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Mistry P, Fox A, Latter S. National evaluation of harm associated with patient safety incident reports related to the provision of parenteral nutrition to patients, using a national incident reporting system. Nutr Clin Pract 2023; 38:1392-1408. [PMID: 37063048 DOI: 10.1002/ncp.10989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/06/2023] [Accepted: 03/13/2023] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND Parenteral nutrition (PN)-related patient safety incidents have been associated with harm. Large-scale studies are scarce, and little is known about contributory factors. This study evaluated PN-related incident reports that described harm using a national database. MATERIALS AND METHODS A retrospective evaluation of incident reports involving PN in England and Wales reported to the National Reporting and Learning System between 2015 and 2020. We described frequency by degree of reported harm and incident characteristics. Content analysis was undertaken to understand contributory factors for reports related to moderate/severe harm or death. RESULTS 12,907 incident reports were identified. After screening, 2242 were evaluated; 1879 (83.8%) reported no harm, 309 (13.8%) low harm, 47 (0.02%) moderate harm, 4 (0.002%) severe harm, 3 (0.001%) deaths. The most reported age group, medication process, and error category were neonates (<28 days) (n = 570/1923, 29.6%), administration (n = 1126/2242, 50%), and omitted medication/ingredient (n = 291/2242, 13%), respectively. Content analysis of reports related to moderate/severe harm and death revealed patient age of <1 year, dependence on home PN (HPN), comorbidities, and staff errors as contributory factors. CONCLUSIONS This is the first evaluation of PN-related incident reports in England and Wales to our knowledge. We demonstrated a low frequency of reports related to moderate or severe harm or death. More incidents were reported for neonates and during the administration processes. To reduce harm, systems/procedures that reduce errors in high-risk patients (eg, neonates, patients receiving HPN) need to be established within organizations. Database limitations of voluntary reporting systems were recognized.
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Affiliation(s)
- Priya Mistry
- Pharmacy Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Andy Fox
- Pharmacy Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sue Latter
- School of Health Sciences, University of Southampton, Southampton, UK
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Simões NCS, Tavares LODM, da Silva CMB, Rodrigues SB, Oliveira SH, Guimarães EADA, de Oliveira VC. Construction and validity of an educational video to prevent immunization errors. Rev Bras Enferm 2023; 76:e20230010. [PMID: 37820157 PMCID: PMC10561952 DOI: 10.1590/0034-7167-2023-0010] [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: 01/22/2023] [Accepted: 04/03/2023] [Indexed: 10/13/2023] Open
Abstract
OBJECTIVE to construct and validate an orientation video, based on a low-fidelity clinical simulation scenario, to prevent immunization errors. METHODS a methodological study with video construction, validated in two stages by different audiences. Content was selected based on a realistic simulation scenario of the vaccine administration process to a patient-actor. Items with concordance greater than 0.8 and 0.6 were considered valid, verified using the Content Validity Index (CVI) and the Content Validity Ratio (CVR), respectively. RESULTS judges' CVI had an average of 97.5%, and CVR, 0.9, and health professionals' CVI, 95.4%, and CVR, 0.8. Successes in administering vaccines were addressed, such as careful reading of labels, double-checking the vaccine, distractions/interruptions and error reporting. CONCLUSIONS the video was constructed and validated in terms of content, and can be used in training professionals working in vaccination.
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Rees P, Purchase T, Ball E, Beggs J, Gabriel F, Gwyn S, Hellard S, Jones E, McFadzean IJ, Paccagnella D, Robb P, Walsh K, Carson-Stevens A. Family role in paediatric safety incidents: a retrospective study protocol. BMJ Open 2023; 13:e075058. [PMID: 37479516 PMCID: PMC10364146 DOI: 10.1136/bmjopen-2023-075058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/23/2023] Open
Abstract
INTRODUCTION Healthcare-associated harm is an international public health issue. Children are particularly vulnerable to this with 15%-35% of hospitalised children experiencing harm during medical care. While many factors increase the risk of adverse events, such as children's dependency on others to recognise illness, children have a unique protective factor in the form of their family, who are often well placed to detect and prevent unsafe care. However, families can also play a key role in the aetiology of unsafe care.We aim to explore the role of families, guardians and parents in paediatric safety incidents, and how this may have changed during the pandemic, to learn how to deliver safer care and codevelop harm prevention strategies across healthcare settings. METHODS AND ANALYSIS This will be a retrospective study inclusive of an exploratory data analysis and thematic analysis of incident report data from the Learning from Patient Safety Events service (formerly National Reporting and Learning System), using the established PatIent SAfety classification system. Reports will be identified by using specific search terms, such as *parent* and *mother*, to capture narratives with explicit mention of parental involvement, inclusive of family members with parental and informal caregiver responsibilities.Paediatricians and general practitioners will characterise the reports and inter-rater reliability will be assessed. Exploratory descriptive analysis will allow the identification of types of incidents involving parents, contributing factors, harm outcomes and the specific role of the parents including inadvertent contribution to or mitigation of harm. ETHICS AND DISSEMINATION This study was approved by Cardiff University Research Ethics Committee (SMREC 22/32). Findings will be submitted to a peer-reviewed journal, presented at international conferences and presented at stakeholder workshops.
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Affiliation(s)
- Philippa Rees
- Division of Population Medicine, Cardiff University, Cardiff, UK
- Population Policy and Practice, Great Ormond Street UCL Institute of Child Health, London, UK
| | - Thomas Purchase
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Emily Ball
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Jillian Beggs
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | - Sioned Gwyn
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Stuart Hellard
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Elena Jones
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | | | - Philippa Robb
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Kathleen Walsh
- Division of General Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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Reith DM, Leitch S, Eggleton K, Wallis K, Lillis S, Williamson M, Cunningham W. Treatment Harms in Paediatric Primary Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6378. [PMID: 37510610 PMCID: PMC10379136 DOI: 10.3390/ijerph20146378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/08/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023]
Abstract
The aim of this study was to describe the epidemiology in children of harms detectable from general practice records, and to identify risk factors. The SHARP study examined 9076 patient records from 44 general practices in New Zealand, with an enrolled population of 210,559 patients. "Harm" was defined as disease, injury, disability, suffering, and death, arising from the health system. The age group studied was ≤20 years of age. There were 193 harms to 141 children and adolescents during the 3-year study period. Harms were reported in one (3.5%) patient aged <2 years, 80 (6.6%) aged 2 to <12 years, 36 (4.9%) aged 12 to <18 years, and 24 (7.5%) aged 18 to ≤20 years. The annualised rates of harm were 36/1000 child and adolescent population for all harms, 20/1000 for medication-related harm (MRH), 2/1000 for severe MRH, and 0.4/1000 for hospitalisation. For MRH, the drug groups most frequently involved were anti-infectives (51.9%), genitourinary (15.4%), dermatologicals (12.5%), and the nervous system (9.6%). Treatment-related harm in children was less common than in a corresponding adult population. MRH was the most common type of harm and was related to the most common treatments used. The risk of harm increased with the number of consultations.
