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Gens-Barberà M, Astier-Peña MP, Hernández-Vidal N, Hospital-Guardiola I, Bejarano-Romero F, Oya-Girona EM, Mengíbar-Garcia Y, Mansergas-Collado N, Vila-Rovira A, Martínez-Torres S, Rey-Reñones C, Martín-Luján F. Patient Safety Incidents in Primary Care: Comparing APEAS-2007 (Spanish Patient Safety Adverse Events Study in Primary Care) with Data from a Health Area in Catalonia (Spain) in 2019. Healthcare (Basel) 2024; 12:1086. [PMID: 38891161 PMCID: PMC11172342 DOI: 10.3390/healthcare12111086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/08/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
The initial APEAS study, conducted in June 2007, examined adverse events (AEs) in Spanish Primary Healthcare (PHC). Since then, significant changes have occurred in healthcare systems. To evaluate these changes, a study was conducted in the Camp de Tarragona PHC region (CTPHC) in June 2019. This cross-sectional study aimed to identify AEs in 20 PHC centres in Camp de Tarragona. Data collection used an online questionnaire adapted from APEAS-2007, and a comparative statistical analysis between APEAS-2007 and CTPHC-2019 was performed. The results revealed an increase in nursing notifications and a decrease in notifications from family doctors. Furthermore, fewer AEs were reported overall, particularly in medication-related incidents and healthcare-associated infections, with an increase noted in no-harm incidents. However, AEs related to worsened clinical outcomes, communication issues, care management, and administrative errors increased. Concerning severity, there was a decrease in severe AEs, coupled with an increase in moderate AEs. Despite family doctors perceiving a reduction in medication-related incidents, the overall preventability of AEs remained unchanged. In conclusion, the reporting patterns, nature, and causal factors of AEs in Spanish PHC have evolved over time. While there has been a decrease in medication-related incidents and severe AEs, challenges persist in communication, care management, and clinical outcomes. Although professionals reported reduced severity, the perception of preventability remains an area that requires attention.
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Affiliation(s)
- Montserrat Gens-Barberà
- Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain (F.B.-R.); (N.M.-C.)
- QiSP-Tar Research Group, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAP Jordi Gol, 08007 Barcelona, Spain (F.M.-L.)
- ISAC Research Group (Intervencions Sanitàries i Activitats Comunitàries; 2021 SGR 00884), Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAPJGol, 08007 Barcelona, Spain
| | - Maria-Pilar Astier-Peña
- QiSP-Tar Research Group, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAP Jordi Gol, 08007 Barcelona, Spain (F.M.-L.)
- Universitas Health Center, Health Service of Aragon, 50080 Zaragoza, Spain
| | - Núria Hernández-Vidal
- Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain (F.B.-R.); (N.M.-C.)
- QiSP-Tar Research Group, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAP Jordi Gol, 08007 Barcelona, Spain (F.M.-L.)
- ISAC Research Group (Intervencions Sanitàries i Activitats Comunitàries; 2021 SGR 00884), Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAPJGol, 08007 Barcelona, Spain
| | - Immaculada Hospital-Guardiola
- Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain (F.B.-R.); (N.M.-C.)
- QiSP-Tar Research Group, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAP Jordi Gol, 08007 Barcelona, Spain (F.M.-L.)
- ISAC Research Group (Intervencions Sanitàries i Activitats Comunitàries; 2021 SGR 00884), Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAPJGol, 08007 Barcelona, Spain
| | - Ferran Bejarano-Romero
- Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain (F.B.-R.); (N.M.-C.)
- QiSP-Tar Research Group, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAP Jordi Gol, 08007 Barcelona, Spain (F.M.-L.)
- ISAC Research Group (Intervencions Sanitàries i Activitats Comunitàries; 2021 SGR 00884), Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAPJGol, 08007 Barcelona, Spain
| | - Eva Mª Oya-Girona
- Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain (F.B.-R.); (N.M.-C.)
- QiSP-Tar Research Group, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAP Jordi Gol, 08007 Barcelona, Spain (F.M.-L.)
- ISAC Research Group (Intervencions Sanitàries i Activitats Comunitàries; 2021 SGR 00884), Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAPJGol, 08007 Barcelona, Spain
| | - Yolanda Mengíbar-Garcia
- Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain (F.B.-R.); (N.M.-C.)
