Reporting of adverse events

A multifaceted risk management program to improve the reporting rate of patient safety incidents in primary care: a cluster-randomised controlled trial

BACKGROUND

While patient safety incident reporting is of key importance for patient safety in primary care, the reporting rate by healthcare professionals remains low. This study aimed to assess the effectiveness of a risk management program in increasing the reporting rate within multiprofessional primary care facilities.

METHODS

A nation-wide cluster-randomised controlled trial was performed in France, with each cluster defined as a primary care facility. The intervention included professional e-learning training, identification of a risk management advisor, and multidisciplinary meetings to address incident analysis. In the first observational period, a patient safety incident reporting system for professionals was implemented in all facilities. Then, facilities were randomised, and the program was implemented. Incidents were reported over the 15-month study period. Quasi-Poisson models were used to compare reporting rates.

RESULTS

Thirty-five facilities (intervention, n = 17; control, n = 18) were included, with 169 and 232 healthcare professionals, respectively, involved. Overall, 7 out of 17 facilities carried out the entire program (41.2%), while 6 did not hold meetings (35.3%); 48.5% of professionals logged on to the e-learning website. The relative rate of incidents reported was 2.7 (95% CI = [0.84-11.0]; p = 0.12). However, a statistically significant decrease in the incident rate between the pre-intervention and post-intervention periods was observed for the control arm (HR = 0.2; 95% CI = [0.05-0.54]; p = 0.02), but not for the intervention arm (HR = 0.54; 95% CI = [0.2-1.54]; p = 0.23).

CONCLUSION

This program didn't lead to a significant improvement in the patient safety incident reporting rate by professionals but seemed to sustain reporting over time. Considering that the program was fully implemented in only 41% of facilities, this highlights the difficulty of implementing such multidisciplinary programs in primary care despite its adaptation to the setting. A better understanding of how risk management is currently organized in these multiprofessional facilities is of key importance to improve patient safety in primary care.

TRIAL REGISTRATIONS

The study has been registered at clinicaltrials.gov (NCT02403388) on 30 March 2015.

Health care safety incidents in paediatric emergency care

OBJECTIVE

To characterize safety incidents in paediatric emergency departments (PEDs): frequency, sources, root causes, and consequences.

MATERIALS AND METHODS

We conducted a cross-sectional, observational and descriptive study in the PED of the Clinical University Hospital XX (blinded for review). Patients were recruited through opportunity sampling and the data were collected during care delivery and one week later through a telephone survey. The methodology was based on the ERIDA study on patient safety incidents related to emergency care, which in turn was based on the ENEAS and EVADUR studies.

RESULTS

The study included a total of 204 cases. At least one incident was detected in 25 cases, with two incidents detected in 3 cases, for a total incidence of 12.3%. Twelve incidents were detected during care delivery and the rest during the telephone call. Ten percent did not reach the patient, 7.1% reached the patient but caused no harm, and 82.1% reached the patient and caused harm. Thirteen incidents (46.4%) did not have an impact on care delivery, 8 (28.6%) required a new visit or referral, 6 (21.4%) required additional observation and 1 (3.6%) medical or surgical treatment. The most frequent root causes were health care delivery and medication. Incidents related to procedures and medication were most frequent. Of all incidents, 78.6% were considered preventable, with 50% identified as clear failures in health care delivery.

CONCLUSIONS

Safety incidents affected 12.3% of children managed in the PED of the HCUVA, of which 78.6% were preventable.

Real-Time Reporting of Complications in Hospitalized Surgical Patients by Surgical Team Members Using a Smartphone Application

BACKGROUND

The surgical morbidity and mortality (M&M) conference is a vital part of a resident's surgical education, but methods to collect and store M&M data are often rudimentary and unreliable. The authors propose a Health Insurance Portability and Accountability Act (HIPAA)-compliant, electronic health record (EHR)-connected application and database to report and store complication data.

METHODS

The app is linked to the patient's EHR, and as a result, basic data on each surgical case-including diagnosis, surgery type, and surgeon-are automatically uploaded to the app. In addition, all data are stored in a secure SQL database-with communications between the app and the database end-to-end encrypted for HIPAA compliance. The full surgical team has access to the app, democratizing complications reporting and allowing for reporting in both the inpatient and outpatient settings. This complication information can then be automatically pulled from the app with a premade presentation for the M&M conference. The data can also be accessed by a Power BI dashboard, allowing for easy quality improvement analyses.

RESULTS

When implemented, the app improved data collection for the M&M conference while providing a database for institutional quality improvement use. The authors also identified additional utility of the app, including ensuring appropriate revenue capture. The general appearance of the app and the dashboard can be found in the article.

CONCLUSION

The app developed in this project significantly improves on more common methods for M&M conference complication reporting-transforming M&M data into a valuable resource for resident education and quality improvement.

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

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.

Evaluating the Integration of Patient Safety in Medical Training in Spain

Objectives: The aim of this study was to determine the degree of integration of patient safety in the training of medical faculties at universities in Spain. Methods: A descriptive, cross-sectional study was conducted. An assessment was made of the curse syllabi of Spanish medical schools, summarizing the proportion of faculties that present each of the topics recommended in the WHO's curriculum guide. Results: Of the 49 faculties, access to the curse syllabus of the subjects for the academic year 2023-2024 was obtained from 38 (78%). Although 82% of the faculties integrated some patient safety topic, only 56% included between 1 and 3 of the 11 topics recommended by WHO. The maximum number of integrated topics was 7, and this was only achieved by 1 faculty. Conclusion: There is progress in the incorporation of fundamental concepts in patient safety, but the comprehensive implementation of all topics recommended by the WHO in Spanish medical schools is insufficient.

Barriers to Medication Error Reporting in a Federally Qualified Health Center

OBJECTIVE

To explore the NCC MERP Categories of Errors health professionals are most likely to report and characterize what barriers to medication error reporting influence decisions to report and the extent they do so at a large Federally Qualified Health Center (FQHC).

DESIGN

Prospective, cross-sectional, survey.

SETTING AND PARTICIPANTS

161 medical professionals at a large FQHC clinic with a small pharmacy team.

OUTCOME MEASURES

Survey responses to explore respondent understanding of medication error categories and the influence of barriers to medication error reporting on their decision to report.

RESULTS

Thirty-six (22.4%) respondents completed the survey. Nearly 40% of respondents would not report a near-miss error and were influenced by workplace/environmental barriers significantly more than those who would report. Regardless of reporting experience or patient-care role, assessed barrier categories influence the decision to report similarly.

CONCLUSION

Near-miss medication errors are inconsistently reported. Efforts to improve reporting should emphasize addressing workplace/environmental barriers.

Six Major Steps to Make Investigations of Suicide Valuable for Learning and Prevention

OBJECTIVE

The decline in suicide rates has leveled off in many countries during the last decade, suggesting that new interventions are needed in the work with suicide prevention. Learnings from investigations of suicide should contribute to the development of these new interventions. However, reviews of investigations have indicated that few new lessons have been learned. To be an effective tool, revisions of the current investigation methods are required. This review aimed to describe the problems with the current approaches to investigations of suicide as patient harm and to propose ways to move forward.

METHODS

Narrative literature review.

RESULTS

Several weaknesses in the current approaches to investigations were identified. These include failures in embracing patient and system perspectives, not addressing relevant factors, and insufficient competence of the investigation teams. Investigation methods need to encompass the progress of knowledge about suicidal behavior, suicide prevention, and patient safety.

