Are we missing the near misses in the OR?-underreporting of safety incidents in pediatric surgery

Health professionals' perceptions of the development needs of incident reporting software: A qualitative systematic review

AIM

To systemically identify and synthesize information on health professionals' and students' perceptions regarding the development needs of incident reporting software.

DESIGN

A systematic review of qualitative studies.

DATA SOURCES

A database search was conducted using Medline, CINAHL, Scopus, Web of Science and Medic without time or language limits in February 2023.

REVIEW METHODS

A total of 4359 studies were identified. Qualitative studies concerning the perceptions of health professionals and students regarding the development needs of incident reporting software were included, based on screening and critical appraisal by two independent reviewers. A thematic synthesis was conducted.

RESULTS

From 10 included studies, five analytical themes were analysed. Health professionals and students desired the following improvements or changes to incident reporting software: (1) the design of reporting software, (2) the anonymity of reporting, (3) the accessibility of reporting software, (4) the classification of fields and answer options and (5) feedback and tracking of reports. Wanted features included suitable reporting forms for various specialized fields that could be integrated into existing hospital information systems. Rapid, user-friendly reporting software using multiple reporting platforms and with flexible fields and predefined answer options was preferred. While anonymous reporting was favoured, the idea of reporting serious incidents with both patient and reporter names was also suggested.

CONCLUSION

Health professionals and students provided concrete insights into the development needs for reporting software. Considering the underreporting of healthcare cases, the perspectives of healthcare professionals must be considered while developing user-friendly reporting tools. Reporting software that facilitates the reporting process could reduce underreporting.

REPORTING METHOD

The ENTREQ reporting guideline was used to support the reporting of this systematic review.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution.

PROTOCOL REGISTRATION

The protocol is registered in the International Prospective Register of Systematic Reviews with register number CRD42023393804.

Patient safety incident reporting software: A cross-sectional survey of nurses and other users' perspectives

AIM

To investigate nurses' and other users' perceptions and knowledge regarding patient safety incident reporting software and incident reporting.

DESIGN

A cross-sectional online survey.

METHODS

The survey, 'The Users' Perceptions of Patient Safety Incident Reporting Software', was developed and used for data collection January-February 2024. We aimed to invite all potential users of reporting software in two wellbeing service counties in Finland to participate in the survey. Potential users (reporters/handlers/others) were nurses, other health professionals and employees. Satisfaction was classified as dissatisfied, neutral, or satisfied. The association between overall satisfaction and demographics was tested using cross-tabulation and a Chi-square test.

RESULTS

The completion rate was 54% (n = 755). Some respondents (n = 25) had never used reporting software, most often due to no perceived need to report, although their average work experience was 15 years. Of other respondents (n = 730), mostly nurses (n = 432), under half agreed that the software was quick to use and easy to navigate. The biggest dissatisfaction was with the report processing features. Over a fifth did not trust that reporting was anonymous. Training and frequency of using the software were associated with overall satisfaction.

CONCLUSION

Reporting software has not reached its full potential and needs development. Report handling is essential for shared learning; however, the processing features require the most improvements. Users' perceptions must be considered when developing reporting software and processes.

IMPACT

Incident reporting software usability is central to reporting, but nurses' and other users' perceptions of software are poorly understood. This survey shows weaknesses in reporting software and emphasizes the importance of training. The survey can contribute to paying more attention to organizing training, getting users to participate in software development, and deepening knowledge of issues in reporting software. Making the needed improvements could improve patient safety.

REPORTING METHOD

The STROBE Checklist (Supplement-S1).

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Analysis of patient safety event report categories at one large academic hospital

Given the persistent safety incidents in operating rooms (ORs) nationwide (approx. 4,000 preventable harmful surgical errors per year), there is a need to better analyze and understand reported patient safety events. This study describes the results of applying the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) supported by the Teamwork Evaluation of Non-Technical Skills (TENTS) instrument to analyze patient safety event reports at one large academic medical center. Results suggest that suboptimal behaviors stemming from poor communication, lack of situation monitoring, and inappropriate task prioritization and execution were implicated in most reported events. Our proposed methodology offers an effective way of programmatically sorting and prioritizing patient safety improvement efforts.

The predictive power of electronic reporting system utilization on voluntary reporting of near-miss incidents among nurses: A PLS-SEM approach

Background

Patient safety is crucial in healthcare, with incident reporting vital for identifying and addressing errors. Near-miss incidents, common yet underreported, serve as red flags requiring attention. Nurses' underreporting, influenced by views and system usability, inhibits learning opportunities. The Electronic Reporting System (ERS) is a modern solution, but its effectiveness remains unclear.

