Critical incident reporting and learning

Anaesthetic practices and attitudes to patient safety in a sample of Australian veterinary practices

OBJECTIVE

To survey anaesthetic practices and attitudes towards veterinary patient safety in Australia.

STUDY DESIGN

This was a cross-sectional sample population from Australian veterinary practices, including first opinion small animal, mixed animal and referral small animal practices. The survey included practices' anaesthetic management, monitoring equipment and topics regarding patient safety.

RESULTS

Responses were obtained from 310/1700 (18%) veterinary practices, with 208 respondents from small animal practices (67%), 71 mixed animal practices (23%) and 31 referral small animal centres (10%). Overall, 61% of respondents reported always having a dedicated staff member monitoring the anaesthetic, who was most commonly a certified veterinary nurse (89%). In 22% of the practices, some of the staff monitoring an anaesthetic did not have any qualification. Completion of anaesthetic plans for each animal prior to an anaesthetic was reported by 24.5% of respondents and labelling of syringes was completed in 80% of practices. Pulse oximetry (98%) and temperature (88%) were the most common clinical variables monitored. The use of capnography (46%) or an electrocardiogram (48%) was also reported by the respondents. Emergency drugs, airway and ventilation equipment are available in 96%, 88% and 59% of practices, respectively. A defibrillator was available in 11% of practices with only 54% respondents being confident in using it. Of the respondents 60% were aware of anaesthesia safety interventions and clinical guidelines regarding patient safety during anaesthesia.

CONCLUSIONS AND CLINICAL RELEVANCE

Despite practices showing a relative improvement over the years in the standard of anaesthesia care, most of them are still not meeting international guidelines. Areas where changes could lead to improved safety practices could include: a trained person dedicated to monitor anaesthesia, pain scoring evaluation in patients recovering from anaesthesia, an increased use of standardised handover checklists, record keeping and an increase in open discussion of adverse events by the veterinary team.

The nature of the response to airway management incident reports in high income countries: A scoping review

Adverse events associated with failed airway management may have catastrophic consequences, and despite many advances in knowledge, guidelines and equipment, airway incidents and patient harm continue to occur. Patient safety incident reporting systems have been established to facilitate a reduction in incidents. However, it has been found that corrective actions are inadequate and successful safety improvements scarce. The aim of this scoping review was to assess whether the same is true for airway incidents by exploring academic literature that describes system changes in airway management in high-income countries over the last 30 years, based on findings and recommendations from incident reports and closed claims studies. This review followed the most recent guidance from the Joanna Briggs Institute (JBI). PubMed, Ovid MEDLINE and Embase, the JBI database, SCOPUS, the Cochrane Library and websites for anaesthetic societies were searched for eligible articles. Included articles were analysed and data synthesised to address the review's aim. The initial search yielded 28,492 results, of which 111 articles proceeded to the analysis phase. These included 23 full-text articles, 78 conference abstracts and 10 national guidelines addressing a range of airway initiatives across anaesthesia, intensive care and emergency medicine. While findings and recommendations from airway incident analyses are commonly published, there is a gap in the literature regarding the resulting system changes to reduce the number and severity of adverse airway events. Airway safety management mainly focuses on Safety-I events and thereby does not consider Safety-II principles, potentially missing out on all the information available from situations where airway management went well.

Results of shared learning of a new radiofrequency identification localization device-a UK iBRA-NET breast cancer localisation study

INTRODUCTION

Localisation methods for surgical excision of impalpable breast lesions have advanced in recent years, with increasing utilization of new wire-free technologies. The Hologic LOCalizer™ radiofrequency identification (RFID) tag is one such device; however, as is the case when new technologies are first introduced, little is known about clinical experiences, potential complications, and learning used to overcome perioperative challenges when changing from guidewires to RFID tags. This study reports shared learning experiences of clinicians using the LOCalizer™ as part of the national iBRA-NET localisation study.

METHODS

This mixed-methods study captured shared-learning themes relating to LOCalizer™ usage as part of a multicentre prospective registry study, which collected data on each LOCalizer™ placement. Prospective, anonymized clinical and demographic data were collected and managed using a Research Electronic Data Capture (REDCap) database. Shared learning was captured prospectively as part of the registry study between January 2021 and July 2022, combined with a virtual qualitative webinar-style focus group. Learning events were then coded, grouped by theme, and suggestions for practice were produced.