CONCLUSIONS

There is a need for a paradigm shift in the approaches to investigations of suicide as potential patient harm to enable learning and insights valuable for healthcare improvement. Actions to support this paradigm shift include involvement of patients and families, education for investigators, multidisciplinary analysis teams with competence in and access to relevant parts across organizations, and triage of cases for extensive analyses. A new model for the investigation of suicide that support these actions should facilitate this paradigm shift.HIGHLIGHTSThere are weaknesses in the current approaches to investigations of suicide.A paradigm shift in investigations is needed to contribute to a better understanding of suicide.New knowledge of suicidal behavior, prevention, and patient safety must be applied.

Reproducibility and predictive value of three grading systems for intraoperative adverse events in a cohort of abdominal surgery

INTRODUCTION

Intraoperative adverse events (iAEs) are increasingly recognized for their impact on patient outcomes. The Kaafarani classification and Surgical Apgar Score (SAS) were developed to assess the intraoperative course; however, both have their drawbacks. ClassIntra was validated for iAEs of any origin. This study compares the Kaafarani and SAS to ClassIntra considering predictive value and interrater reliability in a cohort of abdominal surgery to support implementation of a classification in clinical practice.

METHODS

The authors made use of the LAParotomy or LAParoscopy and ADhesiolysis (LAPAD) study database of elective abdominal surgery. Detailed descriptions on iAEs were collected in real-time by a researcher. For the current research aim, all iAEs were graded according ClassIntra, Kaafarani, and SAS (score ≤4). The predictive value was assessed using univariable and multivariable linear regression and the area under the receiver operating curve (AUROC). Two teams graded ClassIntra and Kaafarani to assess the interrater reliability using Cohen's Kappa.

RESULTS

A total of 755 surgeries were included, in which 335 (44%) iAEs were graded according to ClassIntra, 228 (30%) to Kaafarani, and 130 (20%) to SAS. All classifications were significantly correlated to postoperative complications, with an AUROC of 0.67 (95% CI: 0.62-0.72), 0.64 (0.59-0.70), and 0.71 (0.56-0.76), respectively. For the secondary endpoint, the interrater reliability of ClassIntra with κ 0.87 (95% CI: 0.84-0.90) and Kaafarani 0.90 (95% CI: 0.87-0.93) was both strong.

CONCLUSION

ClassIntra, Kaafarani, and SAS can be used for reporting of iAEs in abdominal surgery with good predictive value for postoperative complications, with strong reliability. ClassIntra, compared with Kaafarani and SAS, included the most iAEs and has the most comprehensive definition suitable for uniform reporting of iAEs in clinical practice and research.

A text mining approach to categorize patient safety event reports by medication error type

Patient safety reporting systems give healthcare provider staff the ability to report medication related safety events and errors; however, many of these reports go unanalyzed and safety hazards go undetected. The objective of this study is to examine whether natural language processing can be used to better categorize medication related patient safety event reports. 3,861 medication related patient safety event reports that were previously annotated using a consolidated medication error taxonomy were used to develop three models using the following algorithms: (1) logistic regression, (2) elastic net, and (3) XGBoost. After development, models were tested, and model performance was analyzed. We found the XGBoost model performed best across all medication error categories. 'Wrong Drug', 'Wrong Dosage Form or Technique or Route', and 'Improper Dose/Dose Omission' categories performed best across the three models. In addition, we identified five words most closely associated with each medication error category and which medication error categories were most likely to co-occur. Machine learning techniques offer a semi-automated method for identifying specific medication error types from the free text of patient safety event reports. These algorithms have the potential to improve the categorization of medication related patient safety event reports which may lead to better identification of important medication safety patterns and trends.

Attitudes of undergraduate medical students toward patients' safety in Jordan: a multi-center cross-sectional study

BACKGROUND

Patient safety practices are crucial in healthcare as they aim to reduce harm, medical errors, and ensure favorable outcomes for patients. Therefore, this study aims to examine the attitudes towards patient safety among undergraduate medical students in Jordanian medical schools.

METHODS

A descriptive cross-sectional study was conducted among undergraduate medical students. Participants completed the Attitudes to Patient Safety Questionnaire- III (APSQ-III), which examines students' attitudes in 26 items distributed in nine domains. Results are represented as mean ± standard deviation for all participants and subgroups.

RESULTS

Our study included 1226 medical students. They reported positive attitudes toward patient safety with a mean score of 4.9 (SD ± 0.65). Participants scored the highest score in "Working hours as error cause" followed by "Team functioning". Gender, academic-year, and first-generation student status had a significant association with certain patient safety domains. Females scored significantly higher than males in four domains, while males scored higher in one domain. First-generation medical students had a significantly lower score for "Professional incompetence as error cause". Interestingly, pre-clinical students recorded more positive attitudes in "Patient safety training received" and "Disclosure responsibility" domains.

CONCLUSION

Undergraduate medical students in Jordan demonstrated positive attitudes towards patient safety concepts. Our study provides baseline data to improve current educational programs and enhance the patient safety culture among medical students. Additional studies are needed to delve into actual attitudes toward patient safety and to assess how educational programs contribute to the cultivation of this culture.

When Mistakes Multiply: How Inadequate Responses to Medical Mishaps Erode Trust in American Medicine

In this essay, we explore consequences of the systemic failure to track and to publicize the prevalence of patient-safety threats in American medicine. Tens of millions of Americans lose trust in medical care every year due to safety shortfalls. Because this loss of trust is long-lasting, the corrosive effects build up over time, yielding a collective maelstrom of mistrust among the American public. Yet no one seems to notice that patient safety is a root cause, because no one is counting. In addition to identifying the origins of this purblindness, we offer an alternative policy approach. This would call for government to transparently track safety threats through the systematic collection and reporting of patients' experiences. This alternative strategy offers real promise for stemming the erosion of trust that currently accompanies patient-safety shortfalls while staying consistent with Americans' preferences for a constrained government role with respect to medical care.

Patient Safety and the Question of Dignitary Harms

Patient safety is a central aspect of healthcare quality, focusing on preventable, iatrogenic harm. Harm, in this context, is typically assumed to mean physical injury to patients, often caused by technical error. However, some contributions to the patient safety literature have argued that disrespectful behavior towards patients can cause harm, even when it does not lead to physical injury. This paper investigates the nature of such dignitary harms and explores whether they should be included within the scope of patient safety as a field of practice. We argue that dignitary harms in health care are-at least sometimes-preventable, iatrogenic harms. While we caution against including dignitary harms within the scope of patient safety just because they are relevantly similar to other iatrogenic harms, we suggest that thinking about dignitary harms can help to elucidate the value of patient safety, and to illuminate the evolving relationship between safety and quality.

Investigation of factors related to the behavior of reporting clinical errors in nurses working in educational and medical centers in Rasht city, Iran

BACKGROUND

Report of medical error is one of the effective components in the quality of healthcare services. A significant part of medical errors can be prevented by acting appropriately. The theory of planned behavior offers a framework in which the nurse intention to perform the behavior of error reporting is investigated. This study was conducted to determine the factors related to the behavior of reporting clinical errors in nurses working in educational and medical centers in Rasht based on the theory of planned behavior in 2020.

METHODS

In this descriptive-analytical study, 326 nurses in all medical centers in Rasht were selected by the multi-stage random sampling method. Data collection tool was a valid and reliable questionnaire based on the theory of planned behavior. Data analysis was conducted using the SPSS software, analysis of variance, correlation, and linear regression.