Objective

This study aimed to investigate the role of the ERS in enhancing the voluntary reporting of near-miss (VRNM) incidents among nurses.

Methods

A cross-sectional study was conducted in the Al Dhafra region of the United Arab Emirates, involving 247 nurses from six hospitals. Data were collected using a questionnaire between April 2022 and August 2022. Structural Equation Modelling Partial Least Square (SEM-PLS) was employed for data analysis.

Results

The average variance extracted for the ERS construct was 0.754, indicating that the common factor accounted for 75.4% of the variation in the ERS scores. The mean ERS score was 4.093, with a standard deviation of 0.680. For VRNM, the mean was 4.104, and the standard deviation was 0.688. There was a positive correlation between ERS utilization and nurses' willingness to report near-miss incidents. Additionally, our research findings suggest a 66.7% relevance when applied to various hospital settings within the scope of this study.

Conclusion

The findings suggest that adopting a user-friendly reporting system and adequate training on the system's features can increase reporting and improve patient safety. Additionally, these systems should be designed to be operated by nursing staff with minimal obstacles.

Learning from Latent Safety Threats Identified During Simulation to Improve Patient Safety

BACKGROUND

Latent safety threats (LSTs-characteristics of design, processes, or physical environment in health care compromising patient safety) are commonly revealed during simulation-based training. Methods of collecting, analyzing, and classifying LSTs are underdeveloped and not standardized. Building on a large simulation program in one organization, the authors aimed to collect LSTs systematically and develop a taxonomy to classify them.

METHODS

The authors modified the Press Ganey Healthcare Performance Improvement Failure Modes Taxonomy (HPI-FMT), a standardized framework for safety event classification in health care, and used three categories: System, Individual, and Medications. The subcategories were revised to reflect simulation LST content and promote consistent data entry into a spreadsheet. Data visualization software was used to analyze LST data and generate dashboards, graphs, and executive summaries to share across the system that depicted data for individual hospitals and outpatient areas and allowed grouping, comparisons, and trending.

RESULTS

Over a year, the researchers identified 1,318 LSTs in 232 simulations across the organization-a rate of 5.7 LSTs/simulation. The top three LST subcategories were Environment/supplies/equipment (System category); Process/structure (System category); and Knowledge or unformed skill/habit (Individual category). Other important LSTs were Missing/malfunctioning supplies/equipment; Unclear or ineffective process or no process; and Unfamiliarity with supplies/equipment. When a repetitive pattern of LSTs was observed (for example, improper dantrolene use during malignant hyperthermia simulations), targeted process improvement or training was implemented.

CONCLUSION

The authors developed, implemented, and refined a systematic method of collecting, analyzing, displaying LSTs, and recommending targeted process improvements or training when LST trends were noted.

The relationships between patient safety culture and sentinel events among hospitals in Saudi Arabia: a national descriptive study

BACKGROUND

Sentinel events (SEs) can result in severe and unwanted outcomes. To minimize the fear of sentinel events reporting and the occurrence of sentinel events, patient safety culture improvements within healthcare organizations is needed. To our knowledge, limited studies explored the relationships between patient safety culture and sentinel events on a local level and no research has been conducted at the national level in Saudi Arabia.

OBJECTIVES

This study aimed to explore the relationships between the patient safety culture and the reported-SEs on a national level during the year 2020 in Saudi hospitals.

METHODS

This was a descriptive study. We utilized two data sources (the reported-SEs and the patient safety culture survey) that were linked using hospitals information. To explore the relationships between patient safety culture and reported-SEs rates, we performed descriptive statistics, a test of independence, post-hoc analysis, correlation analysis, and multivariate regression and stepwise analyses.

RESULTS

The highest positive domain scores in patient safety culture domains in the Saudi hospitals (n = 366) were "Teamwork Within Units" (80.65%) and "Organizational learning-continuous improvement" (80.33%), and the lowest were "Staffing" (32.10%) and "Nonpunitive Response to Error" (26.19%). The highest numbers of reported-SEs in 103 hospitals were related to the contributory factors of "Communication and Information" (63.20%) and "Staff Competency and Performance" (61.04%). The correlation analysis performed on 89 Saudi hospitals showed that higher positive patient safety culture scores were significantly associated with lower rates of reported-SEs in 3 out of the 12 domains, which are "Teamwork Within Units", "Communication Openness", and "Handoffs and Transitions". Multivariate analyses showed that "Handoffs and Transitions", "Nonpunitive Response to Error", and "Teamwork Within Units" domains were significant predictors of the number of SEs. The "Staff Competency and Performance" and "Environmental Factors" were the most contributory factors of SEs in the number of significant correlations with the patient safety culture domains.