RESULTS

Twenty-four UK breast units submitted data on 1188 patient records pertaining to RFID-guided localisation between January 2021 and July 2022, of which 59 (5.0%) included a shared-learning event. The virtual webinar was attended by 108 healthcare professionals, including oncoplastic breast surgeons and breast radiologists. Shared-learning themes were categorized into preoperative, intraoperative, and postoperative events.

CONCLUSIONS

By sharing learning outcomes associated with localisation techniques in this paper, the aim is to shorten the learning curve and potential for adverse events for users new to the LOCalizer™ technique.

Barriers to Incident Reporting by Physicians: A Survey of Surgical Residents and Attending Physicians

Objectives Incident reporting is vital to a culture of safety; however, physicians report at an alarmingly low rate. This study aimed to identify barriers to incident reporting among surgeons at a quaternary care center. Methods A survey was created utilizing components of the Agency for Healthcare Research and Quality (AHRQ) validated survey on patient safety culture. This tool was distributed to residents and attending physicians in general surgery and urology at a single academic medical center. Responses were de-identified and recorded for data analysis using REDCap (Research Electronic Data Capture) database tool (Vanderbilt University, Nashville, Tennessee, United States). Results We received 39 survey responses from 116 residents and attending physicians (34% response rate), including nine urologists and 30 general surgeons (24 attendings, 15 residents). Residents and attendings feel the person is being written up and not the issue (67%) and that there is a lack of feedback after changes are implemented (64%), though most believe adequate action is taken to address patient safety concerns (72%). Most do not report near-misses (64%), only significant adverse events (59%). Residents are likely to stay silent when patient safety events involve those in authority (60%). Faculty feel those in authority are open to patient safety concerns (67%), though residents feel neutral (47%) or disagree (33%). Conclusion Underreporting of incidents among physicians remains multifaceted and complex, from fear of retaliation to lack of feedback. Residents tend to feel less comfortable addressing authority figures when concerned about patient safety. While misunderstanding still exists about the applications and utility of incident reporting, a focus on quality over quantity could afford more meaningful progress toward high reliability in healthcare.

Wake Up Safe in the USA & International Patient Safety

Patient safety is the most important aspect of anesthetic care. For both healthcare professionals and patients, the ideal would be no significant morbidity or mortality under anesthesia. Lessons from harm during healthcare can be shared to reduce harm and to increase safety. Many nations and individual institutions have developed robust safety systems to improve the quality and safety of patient care. Large registries that collect rare events, analyze them, and share findings have been developed. The approach, the funding, the included population, support from institutions and government and the methods of each vary. Wake Up Safe (WUS) is a patient safety organization accredited by Agency for Healthcare Research and Quality. Wake Up Safe was established in the United States in 2008 by the Society for Pediatric Anesthesia. The initiative aims to gather data on adverse events, analyze these incidents to gain insights, and apply this knowledge to ultimately reduce their occurrence. The purpose of this review is to describe the patient safety approaches in the USA. Through a national patient safety database WUS. Similar approaches either through WUS international or independent safety approaches have been described in Australia-New Zealand, India, and Singapore. We examine the patient safety processes across the four countries, evaluating their incident review process and the distribution of acquired knowledge. Our focus is on assessing the potential benefits of a WUS collaboration, identifying existing barriers, and determining how such a collaboration would integrate with current incident review databases or systems.

Understanding an epidemiological view of a retrospective audit of medication errors in an intensive care unit

BACKGROUND

Medication errors in the intensive care setting continue to occur at significant rates and are often associated with adverse events and potentially life-threatening repercussions.

AIM/OBJECTIVE

The aim of this study was to (i) determine the frequency and severity of medication errors reported in the incident management reporting system; (ii) examine the antecedent events, their nature, the circumstances, risk factors, and contributing factors leading to medication errors; and (iii) identify strategies to improve medication safety in the intensive care unit (ICU).

METHOD

A retrospective, exploratory, descriptive design was selected. Retrospective data were collected from the incident report management system and electronic medical records over a 13-month period from a major metropolitan teaching hospital ICU.

