A Tool for the Concise Analysis of Patient Safety Incidents

Telemedicine and Haemodialysis Care during the COVID-19 Pandemic: An Integrative Review of Patient Safety, Healthcare Quality, Ethics and the Legal Considerations in Singapore Practice

The COVID-19 pandemic has been an unprecedented health crisis for the general population as well as for patients with chronic illnesses such as those requiring maintenance dialysis. Patients suffering from chronic kidney disease requiring dialysis are considered a high-risk population. Multiple reports have highlighted an increased need for intensive care and higher death rates among this group of patients. Most maintenance dialysis patients are in-centre haemodialysis patients who receive treatment in shared facilities (community dialysis centres). The inability to maintain social distancing in these facilities has led to case clustering among patients and staff. This poses a substantial risk to the patients, their household members, and the wider community. To mitigate the risks of COVID-19 transmission, telemedicine was rapidly adopted in the past year by nephrologists and other allied-health staff to provide care via remote consultations and reviews. Telemedicine poses unique challenges even in an era where so much is performed online with a high degree of success and satisfaction. In applying distant clinical care for maintenance haemodialysis patients via telemedicine, there is a need to ensure adequate protection for the health and safety of patients as well as understand the ethical and legal implications of telemedicine. We discussed, in this article, these three core aspects of patient safety and quality, ethics and legal implications in telemedicine, and how each of these is crucial to the safe and effective delivery of care in general as well as unique aspects of this in Singapore.

Qualitative content analysis: A framework for the substantive review of hospital incident reports

For decades, incident reports have been utilized as a part of comprehensive healthcare risk management and patient safety programs. As the roles of healthcare risk managers and patient safety professionals become more complex, it is essential that standard tools and strategies used by these professionals, like incident report analysis, be standardized to improve efficiency and effectiveness. Qualitative content analysis provides a structured framework that can be successfully used to describe the categories and themes of incidents, so that, they can be used to develop individual and organizational learning.

A three-tiered approach to investigating patient safety incidents in endoscopy: 4-year experience in a teaching hospital

Background and study aims  Patient safety incidents (PSIs) in endoscopy, although infrequent, can lead to significant morbidity or mortality. There is no commonly agreed strategy to investigate PSIs. We describe a three-tiered approach to investigation to facilitate appropriate action, shared learning, and timely disclosure to patients as mandated in the UK health system by the Duty of Candor (DoC). Methods  PSIs were identified prospectively over a 3-year, 7-month period in a large teaching hospital. Level of investigation was agreed by a group of three senior clinicians. Levels of investigation comprised: 1) rapid desktop review; 2) departmental "mini-root cause analysis" (mini-RCA, developed internally); and 3) hospital-level RCA or mortality review. Results  Of 63006 procedures there were 73 reported cases of significant harm. Eleven resulted in death. Thirty PSIs were related to hepatobiliary endoscopy, 17 to lower gastrointestinal endoscopy, and 26 to upper gastrointestinal endoscopy. Hospital-level RCA was performed in six cases, mini-RCA/mortality review in 14, and 53 were examined by the endoscopy lead. Findings were presented in an endoscopy user group (EUG) meeting. There was learning in relation to informed consent, pre-procedural radiology reviews, pre-procedural treatment, escalation planning, teamwork and communication, preparation of equipment, and recognition of delayed complications. Open and honest communication with patients and relatives was facilitated. Conclusions  The introduction of an endoscopy-tailored investigation tool, the mini-RCA, as part of a three-tiered approach, facilitated investigation, appropriate action, learning, and disclosure after PSIs.

'Case of the month': a novel way to learn from endoscopy-related patient safety incidents

Patient safety incidents (PSIs) are unintended or unexpected incidents which can or do lead to patient harm. The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) acknowledges that PSIs should be reviewed by endoscopy services and learning shared among staff. It is recognised that more could be done to promote shared learning as outlined by the JAG 'Improving Safety and Reducing Error in Endoscopy' strategy. The 'Case of the month' series aims to provide a broad selection of cases and subsequent learning that can be shared among services and their workforce. This review focuses on five case vignettes that highlight a variety of PSIs in endoscopy. A structured approach, based on incident analysis methodology, is applied to each case to categorise PSIs and develop learning points. Learning is directed toward the individual, team and healthcare organisation. A selection of methods to disseminate learning at local, regional and national levels are also described.

Safety analysis over time: seven major changes to adverse event investigation

BACKGROUND

Every safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. In this paper, we reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today.

MAIN TEXT

The primary need for a revised vision of incident analysis is that healthcare itself is changing dramatically. People are living longer, often with multiple co-morbidities which are managed over very long timescales. Our vision of safety analysis needs to expand concomitantly to embrace much longer timescales. Rather than think only in terms of the prevention of specific incidents, we need to consider the balance of benefit, harm and risks over long time periods encompassing the social and psychological impact of healthcare as well as physical effects. We argued for major changes in our approach to the analysis of safety events: assume that patients and families will be partners in investigation and where possible engage them fully from the beginning, examine much longer time periods and assess contributory factors at different time points in the patient journey, be more proportionate and strategic in analysing safety issues, seek to understand success and recovery as well as failure, consider the workability of clinical processes as well as deviations from them and develop a much more structured and wide-ranging approach to recommendations.

CONCLUSIONS

Previous methods of incident analysis were simply adopted and disseminated with little research into the concepts, methods, reliability and outcomes of such analyses. There is a need for significant research and investment in the development of new methods. These changes are profound and will require major adjustments in both practical and cultural terms and research to explore and evaluate the most effective approaches.

Standardizing the classification of abortion incidents: the Procedural Abortion Incident Reporting and Surveillance (PAIRS) Framework

OBJECTIVES

To develop and validate standardized criteria for assessing abortion-related incidents (adverse events, morbidities, near misses) for first-trimester aspiration abortion procedures and to demonstrate the utility of a standardized framework [the Procedural Abortion Incident Reporting & Surveillance (PAIRS) Framework] for estimating serious abortion-related adverse events.

STUDY DESIGN

As part of a California-based study of early aspiration abortion provision conducted between 2007 and 2013, we developed and validated a standardized framework for defining and monitoring first-trimester (≤14weeks) aspiration abortion morbidity and adverse events using multiple methods: a literature review, framework criteria testing with empirical data, repeated expert reviews and data-based revisions to the framework.

RESULTS

The final framework distinguishes incidents resulting from procedural abortion care (adverse events) from morbidity related to pregnancy, the abortion process and other nonabortion related conditions. It further classifies incidents by diagnosis (confirmatory data, etiology, risk factors), management (treatment type and location), timing (immediate or delayed), seriousness (minor or major) and outcome. Empirical validation of the framework using data from 19,673 women receiving aspiration abortions revealed almost an equal proportion of total adverse events (n=205, 1.04%) and total abortion- or pregnancy-related morbidity (n=194, 0.99%). The majority of adverse events were due to retained products of conception (0.37%), failed attempted abortion (0.15%) and postabortion infection (0.17%). Serious or major adverse events were rare (n=11, 0.06%).

CONCLUSIONS

Distinguishing morbidity diagnoses from adverse events using a standardized, empirically tested framework confirms the very low frequency of serious adverse events related to clinic-based abortion care.

IMPLICATIONS

The PAIRS Framework provides a useful set of tools to systematically classify and monitor abortion-related incidents for first-trimester aspiration abortion procedures. Standardization will assist healthcare providers, researchers and policymakers to anticipate morbidity and prevent abortion adverse events, improve care metrics and enhance abortion quality.