CONCLUSION

This study identified patient safety culture areas of improvement where hospitals in Saudi Arabia need actions. Our study confirms that a more positive patient safety culture is associated with lower occurrence of sentinel events. To minimize the fear of sentinel events reporting and to improve overall patient safety a culture change is needed by promoting a blame-free culture and improving teamwork, handoffs, and communication openness.

Automated Capture of Intraoperative Adverse Events Using Artificial Intelligence: A Systematic Review and Meta-Analysis

Intraoperative adverse events (iAEs) impact the outcomes of surgery, and yet are not routinely collected, graded, and reported. Advancements in artificial intelligence (AI) have the potential to power real-time, automatic detection of these events and disrupt the landscape of surgical safety through the prediction and mitigation of iAEs. We sought to understand the current implementation of AI in this space. A literature review was performed to PRISMA-DTA standards. Included articles were from all surgical specialties and reported the automatic identification of iAEs in real-time. Details on surgical specialty, adverse events, technology used for detecting iAEs, AI algorithm/validation, and reference standards/conventional parameters were extracted. A meta-analysis of algorithms with available data was conducted using a hierarchical summary receiver operating characteristic curve (ROC). The QUADAS-2 tool was used to assess the article risk of bias and clinical applicability. A total of 2982 studies were identified by searching PubMed, Scopus, Web of Science, and IEEE Xplore, with 13 articles included for data extraction. The AI algorithms detected bleeding (n = 7), vessel injury (n = 1), perfusion deficiencies (n = 1), thermal damage (n = 1), and EMG abnormalities (n = 1), among other iAEs. Nine of the thirteen articles described at least one validation method for the detection system; five explained using cross-validation and seven divided the dataset into training and validation cohorts. Meta-analysis showed the algorithms were both sensitive and specific across included iAEs (detection OR 14.74, CI 4.7-46.2). There was heterogeneity in reported outcome statistics and article bias risk. There is a need for standardization of iAE definitions, detection, and reporting to enhance surgical care for all patients. The heterogeneous applications of AI in the literature highlights the pluripotent nature of this technology. Applications of these algorithms across a breadth of urologic procedures should be investigated to assess the generalizability of these data.

The Effect of a System-Level Tiered Huddle System on Reporting Patient Safety Events: An Interrupted Time Series Analysis

BACKGROUND

The objective of this research was to evaluate the effect of implementing a system-level tiered huddle system (THS) on the reporting of patient safety events into the official event reporting system.

METHODS

A quasi-experimental study using interrupted time series was conducted to assess the impact and changes to trends in the reporting of patient safety events pre- (February-July 2020; six months) and post- (September 2020-February 2021; six months) THS implementation within one health care system (238 clinics and 4 hospitals). The severity of harm was analyzed in July 2021 using a modified Agency for Healthcare Research and Quality (AHRQ) harm score classification. The primary outcome measure was the number of patient safety events reported per month. Secondary outcomes included the number of patient safety events reported per month by each AHRQ harm score classification.

RESULTS

The system-level THS implementation led to a significant and immediate increase in the total number of patient safety events reported per month (777.73, 95% confidence interval [CI] 310.78-1,244.68, p = 0.004). Similar significant increases were seen for reported numbers of unsafe conditions, near misses, no-harm events that reached patients, and temporary harm (p < 0.05 for each). Reporting of events with permanent harm and deaths also increased but was not statistically significant, likely due to the small number of reported events involving actual harm.

CONCLUSION

These findings suggest that system-level THS implementation may increase reporting of patient safety events in the official event reporting system.

Safety culture and adverse event reporting in Ghanaian healthcare facilities: Implications for patient safety

INTRODUCTION

Recognizing the values and norms significant to healthcare organizations (Safety Culture) are the prerequisites for safety and quality care. Understanding the safety culture is essential for improving undesirable workforce attitudes and behaviours such as lack of adverse event reporting. The study assessed the frequency of adverse event reporting, the patient safety culture determinants of the adverse event reporting, and the implications for Ghanaian healthcare facilities.