RESULTS

A total of 162 medication errors were reported during a 13-month period, of which, 150 were eligible for inclusion. Most medication errors occurred during the administration (89.4%) and dispensing phases (23.3%). The highest reported errors included incorrect doses (25.3%), incorrect medications (12.7%), omissions (10.7%), and documentation errors (9.3%). Narcotic analgesics (20%), anaesthetics (13.3%), and immunomodifiers (10.7%) were the most frequently reported medication classes associated with medication errors. Prevention strategies were found to be focussed on active errors (67.7%) as opposed to latent errors (32.3%) and included various and infrequent levels of education and follow-up. Active antecedent events included action-based errors (39%) and rule-based errors (29.5%), whereas latent antecedent events were most associated with a breakdown in system safety (39.3%) and education (25%).

CONCLUSION

This study presents an epidemiological view and understanding of medication errors in an Australian ICU. This study highlighted the preventable nature of most medication errors in this study. Improving administration-checking procedures would prevent the occurrence of many medication errors. Approaches aimed at both individual- and organisational-level improvements are recommended to address administration errors and inconsistent medication-checking procedures. Areas for further research include determining the most effective system developments for improving administration-checking procedures and verifying the risk and prevalence of immunomodifier administration errors in the ICU as this is an area not reported previously in the literature. In addition, the impact of single- versus two-person checking procedures on medication errors in the ICU should be prioritised to address current evidence gaps.

What is the effectiveness of reporting systems in promoting learning in healthcare?

Patient safety in healthcare remains a top priority. Learning from safety events is vital to move towards safer systems. As a result, reporting systems are recognised as the cornerstone of safety, especially in high-risk industries. However, in healthcare, the benefits of reporting systems in promoting learning remain contentious. Though the strengths of these systems, such as promoting a safety culture and providing information from near misses are noted, there are problems that mean learning is missed. Understanding the factors that both enable and act as barriers to learning from reporting is also important to consider. This review, considers the effectiveness of reporting systems in contributing to learning in healthcare.

[Understanding complex processes better-A case study on increasing patient safety and efficiency in a central operating room]

BACKGROUND

Various professional groups are involved in the daily work of the central operating room with the aim of providing the best possible treatment for each individual using modern medical technology (sociotechnical system) in a cost-effective manner. Ensuring perioperative patient safety is of particular importance. At the same time, the efficient use of the central operating room is essential for the economic success of a hospital. Preoperative preparation is a complex process with many substeps that are often difficult to manage. Historically, the focus has been on retrospective learning from errors and incidents. More recent approaches take a systemic view. A central idea is to consider the mostly positive course of treatment and the adjustments to daily work that are currently required by the people involved (Safety-II). By taking greater account of how the many components of the system interact, processes can be better understood and specific measures derived. This strengthens the system's ability to adapt to changes and disturbances, thus ensuring that goals are achieved. The functional resonance analysis method (FRAM) is an internationally recognized method for modelling work as done compared to work as imagined. This paper presents the application of FRAM to preoperative preparation in a major regional hospital.

OBJECTIVE

Is FRAM suitable for improving process understanding in preoperative preparation?

MATERIAL AND METHODS

An interdisciplinary project team identified relevant functions of preoperative preparation through document analysis and walkthroughs. Based on this, more than 30 guided interviews were conducted with functionaries. The results were presented graphically and specific information, such as safety-related statements or reasons for the variability of functions, were also presented textually. In the next phase, statements were evaluated and compared with the target model and the job descriptions.

RESULTS

The FRAM revealed the process as a complex network of relationships. During the modelling process, a varying degree of centrality and variability of certain functions became apparent. From the observations, the project team selected those with high relevance for patient safety and for the efficiency of the overall process in order to prioritize starting points for deriving measures to increase resilience. These starting points relate either to single functions, such as surgical site marking or to multiple functions that are variable in their execution, such as delays due to nonsynchronized duty times.

CONCLUSION

The FRAM conducted provides valuable new insights into the functioning of complex sociotechnical systems that go far beyond classical linear methods. The awareness of operational processes gained and the resulting dynamic view of interactions within the system enable specific measures to be derived that promote resilient behavior and reduce critical variability, thus contributing to increased patient safety and efficiency.

Safety on the ground: using critical incident technique to explore the factors influencing medical registrars' provision of safe care

BACKGROUND

Avoidable patient harm in hospitals is common, and doctors in training can provide underused but crucial insights into the influencers of patient safety as those working 'on the ground' within the system. This study aimed to explore the factors that influence safe care from the perspective of medical registrars, to identify targets for safety-related improvements.