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Affiliation(s)
- David M Reith
- Dean's Department, Otago Medical School, University of Otago, Dunedin 9016, New Zealand
| | - Sharon Leitch
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin 9016, New Zealand
| | - Kyle Eggleton
- Faculty of Medical and Health Sciences, University of Auckland, Auckland 1010, New Zealand
| | - Katharine Wallis
- Mayne Academy of General Practice, Medical School, The University of Queensland, Brisbane 4067, Australia
| | - Steven Lillis
- Department of General Practice and Primary Health Care, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1010, New Zealand
| | - Martyn Williamson
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin 9016, New Zealand
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Alqenae FA, Steinke D, Carson-Stevens A, Keers RN. Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study. Ther Adv Drug Saf 2023; 14:20420986231154365. [PMID: 36949766 PMCID: PMC10026140 DOI: 10.1177/20420986231154365] [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: 06/01/2022] [Accepted: 01/16/2023] [Indexed: 03/18/2023] Open
Abstract
Introduction Improving medication safety during transition of care is an international healthcare priority. While existing research reveals that medication-related incidents and associated harms may be common following hospital discharge, there is limited information about their nature and contributory factors at a national level which is crucial to inform improvement strategy. Aim To characterise the nature and contributory factors of medication-related incidents during transition of care from secondary to primary care. Method A retrospective analysis of medication incidents reported to the National Reporting and Learning System (NRLS) in England and Wales between 2015 and 2019. Descriptive analysis identified the frequency and nature of incidents and content analysis of free text data, coded using the Patient Safety Research Group (PISA) classification, examined the contributory factors and outcome of incidents. Results A total of 1121 medication-related incident reports underwent analysis. Most incidents involved patients over 65 years old (55%, n = 626/1121). More than one in 10 (12.6%, n = 142/1121) incidents were associated with patient harm. The drug monitoring (17%) and administration stages (15%) were associated with a higher proportion of harmful incidents than any other drug use stages. Common medication classes associated with incidents were the cardiovascular (n = 734) and central nervous (n = 273) systems. Among 408 incidents reporting 467 contributory factors, the most common contributory factors were organisation factors (82%, n = 383/467) (mostly related to continuity of care which is the delivery of a seamless service through integration, co-ordination, and the sharing of information between different providers), followed by staff factors (16%, n = 75/467). Conclusion Medication incidents after hospital discharge are associated with patient harm. Several targets were identified for future research that could support the development of remedial interventions, including commonly observed medication classes, older adults, increase patient engagement, and improve shared care agreement for medication monitoring post hospital discharge. Plain language summary Study using reports about unsafe or substandard care mainly written by healthcare professionals to better understand the type and causes of medication safety problems following hospital discharge Why was the study done? The safe use of medicines after hospital discharge has been highlighted by the World Health Organization as an important target for improvement in patient care. Yet, the type of medication problems which occur, and their causes are poorly understood across England and Wales, which may hamper our efforts to create ways to improve care as they may not be based on what we know causes the problem in the first place.What did the researchers do? The research team studied medication safety incident reports collected across England and Wales over a 5-year period to better understand what kind of medication safety problems occur after hospital discharge and why they happen, so we can find ways to prevent them from happening in future.What did the researchers find? The total number of incident reports studied was 1121, and the majority (n = 626) involved older people. More than one in ten of these incidents caused harm to patients. The most common medications involved in the medication safety incidents were for cardiovascular diseases such as high blood pressure, conditions such as mental illness, pain and neurological conditions (e.g., epilepsy) and other illnesses such as diabetes. The most common causes of these incidents were because of the organisation rules, such as information sharing, followed by staff issues, such as not following protocols, individual mistakes and not having the right skills for the task.What do the findings mean? This study has identified some important targets that can be a focus of future efforts to improve the safe use of medicines after hospital discharge. These include concentrating attention on medication for the cardiovascular and central nervous systems (e.g., via incorporating them in prescribing safety indicators and pharmaceutical prioritisation tools), staff skill mix (e.g., embedding clinical pharmacist roles at key parts of the care pathway where greatest risk is suspected), and implementation of electronic interventions to improve timely communication of medication and other information between healthcare providers.
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Affiliation(s)
| | - Douglas Steinke
- Centre for Pharmacoepidemiology and Drug
Safety, Division of Pharmacy and Optometry, School of Health Sciences,
University of Manchester, Manchester, UK
- Pharmacy Department, Manchester University NHS
Foundation Trust, Manchester, UK
| | - Andrew Carson-Stevens
- Division of Population Medicine, School of
Medicine, Cardiff University, Cardiff, UK
| | - Richard N. Keers
- Centre for Pharmacoepidemiology and Drug
Safety, Division of Pharmacy and Optometry, School of Health Sciences,
University of Manchester, Manchester, UK
- Suicide, Risk and Safety Research Unit, Greater
Manchester Mental Health NHS Foundation Trust, Manchester, UK
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Farias ERGD, Cavalcante CAA, Melo ACAD, Soares AML, Silva DOD, Souza ADMD, Monteiro JSF. Organização do processo de trabalho através de conhecimento, atitudes e práticas para administração segura de vacinas em crianças. REME: REVISTA MINEIRA DE ENFERMAGEM 2022. [DOI: 10.35699/2316-9389.2022.40919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
Objetivo: mapear a organização do processo de trabalho através de conhecimento, atitudes e práticas para administração segura de vacinas em crianças. Método: realizou-se uma revisão de literatura com o método Scoping Review, de acordo com as recomendações do guia internacional PRISMA-ScR, e o método do Joanna Briggs Institute Reviewers Manual. A busca eletrônica dos estudos foi realizada nas bases de dados PubMed, CINAHL, Web of Science, Scopus, COCHRANE, LILACS e PsycINFO e na literatura cinzenta, entre os anos 2000 e 2021. Foram incluídos artigos, revisões, teses, dissertações e manuais disponibilizados na íntegra que estivessem em consonância com o objetivo deste estudo, tendo sido contemplando os idiomas inglês, português, italiano, espanhol e francês. Foram excluídos da revisão estudos não gratuitos pela plataforma CAFe, duplicados, que não tivessem relação com a temática pesquisada e não tivessem sua metodologia bem definida. Resultados: a revisão englobou 19 estudos publicados. O Brasil foi o país com maior número de estudos. Os principais achados propiciaram a construção das categorias conceituais. As sete primeiras se referem às principais características dos estudos incluídos nesta revisão de escopo; as outras três categorias objetivaram responder à questão norteadora e foram compostas por indicadores presentes na organização do processo de trabalho antes, durante e após a administração segura de uma vacina na criança. Conclusão: conclui-se que os objetivos desta pesquisa foram alcançados mediante mapeamento da organização do processo de trabalho através de conhecimento, atitudes e práticas para administração segura de vacinas em crianças. Como limitação deste estudo, evidencia-se a escassez de pesquisas que norteiam os cuidados pós-vacinação e sugere-se que novas pesquisas sejam realizadas.