METHODS

The study employed a multi-centre cross-sectional survey on 1651 health professionals in 13 healthcare facilities in Ghana using the Survey on Patient Safety (SOPS) Culture, Hospital Survey questionnaire. Analyses included descriptive, Spearman Rho correlation, one-way ANOVA, and a Binary logistic regression model.

RESULTS

The majority of health professionals had at least reported adverse events in the past 12 months across all 13 healthcare facilities. Teamwork (Mean: 4.18, SD: 0.566) and response to errors (Mean: 3.40, SD: 0.742) were the satisfactory patient safety culture. The patient safety culture dimensions were statistically significant (χ2 (9, N = 1642) = 69.28, p < .001) in distinguishing between participants who frequently reported adverse events and otherwise.

CONCLUSION

Promoting an effective patient safety culture is the ultimate way to overcome the challenges of adverse event reporting, and this can effectively be dealt with by developing policies to regulate the incidence and reporting of adverse events. The quality of healthcare and patient safety can also be enhanced when healthcare managers dedicate adequate support and resources to ensure teamwork, effective communication, and blame-free culture.

Reporting Incidents in the Psychiatric Intensive Care Unit: A Retrospective Study in an Italian University Hospital

ABSTRACT

To evaluate the characteristics of the reported workplace violence in a psychiatric intensive care unit (PICU) by analyzing an electronic hospital incident reporting system (IRS). One hundred thirty reports were retrieved from January 2017 to June 2020, referring to assaults committed by patients (71% males) with an average age of 29.8 years (SD, 14.9). The most frequent psychiatric diagnosis was a neurodevelopmental disorder (33%). Physical aggression (84%) was more frequent than the other types of aggression. Nurses and unlicensed assistive personnel were the most frequent victims (65%). Aggressions were more frequent on Friday (18%) and between 4 p.m. and 8 p.m. (35%). A total of 64.9% of the incidents happened in the first 5 days of hospitalization. A significant association between physical aggression and diagnosis of neurodevelopmental disorder emerged. IRS could be helpful to identify high-risk patient groups and develop clinical strategies to reduce adverse events in clinical practice.

A pilot study to determine the incidence, type, and severity of non-routine events in neonates undergoing gastrostomy tube placement

BACKGROUND

Non-routine events (NRE) are defined as any suboptimal occurrences in a process being measured in the opinion of the reporter and comes from the field of human factors engineering. These typically occur well up-stream of an adverse event and NRE measurement has not been applied to the complex context of neonatal surgery. We sought to apply this novel safety event measurement methodology to neonates in the NICU undergoing gastrostomy tube placement.

METHODS

A prospective pilot study was conducted between November 2016 and August 2020 in the Level IV NICU and the pediatric operating rooms of an urban academic children's hospital to determine the incidence, severity, impact, and contributory factors of clinician-reported non-routine events (NREs, i.e., deviations from optimal care) and 30-day NSQIP occurrences in neonates receiving a G-tube.

RESULTS

Clinicians reported at least one NRE in 32 of 36 (89%) G-tube cases, averaging 3.0 (Standard deviation: 2.5) NRE reports per case. NSQIP-P review identified 7 cases (19%) with NSQIP-P occurrences and each of these cases had multiple reported NREs. One case in which NREs were not reported was without NSQIP-P occurrences. The odds ratio of having a NSQIP-P occurrence with the presence of an NRE was 0.695 (95% CI 0.06-17.04).

CONCLUSION

Despite being considered a "simple" operation, >80% of neonatal G-tube placement operations had at least one reported NRE by an operative team member. In this pilot study, NRE occurrence was not significantly associated with the subsequent reporting of an NSQIP-P occurrence. Understanding contributory factors of NREs that occur in neonatal surgery may promote surgical safety efforts and should be evaluated in larger and more diverse populations.

LEVEL OF EVIDENCE

IV.

Surgical data science - from concepts toward clinical translation

Recent developments in data science in general and machine learning in particular have transformed the way experts envision the future of surgery. Surgical Data Science (SDS) is a new research field that aims to improve the quality of interventional healthcare through the capture, organization, analysis and modeling of data. While an increasing number of data-driven approaches and clinical applications have been studied in the fields of radiological and clinical data science, translational success stories are still lacking in surgery. In this publication, we shed light on the underlying reasons and provide a roadmap for future advances in the field. Based on an international workshop involving leading researchers in the field of SDS, we review current practice, key achievements and initiatives as well as available standards and tools for a number of topics relevant to the field, namely (1) infrastructure for data acquisition, storage and access in the presence of regulatory constraints, (2) data annotation and sharing and (3) data analytics. We further complement this technical perspective with (4) a review of currently available SDS products and the translational progress from academia and (5) a roadmap for faster clinical translation and exploitation of the full potential of SDS, based on an international multi-round Delphi process.