METHODS

This study used enhanced critical incident technique (CIT), a qualitative methodology that results in a focused understanding of significant factors influencing an activity, to identify practical solutions. We interviewed 12 out of 17 consenting medical registrars in Scotland, asking them to recount their observations during clinical experiences where something happened that positively or negatively impacted on patient safety. Data were analysed manually using a modified content analysis with credibility checks as per enhanced CIT, with data exhaustiveness reached after six registrars.

RESULTS

A total of 221 critical incidents impacting patient safety were identified. These were inductively placed into 24 categories within 4 overarching categories: Individual skills, encompassing individual behavioural and technical skills; Collaboration, regarding how communication, trust, support and flexibility shape interprofessional collaboration; Organisation, concerning organisational systems and staffing and Training environment, relating to culture, civility, having a voice and learning at work. Practical targets for safety-related interventions were identified, such as clear policies for patient care ownership or educational interventions to foster civility.

CONCLUSIONS

This study provides a rigorous and focused understanding of the factors influencing patient safety in hospitals, using the 'insider' perspective of the medical registrar. Safety goes beyond the individual and is reliant on safe system design, interprofessional collaboration and a culture of support, learning and respect. Organisations should also promote flexibility within clinical practice when patient needs do not conform to standardised care pathways. We suggest targeted interventions within educational and organisational priorities to improve safety in hospitals.

Management of adverse events in a Moroccan regional hospital: a state of art and perspectives

Introduction

the risk management system is useful to identify, analyze, and reduce the risk occurrence of adverse events (AEs) in health services. This system suggests useful improvements to patients and to the whole institution and also contributes to the acquisition of a collective and organizational safety culture. This study presented a state of the art of the management of AEs identified in different services of a regional hospital in the north of Morocco.

Methods

this is a retrospective cross-sectional exploratory study carried out from 2017 to 2019 using observations and semi-structured interviews, which were recorded, re-transcribed, and analyzed. Data was also collected from audit reports, results of investigations of the nosocomial infection control committee and the risk management commission, AEs declaration sheets, and meetings reports.

Results

a number of 83 AEs were recorded, 10 of which were urgent. The reported events were related to care, infection risk, the drugs circuit, and medico-technical events. Two hundred cases of nosocomial infections were also recorded, of which 75 occurred in the intensive care unit and 35 in the maternity service. Surgical site infections were the most frequently reported complication. Adverse events were related to organizational failure, equipment problems, and errors related to professional practices.

Conclusion

our findings may guide the improvement of the event management system in order to reduce the occurrence of future incidents. Thus, improving the risk management system requires setting up training strategies for staff on the importance of this system and its mode of operation.

Assessment of Patient Matters in Healthcare Facilities

BACKGROUND AND OBJECTIVES

Ensuring the sustainability of healthcare facilities requires the evaluation of patient matters with appropriate methods and tools. The objective of this research is to develop a new tool for assessing patient matters as a component of social responsibility requirements that contribute to the sustainability of healthcare facilities.

MATERIALS AND METHODS

We carried out an analytical observational study in which, starting from the domains of the reference framework for the sustainability of health facilities (economic, environmental, social, provision of sustainable medical care services and management processes), we designed indicators that describe patient matters. To achieve this, we extracted from the scientific literature the most recent data and aspects related to patient matters that have been reported by representative hospitals from all over the world. These were organized into the four sequences of the quality cycle. We designed the method of evaluating the indicators based on the information couple achievement degree-importance of the indicator. In the experimental part of the study, we validated the indicators for the evaluation of patient matters and the evaluation method at an emergency hospital with an orthopedic profile.

RESULTS

We developed the patient matters indicator matrix, the content of the 8 indicators that make it up, questions for the evaluation of the indicators, and the evaluation grids of the indicators. They describe five levels for each variable of the achievement degree-importance couple. The practical testing of the indicators at the emergency hospital allowed the calculation of sustainability indicators and the development of a prioritization matrix for improvement measures.

CONCLUSIONS

Indicators designed in this research cover social responsibility requirements that describe patient matters. They are compatible and can be used by health facilities along with other implemented national and international requirements. Their added value consists in promoting social responsibility and sustainable development of healthcare facilities.