- QiSP-Tar Research Group, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAP Jordi Gol, 08007 Barcelona, Spain (F.M.-L.)
| | - Nuria Mansergas-Collado
- Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain (F.B.-R.); (N.M.-C.)
- QiSP-Tar Research Group, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAP Jordi Gol, 08007 Barcelona, Spain (F.M.-L.)
| | - Angel Vila-Rovira
- Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain (F.B.-R.); (N.M.-C.)
- QiSP-Tar Research Group, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAP Jordi Gol, 08007 Barcelona, Spain (F.M.-L.)
| | - Sara Martínez-Torres
- QiSP-Tar Research Group, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAP Jordi Gol, 08007 Barcelona, Spain (F.M.-L.)
- ISAC Research Group (Intervencions Sanitàries i Activitats Comunitàries; 2021 SGR 00884), Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAPJGol, 08007 Barcelona, Spain
- Research Support Unit Camp of Tarragona, Department of Primary Care Camp de Tarragona, Institut Català de la Salut, 43202 Reus, Spain
| | - Cristina Rey-Reñones
- QiSP-Tar Research Group, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAP Jordi Gol, 08007 Barcelona, Spain (F.M.-L.)
- ISAC Research Group (Intervencions Sanitàries i Activitats Comunitàries; 2021 SGR 00884), Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAPJGol, 08007 Barcelona, Spain
- Research Support Unit Camp of Tarragona, Department of Primary Care Camp de Tarragona, Institut Català de la Salut, 43202 Reus, Spain
- Department of Medicine and Surgery, School of Medicine and Health Sciences, Universitat Rovira i Virgili, 43201 Reus, Spain
| | - Francisco Martín-Luján
- QiSP-Tar Research Group, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAP Jordi Gol, 08007 Barcelona, Spain (F.M.-L.)
- ISAC Research Group (Intervencions Sanitàries i Activitats Comunitàries; 2021 SGR 00884), Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut—IDIAPJGol, 08007 Barcelona, Spain
- Research Support Unit Camp of Tarragona, Department of Primary Care Camp de Tarragona, Institut Català de la Salut, 43202 Reus, Spain
- Department of Medicine and Surgery, School of Medicine and Health Sciences, Universitat Rovira i Virgili, 43201 Reus, Spain
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de la Torre-Pérez L, Granés L, Prat Marín A, Bertran MJ. A hospital incident reporting system (2016-2019): Learning from notifier's perception on incidents' risk, severity and frequency of adverse events. J Healthc Qual Res 2023; 38:93-104. [PMID: 36151046 DOI: 10.1016/j.jhqr.2022.08.004] [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: 04/18/2022] [Revised: 06/28/2022] [Accepted: 08/14/2022] [Indexed: 11/16/2022]
Abstract
Incident reporting systems (IRSs) are considered safety culture promoters. Nevertheless, they have not been contemplated to monitor professionals' perception about patient safety related risks. This study aims to describe the characteristics and evolution of incident notifications reported between 2016 and 2019 in a high complexity reference hospital in Barcelona and explores the association between notifications' characteristics and notifier's perception about incidents severity, probability of occurrence and risk. The main analysis unit was notifications reported. A descriptive analysis was performed and taxes by hospital activity were calculated. Odds ratios were obtained to study the association between the type of incident, the moment of incident, notifiers' professional category, reported incident's severity, probability and incidents' calculated risk. Through the study period, a total of 6379 notifications were reported, observing an annual increase of notifications until 2018. Falls (21.22%), Medical and procedures management (18.91%) and Medication incidents (15.49%) were the most frequently notified. Departments reporting the highest number of notifications were Emergency room and Obstetrics & Gynaecology. Incident type and notifiers' characteristics were consistently included in the models constructed to assess risk perception. Pharmaceutics were the most frequent notifiers when considering the proportion of staff members. Notification patterns can inform professionals' patient risk perception and increase awareness of professionals' misconceptions regarding patient safety.