Classification strategies for non-routine events occurring in high-risk patient care settings: A scoping review

INTRODUCTION

Non-routine events (NREs) are atypical or unusual occurrences in a pre-defined process. Although some NREs in high-risk clinical settings have no adverse effects on patient care, others can potentially cause serious patient harm. A unified strategy for identifying and describing NREs in these domains will facilitate the comparison of results between studies.

METHODS

We conducted a literature search in PubMed, CINAHL, and EMBASE to identify studies related to NREs in high-risk domains and evaluated the methods used for event observation and description. We applied The Joint Commission on Accreditation of Healthcare Organization (JCAHO) taxonomy (cause, impact, domain, type, prevention, and mitigation) to the descriptions of NREs from the literature.

RESULTS

We selected 25 articles that met inclusion criteria for review. Real-time documentation of NREs was more common than a retrospective video review. Thirteen studies used domain experts as observers and seven studies validated observations with interrater reliability. Using the JCAHO taxonomy, "cause" was the most frequently applied classification method, followed by "impact," "type," "domain," and "prevention and mitigation."

CONCLUSIONS

NREs are frequent in high-risk medical settings. Strengths identified in several studies included the use of multiple observers with domain expertise and validation of the event ascertainment approach using interrater reliability. By applying the JCAHO taxonomy to the current literature, we provide an example of a structured approach that can be used for future analyses of NREs.

Barriers to Incident Reporting among Nurses: A Qualitative Systematic Review

Incident reporting in health care prevents error recurrence, ultimately improving patient safety. A qualitative systematic review was conducted, aiming to identify barriers to incident reporting among nurses. Joanna Briggs Institute methodology for qualitative systematic reviews was followed, with data extracted using JBI QARI tools, and selected studies assessed for methodological quality using Critical Appraisal Skills Program (CASP). A meta-aggregation synthesis was carried out, and confidence in findings was assessed using GRADE ConQual. A total of 921 records were identified, but only five studies were included. The overall methodological quality of these studies was good and GRADE ConQual assessment score was "moderate." Fear of negative consequences was the most cited barrier to nursing incident reporting. Barriers also included inadequate incident reporting systems and lack of interdisciplinary and interdepartmental cooperation. Lack of nurses' necessary training made it more difficult to understand the importance of incident reporting and the definition of error. Lack of effective feedback and motivation and a pervasive blame culture were also identified.

Medication-related incidents at 19 hospitals: A retrospective register study using incident reports

Aim

To examine (a) when medication incidents occur and which type is most frequent; (b) consequences for patients; (c) incident reporters' perceptions of causes; and (d) professional categories reporting the incidents.

Design

A descriptive multicentre register study.

Methods

This study included 775 medication incident reports from 19 Swedish hospitals during 2016-2017. From the 775 reports, 128 were chosen to establish the third aim. Incidents were classified and analysed statistically. Perceived causes of incidents were analysed using content analysis.

Results

Incidents occurred as often in prescribing as in administering. Wrong dose was the most common error, followed by missed dose and lack of prescription. Most incidents did not harm the patients. Errors in administering reached the patients more often than errors in prescribing. The most frequently perceived causes were shortcomings in knowledge, skills and abilities, followed by workload. Most medication incidents were reported by nurses.

Prospective methods for identifying perioperative risk-assessment methods for patient safety over 20 years: a systematic review

BACKGROUND

Serious preventable surgical events still occur despite considerable efforts to improve patient safety. In addition to learning from retrospective analyses, prospective risk-assessment methods may help to decrease preventable events further by targeting perioperative hazards. The aim of this systematic review was to assess the methods used to identify perioperative patient safety risks prospectively, and to describe the risk areas targeted, the quality characteristics and feasibility of methods.

METHODS

MEDLINE, Embase, CINAHL and Cochrane databases were searched, adhering to PRISMA guidelines. All studies describing the development and results of prospective methods to identify perioperative patient safety risks were included and assessed on methodological quality. Exclusion criteria were interventional studies, studies targeting one specific issue, studies reporting on structural factors relating to fundamental hospital items, and non-original or case studies.