A retrospective analysis of adverse events reported by Tunisian intensive care units' professionals

INTRODUCTION

Adverse events (AEs) that occur in hospitals remain a challenge worldwide, and especially in intensive care units (ICUs) where they are more likely to occur. Monitoring of AEs can provide insight into the status and advances of patient safety. This study aimed to examine the AEs reported during the 20 months after the implementation of the AE reporting system.

METHODS

We conducted a retrospective analysis of a voluntary ICU AE reporting system. Incidents were reported by the staff from ten ICUs in the Sahloul University Hospital (Tunisia) between February 2020 and September 2021.

RESULTS

A total of 265 reports were received, of which 61.9% were deemed preventable. The most frequently reported event was healthcare-associated infection (30.2%, n = 80), followed by pressure ulcers (18.5%, n = 49). At the time of reporting, 25 patients (9.4%) had died as a result of an AE and in 51.3% of cases, the event had resulted in an increased length of stay. Provider-related factors contributed to 64.2% of the events, whilst patient-related factors contributed to 53.6% of the events. As for criticality, 34.3% of the events (n = 91) were unacceptable (c3) and 36.3% of the events (n = 96) were 'acceptable under control' (c2).

CONCLUSIONS

The reporting system provided rich information on the characteristics of reported AEs that occur in ICUs and their consequences and may be therefore useful for designing effective and evidence-based interventions to reduce the occurrence of AEs.

Implementation and evaluation of an event reporting system in an academic anaesthesia department

BACKGROUND

Reporting adverse clinical events is essential to a culture of safety in healthcare. However, self-reporting such events is generally not widely prevalent in a typical academic anaesthesia department.

METHODS

We set out to create a self-reporting tool to securely accept data from multiple anaesthesia service locations, including data linked to our electronic anaesthesia record, and combine them into an accessible database.We created a web-based database module for incident reporting integrated into the department's intranet. The system was also designed to actively prompt anaesthesia providers for reports following each day of clinical work.

RESULTS

478 events were recorded in the database in the first year of implementation. There were 33 347 anaesthesia encounters in that period, translating to a reporting rate of 1.43% (95% CI 1.31% to 1.57%). In the second year, which coincided with the second phase of implementation, 608 events were reported out of 45 985 anaesthesia encounters, for a reporting rate of 1.32% (95% CI 1.22% to 1.43%). Approximately 40% of events entered into the database occurred in a non-operating room location. The annual reporting rates for 2014, 2015, 2016, 2017, 2018 and 2019 were 1.26% (95% CI 1.16% to 1.37%), 1.15% (95% CI 1.05% to 1.25%), 1% (95% CI 0.9% to 1.1%), 0.6% (95% CI 0.53% to 0.68%), 0.5% (95% CI 0.44% to 0.57%), 0.4% (95% CI 0.3% to 0.5%), respectively.

CONCLUSIONS

Our incident reporting system facilitated reporting of events within and outside the operating room. The system captured event data valid for quality improvement within the anaesthesia department.

Uncovering the Risks of Anticancer Therapy Through Incident Report Analysis Using a Newly Developed Medical Oncology Incident Taxonomy

BACKGROUND

Incident reporting systems were developed to identify possible and actual harm in healthcare facilities. They have the potential to capture important safety trends and to enable improvements that can mitigate the risk of future patient harm and suffering. We recently developed and validated a taxonomy specific for medical oncology designed to enhance the identification, tracking, and trending of incidents that may lead to patient harm. The current project was designed to test the ability of such a taxonomy to be applied across different organizations delivering medical oncology care and to identify specific risks that could result in future harm.

METHODS

We analyzed 309 randomly selected medical oncology-related incident reports from 3 different cancer centers that had been posted between January 2019 and December 2020. Each report was assigned up to 2 incident categories. We used a 2-step process to reconcile reviewer discrepancies. In a secondary analysis, each of the incidents was reviewed and recoded to identify events which may result in major or catastrophic harm.

RESULTS

Three hundred four incidents met criteria for inclusion. Three hundred incidents (98.7%) were successfully coded. Sixty-seven percent of incidents were encompassed by the following 4 of 21 categories: prescriber ordering (22%), nursing care (15%), pharmacy (14%), and relational/communication issues (15%). Of 297 evaluable incidents, 47% did not reach the patient, 44.7% reached the patient without harm, 7.7% caused minor injury, and 0.7% caused severe injury or death. Submission rates by physicians varied between the 3 sites accounting for 1.7%, 10.7%, and 16.1% of reports. Secondary analysis identified 9 distinct scenarios that may result in major or catastrophic patient harm.

