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Tlili MA, Aouicha W, Gambashidze N, Ben Cheikh A, Sahli J, Weigl M, Mtiraoui A, Chelbi S, Said Laatiri H, Mallouli M. A retrospective analysis of adverse events reported by Tunisian intensive care units' professionals. BMC Health Serv Res 2024; 24:77. [PMID: 38229159 DOI: 10.1186/s12913-024-10544-9] [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: 06/10/2023] [Accepted: 01/02/2024] [Indexed: 01/18/2024] Open
Abstract
INTRODUCTION Adverse events (AEs) that occur in hospitals remain a challenge worldwide, and especially in intensive care units (ICUs) where they are more likely to occur. Monitoring of AEs can provide insight into the status and advances of patient safety. This study aimed to examine the AEs reported during the 20 months after the implementation of the AE reporting system. METHODS We conducted a retrospective analysis of a voluntary ICU AE reporting system. Incidents were reported by the staff from ten ICUs in the Sahloul University Hospital (Tunisia) between February 2020 and September 2021. RESULTS A total of 265 reports were received, of which 61.9% were deemed preventable. The most frequently reported event was healthcare-associated infection (30.2%, n = 80), followed by pressure ulcers (18.5%, n = 49). At the time of reporting, 25 patients (9.4%) had died as a result of an AE and in 51.3% of cases, the event had resulted in an increased length of stay. Provider-related factors contributed to 64.2% of the events, whilst patient-related factors contributed to 53.6% of the events. As for criticality, 34.3% of the events (n = 91) were unacceptable (c3) and 36.3% of the events (n = 96) were 'acceptable under control' (c2). CONCLUSIONS The reporting system provided rich information on the characteristics of reported AEs that occur in ICUs and their consequences and may be therefore useful for designing effective and evidence-based interventions to reduce the occurrence of AEs.
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Affiliation(s)
- Mohamed Ayoub Tlili
- University of Sousse, Faculty of Medicine of Sousse, Department of Family and Community Medicine, LR12ES03, 4002, Sousse, Tunisia.
| | - Wiem Aouicha
- University of Sousse, Faculty of Medicine of Sousse, Department of Family and Community Medicine, LR12ES03, 4002, Sousse, Tunisia
| | - Nikoloz Gambashidze
- Institute for Patient Safety, University Hospital Bonn, Venusberg-Campus-1, 53127, Bonn, Germany
| | - Asma Ben Cheikh
- Department of Prevention and Care Safety, Sahloul University Hospital, 4054, Sousse, Tunisia
| | - Jihene Sahli
- University of Sousse, Faculty of Medicine of Sousse, Department of Family and Community Medicine, LR12ES03, 4002, Sousse, Tunisia
| | - Matthias Weigl
- Institute for Patient Safety, University Hospital Bonn, Venusberg-Campus-1, 53127, Bonn, Germany
| | - Ali Mtiraoui
- University of Sousse, Faculty of Medicine of Sousse, Department of Family and Community Medicine, LR12ES03, 4002, Sousse, Tunisia
| | - Souad Chelbi
- University of Sousse, Faculty of Medicine of Sousse, Department of Family and Community Medicine, LR12ES03, 4002, Sousse, Tunisia
| | - Houyem Said Laatiri
- Department of Prevention and Care Safety, Sahloul University Hospital, 4054, Sousse, Tunisia
| | - Manel Mallouli
- University of Sousse, Faculty of Medicine of Sousse, Department of Family and Community Medicine, LR12ES03, 4002, Sousse, Tunisia
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Griffeth EM, Gajic O, Schueler N, Todd A, Ramar K. Multifaceted Intervention to Improve Patient Safety Incident Reporting in Intensive Care Units. J Patient Saf 2023; 19:422-428. [PMID: 37466643 PMCID: PMC10526728 DOI: 10.1097/pts.0000000000001151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
OBJECTIVES Patient safety incident reporting in our institution's intensive care units (ICUs) had fallen 30% below national benchmarks during the COVID-19 pandemic. Underreporting diminishes awareness of risks and precludes organizational learning from near misses. We aimed to increase the ICU number of patient safety incident reports by 30% from 27 to 35 reports/1000 patient-days without negatively impacting culture of safety as measured by patient-care staff surveys. METHODS Single-institution prospective interventional study with 9 ICUs receiving a multifaceted intervention developed using quality improvement methodology during February-April 2022. Study intervention involved creation of patient safety peer-leadership role, feedback process, interactive dashboards for patient safety data, and education resources accessible via quick response codes. Primary outcome was patient safety incident reports/1000 patient-days. Intensive care unit patient-care staff culture of safety was assessed with surveys. RESULTS Intensive care unit patient safety incident reporting increased by 48% after intervention (40 versus 27 reports/1000 patient-days [ P = 0.136]). Near misses were the most common incident report. Intensive care unit patient-care staff ratings of patient safety did not change; 80% rated patient safety as good or better after intervention versus 78% at baseline ( P = 0.465). However, significant improvement was observed for subcomponents related to learning culture and support for staff involved in patient safety incidents. Most reports (>80%) were submitted by nurses. CONCLUSIONS This multifaceted quality improvement intervention increased patient safety incident reporting in the ICUs. Increases in ratings of learning culture and support for staff underline the importance of a well-functioning patient safety incident reporting system in an institutional culture of safety.
