashboard' development as highly relevant. CONCLUSION Through the development process with several adjustments, stakeholders found the systematic approach useful for quality improvement. The hospital management evaluated the approach as promising and decided to test the approach in clinical practice.
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Affiliation(s)
- Lars Morsø
- OPEN Research Unit, Odense Universitetshospital, Odense, Denmark .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Søren Fryd Birkeland
- OPEN Research Unit, Odense Universitetshospital, Odense, Denmark,Department of Clinical Research, University of Southern Denmark, Odense, Denmark,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Sisse Walløe
- OPEN Research Unit, Odense Universitetshospital, Odense, Denmark,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Helle Rexbye
- Clinical Development, Odense University Hospital, Odense, Denmark
| | - Søren Bie Bie Bogh
- OPEN Research Unit, Odense Universitetshospital, Odense, Denmark,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Senica SO, Gasparella P, Soldatenkova K, Smits L, Ābola Z. Cardiac perforation during minimally invasive repair of pectus excavatum: a rare complication. J Surg Case Rep 2022; 2022:rjac538. [PMID: 36452283 PMCID: PMC9701555 DOI: 10.1093/jscr/rjac538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/03/2022] [Indexed: 09/26/2023] Open
Abstract
Life-threatening complications (LTCs) and negative results of surgical treatments often go unreported. Minimally invasive repair of pectus excavatum (MIRPE) represents a procedure with a low incidence of adverse outcomes. However, 15 potentially fatal cases of MIRPE-related heart injury have been published. We report a case of cardiac perforation (CP) during MIRPE. A 12-year-old female was admitted for elective repair of a severe asymmetric pectus excavatum. Preoperative computed tomography showed a Haller index of 4.9. MIRPE was performed under bilateral video-assisted thoracoscopy. After the placement of the pectus bar, cardiac arrhythmias, hypotension and bilateral hemothorax occurred. Emergency thoracotomy without pectus bar removal showed CP. The wound sites were repaired and the pectus bar was eventually successfully implanted. The patient was discharged on postoperative day 11. After 10 months, she remains asymptomatic. Reporting rare complications is essential for accurate calculations of the true prevalence of LTCs, maintaining high alertness in pediatric surgeons.
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Affiliation(s)
| | - Paolo Gasparella
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, Graz 8036, Austria
| | - Ksenija Soldatenkova
- Department of Pediatric Surgery, Children's Clinical University Hospital, Riga 1004, Latvia
| | - Lauris Smits
- Department of Heart Surgery, Children's Clinical University Hospital, Riga 1004, Latvia
| | - Zane Ābola
- Department of Pediatric Surgery, Children's Clinical University Hospital, Riga 1004, Latvia
- Department of Pediatric Surgery, Riga Stradins University, Riga 1007, Latvia
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Zhao X, Shi C, Zhao L. Nurses' Intentions, Awareness and Barriers in Reporting Adverse Events: A Cross-Sectional Survey in Tertiary Hospitals in China. Risk Manag Healthc Policy 2022; 15:1987-1997. [PMID: 36329826 PMCID: PMC9624208 DOI: 10.2147/rmhp.s386458] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/20/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose This study explored nurses’ intentions, awareness and barriers in reporting adverse events in tertiary hospitals in China. We also analyzed its associated factors to increase the chance to evaluate preventable errors, enhance care delivery, and improve patient outcomes. Patients and Methods A cluster sampling method was used to recruit 1382 nurses from two tertiary hospitals in Chenzhou and Handan City. An online structured questionnaire was used to collect data, which included general information questionnaire (eight questions), reporting awareness questionnaire (eight items with scores ranging from 0 to 8), reporting intention questionnaire (15 items with scores ranging from 0 to 15), and reporting barriers questionnaire (22 items with scores ranging from 22 to 110). Results We received 1565 completed questionnaires from 1734 potential participants (a response rate of 90.25%), with 1382 valid questionnaires, yielding an effective rate of 88.31%. The scores of reporting awareness, reporting intention, and reporting barriers in adverse events for nurses in tertiary hospitals were 8 (1), 15 (0), and 83.04 (±12.21) out of 110, respectively. Reporting awareness and barriers to adverse events were positively correlated with nurses’ intention to report adverse events (rs = 0.237 and 0.361, respectively; P < 0.001). Regression analyses showed that reporting awareness and barriers in adverse events and professional title influenced nurses’ intention to report adverse events (P < 0.05) in tertiary hospitals. Conclusion Nurses in tertiary hospitals have a strong intention to report adverse events. The higher the reporting awareness of adverse events or the fewer perceived reporting barriers, the stronger the nurses’ intention to report. Hospital managers should deliver patient safety education and training for nurses, to increase their reporting awareness and decrease their perceived reporting barriers, improve their intention to report adverse events.