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Affiliation(s)
| | - L Granés
- Preventive Medicine and Epidemiology Department, Clinic Institute of Medicine and Dermatology (ICMiD), Hospital Clínic of Barcelona, Barcelona, Spain
| | - A Prat Marín
- Preventive Medicine and Epidemiology Department, Clinic Institute of Medicine and Dermatology (ICMiD), Hospital Clínic of Barcelona, Barcelona, Spain; Medicine Department, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - M J Bertran
- Preventive Medicine and Epidemiology Department, Clinic Institute of Medicine and Dermatology (ICMiD), Hospital Clínic of Barcelona, Barcelona, Spain
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Beltran Vilagrasa M, Varó Curbelo A, Fa Asensio X, García Relancio D, Giralt López de Sagredo J. [Safety in radiationtherapy. Results after 9 years implementation of incidents reporting system]. J Healthc Qual Res 2020; 35:173-181. [PMID: 32467079 DOI: 10.1016/j.jhqr.2020.01.009] [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: 08/01/2019] [Revised: 01/08/2020] [Accepted: 01/10/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Radiation therapy (RT) is a complex process that employs high-dose radiation for therapeutic purposes. Incident reporting and analysis, in addition to being a legal requirement in RT, provides information that helps to improve patient safety. This paper describes our experiences over a 9 year period in which a local incident reporting and learning system (SNAI) specific to RT was employed. MATERIALS AND METHODS The center has 4 lineal accelerators that treat a total of 1900 patients annually. The first action taken with a view to improving patient safety was the implementation of a multidisciplinary RT safety group (GSRT), who decided to employing a methodology based on incident reporting. For this purpose, a local SNAI was implemented, adapting the ROSEIS incident reporting system used and consolidated by the European Society of Radiation Oncology Therapy (ESTRO). All incidents in which patients received an incorrect RT session were considered adverse events (AE) and were thus analyzed. Finally, the opinion of the professionals involved in relation to the SNAI and the functioning of the safety group was evaluated by means of a survey. RESULTS From June 2009 to October 2018, 1708 incidents were recorded, with an increasing incidence observed over time. Approximately 2.5% of the incidents reported were AE. The remainders were events that did not affect the patient. As many as 55% of incidents were detected in the treatment administration phase. Radiotherapy technicians were the professionals who reported more incidents. The majority of recorded cases originated from procedural shortcomings relating to communication or work protocols. Implemented remedial actions were aimed at reducing the frequency of AE and facilitating its early detection. Actions employed were essentially: drafting and revision of protocols and circuits, implementation of checklists, and training actions. Of the workers surveyed, 85% positively valued the incorporation of the SNAI and the existence of a safety group. However, 15% of the professionals considered that the methodology used in the analysis of incidents was not totally objective i.e punitive in nature. CONCLUSIONS The safety of the patient receiving RT has been approached from a methodology based on a local SNAI. The analysis of reported incidents has promoted various actions aimed at improving the safety of patients receiving RT. The methodology used has been well received by the workers and has helped to introduce a culture of patient safety for the majority of professionals involved. Furthermore, the local SNAI facilitates compliance with European regulations regarding the obligation to record incidents in RT.
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Affiliation(s)
- M Beltran Vilagrasa
- Servicio de Física y Protección Radiológica, Hospital Universitario Vall d'Hebron, Barcelona, España.
| | - A Varó Curbelo
- Servicio de Física y Protección Radiológica, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - X Fa Asensio
- Servicio de Física y Protección Radiológica, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - D García Relancio
- Servicio de Oncología Radioterápica, Hospital Universitario Vall d'Hebron, Barcelona, España
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Cruz Antolin AJ, Otin Grasa JM, Mir Abellán R, Miñambres Donaire A, Grimal Melendo I, de la Puente Martorell ML. [Patient safety in psychiatric hospitalization - What incidents are reported and managed?]. J Healthc Qual Res 2018; 33:290-297. [PMID: 30337130 DOI: 10.1016/j.jhqr.2018.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 06/23/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Reporting and management systems monitoring patient safety incidents (PSIs) facilitate the understanding of mechanisms of action and allow work on improvement activities to minimise their occurrence. In our country, little is known about the adverse effects of healthcare during psychiatric hospitalisation (PH). The aim of this study is to determine the occurrence and characteristics of the PSIs, as well as the improvement actions resulting from them, in the PH services being offered at the Parc Sanitari Sant Joan de Deu (an institution specialized in mental healthcare). MATERIAL AND METHOD An observational, descriptive, and cross-sectional study was conducted, covering the period 2013-2016. Analysis was made of the PSIs reported in the following areas of PH: acute and sub-acute (ASA), and medium and long-term stay (MLS). The following variables were identified: number, type and level of harm resulting from the PSIs, professional category of the person declaring the PSI, method of analysis used to investigate the PSI, and improvement actions generated by those PSIs that required either root-cause analysis or audit reports. The chi-squared test was used for statistical purposes when comparing percentages. RESULTS A total of 2,940 PSIs were reported. The frequency in ASA was significantly higher (7.1 per 1,000 stays) than in MLS (5.3). Almost all (97.6%) of the incidents were related to falls, aggressive and/or disturbed behaviour, mind-altering drugs, self-harm, medication, dangerous objects, and patients escaping. PSIs recording moderate or severe harm were similar in the 2 different areas (16.5% in ASA vs. 14.2% in MLS). A small percentage (1.02%) of the PSIs resulted in root cause analysis or audit reporting, due to their severity, and from those incidents, 56 improvement actions were generated. CONCLUSIONS PH demonstrates its own characteristics with regard to the type of PSIs and differs from general hospitalisation. Reporting of PSIs is higher in ASA than in MLS, although the level of harm experienced by the patients is similar. There is a clear understanding of reporting in PH, demonstrated by the steady increase in the numbers declared and also highlights the high level of awareness of the nursing staff.