RESULTS

39% of nurses reported that they had reported a medical error, and the average number of error reports per nurse during the last 3 months was 1.42 errors. The predictive power of the theory of behavioral intention was 47%, and predictive constructs were attitude (B = .43), perceived behavioral control (B = .33), and subjective norm (B = .04) using linear regression. The predictive power of the theory for nurses' behavior was 3.1%. None of the demographic variables played a role in predicting the behavior of nurses' reporting clinical error, and no behavioral intention predicted the behavior of nurses' reporting clinical errors.

CONCLUSION

The theory of planned behavior expresses the factors affecting the behavior intention of nurses' reporting clinical errors satisfactorily. However, it was an inappropriate theory in behavior prediction. It appears that factors, such as fear of consequences of error reporting, social pressures by colleagues and officials, and lack of knowledge and skills required to identify medical errors, are the barriers to conversion of intention to the behavior of reporting clinical errors. It is necessary to provide the ground to increase nurses' report of clinical errors by acting appropriately.

Overview of Patient Safety Culture in Bosnia and Herzegovina With Improvement Recommendations for Hospitals

OBJECTIVES

This study investigates the patient safety culture (PSC) in Bosnia and Herzegovina (BiH). We identify factors that contribute to higher patient safety and improved reporting of adverse events, thereby developing recommendations to improve PSC.

METHODS

The study used a correlation design based on cross-sectional surveys in the healthcare sector of BiH (N = 2617). We analyzed the correlation between 9 PSC factors, 4 background characteristics (explanatory variables), and 2 outcome variables (patient safety grade and number of events reported). We also analyzed the variance to determine perceived differences in PSC across the various staff roles in hospitals.

RESULTS

The highest rated PSC factors were Hospital handoffs and transitions and Hospital management support for patient safety and the lowest rated factor was Nonpunitive response to error. Each of the 9 factors showed considerable potential to improve from a hospital, department, and outcome perspective. A comparison of the various employee positions shows significant differences in the PSC perceptions of managers versus nurses and doctors as well as nurses versus doctors.

CONCLUSIONS

We found average scores for most PSC factors, leaving the considerable potential for improvement. Compared with the number of events reported and background characteristics, it is evident that PSC factors contribute significantly to patient safety. These factors are essential for the targeted development of PSC. We propose evidence-based practices as recommendations for improving patients' safety factors.

Evaluating medical students' ability to identify and report errors: finding gaps in patient safety education

BACKGROUND

Although there are frequent complaints of medical students' incompetence in reporting errors, few studies have examined their error-reporting abilities in the real world.

OBJECTIVES

Three sub-functions of self-regulation theory were used to evaluate medical students' ability to identify errors (self-monitoring), analyse root causes (self-judgment), and devise improvement plans (self-reactions). In addition, whether students reacted differently to their errors and those of others (three sub-functions) was also examined.

METHODS

A total of 952 patient safety reports were reviewed retrospectively, submitted by third-year medical students between 2016 and 2018. Data were quantitatively and qualitatively analysed to investigate who committed the error, to identify the type of error and its root causes, and to find suggested improvement plans. Chi-square and Fisher's exact tests were used to compare students' responses to error origins.

RESULTS

Students reported other errors more frequently than their own (67.6% vs. 32.4%). They reported common critical medical errors, including errors related to engaging with patients (34.5%), invasive procedures (20.2%), and infection (18.5%). The root causes identified were more precise than the improvement plans by the students (75.5% vs. 18.4%, respectively). The students' improvement plans were not practical, especially at the patient level (25.8%). When students committed errors, they considered human factors such as fatigue, scheduling, and training as the most common root cause, focussing on improvement plans at the individual level.

CONCLUSIONS

The results suggest that students were good at self-judgment, but not at self-monitoring and self-reactions. They reacted differently, based on who committed the error. To enhance self-regulated learning, Educators should encourage students to confront their errors, reflect on their self-reactions towards errors, develop well-being with time management, and think about the meaning of patient-centredness. Finally, active participation in clinical clerkship longitudinally may provide students with opportunities to learn from their errors.

A Narrative Review of Adverse Event Detection, Monitoring, and Prevention in Indian Hospitals

An adverse event is any abnormal clinical finding associated with the use of a therapy. Adverse events are classified by reporting an event's seriousness, expectedness, and relatedness. Monitoring patient safety is of utmost importance as more and more data becomes available. In reality, very low numbers of adverse events are reported via the official path. Chart review, voluntary reporting, computerized surveillance, and direct observation can detect adverse drug events. Medication errors are commonly seen in hospitals and need provider and system-based interventions to prevent them. The need of the hour in India is to develop and implement medication safety best practices to avoid adverse events. The utility of artificial intelligence techniques in adverse event detection remains unexplored, and their accuracy and precision need to be studied in a controlled setting. There is a need to develop predictive models to assess the likelihood of adverse reactions while testing novel pharmaceutical drugs.

Usability and Accessibility of Publicly Available Patient Safety Databases

OBJECTIVES

The aims of the study were to identify publicly available patient safety report databases and to determine whether these databases support safety analyst and data scientist use to identify patterns and trends.

METHODS

An Internet search was conducted to identify publicly available patient safety databases that contained patient safety reports. Each database was analyzed to identify features that enable patient safety analyst and data scientist use of these databases.

RESULTS

Seven databases (6 hosted by federal agencies, 1 hosted by a nonprofit organization) containing more than 28.3 million safety reports were identified. Some, but not all, databases contained features to support patient safety analyst use: 57.1% provided the ability to sort/compare/filter data, 42.9% provided data visualization, and 85.7% enabled free-text search. None of the databases provided regular updates or monitoring and only one database suggested solutions to patient safety reports. Analysis of features to support data scientist use showed that only 42.9% provided an application programing interface, most (85.7%) provided batch downloading, all provided documentation about the database, and 71.4% provided a data dictionary. All databases provided open access. Only 28.6% provided a data diagram.

CONCLUSIONS

Patient safety databases should be improved to support patient safety analyst use by, at a minimum, allowing for data to be sorted/compared/filtered, providing data visualization, and enabling free-text search. Databases should also enable data scientist use by, at a minimum, providing an application programing interface, batch downloading, and a data dictionary.

Root Cause Analysis Using the Prevention and Recovery Information System for Monitoring and Analysis Method in Healthcare Facilities: A Systematic Literature Review

OBJECTIVES

Unintended events (UEs) are prevalent in healthcare facilities, and learning from them is key to improve patient safety. The Prevention and Recovery Information System for Monitoring and Analysis (PRISMA)-method is a root cause analysis method used in healthcare facilities. The aims of this systematic review are to map the use of the PRISMA-method in healthcare facilities worldwide, to assess the insights that the PRISMA-method offers, and to propose recommendations to increase its usability in healthcare facilities.

METHODS

PubMed, EMBASE.com, CINAHL, and The Cochrane Library were systematically searched from inception to February 26, 2020. Studies were included if the PRISMA-method for analyzing UEs was applied in healthcare facilities. A quality appraisal was performed, and relevant data based on an appraisal checklist were extracted.