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Ensaldo-Carrasco E, Sheikh A, Cresswell K, Bedi R, Carson-Stevens A, Sheikh A. Patient Safety Incidents in Primary Care Dentistry in England and Wales: A Mixed-Methods Study. J Patient Saf 2021; 17:e1383-e1393. [PMID: 34852417 DOI: 10.1097/pts.0000000000000530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In recent decades, there has been considerable international attention aimed at improving the safety of hospital care, and more recently, this attention has broadened to include primary medical care. In contrast, the safety profile of primary care dentistry remains poorly characterized. OBJECTIVES We aimed to describe the types of primary care dental patient safety incidents reported within a national incident reporting database and understand their contributory factors and consequences. METHODS We undertook a cross-sectional mixed-methods study, which involved analysis of a weighted randomized sample of the most severe incident reports from primary care dentistry submitted to England and Wales' National Reporting and Learning System. Drawing on a conceptual literature-derived model of patient safety threats that we previously developed, we developed coding frameworks to describe and conduct thematic analysis of free text incident reports and determine the relationship between incident types, contributory factors, and outcomes. RESULTS Of 2000 reports sampled, 1456 were eligible for analysis. Sixty types of incidents were identified and organized across preoperative (40.3%, n = 587), intraoperative (56.1%, n = 817), and postoperative (3.6%, n = 52) stages. The main sources of unsafe care were delays in treatment (344/1456, 23.6%), procedural errors (excluding wrong-tooth extraction) (227/1456; 15.6%), medication-related adverse incidents (161/1456, 11.1%), equipment failure (90/1456, 6.2%) and x-ray related errors (87/1456, 6.0%). Of all incidents that resulted in a harmful outcome (n = 77, 5.3%), more than half were due to wrong tooth extractions (37/77, 48.1%) mainly resulting from distraction of the dentist. As a result of this type of incident, 34 of the 37 patients (91.9%) examined required further unnecessary procedures. CONCLUSIONS Flaws in administrative processes need improvement because they are the main cause for patients experiencing delays in receiving treatment. Checklists and standardization of clinical procedures have the potential to reduce procedural errors and avoid overuse of services. Wrong-tooth extractions should be addressed through focused research initiatives and encouraging policy development to mandate learning from serious dental errors like never events.
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Affiliation(s)
- Eduardo Ensaldo-Carrasco
- From the Centre of Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh
| | - Asiyah Sheikh
- College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, Scotland
| | - Kathrin Cresswell
- From the Centre of Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh
| | - Raman Bedi
- King's College London Dental Institute at Guy's, King's College and St Thomas's Hospitals, Division of Population and Patient Health, King's College London, United Kingdom
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da Silva TPR, da Silva SF, Dutra MM, da Silva RB, Gusmão JD, Matozinhos FP. Analysis of immunization errors in pregnant women. Rev Esc Enferm USP 2021; 55:e20200544. [PMID: 34605531 DOI: 10.1590/1980-220x-reeusp-2020-0544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 06/29/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To analyze immunization errors in pregnant women from Minas Gerais, according to the absence and presence of Adverse Events Following Immunization. METHODS This is a cross-sectional study, carried out with data on immunization errors in pregnant women, between 2015 and 2019, registered in the Information System for the Surveillance of Adverse Events, in Minas Gerais. The trend of the incidence rate of immunization error per 100,000 doses applied was checked using Prais-Winsten models. RESULTS Of all notifications, 3.72% were vaccination errors with adverse events following immunization. The highest proportion of immunization errors with no adverse events (32.40%) was in the macro-region Centro and, with adverse events (27.78%), in Triângulo do Sul, both with a stationary trend in the period. Regarding the incidence rate, the macro-region with the highest immunization errors with no adverse events was Vale do Aço and the macro-region with the highest incidence rate of immunization errors with adverse events was Triângulo do Sul. CONCLUSION In this study, the notifications of Adverse Events Following Immunization resulting from vaccination errors with and without adverse events occurred with no significant trend within the years of the study.
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Affiliation(s)
- Thales Philipe Rodrigues da Silva
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Programa de Pós-graduação em Ciências da Saúde - Saúde da Criança e do Adolescente, Belo Horizonte, MG, Brazil
| | - Soleane Franciele da Silva
- Universidade Federal de Minas Gerais, Escola de Enfermagem, Graduação em Enfermagem, Belo Horizonte, MG, Brazil
| | - Marcella Marinho Dutra
- Universidade Federal de Minas Gerais, Escola de Enfermagem, Graduação em Enfermagem, Belo Horizonte, MG, Brazil
| | - Roberta Barros da Silva
- Secretaria de Estado da Saúde de Minas, Subsecretaria de Vigilância em Saúde, Superintendência de Vigilância Epidemiológica, Coordenação Estadual do Programa de Imunizações, Belo Horizonte, MG, Brazil
| | - Josianne Dias Gusmão
- Secretaria de Estado da Saúde de Minas, Subsecretaria de Vigilância em Saúde, Superintendência de Vigilância Epidemiológica, Coordenação Estadual do Programa de Imunizações, Belo Horizonte, MG, Brazil
| | - Fernanda Penido Matozinhos
- Universidade Federal de Minas Gerais, Escola de Enfermagem, Departamento de Enfermagem Materno Infantil e Saúde Pública, Belo Horizonte, MG, Brazil
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Ensaldo-Carrasco E, Suarez-Ortegon MF, Carson-Stevens A, Cresswell K, Bedi R, Sheikh A. Patient Safety Incidents and Adverse Events in Ambulatory Dental Care: A Systematic Scoping Review. J Patient Saf 2021; 17:381-391. [PMID: 27611771 DOI: 10.1097/pts.0000000000000316] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There have been efforts to understand the epidemiology of iatrogenic harm in hospitals and primary care and to improve the safety of care provision. There has in contrast been very limited progress in relation to the safety of ambulatory dental care. OBJECTIVES To provide a comprehensive overview of the range and frequencies of existing evidence on patient safety incidents and adverse events in ambulatory dentistry. METHODS We searched MEDLINE and EMBASE for articles reporting events that could have or did result in unnecessary harm in ambulatory dental care. We extracted and synthesized data on the types and frequencies of patient safety incidents and adverse events. RESULTS Forty articles were included. We found that the frequencies varied very widely between studies; this reflected differences in definitions, populations studied, and sampling strategies. The main 5 PSIs we identified were errors in diagnosis and examination, treatment planning, communication, procedural errors, and the accidental ingestion or inhalation of foreign objects. However, little attention was paid to wider organizational issues. CONCLUSIONS Patient safety research in dentistry is immature because current evidence cannot provide reliable estimates on the frequency of patient safety incidents in ambulatory dental care or the associated disease burden. Well-designed epidemiological investigations are needed that also investigate contributory factors.