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Affiliation(s)
- Xiaoying Zhao
- Handan First Hospital, Handan, 056000, People’s Republic of China
| | - Chunhong Shi
- School of Nursing, Xiangnan University, Chenzhou, People’s Republic of China,Affiliated Hospital of Xiangnan University, Chenzhou, 423000, People’s Republic of China,Correspondence: Chunhong Shi, School of Nursing, Xiangnan University, 889 Chenzhou Avenue, Suxian District, Chenzhou, 423000, People’s Republic of China, Tel +86 15907354840, Fax +86-735-2325007, Email
| | - Lihua Zhao
- Handan First Hospital, Handan, 056000, People’s Republic of China
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Chen Y, Broman AT, Priest G, Landrigan CP, Rahman SA, Lockley SW. The Effect of Blue-Enriched Lighting on Medical Error Rate in a University Hospital ICU. Jt Comm J Qual Patient Saf 2020; 47:165-175. [PMID: 33341396 DOI: 10.1016/j.jcjq.2020.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 11/05/2020] [Accepted: 11/11/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Fatigue-related errors that occur during patient care impose a tremendous socioeconomic impact on the health care system. Blue-enriched light has been shown to promote alertness and attention. The present study tested whether blue-enriched light can help to reduce medical errors in a university hospital adult ICU. METHODS In this interventional study, a blue-enriched white light emitting diode was used to enhance traditional fluorescent light at the nurse workstation and common areas in the ICU. Medical errors were identified retrospectively using an established two-step surveillance process. Suspected incidents of potential errors detected on nurse chart review were subsequently reviewed by two physicians blinded to lighting conditions, who made final classifications. Error rates were compared between the preintervention fluorescent and postintervention blue-enriched lighting conditions using Poisson regression. RESULTS The study included a total of 1,073 ICU admissions, 522 under traditional and 551 under interventional lighting (age range 17-97 years, mean age ± standard deviation 58.5 ± 15.8). No difference was found in overall medical error rate (harmful and non-harmful) pre- vs. postintervention, 45.5 vs. 42.7 per 1,000 patient-days (rate ratio: 0.94, 95% confidence interval = 0.71-1.23, p = 0.64). CONCLUSION Interventional lighting did not have an effect on overall medical error rate. The study was likely underpowered to detect the 25% error reduction predicted. Future studies are required that are powered to assess more modest effects for lighting to reduce the risk of fatigue-related medical errors and errors of differing severity.
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Gqaleni TM, Bhengu BR. Analysis of Patient Safety Incident reporting system as an indicator of quality nursing in critical care units in KwaZulu-Natal, South Africa. Health SA 2020; 25:1263. [PMID: 32284886 PMCID: PMC7136690 DOI: 10.4102/hsag.v25i0.1263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 12/16/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Patient Safety Incidents occur frequently in critical care units, contribute to patient harm, compromise quality of patient care and increase healthcare costs. It is essential that Patient Safety Incidents in critical care units are continually measured to plan for quality improvement interventions. AIM To analyse Patient Safety Incident reporting system, including the evidence of types, frequencies, and patient outcomes of reported incidents in critical care units. SETTING The study was conducted in the critical care units of ten hospitals of eThekwini district, in KwaZulu-Natal, South Africa. METHODS A quantitative approach using a descriptive cross sectional survey was adopted to collect data from the registered nurses working in critical care units of randomly selected hospitals. Self-administered questionnaires were distributed to 270 registered nurses of which 224 (83%) returned completed questionnaires. A descriptive statistical analysis was initially conducted, then the Pearson Chi-square test was performed between the participating hospitals. FINDINGS One thousand and seventeen (n = 1017) incidents in ten hospitals were self-reported. Of these incidents, 18% (n = 70) were insignificant, 35% (n = 90) minor, 25% (n = 75) moderate, 12% (n = 32) major and 10% (n = 26) catastrophic. Patient Safety Incidents were classified into six categories: (a) Hospital-related incidents (42% [n = 416]); (b) Patient care-related incidents (30% [n = 310]); (c) (Death 12% [n = 124]); (d) Medication-related incidents, (7% [n = 75]); (e) Blood product-related incidents (5% [n = 51]) and (f) Procedure-related incidents (4% [n = 41]). CONCLUSION This study's findings indicating 1017 Patient Safety Incidents of predominantly serious nature, (47% considering moderate, major and catastrophic) are a cause for concern.