RESULTS

The search provided 2773 references, of which 25 articles reporting 10,816 UEs met our inclusion criteria. The most frequently identified root causes were human-related, followed by organizational factors. Most studies took place in the Netherlands (n = 20), and the sample size ranged from 1 to 2028 UEs. The study setting and collected data used for PRISMA varied widely. The PRISMA-method performed by multiple persons resulted in more root causes per event.

CONCLUSIONS

To better understand UEs in healthcare facilities and formulate optimal countermeasures, our recommendations to further improve the PRISMA-method mainly focus on combining information from patient files and reports with interviews, including multiple PRISMA-trained researchers in an analysis, and modify the Eindhoven Classification Model if needed.

Healthcare professionals and pharmacovigilance of pediatric adverse drug reactions: a 5-year analysis of Adverse Events Reporting System Database of the Food and Drug Administration

BACKGROUND

The aim of this study was to analyze the Adverse Events Reporting System (AERS) Database of the Food and Drug Administration (FDA), investigating the characteristics of pediatric adverse drug reactions (ADRs) and describing the effective participation of healthcare professionals in the reporting activity.

METHODS

Reports of ADRs were obtained from the FDA website. Only ADRs in pediatric subjects (divided by age, by country and by professional category) were included into the analysis. The drugs suspected as primary cause of the ADRs in pediatric subjects and their principal anatomic group according to the Anatomical Therapeutic Chemical Classification system were considered. To classify the ADRs, the Medical Dictionary for Regularity Activities terminology was adopted.

RESULTS

Between 2008 and 2012, FDA collected 113,077 ADRs in pediatric patients. Of the total pediatric ADR reports, those performed by medical doctors were 32%, followed by consumers (26%) and healthcare professionals (25%). Most of the ADR reports were related to the adolescent group (39%). Healthcare professionals resulted the category with the highest rate of ADR reports in neonates and infants. Drugs acting on nervous system and antineoplastic/immunomodulating agents were the most involved the pediatric ADR reports. Pyrexia, convulsion, vomiting and accidental overdose were the reactions more reported both from healthcare professionals and medical doctors.

CONCLUSIONS

The present study describes the pediatric ADR reports of the FDA database through healthcare professional's perspective, describing the various aspects of pediatric pharmacovigilance.

Rates and Factors Associated With Serious Outcomes of Patient Safety Incidents in Malaysia: An Observational Study

Introduction

This study aimed to examine the reporting rate and the factors associated with serious outcomes of patient safety incidents at public hospitals in Malaysia.

Methods

All patient safety incidents reported in the e-Incident-Reporting System from January to December 2019 were included in the study. A descriptive study was used to describe the characteristics of incidents, and logistic models were used to identify factors associated with low reporting rates and severe harm or death outcomes of incidents.

Results

There were 9431 patient safety incidents reported in the system in 2019. The mean reporting rate was 2.1/1000 patient bed-days or 1.5% of hospital admissions. The major category of incidents was drug-related incidents (32.4%). No-harm incidents contributed to 56.1% of all the incidents, while 1.1% resulted in death. More hospitals in the eastern (odds ratio [OR], 12.1) and southern regions (OR, 6.1) had low reporting rates compared to the central region. Incidents with severe harm or death outcomes were associated with more males (OR, 1.4) than females and with the emergency department (OR, 10.6), internal medicine (OR, 5.7), obstetrics and gynecology (OR, 2.4), and surgical department (OR, 5.0) more than the pharmacy department. Compared to drug-related incidents, operation-related (OR, 3.0), procedure-related (OR, 3.5), and therapeutic-related (OR, 4.8) incidents had significantly more severe harm or death outcomes, and patient falls (OR, 0.4) had less severe harm or death outcomes.

Conclusion

The mean reporting rate was 2.1/1000 patient bed-days or 1.5% of hospital admissions. More hospitals in the eastern and southern regions had low reporting rates. Certain categories of incidents had significantly more severe outcomes.

Resident physicians' advice seeking and error making: A social networks approach

BACKGROUND

Resident physicians are especially at risk of being involved in medical errors because they bear tremendous responsibility for patient care yet are still in the process of learning and mastering their profession. To increase knowledge and gain information, they create a professional-instrumental network, that is, the deliberate initiation of advice ties with senior physicians.

PURPOSE

We aim to explore whether and how residents' networking with senior physicians is associated with their error rates. Specifically, we aim to identify whether the centralities of residents (advice seekers) and senior physicians (advice givers) in the social network are associated with residents' error rates.

METHODOLOGY

We surveyed 142 resident physicians working in 22 wards in two general hospitals about whom and how frequently they consult using a sociometric technique. Information about errors made in a 3-month period was collected independently.

RESULTS

Residents made less errors when they sought advice from few senior physicians but consulted more frequently with focal senior physicians (those whom many other advice seekers frequently consult). However, when residents sought advice from many senior physicians, their frequency of consultation with focal senior physicians was not associated with their number of errors. These effects were more pronounced for residents at the beginning of their residency period.

CONCLUSIONS

Results of this study provide evidence of a specific association between resident physicians' consultation patterns and their error rates.

PRACTICE IMPLICATIONS

Results inform ward managers about ways to leverage opportunities and remove constraints for residents to ask for advice and for focal physicians to provide it.

Clinical events classification (CEC) in clinical trials: Report on the current landscape and future directions - proceedings from the CEC Summit 2018

IMPORTANCE

Clinical events adjudication is pivotal for generating consistent and comparable evidence in clinical trials. The methodology of event adjudication is evolving, but research is needed to develop best practices and spur innovation.

OBSERVATIONS

A meeting of stakeholders from regulatory agencies, academic and contract research organizations, pharmaceutical and device companies, and clinical trialists convened in Chicago, IL, for Clinical Events Classification (CEC) Summit 2018 to discuss key topics and future directions. Formal studies are lacking on strategies to optimize CEC conduct, improve efficiency, minimize cost, and generally increase the speed and accuracy of the event adjudication process. Major challenges to CEC discussed included ensuring rigorous quality of the process, identifying safety events, standardizing event definitions, using uniform strategies for missing information, facilitating interactions between CEC members and other trial leadership, and determining the CEC's role in pragmatic trials or trials using real-world data. Consensus recommendations from the meeting include the following: (1) ensure an adequate adjudication infrastructure; (2) use negatively adjudicated events to identify important safety events reported only outside the scope of the primary endpoint; (3) conduct further research in the use of artificial intelligence and digital/mobile technologies to streamline adjudication processes; and (4) emphasize the importance of standardizing event definitions and quality metrics of CEC programs.

CONCLUSIONS AND RELEVANCE

As novel strategies for clinical trials emerge to generate evidence for regulatory approval and to guide clinical practice, a greater understanding of the role of the CEC process will be critical to optimize trial conduct and increase confidence in the data generated.

'Are they really allowed to treat me like that?' - A qualitative study to explore the nature of formal patient complaints about mental healthcare services in Sweden

The improvement of mental healthcare services requires patients' experiences to identify problems and possible deficits in care. In this study, we explored the nature and meaning of formal patient complaints about mental healthcare services in one region of Sweden using a descriptive design with a qualitative approach. A systematic random sample of 106 formal patient complaints about mental healthcare services in 1 Swedish county was selected and analysed thematically, based on descriptive phenomenology. Themes identified were: lack of access to mental healthcare services and specialist treatment, problems related to unmet needs and difficulties with healthcare staff, insufficient care and treatment and lack of continuity in care, and experiences of not been taken seriously or feeling abused by staff. The vulnerability of patients already in the system is a greater issue than realized. The human right to health and the healthcare of patients with mental ill health can be strengthened by increased access to care, listening to patients properly, and delivering continuity in care.