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Affiliation(s)
| | - Milton Fabian Suarez-Ortegon
- Centre for Population Health Sciences, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Scotland, UK
| | - Andrew Carson-Stevens
- Patient Safety Research Lead, Primary and Emergency Care Research (PRIME) Centre, Cardiff University, Wales; and Visiting Professor of Healthcare Improvement, Department of Family Practice, University of British Columbia
| | | | - Raman Bedi
- Professor and Head Centre for International Child Oral Health. King's College London Dental Institute at Guy's, King's College and St Thomas's Hospitals, Division of Population and Patient Health, King's College London, UK
| | - Aziz Sheikh
- Professor of Primary Care Research & Development and Co-Director, Centre of Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Scotland
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Alghamdi AA, Keers RN, Sutherland A, Carson-Stevens A, Ashcroft DM. A Mixed-Methods Analysis of Medication Safety Incidents Reported in Neonatal and Children's Intensive Care. Paediatr Drugs 2021; 23:287-297. [PMID: 33830469 PMCID: PMC8119278 DOI: 10.1007/s40272-021-00442-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2021] [Indexed: 10/28/2022]
Abstract
BACKGROUND Critically ill neonates and paediatric patients may be at a greater risk of medication-related safety incidents than those in other clinical areas. OBJECTIVE This study aimed to examine the nature of, and contributory factors associated with, medication-related safety incidents reported in neonatal and paediatric intensive care units (ICUs). METHODS We carried out a mixed-methods analysis of anonymised medication safety incidents reported to the National Reporting and Learning System that involved children (aged ≤ 18 years) admitted to ICUs across England and Wales over a 9-year period (2010-2018). Data were analysed descriptively, and free-text descriptions of harmful incidents were examined to explore potential contributory factors associated with incidents. RESULTS In total, 25,567 eligible medication-related incident reports were examined. Incidents commonly occurred during the medicines administration (n = 13,668 [53.5%]) and prescribing stages (n = 7412 [29%]). The most commonly implicated error types were drug omission (n = 4812 [18.8%]) and dosing errors (n = 4475 [17.5%]). Neonates were commonly involved in reported incidents (n = 12,235 [47.9%]). Anti-infectives (n = 6483 [25.4%]) were the medications most commonly associated with incidents and commonly involved neonates. Incidents that were reported to have caused patient harm accounted for 12.2% (n = 3129) and commonly involved neonates (n = 1570/3129 [50.2%]). Common contributing factors to harmful incidents included staff-related factors (68.7%), such as failure to follow protocols or errors in documentation, which were often associated with working conditions, inadequate guidelines, and design of systems and protocols. CONCLUSIONS Neonates were commonly involved in medication-related incidents reported in children's intensive care settings. Improvements in staffing and workload, design of systems and processes, and the use of anti-infective medications may reduce this risk.
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Affiliation(s)
- Anwar A Alghamdi
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PT, UK.
- Health Information Technology Department, Faculty of Applied Studies, King Abdul Aziz University, Jeddah, 21589, Kingdom of Saudi Arabia.
| | - Richard N Keers
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PT, UK
- Medicines Management Team, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, Manchester, M25 3BL, UK
| | - Adam Sutherland
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PT, UK
- Pharmacy Department, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YS, UK
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PT, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PL, UK
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Teixeira TBC, Raponi MBG, Felix MMDS, Ferreira LA, Barichello E, Barbosa MH. ASSESSMENT OF PATIENT SAFETY IN VACCINATION ROOMS. TEXTO & CONTEXTO ENFERMAGEM 2021. [DOI: 10.1590/1980-265x-tce-2020-0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: identify adherence to patient safety recommendations in the vaccination room. Method: this is a cross-sectional study that analyzed 463 vaccination procedures in six vaccination rooms in Minas Gerais from June to July 2018. Data were obtained with the application of the Patient Safety Checklist for Vaccination Rooms through systematic observation of the vaccination procedure. Descriptive statistics were used for data analysis. Results: 463 vaccination procedures were observed, and the mean overall adherence score was 58.5%, min. 43.3% and max. 74.1%. The items of higher adherence were related to the records of vaccine data (name, date, and batch) on the vaccination card; vaccine application with dose, route of administration, location and correct materials; and records in an information system. The items of lower adherence were related to health guidance; investigation of adverse events following immunization and the health status of the vaccinated person; records of vaccine laboratory and vaccination center on the vaccination card; vaccine workforce handwashing; and proper vaccine preparation. Conclusion: the mean overall score found in this study was 58.5% for the adherence to recommendations for vaccination procedures. This result highlights the need for educational interventions that promote patient safety in the vaccination room and studies analyzing the factors that prevent such adherence.
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12
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Huth K, Hotz A, Starmer AJ. Patient Safety in Ambulatory Pediatrics. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2020; 6:350-365. [PMID: 38624507 PMCID: PMC7553853 DOI: 10.1007/s40746-020-00213-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 05/16/2023]
Abstract
Purpose of Review The majority of patient care occurs in the ambulatory setting, and pediatric patients are at high risk of medical error and harm. Prior studies have described various safety threats in ambulatory pediatrics, and little is known about effective strategies to minimize error. The purpose of this review is to identify best practices for optimizing safety in ambulatory pediatrics. Recent Findings The majority of the patient safety literature in ambulatory pediatrics describes frequencies and types of medical errors. Study of effective interventions to reduce error, and particularly to reduce harm, have been limited. There is evidence that medical complexity and social context are important modifiers of risk. Telemedicine has emerged as a care delivery model with potential to ameliorate and exacerbate safety threats. Though there is variation across studies, developing a safety culture, partnerships with patients and families, and use of structured communication are strategies that support patient safety. Summary There is no standardized taxonomy for errors in ambulatory pediatrics, but errors related to medications, vaccines, diagnosis, and care coordination and care transitions are commonly described. Evidence-based approaches to optimize safety include standardized prescribing and medication reconciliation practices, appropriate use of decision support tools in the electronic health record, and communication strategies like teach-back. Further high-quality intervention studies in pediatric ambulatory care that assess impact on patient harm and clinical outcomes should be prioritized.
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Affiliation(s)
- Kathleen Huth
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Arda Hotz
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Amy J. Starmer
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
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13
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Conn RL, Tully MP, Shields MD, Carrington A, Dornan T. Characteristics of Reported Pediatric Medication Errors in Northern Ireland and Use in Quality Improvement. Paediatr Drugs 2020; 22:551-560. [PMID: 32627136 DOI: 10.1007/s40272-020-00407-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND To protect children from harm, clinicians, educators, and patient safety champions need information to direct improvement efforts. Critical incident data could provide this but are often disregarded as a source of evidence because under-reporting makes them an inaccurate measure of error rates. OBJECTIVE Our aim was to identify key targets for pediatric healthcare quality improvement. The objective was to evaluate the types, characteristics, and areas of risk within reported medication errors in pediatric patients. METHODS We conducted a retrospective study of a large regional dataset of 1522 pediatric medication errors reported from secondary care between 2011 and 2015, including all hospitals and community pediatric settings in Northern Ireland. The following characteristics were included: error severity, patient age, drug involved, error type, and area of practice. Two academic pediatricians, a senior medicines governance pharmacist, a Reader in Pharmacy Practice, and a Professor of Medical Education analyzed the data. Validity checks included comparing the findings against key published literature and discussion by a practitioner panel representing five multidisciplinary stakeholder groups. RESULTS Neonates, particularly in intensive care, were implicated in 19% of all errors. The medications most represented in risk were antimicrobials, paracetamol, vaccines, and intravenous fluids. The error types most implicated were dosing errors (32%) and omissions (21%). CONCLUSIONS Incident reports identified neonates, a shortlist of drugs, and specific error types, associated with modifiable behaviors, as priority improvement targets. These findings direct further study and inform intervention development, such as specific training in calculations to prevent dosing errors. Involving experienced practitioners both endorsed the findings and engaged the practice community in their future implementation. The utility of incident reports to direct improvement efforts may offset the limitations in their representativeness.