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Affiliation(s)
- Elaine M. Griffeth
- Department of Surgery; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
| | - Nicole Schueler
- Patient Safety; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
| | - Austin Todd
- Department of Quantitative Health Sciences Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
| | - Kannan Ramar
- Division of Pulmonary and Critical Care Medicine; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
- Patient Safety; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
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Seino Y, Sato N, Idei M, Nomura T. The Reduction in Medical Errors on Implementing an Intensive Care Information System in a Setting Where a Hospital Electronic Medical Record System is Already in Use: Retrospective Analysis. JMIR Perioper Med 2022; 5:e39782. [PMID: 35964333 PMCID: PMC9475405 DOI: 10.2196/39782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/01/2022] [Accepted: 08/14/2022] [Indexed: 11/30/2022] Open
Abstract
Background Although the various advantages of clinical information systems in intensive care units (ICUs), such as intensive care information systems (ICISs), have been reported, their role in preventing medical errors remains unclear. Objective This study aimed to investigate the changes in the incidence and type of errors in the ICU before and after ICIS implementation in a setting where a hospital electronic medical record system is already in use. Methods An ICIS was introduced to the general ICU of a university hospital. After a step-by-step implementation lasting 3 months, the ICIS was used for all patients starting from April 2019. We performed a retrospective analysis of the errors in the ICU during the 6-month period before and after ICIS implementation by using data from an incident reporting system, and the number, incidence rate, type, and patient outcome level of errors were determined. Results From April 2018 to September 2018, 755 patients were admitted to the ICU, and 719 patients were admitted from April 2019 to September 2019. The number of errors was 153 in the 2018 study period and 71 in the 2019 study period. The error incidence rates in 2018 and 2019 were 54.1 (95% CI 45.9-63.4) and 27.3 (95% CI 21.3-34.4) events per 1000 patient-days, respectively (P<.001). During both periods, there were no significant changes in the composition of the types of errors (P=.16), and the most common type of error was medication error. Conclusions ICIS implementation was temporally associated with a 50% reduction in the number and incidence rate of errors in the ICU. Although the most common type of error was medication error in both study periods, ICIS implementation significantly reduced the number and incidence rate of medication errors. Trial Registration University Hospital Medical Information Network Clinical Trials Registry UMIN000041471; https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000047345
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Affiliation(s)
- Yusuke Seino
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Nobuo Sato
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Masafumi Idei
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
- Department of Anesthesiology and Intensive Care Medicine, Yokohama City University, Yokohama, Japan
| | - Takeshi Nomura
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
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Tlili MA, Aouicha W, Sahli J, Mtiraoui A, Ajmi T, Laatiri H, Chelbi S, Ben Rejeb M, Mallouli M. An Intervention to Optimize Attitudes Toward Adverse Events Reporting Among Tunisian Critical Care Nurses. J Patient Saf 2022; 18:e872-e876. [PMID: 35044996 DOI: 10.1097/pts.0000000000000961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed at evaluating the impact of a combined-strategies intervention on ICUs nurses' attitudes toward AE reporting. METHODS We conducted a quasi-experimental study from January to October 2020 which consisted of an intervention to improve attitudes toward incident reporting among nurses working in 10 intensive care units at a university hospital using the Reporting of Clinical Adverse Events Scale. The intervention consisted of a 2-hour educational presentation for nurse unit managers and a 30-minute in-units educational training for intensive care unit nurses, which encompassed technical aspects of reporting, the reporting process, a nonpunitive environment, and the importance of submitting reports. The educational presentation was reinforced with distributing posters and brochures and biweekly patient safety rounds that inquired about events, reinforced education, and provided follow-up to incident reports. RESULTS All dimensions were significantly improved. Score increased from 27.4% to 42.1% ( P < 0.01) for perceived blame, from 35.2% to 52.5% for perceived criteria for identifying events that should be reported ( P < 0.01), from 34.3% to 46% for perceptions of colleagues' expectations ( P = 0.04), from 37.1% to 51.4% for perceived benefits of reporting ( P = 0.01), and from 29.2% to 51.4% for perceived clarity of reporting procedures ( P < 0.01). CONCLUSIONS Interventions using a combination of several strategies such as training, safety round, and messaging can be effective and should be considered by hospitals attempting to increase adverse events reporting. Results reinforce the assumption that a nonpunitive environment and the resulting feeling of safety and reassurance are crucial to foster the submission of reports.