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Affiliation(s)
- A J Cruz Antolin
- Unidad Funcional de Seguridad del Paciente, Parc Sanitari Sant Joan de Déu, Barcelona, España; Unidad de Calidad y Seguridad del Paciente, Parc Sanitari Sant Joan de Déu, Barcelona, España.
| | - J M Otin Grasa
- Dirección Salud Mental, Parc Sanitari Sant Joan de Déu, Barcelona, España
| | - R Mir Abellán
- Dirección Enfermería, Parc Sanitari Sant Joan de Déu, Barcelona, España
| | | | - I Grimal Melendo
- Dirección Enfermería, Parc Sanitari Sant Joan de Déu, Barcelona, España
| | - M L de la Puente Martorell
- Unidad Funcional de Seguridad del Paciente, Parc Sanitari Sant Joan de Déu, Barcelona, España; Unidad de Calidad y Seguridad del Paciente, Parc Sanitari Sant Joan de Déu, Barcelona, España
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Freixas Sala N, Monistrol Ruano O, Espuñes Vendrell J, Sallés Creus M, Gallardo González M, Ramón Cantón C, Bueno Domínguez MJ, Llinas Vidal M, Campo Osaba MA. Patient safety and nursing implication: Survey in Catalan hospitals. ENFERMERIA CLINICA 2016; 27:94-100. [PMID: 27160917 DOI: 10.1016/j.enfcli.2016.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 02/29/2016] [Accepted: 03/09/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study aims to describe the implementation of the patient safety (PS) programs in catalan hospitals and to analyze the level of nursing involvement. METHOD Multicenter cross-sectional study. To obtain the data two questionnaires were developed; one addressed to the hospital direction and another to the nurse executive in PS. The survey was distributed during 2013 to the 65 acute care hospitals in Catalonia. RESULTS The questionnaire was answered by 43 nursing directors and 40 nurse executive in PS. 93% of the hospitals responded that they had a PS Program and 81.4% used a specific scoreboard with PS indicators. The referent of the hospital in PS was a nurse in 55.8% of the centres. 92.5% had a system of notification of adverse effects with an annual average of 190.3 notifications. In 86% of the centres had a nurse involved in the PS program but only in the 16% of the centres the nurse dedication was at full-time. The nurse respondents evaluate the degree of implementation of the PBS program with a note of approved and they propound as improvement increase the staff dedicated to the PS and specific academic training in PS. CONCLUSIONS The degree of implementation of programs for patient safety is high in Catalan acute hospitals, while the organizational structure is highly diverse. In more than half of the hospitals the PS referent was a nurse, confirming the nurse involvement in the PS programs.
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Affiliation(s)
- Núria Freixas Sala
- Área de Desarrollo y formación, Hospital Universitari Mútua Terrassa, Barcelona, España.
| | - Olga Monistrol Ruano
- Seguridad del paciente e investigación, Hospital Universitari Mútua Terrassa, Barcelona, España
| | - Jordi Espuñes Vendrell
- Vigilancia epidemiológica, Departament de Salut de la Generalitat de Catalunya, Barcelona, España
| | - Montserrat Sallés Creus
- Dirección de calidad y seguridad clínica, Hospital Universitari Clínic i Provincial de Barcelona, Barcelona, España
| | | | | | | | | | - María Antonia Campo Osaba
- Vocal de cuidados medico quirúrgicos, Collegi Oficial d'Infermeres i Infermers de Barcelona, Barcelona, España
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