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Affiliation(s)
- Richard L Conn
- Centre for Medical Education, Queen's University Belfast, Whitla Medical Building, 97 Lisburn Road, Belfast, UK.
| | - Mary P Tully
- Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Michael D Shields
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Angela Carrington
- Medicines Governance Team, Belfast Health and Social Care Trust, Belfast, UK
| | - Tim Dornan
- Centre for Medical Education, Queen's University Belfast, Whitla Medical Building, 97 Lisburn Road, Belfast, UK
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14
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Omar A, Rees P, Cooper A, Evans H, Williams H, Hibbert P, Makeham M, Parry G, Donaldson L, Edwards A, Carson-Stevens A. Health and social care-associated harm amongst vulnerable children in primary care: mixed methods analysis of national safety reports. Arch Dis Child 2020; 105:731-737. [PMID: 32144091 DOI: 10.1136/archdischild-2019-318406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/24/2020] [Accepted: 02/07/2020] [Indexed: 11/03/2022]
Abstract
PURPOSE Patient safety failures are recognised as a global threat to public health, yet remain a leading cause of death internationally. Vulnerable children are inversely more in need of high-quality primary health and social-care but little is known about the quality of care received. Using national patient safety data, this study aimed to characterise primary care-related safety incidents among vulnerable children. METHODS This was a cross-sectional mixed methods study of a national database of patient safety incident reports occurring in primary care settings. Free-text incident reports were coded to describe incident types, contributory factors, harm severity and incident outcomes. Subsequent thematic analyses of a purposive sample of reports was undertaken to understand factors underpinning problem areas. RESULTS Of 1183 reports identified, 572 (48%) described harm to vulnerable children. Sociodemographic analysis showed that included children had child protection-related (517, 44%); social (353, 30%); psychological (189, 16%) or physical (124, 11%) vulnerabilities. Priority safety issues included: poor recognition of needs and subsequent provision of adequate care; insufficient provider access to accurate information about vulnerable children, and delayed referrals between providers. CONCLUSION This is the first national study using incident report data to explore unsafe care amongst vulnerable children. Several system failures affecting vulnerable children are highlighted, many of which pose internationally recognised challenges to providers aiming to deliver safe care to this at-risk cohort. We encourage healthcare organisations globally to build on our findings and explore the safety and reliability of their healthcare systems, in order to sustainably mitigate harm to vulnerable children.
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Affiliation(s)
- Adhnan Omar
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Philippa Rees
- Division of Population Medicine, Cardiff University, Cardiff, UK.,Population Policy and Practice, University College London Institute of Child Health, London, UK
| | - Alison Cooper
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Huw Evans
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Huw Williams
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Peter Hibbert
- Australian Institute of Health Innovation, Macquarie University Faculty of Medicine and Health Sciences, Sydney, New South Wales, Australia.,Division of Health Sciences, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Meredith Makeham
- Department on Clinical Medicine, Macquarie University Faculty of Medicine and Health Sciences, Sydney, New South Wales, Australia
| | - Gareth Parry
- Institute for Healthcare Improvement, Cambridge, Massachusetts, USA.,Harvard Medical School, Harvard University, Cambridge, Massachusetts, USA
| | - Liam Donaldson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Andrew Carson-Stevens
- Division of Population Medicine, Cardiff University, Cardiff, UK .,Australian Institute of Health Innovation, Macquarie University Faculty of Medicine and Health Sciences, Sydney, New South Wales, Australia
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15
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Barboza TC, Guimarães RA, Gimenes FRE, Silva AEBDC. Retrospective study of immunization errors reported in an online Information System. Rev Lat Am Enfermagem 2020; 28:e3303. [PMID: 32578753 PMCID: PMC7304978 DOI: 10.1590/1518-8345.3343.3303] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 03/20/2020] [Indexed: 11/30/2022] Open
Abstract
Objective: to analyze the immunization errors reported in an online Information
System. Method: retrospective study conducted with data from the Adverse Event Following
Immunization Surveillance Information System. Immunization errors were
analyzed with respect to demographic characteristics and the vaccination
process. Frequencies and error incidence rates have been calculated.
Binomial and chi-square tests were used to verify differences in the
proportions of the variables. Results: 501 errors were analyzed, the majority involving routine doses (92.6%),
without Adverse Event Following Immunization (90.6%) and in children under
five years old (55.7%). The most frequent types of errors were inadequacy in
the indication of the immunobiological (26.9%), inadequate interval between
doses (18.2%) and error in the administration technique (14.2%). The overall
error incidence rate was 4.05/100,000 doses applied; the highest incidences
of routine vaccines were for human rabies vaccine, human papillomavirus and
triple viral; the incidence rate of errors with Adverse Events Following
Immunization was 0.45/100,000 doses applied. Conclusion: it was found that immunization errors are a reality to be faced by the health
systems, but they are amenable to prevention through interventions such as
the adoption of protocols, checklists and permanent education in health.
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Affiliation(s)
- Tânia Cristina Barboza
- Secretaria de Estado de Saúde de Goiás, Superintendência de Vigilância em Saúde, Goiânia, GO, Brazil
| | | | - Fernanda Raphael Escobar Gimenes
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
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16
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Cabello LO, Ortiz CG. Estrategias de enfermería para la prevención de errores programáticos en vacunatorio. REVISTA MÉDICA CLÍNICA LAS CONDES 2020. [DOI: 10.1016/j.rmclc.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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17
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Morse-Brady J, Marie Hart A. Prevalence and types of vaccination errors from 2009 to 2018: A systematic review of the medical literature. Vaccine 2020; 38:1623-1629. [PMID: 31862198 DOI: 10.1016/j.vaccine.2019.11.078] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/20/2019] [Accepted: 11/25/2019] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Vaccination practices and the programmatic factors that influence them are essential for public health. Several barriers impact vaccination efforts, including vaccination errors, which pose the risk of reduced population-wide vaccination efficacy and individual adverse drug events. This study aimed to define the prevalence of vaccination errors documented in English language medical literature between 2009 and 2018 and to identify the common types of errors that occurred during this period. METHODS This systematic review followed the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines. The study protocol was registered with the International Prospective Register of Systematic Reviews prior to research activities. The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Google Scholar, ProQuest Central, PubMed, Scopus, and Web of Science were searched using predetermined search terms. Included data were from primary studies or retrospective analyses that assessed the prevalence and/or type of vaccination errors and that were peer-reviewed, conducted between 2009 and 2018, and published in English. Data were extracted using the Cochrane Data Extraction and Assessment Template and assessed using the Appraisal tool for Cross-Sectional Studies. Pooled vaccination error prevalence was then calculated. RESULTS Of the 1310 independent records that were identified and screened, 17 studies from five countries met all inclusion criteria. Pooled vaccination error prevalence was calculated to be 1.15 per 10,000 vaccine doses (range, 0.005-141.69 per 10,000 doses). The most commonly reported vaccination errors were "wrong vaccine administered" and "off-schedule administration." CONCLUSIONS International rates of vaccination error reporting remain low, with few reports of significant adverse reactions. Vaccination programs should consider the impact of vaccination errors on individual and population health, particularly focusing on the impact of "wrong vaccine" administration. Continued monitoring and promotion of error reporting will enable further understanding of this topic.