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Affiliation(s)
- Mohamed Ayoub Tlili
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
| | - Wiem Aouicha
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
| | - Jihene Sahli
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
| | - Ali Mtiraoui
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
| | - Thouraya Ajmi
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
| | - Houyem Laatiri
- Department of Prevention and Care Safety, Sahloul University Hospital
| | - Souad Chelbi
- Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia
| | - Mohamed Ben Rejeb
- Department of Prevention and Care Safety, Sahloul University Hospital
| | - Manel Mallouli
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
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Examining the Effectiveness of Strategies Developed to Create an Error Reporting Culture. CLIN NURSE SPEC 2021; 35:253-263. [PMID: 34398547 DOI: 10.1097/nur.0000000000000621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE This study was conducted to develop strategies for creating an error reporting culture and to assess their effectiveness. DESIGN This study was planned to explore how to improve patient safety. The study used a quasi-experimental 1-group pre-post design. It examined the culture of reporting through an analysis of employees' attitudes toward medical errors, along with rates of medical error reporting. METHODS Four different forms were used as data collection tools. The multiple strategies used in this study constituted the research interventions. These strategies were as follows: "Education on Medical Errors and Medical Error Reporting," "Posting Banners and Posters about the Subject," "Using Social Networks and Creating a Facebook Page Titled 'Leaders of Patient Safety'," "Revising the Institution's Incident/Error Reporting System," and "Patient Safety Symposium." Data were evaluated using descriptive statistics and paired sample t test. RESULTS It was determined that medical error reporting rates increased in the first 6 months after the initiative, and this increase continued in the second 6 months. Medical error reports in the institution where this study was conducted increased by 10 times at the end of the first year. CONCLUSIONS Multiple strategies applied for creating an error reporting culture and assessing their effectiveness positively affected health professionals' medical error attitudes and increased error reporting rates.
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Views of Workers on Eliminating the Culture of Fear in Error Reporting. JOURNAL OF BASIC AND CLINICAL HEALTH SCIENCES 2021. [DOI: 10.30621/jbachs.906812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
OBJECTIVE To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill. DATA SOURCES PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015. STUDY SELECTION Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system. The committee collectively developed Population, Intervention, Comparator, Outcome questions and quality of evidence statements pertaining to medication errors and adverse drug events addressing the key components. A total of 34 Population, Intervention, Comparator, Outcome questions, five quality of evidence statements, and one commentary on disclosure was developed. DATA EXTRACTION Subcommittee members were assigned selected Population, Intervention, Comparator, Outcome questions or quality of evidence statements. Subcommittee members completed their Grading of Recommendations Assessment, Development, and Evaluation of the question with his/her quality of evidence assessment and proposed strength of recommendation, then the draft was reviewed by the relevant subcommittee. The subcommittee collectively reviewed the evidence profiles for each question they developed. After the draft was discussed and approved by the entire committee, then the document was circulated among all members for voting on the quality of evidence and strength of recommendation. DATA SYNTHESIS The committee followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation system to determine quality of evidence and strength of recommendations. CONCLUSIONS This guideline evaluates the ICU environment as a risk for medication-related events and the environmental changes that are possible to improve safe medication use. Prevention strategies for medication-related events are reviewed by medication use process node (prescribing, distribution, administration, monitoring). Detailed considerations to an active surveillance system that includes reporting, identification, and evaluation are discussed. Also, highlighted is the need for future research for safe medication practices that is specific to critically ill patients.