Diagnostic Error in Pediatrics: A Narrative Review

A priority topic for patient safety research is diagnostic errors. However, despite the significant growth in awareness of their unacceptably high incidence and associated harm, a relative paucity of large, high-quality studies of diagnostic error in pediatrics exists. In this narrative review, we present what is known about the incidence and epidemiology of diagnostic error in pediatrics as well as the established research methods for identifying, evaluating, and reducing diagnostic errors, including their strengths and weaknesses. Additionally, we highlight that pediatric diagnostic error remains an area in need of both innovative research and quality improvement efforts to apply learnings from a rapidly growing evidence base. We propose several key research questions aimed at addressing persistent gaps in the pediatric diagnostic error literature that focus on the foundational knowledge needed to inform effective interventions to reduce the incidence of diagnostic errors and their associated harm. Additional research is needed to better establish the epidemiology of diagnostic error in pediatrics, including identifying high-risk clinical scenarios, patient populations, and groups of diagnoses. A critical need exists for validated measures of both diagnostic errors and diagnostic processes that can be adapted for different clinical settings and standardized for use across varying institutions. Pediatric researchers will need to work collaboratively on large-scale, high-quality studies to accomplish the ultimate goal of reducing diagnostic errors and their associated harm in children by addressing these fundamental gaps in knowledge.

Incident Management in Health Care: A Pan-Canadian Perspective

BACKGROUND

Nearly 10% of patients experience a harmful patient safety incident in the hospital setting. Current evidence focuses on incident reporting, whereas little is known about how incidents are managed within organizations.

PURPOSE

The aim of this study was to explore processes, tools, and resources for incident management in Canadian health care organizations.

METHODS

Qualitative focus groups were conducted with key stakeholders, representing clinicians, managers, executives, governors, patients, and families (n = 45).

RESULTS

Qualitative data were thematically analyzed and presented as 3 themes: (1) variations in incident reporting and management; (2) simplification of the incident management process; and (3) need for leadership to support just culture and redefine harm.

CONCLUSION

The study findings support and inform efforts to create a patient safety culture in Canadian and international health care organizations. There is a need to develop a standardized, accessible incident reporting and management system for use across health care sectors to promote continuous learning and improvement about patient safety.

Inconsistencies Between Two Cross-Cultural Adaptations of the Hospital Survey on Patient Safety Culture Into French

OBJECTIVES

Two cross-cultural adaptations of the 12-dimension Hospital Survey on Patient Safety Culture (HSOPSC) into French coexist: the Occelli and Vlayen versions. The objective of this study was to assess the psychometric properties of the Occelli version in comparison with those reported for the Vlayen and the original US versions of this instrument.

METHODS

Using the original data from a cross-sectional study of 5,064 employees at a single university hospital in France, we examined the acceptability, internal consistency, factorial structure, and construct validity of the Occelli version of the HSOPSC.

RESULTS

The response rate was 76.8% (n = 3888). Our study yielded lower missing value rates (median, 0.4% [range, 0.0%-2.4%] versus 0.8% [range, 0.2%-11.4%]) and lower dimension scores (median, 3.19 [range, 2.67-3.54] versus 3.42 [range, 2.92-3.96]) than those reported for the Vlayen version. Cronbach alphas (median, 0.64; range, 0.56-0.84) compared unfavorably with those reported for the Vlayen (median, 0.73; range, 0.57-0.86) and original US (median, 0.78; range, 0.63-0.84) versions. The results of the confirmatory factor analysis were consistent between the Vlayen and Occelli versions, making it possible to conduct surveys from the 12-dimensional structure with both versions.

CONCLUSIONS

The inconsistencies observed between the Occelli and Vlayen versions of the HSOPSC may reflect either differences between the translations or heterogeneity in the study population and context. Current evidence does not clearly support the use of one version over the other. The two cross-cultural adaptations of the HSOPSC can be used interchangeably in French-speaking countries.

Factors Related to Medication Administration Incidents in England and Wales Between 2007 and 2016: A Retrospective Trend Analysis

OBJECTIVES

The aims of the study were to describe medication administration incidents reported in England and Wales between 2007 and 2016, to identify which factors (reporting year, type of incident, patients' age) are most strongly related to reported severity of medication administration incidents, and to assess the extent to which relevant information was underreported or indeterminate.

METHODS

Medication administration incidents reported to the National Reporting & Learning System between January 1, 2007, and December 31, 2016 were obtained. Characteristics of the data were described using frequencies, and relationships between variables were explored using cross-tabulation.

RESULTS

A total of 517,384 incident reports were analyzed. Of these, 97.1% (n = 502,379) occurred in acute/general hospitals, mostly on wards (69.1%, n = 357,463), with medicine the most common specialty area (44.5%, n = 230,205). Medication errors were most commonly omitted doses (25.8%, n = 133,397). The majority did not cause patient harm (83.5%, n = 432,097). When only incidents causing severe harm or death (n = 1,116) were analyzed, the most common type of error was omitted doses (24.1%). Most incidents causing severe harm or death occurred in patients aged 56 years or older. For the 10-year period, the percentage of incidents with "no harm" increased (74.1% in 2007 to 86.3% in 2016). For some variables, data were often missing or indeterminate, which has implications for data analysis.

CONCLUSIONS

Medication administration incidents that do not cause harm are increasingly reported, whereas incidents reported as severe harm and death have declined. Data quality needs to be improved. Underreporting and indeterminate data, inaccuracies in reporting, and coding jeopardize the overall usefulness of these data.

Burnout, Engagement, and Dental Errors Among U.S. Dentists

BACKGROUND

Errors can happen during patient care, and some result in harm to the patient. Work place stress has been well established in dentistry, but its relation with errors in the delivery of patient care is less understood. The authors evaluated the relationship between burnout, work engagement, and self-reported dental errors among American dentists.

METHODS

From May to August 2016, a national sample of American Dental Association member dentists were sent a validated, electronic survey assessing their levels of burnout, work engagement, and dental errors.

RESULTS

Of the 391 responding dentists, 46.1% reported concern that they had made a dental error in the last 6 months, 12.1% of the dentists were informed by dental staff that they may have committed an error in the last 6 months, 16% were concerned that a malpractice lawsuit would be filed against them, and 3.6% were actively involved in a malpractice lawsuit. In the adjusted analysis, multivariate logistic regression showed that dentists with either high burnout risk were more likely to report concern over a perceived error within the last 6 months.

CONCLUSIONS

The results suggest that dental provider burnout is potentially a key predictor of reporting perceived dental errors. It is imperative that the dental profession continue to study the effects of work-related stress, develop professional practices that decrease burnout, and reduce errors.

PRACTICAL IMPLICATIONS

Efforts that minimize the potential for burnout may help reduce the occurrence of errors and improve the quality of care provided to dental patients.

Involvement in Root Cause Analysis and Patient Safety Culture Among Hospital Care Providers

BACKGROUND

The experience feedback committee (EFC) is a tool designed to involve medical teams in patient safety management, through root cause analysis within the team.

OBJECTIVE

The aim of the study was to determine whether patient safety culture, as measured by the Hospital Survey on Patient Safety Culture (HSOPS), differed regarding care provider involvement in EFC activities.