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Affiliation(s)
- Jesse Morse-Brady
- University of Wyoming, Fay W. Whitney School of Nursing, Dept. 3065, 1000 E. University Avenue, Laramie, WY 82071, United States.
| | - Ann Marie Hart
- University of Wyoming, Fay W. Whitney School of Nursing, Dept. 3065, 1000 E. University Avenue, Laramie, WY 82071, United States
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18
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Hussain F, Cooper A, Carson-Stevens A, Donaldson L, Hibbert P, Hughes T, Edwards A. Diagnostic error in the emergency department: learning from national patient safety incident report analysis. BMC Emerg Med 2019; 19:77. [PMID: 31801474 PMCID: PMC6894198 DOI: 10.1186/s12873-019-0289-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 11/08/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diagnostic error occurs more frequently in the emergency department than in regular in-patient hospital care. We sought to characterise the nature of reported diagnostic error in hospital emergency departments in England and Wales from 2013 to 2015 and to identify the priority areas for intervention to reduce their occurrence. METHODS A cross-sectional mixed-methods design using an exploratory descriptive analysis and thematic analysis of patient safety incident reports. Primary data were extracted from a national database of patient safety incidents. Reports were filtered for emergency department settings, diagnostic error (as classified by the reporter), from 2013 to 2015. These were analysed for the chain of events, contributory factors and harm outcomes. RESULTS There were 2288 cases of confirmed diagnostic error: 1973 (86%) delayed and 315 (14%) wrong diagnoses. One in seven incidents were reported to have severe harm or death. Fractures were the most common condition (44%), with cervical-spine and neck of femur the most frequent types. Other common conditions included myocardial infarctions (7%) and intracranial bleeds (6%). Incidents involving both delayed and wrong diagnoses were associated with insufficient assessment, misinterpretation of diagnostic investigations and failure to order investigations. Contributory factors were predominantly human factors, including staff mistakes, healthcare professionals' inadequate skillset or knowledge and not following protocols. CONCLUSIONS Systems modifications are needed that provide clinicians with better support in performing patient assessment and investigation interpretation. Interventions to reduce diagnostic error need to be evaluated in the emergency department setting, and could include standardised checklists, structured reporting and technological investigation improvements.
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Affiliation(s)
| | | | | | - Liam Donaldson
- London School of Hygiene and Tropical Medicine, London, UK
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19
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Reed L, Tarini BA, Andreae MC. Vaccine administration error rates at a large academic medical center and its affiliated clinics - Familiarity matters. Vaccine 2019; 37:5390-5396. [PMID: 31350155 DOI: 10.1016/j.vaccine.2019.07.027] [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: 12/16/2018] [Revised: 06/29/2019] [Accepted: 07/05/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The purpose of this study was to track and describe the absolute number of vaccine administration errors and corresponding error rates over time and by patient age and vaccine type. METHODS Total vaccines administered to patients aged 0 through 19 years 364 days from 1/1/2006 through 12/31/2017 at a large academic health system in the Midwest United States with primary, specialty and school-based clinics, and a pediatric hospital were obtained from an electronic medical record. Vaccine administration errors over the same time period for the same patient criteria were analyzed from the health system's incident reporting system and further compared to the frequency of all incidents reported. Vaccine administration error rates were calculated. Data were analyzed by patient age, vaccine type and year administered. RESULTS Of the 1,431,206 vaccine doses given, 552 vaccine administration errors were identified (0.04%). The highest error rates occurred in children aged 2, 3, and 19 years. Vaccine types with the highest error rate were Td, rabies and pneumococcal polysaccharide vaccines. Overall vaccine doses given and errors reported increased over the study period. However, the increase was disproportionate, resulting in an increase in the error rate initially followed by a stabilization at the end of the study period. CONCLUSIONS Vaccine administration errors are uncommon. The error rate appears to be stabilizing. Errors are more likely at ages when vaccines are not commonly given, with vaccines that have age-specific dosing and with vaccines that are given less often. This suggests more safety checks are needed for vaccines that are rarely used or given off-schedule, and manufacturers should avoid vaccines with age-specific dosing.
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Affiliation(s)
- Lauren Reed
- Division of General Pediatrics, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI 48105, United States.
| | - Beth A Tarini
- Center for Translational Research, Children's National Health System, Washington, DC 20010, United States
| | - Margie C Andreae
- Division of General Pediatrics, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI 48105, United States
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20
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Mohanty S, Carroll-Scott A, Wheeler M, Davis-Hayes C, Turchi R, Feemster K, Yudell M, Buttenheim AM. Vaccine Hesitancy in Pediatric Primary Care Practices. QUALITATIVE HEALTH RESEARCH 2018; 28:2071-2080. [PMID: 29947574 DOI: 10.1177/1049732318782164] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Understanding how pediatric practices handle parental vaccine hesitancy is important as it impacts the efficiency and effectiveness of pediatric practices. In total, 21 semi-structured interviews with pediatric practice staff within a primary care network were conducted between May 2012 and March 2013. Thematic analysis focused on the barriers and challenges of vaccine hesitancy and strategies to reduce the burden at the practice level. Barriers and challenges of vaccine hesitancy included time constraints, administrative challenges, financial challenges and strained patient-provider relationships. Strategies to minimize the burden of vaccine hesitancy included training for vaccine counseling, screening for vaccine hesitancy prior to immunization visits, tailored vaccine counseling, and primary care provider visits for follow-up immunization. Pediatric practices reported many challenges when caring for vaccine-hesitant families. Multiple strategies were identified to reduce the burden of vaccine hesitancy, which future studies should explore to determine how effective they are in increasing vaccine acceptance in pediatric practices.
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Affiliation(s)
- Salini Mohanty
- 1 University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- 2 Drexel University, Philadelphia, Pennsylvania, USA
| | | | - Marissa Wheeler
- 1 University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Cecilia Davis-Hayes
- 3 Columbia University College of Physicians and Surgeons, New York City, New York, USA
| | - Renee Turchi
- 2 Drexel University, Philadelphia, Pennsylvania, USA
- 4 St Christopher's Hospital for Children, Philadelphia, Pennsylvania, USA
| | - Kristen Feemster
- 5 Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Alison M Buttenheim
- 1 University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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21
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Carson-Stevens A, Donaldson L, Sheikh A. The Rise of Patient Safety-II: Should We Give Up Hope on Safety-I and Extracting Value From Patient Safety Incidents? Comment on "False Dawns and New Horizons in Patient Safety Research and Practice". Int J Health Policy Manag 2018; 7:667-670. [PMID: 29996588 PMCID: PMC6037499 DOI: 10.15171/ijhpm.2018.23] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 02/25/2018] [Indexed: 11/09/2022] Open
Abstract
Who could disagree with the seemingly common-sense reasoning that: "We must learn from the things that go wrong."? Despite major investments to improve patient safety, relatively few evaluations demonstrate convincing reductions in risk, harm, serious error or death. This disappointing trajectory of improvement from learning from errors or Safety-I as it is sometimes known has led some researchers to argue that there is more to be gained by learning from the majority of healthcare episodes: the things that go right. Based on this premise, socalled Safety-II has emerged as a new paradigm. In this commentary, we consider the ongoing value of Safety-I based approaches and explore whether now is the time to abandon learning from "the bad" and re-energise data collection and analysis by focusing on "the good."