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Roque KE, Tonini T, Melo ECP. Adverse events in the intensive care unit: impact on mortality and length of stay in a prospective study. CAD SAUDE PUBLICA 2016; 32:e00081815. [PMID: 27783755 DOI: 10.1590/0102-311x00081815] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 02/22/2016] [Indexed: 02/24/2023] Open
Abstract
This study sought to evaluate the occurrence of adverse events and their impacts on length of stay and mortality in an intensive care unit (ICU). This is a prospective study carried out in a teaching hospital in Rio de Janeiro, Brazil. The cohort included 355 patients over 18 years of age admitted to the ICU between August 1, 2011 and July 31, 2012. The process we used to identify adverse events was adapted from the method proposed by the Institute for Healthcare Improvement. We used a logistical regression to analyze the association between adverse event occurrence and death, adjusted by case severity. We confirmed 324 adverse events in 115 patients admitted over the year we followed. The incidence rate was 9.3 adverse events per 100 patients-day and adverse event occurrence impacted on an increase in length of stay (19 days) and in mortality (OR = 2.047; 95%CI: 1.172-3.570). This study highlights the serious problem of adverse events in intensive care and the risk factors associated with adverse event incidence. Resumo: Este estudo teve como objetivo avaliar a ocorrência de eventos adversos e o impacto deles sobre o tempo de permanência e a mortalidade na unidade de terapia intensiva (UTI). Trata-se de um estudo prospectivo desenvolvido em um hospital de ensino do Rio de Janeiro, Brasil. A coorte foi formada por 355 pacientes maiores de 18 anos, admitidos na UTI, no período de 1º de agosto de 2011 a 31 de julho de 2012. O processo de identificação de eventos adversos baseou-se em uma adaptação do método proposto pelo Institute for Healthcare Improvement. A regressão logística foi utilizada para analisar a associação entre a ocorrência de evento adverso e o óbito, ajustado pela gravidade do paciente. Confirmados 324 eventos adversos em 115 pacientes internados ao longo de um ano de seguimento. A taxa de incidência foi de 9,3 eventos adversos por 100 pacientes-dia, e a ocorrência de evento adverso impactou no aumento do tempo de internação (19 dias) e na mortalidade (OR = 2,047; IC95%: 1,172-3,570). Este estudo destaca o sério problema dos eventos adversos na assistência à saúde prestada na terapia intensiva e os fatores de risco associados à incidência de eventos.
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Affiliation(s)
- Keroulay Estebanez Roque
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil
| | - Teresa Tonini
- Escola de Enfermagem Alfredo Pinto, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brasil
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Heavner JJ, Siner JM. Adverse Event Reporting and Quality Improvement in the Intensive Care Unit. Clin Chest Med 2015; 36:461-7. [PMID: 26304283 DOI: 10.1016/j.ccm.2015.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patients in the intensive care unit are at high risk for experiencing adverse events and errors. The high-acuity health care needs of these vulnerable patients expose them to numerous medications, procedures, and health care providers. The occurrence of adverse events is associated with detriments to patient outcomes including increased mortality. Adverse event reporting is the most commonly used event-detection tool, but it should also be complimented with other tools such as trigger tools, chart review, and direct observation. Although adverse event reporting is essential for continuous improvement processes and is associated with improvements in safety culture, it remains significantly underutilized.
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Affiliation(s)
- Jason J Heavner
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
| | - Jonathan M Siner
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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Lipshutz AKM, Caldwell JE, Robinowitz DL, Gropper MA. An analysis of near misses identified by anesthesia providers in the intensive care unit. BMC Anesthesiol 2015; 15:93. [PMID: 26082147 PMCID: PMC4468961 DOI: 10.1186/s12871-015-0075-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 06/09/2015] [Indexed: 11/23/2022] Open
Abstract
Background Learning from adverse events and near misses may reduce the incidence of preventable errors. Current literature on adverse events and near misses in the ICU focuses on errors reported by nurses and intensivists. ICU near misses identified by anesthesia providers may reveal critical events, causal mechanisms and system weaknesses not identified by other providers, and may differ in character and causality from near misses in other anesthesia locations. Methods We analyzed events reported to our anesthesia near miss reporting system from 2009 to 2011. We compared causative mechanisms of ICU near misses with near misses in other anesthesia locations. Results A total of 1,811 near misses were reported, of which 22 (1.2 %) originated in the ICU. Five causal mechanisms explained over half of ICU near misses. Compared to near misses from other locations, near misses from the ICU were more likely to occur while on call (45 % vs. 19 %, p = 0.001), and were more likely to be associated with airway management (50 % vs. 12 %, p < 0.001). ICU near misses were less likely to be associated with equipment issues (23 % vs. 48 %, p = 0.02). Conclusions A limited number of causal mechanisms explained the majority of ICU near misses, providing targets for quality improvement. Errors associated with airway management in the ICU may be underappreciated. Specialist consultants can identify systems weaknesses not identified by critical care providers, and should be engaged in the ICU patient safety movement.