METHODS

Using the original data from a cross-sectional survey of 5064 employees at a single university hospital in France, we analyzed the differences in HSOPS dimension scores according involvement in EFC activities.

RESULTS

Of 5064 eligible employees, 3888 (76.8%) participated in the study. Among the respondents, 440 (11.3%) participated in EFC activities. Experience feedback committee participants had a more developed patient safety culture, with 9 of the 12 HSOPS dimension scores significantly higher than EFC nonparticipants (overall effect size = 0.31, 95% confidence interval = 0.21 to 0.41, P < 0.001). A multivariate analysis of variance indicated that all 12 dimension scores, taken together, were significantly different between EFC participants and nonparticipants (P < 0.0001), independently of sex, hospital department, and healthcare profession category. The largest differences in scores related to the "feedback and communication about error," "organizational learning," and "Nonpunitive response to error" dimensions. The analysis of the subgroup of professionals who worked in a department with a productive EFC, defined as an EFC implementing at least five actions per year, showed a higher patient safety culture level for seven of the 12 HSOPS dimensions (overall effect size = 0.19, 95% confidence interval = 0.10 to 0.27, P < 0.001).

DISCUSSION AND CONCLUSIONS

Participation in EFC activities was associated with higher patient safety culture scores. The findings suggest that root cause analysis in the team's routine may improve patient safety culture.

A Machine Learning Approach to Reclassifying Miscellaneous Patient Safety Event Reports

BACKGROUND AND OBJECTIVES

Medical errors are a leading cause of death in the United States. Despite widespread adoption of patient safety reporting systems to address medical errors, making sense of the reports collected in these systems is challenging in practice. Event classification taxonomies used in many reporting systems can be complex and difficult to understand by frontline reporters, leading reporters to classify reports as "miscellaneous" as opposed to assigning a specific event-type category, which may facilitate analysis.

METHODS

To assist patient safety analysts in their analysis of "miscellaneous" reports, we developed an ensemble machine learning natural language processing model to reclassify these reports. We integrated the model into a clinical workflow dashboard, evaluated user feedback, and compared differences in user thresholds for model performance.

RESULTS AND CONCLUSIONS

Integrating an ensemble model to classify "miscellaneous" event reports with an interactive visualization was helpful to patient safety analysts review "miscellaneous" reports. However, patient safety analysts have different thresholds for model reclassification depending on their role and experience with "miscellaneous" event reports.

Hospital Adverse Event Reporting Systems: A Systematic Scoping Review of Qualitative and Quantitative Evidence

INTRODUCTION

Reducing the incidence of reportable events with undesirable effects (REUE) is a priority in the hospital environment, which is why reporting systems have been implemented to identify and manage them. Information is required regarding the performance of reporting systems, barriers, or facilitators for reporting and strategies that improve passive reporting.

METHODOLOGY

Systematic scoping review of the literature that included studies performed in the population exposed to the occurrence of REUE in the health system (teams, patients, and family). A search was performed in Cochrane Database of Systematic Reviews, Epistemonikos, MEDLINE (PubMed), MEDLINE In-Process and MEDLINE Daily Update, EMBASE, LILACS, and databases of the World Health Organization and Pan-American Health Organization.

RESULTS

Fifteen studies were found, 1 systematic review, 2 clinical trials, 8 observational studies, 3 qualitative studies, and 1 mixed study. In 4 of them, the effectiveness of active versus passive reporting systems was compared. The measures to improve the passive systems were education about REUE, simplification of the reporting format, activities focused on increasing the motivation for self-report, adoption of self-report as an obligatory institutional policy, and using specific report formats for each service.

CONCLUSIONS

There is information that allows to find differences between the performance of the active and passive reporting systems. The reviewed research articles found that passive techniques significantly underreported adverse events. It is recommended that institutions adopt both active and passive techniques in adverse event surveillance. New studies should be directed to answer the comparative efficiency of the reporting systems.

The Incidence and Nature of Adverse Medical Device Events in Dutch Hospitals: A Retrospective Patient Record Review Study

OBJECTIVES

Despite widespread use of medical devices and their increasing complexity, their contribution to unintended injury caused by healthcare (adverse events, AEs) remains relatively understudied. The aim of this study was to gain insight in the incidence and types of AEs involving medical devices (AMDEs).

METHODS

Data from two patient record studies for the identification of AEs were used. Identification of AMDEs was part of these studies. Patient records of 6894 admissions of a random sample of 20 hospitals in 2011/2012 and 19 hospitals in 2015/2016 were reviewed for AMDEs by trained nurses and physicians.

RESULTS

In 98.7% of the admissions, a medical device was used. Adverse events involving medical devices were present in 2.8% of the admissions, with 24% of the AMDEs being potentially preventable. Of all AEs, in 40%, medical devices were involved. Of all potentially preventable AEs, in 44%, medical devices were involved. Implants were most often involved in potentially preventable AMDEs.

CONCLUSIONS

Medical devices are substantially involved in potentially preventable AEs in hospitals. Research into AMDEs is of great importance because of the increasing use and complexity of medical devices. Based on patient records, most improvements could be made for placement of implants and prevention of infections related to medical devices. Safety and safe use of medical devices should be a subject of attention and further research.

The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center

Adverse event reporting systems are important tools for identifying areas of risk and opportunities for education and improvement. Our goal was to examine the nature of perioperative incident reports related to care coordination that were filed by staff at an academic tertiary care center. In this retrospective data review, perioperative safety reports between 2015 and 2020 were analyzed. Information examined included the type of staff who initiated the report, location of the incident, type of incident and the severity level of event, including patient harm. Out of the 7827 reports evaluated, 61.2% of reports were filed by nurses, and 5.6% by physicians. We investigated one particular category called "coordination of care" and found the specific event most commonly reported was insufficient handoff (15.0%-26.9%), with severity level reported primarily being no to minor harm reaching the patient. However, communication failures were judged to be one of leading causes of inadvertent harm. It is imperative for hospital incident reporting systems to collect data on issues related to communication failures and to design interventions with the help of frontline staff to provide high quality, safe care to patients and to remain compliant with regulatory requirements and hospital policies.

Impact of an Original Methodological Tool on the Identification of Corrective and Preventive Actions After Root Cause Analysis of Adverse Events in Health Care Facilities: Results of a Randomized Controlled Trial

OBJECTIVE

The aim of the study was to assess the effectiveness of a new methodological tool for the identification of corrective and preventive actions (CAPAs) after root cause analysis of health care-related adverse events.

METHODS

From January to June 2010, we conducted a randomized controlled trial involving risk managers from 111 health care facilities of the Aquitaine Regional Center for Quality and Safety in Health Care (France). Fifty-six risk managers, randomly assigned to two groups (intervention and control), identified CAPAs in response to two sequentially presented adverse event scenarios. For the baseline measure, both groups used their usual adverse event management tools to identify CAPAs in each scenario. For the experimental measure, the control group continued using their usual tools, whereas the intervention group used a new tool involving a systemic approach for CAPA identification. The main outcome measure was the number of CAPAs the participants identified that matched a criterion standard established by eight experts.

RESULTS

Baseline mean number of identified CAPAs did not differ between the two groups (P = 0.83). For the experimental measure, significantly more CAPAs (P = 0.001) were identified by the intervention group (mean [SD] = 4.6 [1.7]) than by the control group (mean [SD] = 2.8 [1.2]).