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Affiliation(s)
- Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Liam Donaldson
- London School of Hygiene and Tropical Medicine, London, UK
| | - Aziz Sheikh
- Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
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22
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Developing agreement on never events in primary care dentistry: an international eDelphi study. Br Dent J 2018; 224:733-740. [DOI: 10.1038/sj.bdj.2018.351] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2017] [Indexed: 11/08/2022]
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23
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Cooper J, Williams H, Hibbert P, Edwards A, Butt A, Wood F, Parry G, Smith P, Sheikh A, Donaldson L, Carson-Stevens A. Classification of patient-safety incidents in primary care. Bull World Health Organ 2018; 96:498-505. [PMID: 29962552 PMCID: PMC6022620 DOI: 10.2471/blt.17.199802] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 03/22/2018] [Accepted: 03/28/2018] [Indexed: 11/27/2022] Open
Abstract
Primary care lags behind secondary care in the reporting of, and learning from, incidents that put patient safety at risk. In primary care, there is no universally agreed approach to classifying the severity of harm arising from such patient-safety incidents. This lack of an agreed approach limits learning that could lead to the prevention of injury to patients. In a review of research on patient safety in primary care, we identified 21 existing approaches to the classification of harm severity. Using the World Health Organization’s (WHO’s) International Classification for Patient Safety as a reference, we undertook a framework analysis of these approaches. We then developed a new system for the classification of harm severity. To assess and classify harm, most existing approaches use measures of symptom duration (11/21), symptom severity (11/21) and/or the level of intervention required to manage the harm (14/21). However, few of these approaches account for the deleterious effects of hospitalization or the psychological stress that may be experienced by patients and/or their relatives. The new classification system we developed builds on WHO’s International Classification for Patient Safety and takes account not only of hospitalization and psychological stress but also of so-called near misses and uncertain outcomes. The constructs we have outlined have the potential to be applied internationally, across primary-care settings, to improve both the detection and prevention of incidents that cause the most severe harm to patients.
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Affiliation(s)
- Jennifer Cooper
- 5th Floor Neuadd Meirionnydd, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YS, Wales
| | - Huw Williams
- 5th Floor Neuadd Meirionnydd, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YS, Wales
| | - Peter Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Adrian Edwards
- 5th Floor Neuadd Meirionnydd, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YS, Wales
| | - Asim Butt
- Office for National Statistics, Newport, Wales
| | - Fiona Wood
- 5th Floor Neuadd Meirionnydd, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YS, Wales
| | - Gareth Parry
- Institute for Healthcare Improvement, Boston, United States of America
| | - Pam Smith
- School of Health in Social Science, University of Edinburgh, Edinburgh, Scotland
| | - Aziz Sheikh
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland
| | - Liam Donaldson
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, England
| | - Andrew Carson-Stevens
- 5th Floor Neuadd Meirionnydd, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YS, Wales
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24
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Yardley IE, Carson-Stevens A, Donaldson LJ. Serious incidents after death: content analysis of incidents reported to a national database. J R Soc Med 2018; 111:57-64. [PMID: 29169009 PMCID: PMC5814035 DOI: 10.1177/0141076817744561] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 11/06/2017] [Indexed: 11/16/2022] Open
Abstract
Objectives To describe serious incidents occurring in the management of patient remains after their death. Design Incidents occurring after patient deaths were analysed using content analysis to determine what happened, why it happened and the outcome. Setting The Strategic Executive Information System database of serious incidents requiring investigation occurring in the National Health Service in England. Participants All cases describing an incident that occurred following death, regardless of the age of the patient. Main outcome measures The nature of the incident, the underlying cause or causes of the incident and the outcome of the incident. Results One hundred and thirty-two incidents were analysed; these related to the storage, management or disposal of deceased patient remains. Fifty-four incidents concerned problems with the storage of bodies or body parts. Forty-three incidents concerned problems with the management of bodies, including 25 errors in postmortem examination, or postmortems on the wrong body. Thirty-one incidents related to the disposal of bodies, 25 bodies were released from the mortuary to undertakers in error; of these, nine were buried or cremated by the wrong family. The reported underlying causes were similar to those known to be associated with safety incidents occurring before death and included weaknesses in or failures to follow protocol and procedure, poor communication and informal working practices. Conclusions Serious incidents in the management of deceased patient remains have significant implications for families, hospitals and the health service more broadly. Safe mortuary care may be improved by applying lessons learned from existing patient safety work.
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Affiliation(s)
- Iain E Yardley
- Department of Paediatric Surgery, Evelina London Children’s Hospital, London SE1 7EH, UK
- Kings College London, London WC2R 2LS, UK
| | - Andrew Carson-Stevens
- Wales Centre for Primary and Emergency Care Research, Cardiff University, Cardiff CF10 3AT, UK
- Australian Institute of Health Innovation, Macquarie University, Sydney NSW 2109, Australia
- Department of Family Practice, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
| | - Liam J Donaldson
- Department of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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25
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Wise KA, Sebastian SJ, Haas-Gehres AC, Moore-Clingenpeel MD, Lamberjack KE. Pharmacist impact on pediatric vaccination errors and missed opportunities in the setting of clinical decision support. J Am Pharm Assoc (2003) 2017; 57:356-361. [PMID: 28427898 DOI: 10.1016/j.japh.2017.02.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 02/03/2017] [Accepted: 02/07/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine pharmacist impact on vaccination errors and missed opportunities in the pediatric primary care setting with the presence of clinical decision support (CDS) by comparing a clinic with a pharmacist and CDS to a clinic with CDS alone. DESIGN A retrospective chart review of patients' electronic medical records compared vaccination errors and missed opportunities between 2 pediatric primary care clinics. SETTING Two urban, pediatric primary care clinics were selected for the study. PARTICIPANTS Encounters were included in the analysis for children presenting for any visit over a 3-month period. INTERVENTION The intervention clinic had a full-time clinical pharmacist and CDS. The comparison clinic had CDS alone. MAIN OUTCOME MEASURES Vaccination errors were defined as follows: doses administered before minimum recommended age, doses administered before minimum recommended dosing interval, unnecessary doses, and invalid doses for a combination of these reasons. Missed opportunities were defined as vaccine doses due at the date of encounter but not administered, without documented reason for vaccination delay or refusal by provider or patient. The likelihood of missing an opportunity was also assessed for patient age, visit type, and provider type. RESULTS One thousand and twenty patient encounters were randomly selected and reviewed. The vaccination error rate was 0.4% in the comparison group and 0% in the intervention group (P = 0.4995). The number of encounters with a missed opportunity was significantly higher in the comparison group compared with the intervention group (51 vs. 30 encounters with missed opportunities; P = 0.015; adjusted odds ratio, 2.14 [95% CI 1.3-35]). CONCLUSION Although the use of CDS results in a low rate of vaccination errors, technology cannot be solely relied on for vaccination recommendations in the pediatric population because of the rigidity of CDS configuration. Pharmacists continue to play a vital role to ensure that children are appropriately vaccinated in the primary care setting.