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Affiliation(s)
- Angela K M Lipshutz
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - James E Caldwell
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - David L Robinowitz
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - Michael A Gropper
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA.
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Mbaye S, Kouabenan DR. How perceptions of experience-based analysis influence explanations of work accidents. JOURNAL OF SAFETY RESEARCH 2013; 47:75-83. [PMID: 24237873 DOI: 10.1016/j.jsr.2013.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 09/13/2013] [Accepted: 09/24/2013] [Indexed: 06/02/2023]
Abstract
INTRODUCTION This article looks into how perceptions of experience-based analysis (EBA) influence causal explanations of accidents given by managers and workers in the chemical industry (n=409) and in the nuclear industry (n=222). METHOD The approach is based on the model of naive explanations of accidents (Kouabenan, 1999, 2006, 2009), which recommends taking into account explanations of accidents spontaneously given by individuals, including laypersons, not only to better understand why accidents occur but also to design and implement the most appropriate prevention measures. The study reported here describes the impact of perceptions about EBA (perceived effectiveness, personal commitment, and the feeling of being involved in EBA practices) on managers' and workers' explanations of accidents likely to occur at the workplace. RESULTS The results indicated that both managers and workers made more internal explanations than external ones when they perceived EBA positively. Moreover, the more the participants felt involved in EBA, were committed to it, and judged it effective, the more they explained accidents in terms of factors internal to the workers. PRACTICAL APPLICATIONS Recommendations are proposed for reducing defensive reactions, increasing personal commitment to EBA, and improving EBA effectiveness.
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Affiliation(s)
- Safiétou Mbaye
- Groupe Facteurs Humains, EDF Recherche et Développement, 1 avenue du Général de Gaulle, 92141 Clamart Cedex, France.
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Wang SC, Li YC, Huang HC. The effect of a workflow-based response system on hospital-wide voluntary incident reporting rates. Int J Qual Health Care 2012; 25:35-42. [DOI: 10.1093/intqhc/mzs078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
Improving the quality and safety of intensive care unit (ICU) care in the United States is a significant challenge for the future. Obtaining improvement in systems of care is difficult given the reactionary mode physicians tend to enter when dealing with moment-to-moment crises. It will be important to implement quality and safety measures that are already supported by evidence. Improvement of device safety will be critical to reducing the large number of device-related complications that occur in US ICUs. Prospective collection of adverse events with rigorous analysis will be important to allow systematic errors to be exposed and corrected.
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Affiliation(s)
- Peter J Rossi
- Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Ilan R, Doan J, Cload B, Squires M, Day A. Removing nonessential central venous catheters: evaluation of a quality improvement intervention. Can J Anaesth 2012; 59:1102-10. [PMID: 23055033 DOI: 10.1007/s12630-012-9794-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 09/17/2012] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Nonessential central venous catheters (CVCs) should be removed promptly to prevent adverse events. Little is known about effective strategies to achieve this goal. The present study evaluates the effectiveness of a quality improvement (QI) initiative to remove nonessential CVCs in the intensive care unit (ICU). METHODS A prospective observational study was performed in two ICUs following a QI intervention that included a daily checklist, education, and reminders. During 28 consecutive days, all CVCs were identified and the presence of ongoing indications for CVC placement was recorded. The proportions of nonessential CVCs and CVC days were compared with pre-intervention proportions and between the participating units. Rates of central line-associated bloodstream infections (CLABSI) were measured separately through Ontario's Critical Care Information System. RESULTS One hundred and ten patients and 159 CVCs were reviewed. Eighty-eight (11%) of 820 catheter days showed no apparent indication for CVC placement, and compared with the pre-intervention period, the proportion of patients with any number of nonessential CVC days decreased from 51% to 26% (relative risk 0.51; 95% confidence interval 0.34 to 0.74; P < 0.001). There was no significant difference in the proportion of nonessential catheter days between participating units. Reported rates of CLABSI decreased substantially during the intervention. DISCUSSION A checklist tool supported by a multifaceted QI intervention effectively ensured prompt removal of nonessential CVCs in two ICUs.
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Affiliation(s)
- Roy Ilan
- Department of Medicine and Critical Care Program, Queen's University, Kingston General Hospital, 94 Stuart Street, Kingston, Ontario, Canada.
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