CONCLUSIONS

For the two scenarios tested, more relevant CAPAs were identified with the new tool than with usual tools. Further research is needed to assess the effectiveness of the new tool for other types of adverse events and its impact on patient safety.

Making Patient Safety Event Data Actionable: Understanding Patient Safety Analyst Needs

OBJECTIVES

The increase in patient safety reporting systems has led to the challenge of effectively analyzing these data to identify and mitigate safety hazards. Patient safety analysts, who manage reports, may be ill-equipped to make sense of report data. We sought to understand the cognitive needs of patient safety analysts as they work to leverage patient safety reports to mitigate risk and improve patient care.

METHODS

Semistructured interviews were conducted with 21 analysts, from 11 hospitals across 3 healthcare systems. Data were parsed into utterances and coded to extract major themes.

RESULTS

From 21 interviews, 516 unique utterances were identified and categorized into the following 4 stages of data analysis: input (15.1% of utterances), transformation (14.1%), extrapolation (30%), and output (14%). Input utterances centered on the source (35.9% of inputs) and preprocessing of data. Transformation utterances centered on recategorizing patient safety events (57.5% of transformations) or integrating external data sources (42.5% of transformations). The focus of interviews was on extrapolation and trending data (56.1% of extrapolations); alarmingly, 16.1% of trend utterances explicitly mentioned a reliance on memory. The output was either a report (56.9% of outputs) or an action (43.1% of outputs).

CONCLUSIONS

Major gaps in the analysis of patient safety report data were identified. Despite software to support reporting, many reports come from other sources. Transforming data are burdensome because of recategorization of events and integration with other data sources, processes that can be automated. Surprisingly, trend identification was mostly based on patient analyst memory, highlighting a need for new tools that better support analysts.

The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems

Background: Population-based studies from several countries have constantly shown excessively high rates of medication errors and avoidable deaths. An efficient medication error reporting system is the backbone of reliable practice and a measure of progress towards achieving safety. Improvement efforts and system changes of medication error reporting systems should be targeted towards reductions in the likelihood of injury to future patients. However, the aim of this review is to provide a summary of medication errors reporting culture, incidence reporting systems, creating effective reporting methods, analysis of medication error reports, and recommendations to improve medication errors reporting systems. Methods: Electronic databases (PubMed, Ovid, EBSCOhost, EMBASE, and ProQuest) were examined from 1 January 1998 to 30 June 2020. 180 articles were found and 60 papers were ultimately included in the review. Data were mined by two reviewers and verified by two other reviewers. The search yielded 684 articles, which were then reduced to 60 after the deletion of duplicates via vetting of titles, abstracts, and full-text papers. Results: Studies were principally from the United States of America and the United Kingdom. Limited studies were from Canada, Australia, New Zealand, Korea, Japan, Greece, France, Saudi Arabia, and Egypt. Detection, measurement, and analysis of medication errors require an active rather than a passive approach. Efforts are needed to encourage medication error reporting, including involving staff in opportunities for improvement and the determination of root cause(s). The National Coordinating Council for Medication Error Reporting and Prevention taxonomy is a classification system to describe and analyze the details around individual medication error events. Conclusion: A successful medication error reporting program should be safe for the reporter, result in constructive and useful recommendations and effective changes while being inclusive of everyone and supported with required resources. Health organizations need to adopt an effectual reporting environment for the medication use process in order to advance into a sounder practice.

Motivating Physicians to Report Adverse Medical Events in China: Stick or Carrot?

BACKGROUND

Adverse medical events (AMEs) pose serious threats to patient safety. One of the major challenges of AME reporting is low physician engagement. This study attempted to examine how punishment and reward can improve physicians' AME reporting in China.

METHODS

A survey was conducted in a large hospital with 1693 beds in China. Data were collected from 311 physicians. Ordinal and binary logistic regression was used for data analysis.

RESULTS

This study reveals that both punishment and reward are positively associated with intention to report AMEs. There is a negative interaction effect between punishment and reward. Although collective punishment is positively associated with intention to report AMEs, collective reward is not. Moreover, the physicians who have fear of negative consequences of AMEs and lack knowledge of AME reporting have lower intention to report AMEs. These findings do not differ between male and female physicians.

CONCLUSIONS

This survey suggests that punishment and reward have potential to motivate Chinese physicians to report AMEs. However, the implementation strategies of these control mechanisms may not be universally applicable and should be carefully designed on the basis of the specific characteristics of the practice site.

Team training and surgical crisis management

Team training and crisis management derive their roots from fundamental learning theory and the culture of safety that burgeoned forth from the industrial revolution through the rise of nuclear energy and aviation. The integral nature of telemedicine to many simulation-based activities, whether to bridge distances out of convenience or necessity, continues to be a common theme moving into the next era of surgical safety as newer, more robust technologies become available.

Frequency of outpatient care adverse events in an occupational mutual insurance company in Spain

BACKGROUND

Occupational mutual insurance companies (OMICs), in collaboration with the Spanish Social Security System, provide healthcare and manage the economic benefits for the workers in Spain. They have ambulatory care centers that attend outpatient trauma pathology, although most of the studies published have focused on surgical and hospital activity. The aim of this study was to detect adverse events (AEs) in outpatient trauma care in the context of an OMIC.

METHODS

A cohort study designed to identify harmful safety incidents (adverse events, AEs) in 2017 was conducted. A random sample of 313 medical records among patients who were visited more than 3 medical and nursing attendances during their outpatient process. The AEs detected were classified according to category, severity and preventability.

RESULTS

We identified 48 AEs (15.3% of medical records, 95% CI 11.3-19.3), most of them procedure-related, while 27 (56.2%) were preventable and 46 mild (95.8%).

CONCLUSIONS

The AEs identified are double than those found in primary care general consultations in Spain and are close to the lower range of studies on surgical AEs in traumatology and orthopedics. Preventable AEs were within expected limits. Over half of AEs are preventable, within that group, the mild AEs have an increased rate of preventability. These results highlight the relevance of research of patient safety in the outpatient care of trauma and orthopaedic procedures in an OMIC for patient safety and contribute to introduce improvements in outpatient care.

Communication about medical errors

Communication about medical errors with patients and families demonstrates respect, compassion, and commitment by providing information, acknowledging harm, and maintaining trust through a process of dialogue that involves multiple conversations. This communication requires knowledge, skills, and attitudes that allow healthcare professionals to discuss facts transparently, take responsibility for what happened, and express regret and (as appropriate) apologize; these abilities also allow professionals to describe what will happen next for the patient and explain what will be done to prevent the error from happening to others in the future. Communication about medical errors also encompasses two other contexts: reporting information about errors to healthcare organizations through data collection systems designed to improve patient safety, and discussing errors with fellow healthcare professionals to promote professional learning and receive emotional support. Communication about errors in these three contexts depends on healthcare professionals who are honest, reflective, compassionate, courageous, accountable, reassuring, and willing to acknowledge and engage their own feelings of sadness, fear, and guilt. Healthcare organizations should promote a systems approach to patient safety and cultivate a culture of transparency and learning in which healthcare professionals are supported as they cope with the distress they experience after an error. Communication about errors should be incorporated into all healthcare practice settings (medical, surgical, in-patient, out-patient), and can be taught to medical students and residents using didactic, role-playing, or simulation methodologies.