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Rees P, Edwards A, Powell C, Hibbert P, Williams H, Makeham M, Carter B, Luff D, Parry G, Avery A, Sheikh A, Donaldson L, Carson-Stevens A. Patient Safety Incidents Involving Sick Children in Primary Care in England and Wales: A Mixed Methods Analysis. PLoS Med 2017; 14:e1002217. [PMID: 28095408 PMCID: PMC5240916 DOI: 10.1371/journal.pmed.1002217] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 12/08/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The UK performs poorly relative to other economically developed countries on numerous indicators of care quality for children. The contribution of iatrogenic harm to these outcomes is unclear. As primary care is the first point of healthcare contact for most children, we sought to investigate the safety of care provided to children in this setting. METHODS AND FINDINGS We undertook a mixed methods investigation of reports of primary care patient safety incidents involving sick children from England and Wales' National Reporting and Learning System between 1 January 2005 and 1 December 2013. Two reviewers independently selected relevant incident reports meeting prespecified criteria, and then descriptively analyzed these reports to identify the most frequent and harmful incident types. This was followed by an in-depth thematic analysis of a purposive sample of reports to understand the reasons underpinning incidents. Key candidate areas for strengthening primary care provision and reducing the risks of systems failures were then identified through multidisciplinary discussions. Of 2,191 safety incidents identified from 2,178 reports, 30% (n = 658) were harmful, including 12 deaths and 41 cases of severe harm. The children involved in these incidents had respiratory conditions (n = 387; 18%), injuries (n = 289; 13%), nonspecific signs and symptoms, e.g., fever (n = 281; 13%), and gastrointestinal or genitourinary conditions (n = 268; 12%), among others. Priority areas for improvement included safer systems for medication provision in community pharmacies; triage processes to enable effective and timely assessment, diagnosis, and referral of acutely sick children attending out-of-hours services; and enhanced communication for robust safety netting between professionals and parents. The main limitations of this study result from underreporting of safety incidents and variable data quality. Our findings therefore require further exploration in longitudinal studies utilizing case review methods. CONCLUSIONS This study highlights opportunities to reduce iatrogenic harm and avoidable child deaths. Globally, healthcare systems with primary-care-led models of delivery must now examine their existing practices to determine the prevalence and burden of these priority safety issues, and utilize improvement methods to achieve sustainable improvements in care quality.
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Affiliation(s)
- Philippa Rees
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
- Institute of Child Health, University College London, London, United Kingdom
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
| | - Colin Powell
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
| | - Peter Hibbert
- Australian Institute for Healthcare Innovation, Macquarie University, Macquarie, Australia
| | - Huw Williams
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
| | - Meredith Makeham
- Australian Institute for Healthcare Innovation, Macquarie University, Macquarie, Australia
| | - Ben Carter
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Donna Luff
- Institute for Professionalism and Ethical Practice, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Anesthesia, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America
| | - Gareth Parry
- Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America
- Institute for Healthcare Improvement, Cambridge, Massachusetts, United States of America
| | - Anthony Avery
- Division of General Practice, University of Nottingham, Nottingham, United Kingdom
| | - Aziz Sheikh
- Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Liam Donaldson
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Andrew Carson-Stevens
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
- Australian Institute for Healthcare Innovation, Macquarie University, Macquarie, Australia
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
- * E-mail:
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Samuriwo R, Williams H, Cooper J, Carson-Stevens A. Improving skin care through data: a pitch for patient safety incident reporting. J Wound Care 2016; 25:691. [DOI: 10.12968/jowc.2016.25.12.691] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ray Samuriwo
- Primary Care Patient Safety (PISA), Division of Population Medicine, School of Medicine, Cardiff University
- School of Healthcare Sciences, Cardiff University, UK
- Cardiff Institute for Tissue Engineering and Repair (CITER), Cardiff University, UK
| | - Huw Williams
- Primary Care Patient Safety (PISA), Division of Population Medicine, School of Medicine, Cardiff University
| | - Jennifer Cooper
- Primary Care Patient Safety (PISA), Division of Population Medicine, School of Medicine, Cardiff University
| | - Andrew Carson-Stevens
- Primary Care Patient Safety (PISA), Division of Population Medicine, School of Medicine, Cardiff University
- Patient Safety Research Leader, Primary & Emergency Care Research (PRIME) Centre Wales, Cardiff University, UK
- Visiting Professor of Healthcare Improvement, Department of Family Practice, University of British Columbia, Canada
- Honorary Professor, Institute of Healthcare Policy and Practice, University of the West of Scotland, UK
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Evans HP, Cooper A, Williams H, Carson-Stevens A. Improving the safety of vaccine delivery. Hum Vaccin Immunother 2016; 12:1280-1. [PMID: 26901375 DOI: 10.1080/21645515.2015.1137404] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Vaccines save millions of lives per annum as an integral part of community primary care provision worldwide. Adverse events due to the vaccine delivery process outnumber those arising from the pharmacological properties of the vaccines themselves. Whilst one in three patients receiving a vaccine will encounter some form of error, little is known about their underlying causes and how to mitigate them in practice. Patient safety incident reporting systems and adverse drug event surveillance offer a rich opportunity for understanding the underlying causes of those errors. Reducing harm relies on the identification and implementation of changes to improve vaccine safety at multiple levels: from patient interventions through to organizational actions at local, national and international levels. Here we highlight the potential for maximizing learning from patient safety incident reports to improve the quality and safety of vaccine delivery.
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Affiliation(s)
- Huw P Evans
- a Primary Care Patient Safety (PISA) Research Group, School of Medicine, Cardiff University , Cardiff , Wales
| | - Alison Cooper
- a Primary Care Patient Safety (PISA) Research Group, School of Medicine, Cardiff University , Cardiff , Wales
| | - Huw Williams
- a Primary Care Patient Safety (PISA) Research Group, School of Medicine, Cardiff University , Cardiff , Wales
| | - Andrew Carson-Stevens
- a Primary Care Patient Safety (PISA) Research Group, School of Medicine, Cardiff University , Cardiff , Wales.,b Department of Family Practice , Faculty of Medicine, University of British Columbia , Vancouver , Canada.,c Institute of Healthcare Policy and Practice, University of the West of Scotland , Paisley , Scotland
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Williams H, Cooper A, Carson-Stevens A. Opportunities for incident reporting. Response to: ‘The problem with incident reporting’ by Macraeet al. BMJ Qual Saf 2015; 25:133-4. [DOI: 10.1136/bmjqs-2015-004962] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2015] [Indexed: 11/04/2022]
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