RESULTS

The electronic search resulted in 16 708 publications, but only 20 were included for final analysis, describing five prospective risk-assessment methods. Direct observation was used in most studies, often in combination. Direct (16 studies) and indirect (4 studies) observations identified (potential) adverse events (P)AEs, process flow disruptions, poor protocol compliance and poor practice performance. (Modified) Healthcare Failure Mode and Effect Analysis (HFMEA™) (5 studies) targeted potential process flow disruption failures, and direct (P)AE surveillance (3 studies) identified (P)AEs prospectively. Questionnaires (3 studies) identified poor protocol compliance, surgical flow disturbances and patients' willingness to ask questions about their care. Overall, quality characteristics and feasibility of the methods were poorly reported.

CONCLUSION

The direct (in-person) observation appears to be the primary prospective risk-assessment method that currently may best help to target perioperative hazards. This is a reliable method and covers a broad spectrum of perioperative risk areas.

Good Catch Campaign: Improving the Perioperative Culture of Safety

Although health care workers feel pressure to reduce adverse events in the perioperative department, a lack of education, communication, and leadership can prevent hospital personnel from reporting good catches. The purpose of this evidence-based quality improvement project was to improve the culture of safety in our perioperative department by implementing the Good Catch Campaign. An interprofessional team led staff member education after implementing a standardized electronic reporting system and debriefing process to occur after good catches. Staff members reported 391 good catches from all perioperative areas during the six-month postimplementation period. Staff members completed the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture before and six months after implementation; scores improved in five areas: communication openness, feedback and communication about error, frequency of event reporting, nonpunitive response to error, and organizational learning and continuous improvement. The campaign was a successful strategy for improving perioperative patient safety.

Using a Second Stakeholder-Driven Variance Reporting System Improves Pediatric Perioperative Safety

Despite recognizing the occurrence of variances, we noted a low rate of reporting with the established computer variance program. Therefore, we developed and introduced a simple, handwritten variance reporting system. The goal of this study was to compare our pediatric perioperative handwritten variance cards to our established computerized variance reporting system.

Methods

We developed a handwritten variance card program through a stakeholder-driven quality-improvement initiative. We collected variances from handwritten cards in 4 perioperative locations and also from the established computerized variance system. We analyzed the variances and categorized them into 6 safety domains and 5 variance categories.

Results

Over 6 consecutive years, 3,434 variances were reported (687 computerized and 2,747 handwritten). For safety domains, the computerized system was more likely to capture adverse events and near-misses (8.7% vs. 1.1%, P < 0.001; 23.5% vs. 8.6%, P < 0.001, respectively) while the handwritten system was more likely to identify the safety process and other non-safety issues (20.1% vs. 38.3%, P < 0.001). Both systems addressed policy/process issues most often, with 37.9% of the handwritten cards and 66.6% of the computerized variance reports. Of the handwritten cards with a patient identifier (n = 1,407), only 5.1% (n = 72) also had a computerized variance filed about the same event. Thus, staff reported >1,300 additional variances that were not identified with the computerized variance system alone.

Conclusion

The handwritten, stakeholder-driven variance reporting system was essential to identify local and system issues that would not have been identified by the computerized variance reporting system alone.

Medical Errors Cause Harm in Veterinary Hospitals

Medical errors are a leading cause of mortality in human medicine. In contrast, errors in veterinary medicine are rarely discussed, and there is little known about their nature and frequency. This study aimed to evaluate the type and severity of medical errors reported in three veterinary hospitals. The voluntary online incident reporting systems of a small animal teaching hospital, large animal teaching hospital, and small animal multi-specialty practice were reviewed. Reports were included if they were entered between February 2015 and March 2018, and involved an incident pertaining to patient safety. The reporting systems classified errors into the following categories: drug, iatrogenic, system, communication, lab, oversight, staff, or equipment errors. In addition, all incidents were classified as resulting in either a near miss, harmless hit, adverse incident, or unsafe condition. Adverse incidents were further evaluated retrospectively for error severity. A total of 560 incident reports were included for analysis. Drug errors were the most frequently reported in all three hospitals, followed by failures of communication. Errors most commonly reached patients without causing harm (45%); however, 15% of all incidents resulted in patient harm. Eight percent of patients harmed suffered permanent morbidity or death. A higher proportion of adverse incidents were reported in the small animal teaching hospital than in the other two practice settings. This study demonstrates that medical errors have a substantial impact on veterinary patients. Establishing that drug and communication errors are most frequent in a variety of hospitals is the first step toward interventions to improve patient safety and outcomes in veterinary medicine.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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