Errors linked to medication management in nursing homes: an interview study

Background

The number of errors in medication management in nursing homes is increasing, which may lead to potentially life-threatening harm. Few studies on this subject are found in the municipal nursing home setting, and causes need to be identified. The aim of this study was to explore perceptions of errors connected to medication management in nursing homes by exploring the perspective of first-line registered nurses, registered nurses, and non-licensed staff involved in the care of older persons.

Methods

A qualitative research approach was applied based on semi-structured interviews with 21 participants at their workplaces: Seven in each of the occupational categories of first-line registered nurses, registered nurses, and non-licensed staff. Subcategories were derived from transcribed interviews by content analysis and categorized according to the Man, Technology, and Organization concept of error causation, which is as a framework to identify errors.

Results

Mistakes in medication management were commonly perceived as a result of human shortcomings and deficiencies in working conditions such as the lack of safe tools to facilitate and secure medication management. The delegation of drug administration to non-licensed staff, the abandonment of routines, carelessness, a lack of knowledge, inadequate verbal communication between colleagues, and a lack of understanding of the difficulties involved in handling the drugs were all considered as risk areas for errors. Organizational hazards were related to the ability to control the delegation, the standard of education, and safety awareness among staff members. Safety issues relating to technology involved devices for handling prescription cards and when staff were not included in the development process of new technological aids. A lack of staff and the lack of time to act safely in the care of the elderly were also perceived as safety hazards, particularly with the non-licensed staff working in nursing homes.

Conclusions

The staff working in nursing homes perceive that the risks due to medication management are mainly caused by human limitations or technical deficiencies. Organizational factors, such as working conditions, can often facilitate the occurrence of malpractice. To minimize mistakes, care managers need to have a systemwide perspective on safety issues, where organizational issues are essential.

Dental Patient Safety in the Military Health System: Joining Medicine in the Journey to High Reliability

INTRODUCTION

Delivering consistent high quality care in a safe environment is the goal of the modern dental delivery system. Preventable adverse events, however, are still commonplace in dentistry. As has been demonstrated in the medical field, a concerted and persistent effort will be required to objectively understand and begin to eliminate the sources of dental error. In civilian dental practice this effort is hampered by the underreporting of patient safety events in comparison to the medical field. Patient safety reporting in the Military Health System (MHS) is robust and includes dentistry. This provides an important opportunity to analyze these data as the foundation for improvements in dental care and the elimination of preventable harm. The purpose of this article is to review MHS dental patient safety data, identify the primary sources of dental error and describe current initiatives based on the adoption of the High Reliability Organization (HRO) model of care that has been profitably embraced by the medical community.

METHODS

Dental patient safety report data from the Defense Health Agency Patient Safety Analysis Center (PSAC) for the period 2013-2016 were analyzed to determine the type, incidence, contributing factors, setting and trends for dental errors occurring within the MHS. Comparison to medical data was also performed.

RESULTS

From 2013 to 2016, there was a 32.1% increase in dental patient safety reports in the MHS. For this period, dentistry accounted for the highest number of Sentinel Events (SEs) compared to other clinical specialties and accounted for 32.7% of all SEs for the period. From 2013 to 2016, there was a five-fold increase in reported dental SEs. Wrong-Site Surgeries (WSS) comprised the highest proportion of SEs followed by intraoperative or immediate post-operative/post-procedure or surgery issues (63% and 14%, respectively). Within the WSS category, wrong-site anesthesia and wrong-tooth treated were the two largest sub-categories (40% and 32%, respectively). The data reviewed are not rates and do not take into account the total number of procedures performed by dentistry in comparison to medicine. Root cause analysis identified communication failures and inconsistent adoption of the Universal Protocol as the leading contributing factors for WSSs.

CONCLUSION

Safety initiatives in the dental profession remain immature in comparison to the medical field and the use of an HRO framework is just beginning to emerge in dentistry. The MHS benefits from a robust dental patient safety reporting system when compared to civilian practice in the United States. Review of these data demonstrates that a high priority focus should be the elimination of WSS. Initiatives based on high reliability strategies to address this issue will be discussed. A commitment to reporting and analyzing its performance and adopting the principles and behaviors of HROs will accelerate the MHS goal of providing ever increasing safety and quality in the dental care it provides.

Barriers to Incident Reporting among Nurses: A Qualitative Systematic Review

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

Suicide as an incident of severe patient harm: a retrospective cohort study of investigations after suicide in Swedish healthcare in a 13-year perspective

OBJECTIVES

To explore how mandatory reporting to the supervisory authority of suicides among recipients of healthcare services has influenced associated investigations conducted by the healthcare services, the lessons obtained and whether any suicide-prevention-related improvements in terms of patient safety had followed.

DESIGN AND SETTINGS

Retrospective study of reports from Swedish primary and secondary healthcare to the supervisory authority after suicide.

PARTICIPANTS

Cohort 1: the cases reported to the supervisory authority in 2006, from the time the reporting of suicides became mandatory, to 2007 (n=279). Cohort 2: the cases reported in 2015, a period of well-established reporting (n=436). Cohort 3: the cases reported from September 2017, which was the time the law regarding reporting was removed, to November 2019 (n=316).

PRIMARY AND SECONDARY OUTCOME MEASURES

Demographic data and received treatment in the months preceding suicide were registered. Reported deficiencies in healthcare and actions were categorised by using a coding scheme, analysed per individual and aggregated per cohort. Separate notes were made when a deficiency or action was related to a healthcare-service routine.

RESULTS

The investigations largely adopted a microsystem perspective, focusing on final patient contact, throughout the overall study period. Updating existing or developing new routines as well as educational actions were increasingly proposed over time, while sharing conclusions across departments rarely was recommended.

CONCLUSIONS

The mandatory reporting of suicides as potential cases of patient harm was shown to be restricted to information transfer between healthcare providers and the supervisory authority, rather than fostering participative improvement of patient safety for suicidal patients.The similarity in outcomes across the cohorts, regardless of changes in legislation, suggests that the investigations were adapted to suit the structure of the authority's reports rather than the specific incident type, and that no new service improvements or lessons are being identified.

A Multilevel Analysis of U.S. Hospital Patient Safety Culture Relationships With Perceptions of Voluntary Event Reporting

OBJECTIVES

Patient safety events offer opportunities to improve patient care, but, unfortunately, events often go unreported. Although some barriers to event reporting can be reduced with electronic reporting systems, insight on organizational and cultural factors that influence reporting frequency may help hospitals increase reporting rates and improve patient safety. The purpose of this study was to evaluate the associations between dimensions of patient safety culture and perceived reporting practices of safety events of varying severity.

METHODS

We conducted a cross-sectional survey study using previously collected data from The Agency for Healthcare Research and Quality Hospital Survey of Patient Safety Culture as predictors and outcome variables. The dataset included health-care professionals in U.S. hospitals, and data were analyzed using multilevel modeling techniques.

RESULTS

Data from 223,412 individuals, 7816 work areas/units, and 967 hospitals were analyzed. Whether examining near miss, no harm, or potential for harm safety events, the dimension feedback about error accounted for the most unique predictive variance in the outcome frequency of events reported. Other significantly associated variables included organizational learning, nonpunitive response to error, and teamwork within units (all P < 0.001). As the perceived severity of the safety event increased, more culture dimensions became significantly associated with voluntary reporting.

CONCLUSIONS

To increase the likelihood that a patient safety event will be voluntarily reported, our study suggests placing priority on improving event feedback mechanisms and communication of event-related improvements. Focusing efforts on these aspects may be more efficient than other forms of culture change.