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Affiliation(s)
- Thusile M Gqaleni
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Busisiwe R Bhengu
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Williams GD, Muffly MK, Mendoza JM, Wixson N, Leong K, Claure RE. Reporting of Perioperative Adverse Events by Pediatric Anesthesiologists at a Tertiary Children's Hospital: Targeted Interventions to Increase the Rate of Reporting. Anesth Analg 2017; 125:1515-1523. [PMID: 28678071 DOI: 10.1213/ane.0000000000002208] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Incident reporting systems (IRSs) are important patient safety tools for identifying risks and opportunities for improvement. A major IRS limitation is underreporting of incidents. Perioperative anesthesia IRSs have been established at multiple pediatric institutions and a national pediatric anesthesia IRS for perioperative serious adverse events (SAEs) is maintained by Wake Up Safe (WUS), a patient safety organization dedicated to pediatric anesthesia quality improvement. A confidential, electronic, perioperative IRS was instituted at our tertiary children's hospital, which is a WUS member. The primary study aim was to increase the rate of incident reporting by anesthesiologists at our institution through a series of interventions. The secondary aim was to characterize our reporting behavior relative to national practice by referencing SAE data from WUS. METHODS Perioperative adverse events reported over a 71-month period (November 2010 to September 2016) were categorized and the monthly reporting rates determined. Effects of 6 interventions targeted to increase the reporting rate were analyzed using control charts. Intervention 5 involved interviewing pediatric anesthesiologists to ascertain incident reporting barriers and motivators. A key driver diagram was developed and used to guide an improvement initiative. Incidents that fulfilled WUS criteria for SAEs were identified and categorized. SAE reporting rates over a 27-month period for 12 WUS member institutions were determined. RESULTS 2689 perioperative adverse events were noted in 1980 of 72,384 anesthetics. Mean monthly adverse event case rate was 273 (95% confidence interval, 250-297) per 10,000 anesthetics. A subgroup involving 54,469 cases had 529 SAEs in 440 anesthetics; a mean monthly SAE case rate of 80 (95% confidence interval, 69-91) per 10,000 anesthetics. Cardiac, respiratory, and airway events predominated. Relative to WUS peer members, our institution is a high-reporting outlier. The rate of incident reporting per 10,000 anesthetics was sustainably increased from 149 ± 35 to 387 ± 73 (mean ± SD) after implementing mandatory IRS data entry and Intervention 5 quality improvement initiative. Barriers to reporting included concern for punitive repercussions, feelings of incompetence, poor education about what constitutes an event, lack of feedback, and the perception that reporting had no value. These were addressed by IRS education, cultivation of a culture of safety where reporting is encouraged, reporter feedback, and better inclusion of anesthesiologists in patient safety work. CONCLUSIONS Electronic mandatory IRS data entry and an initiative to understand and address reporting barriers and motivators were associated with sustained increases in the adverse event reporting rate. These strategies to minimize underreporting enhance IRS value for learning and may be generalizable.
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Affiliation(s)
- Glyn D Williams
- From the *Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California; and †Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital Stanford, Palo Alto, California
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Auditing an Online Self-reported Interventional Radiology Adverse Event Database for Compliance and Accuracy. J Am Coll Radiol 2017; 14:494-498. [DOI: 10.1016/j.jacr.2016.09.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/20/2016] [Accepted: 09/22/2016] [Indexed: 02/03/2023]
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Nurse workload and inexperienced medical staff members are associated with seasonal peaks in severe adverse events in the adult medical intensive care unit: A seven-year prospective study. Int J Nurs Stud 2016; 62:60-70. [DOI: 10.1016/j.ijnurstu.2016.07.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 07/13/2016] [Accepted: 07/13/2016] [Indexed: 11/22/2022]
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