CONCLUSIONS

A medical oncology-specific incident reporting taxonomy has the potential to increase our understanding of inherent risks and may lead to process improvements that improve patient safety.

Planned improvement actions based on patient safety incident reports in Estonian hospitals: a document analysis

AIM

Aim of this study was to describe and analyse associations of incidents and their improvement actions in hospital setting.

METHODS

It was a retrospective document analysis of incident reporting systems' reports registered during 2018-2019 in two Estonian regional hospitals. Data were extracted, organised, quantified and analysed by statistical methods.

RESULTS

In total, 1973 incident reports were analysed. The most commonly reported incidents were related to patient violent or self-harming behaviour (n=587), followed by patient accidents (n=379), and 40% of all incidents were non-harm incidents (n=782). Improvement actions were documented in 83% (n=1643) of all the reports and they were focused on (1) direct patient care, (2) staff-related actions; (3) equipment and general protocols and (4) environment and organisational issues. Improvement actions were mostly associated with medication and transfusion treatment and targeted to staff. The second often associated improvement actions were related to patient accidents and were mostly focused on that particular patient's further care. Improvement actions were mostly planned for incidents with moderate and mild harm, and for incidents involving children and adolescents.

CONCLUSION

Patient safety incidents-related improvement actions need to be considered as a strategy for long-term development in patient safety in organisations. It is vital for patient safety that the planned changes related to the reporting will be documented and implemented more visibly. As a result, it will boost the confidence in managers' work and strengthens all staff's commitment to patient safety initiatives in an organisation.

Mitigating work conditions that can inhibit learning from errors: Benefits of error management climate perceptions

Introduction

Professionals do not always learn from their errors; rather, the way in which professionals experience errors and their work environment may not foster, but can rather inhibit error learning. In the wake of a series of accounting scandals, including Royal Ahold in Netherlands, Lehman Brothers in the United States, and Wirecard in Germany, within the context of financial auditing, we explore four audit-specific conditions at the workplace that could be negatively associated with learning: small error consequences, routine-type errors, negative emotions, and high time pressure. Then, we examine how perceptions of an open or blame error management climate (EMC) moderate the negative relationship between the four work conditions and learning from errors.

Methods

Using an experiential questionnaire approach, we analyze data provided by 141 Dutch auditors across all hierarchical ranks from two audit firms.

Results

Our results show that open EMC perceptions mitigate the negative relationship between negative emotions and error learning, as well as the negative relationship between time pressure and error learning. While we expected that blame EMC perceptions would exacerbate the negative relationship between negative emotions and error learning, we find a mitigating effect of low blame EMC perceptions. Further, and contrary to our expectations, we find that blame EMC perceptions mitigate the negative relationship between small error consequences and error learning, so that overall, more error learning takes place regardless of consequences when participants experience a blame EMC. Post-hoc analyses reveal that there is in fact an inverted- U-shaped relationship between time pressure and error learning.

Discussion

We derive several recommendations for future research, and our findings generate specific implications on how (audit) organizations can foster learning from errors.

Strengths and weaknesses of the incident reporting system: An Italian experience

One of the cornerstones for enhancing the patient safety culture is the incident reporting system (IRS). It is a process for detecting, reporting, collecting, and summarizing adverse events (AEs) and near-misses in healthcare, and so it represents a vital tool for clinical risk management. We analyzed the 5-year experience of a third-level hospital's IRSs, showing its trends and highlighting its main strengths and weaknesses. Patients’ falls and physical or verbal aggression toward the providers or between patients are the most reported events. Underreporting is the main limitation of the system, especially among nurses. Visible actions, forceful analysis of the reports, operators’ education, no-blame culture promotion, and organizational adjustments may improve operators’ adherence to IRS. Providers do not willingly inform patients’ relatives about fatal incidents. Despite that, the IRS is far from its potential, and the number of data collected has increased.

Addressing Patient Safety Hazards Using Critical Incident Reporting in Hospitals: A Systematic Review

INTRODUCTION

Critical incident reporting systems (CIRS) are in use worldwide. They are designed to improve patient care by detecting and analyzing critical and adverse patient events and by taking corrective actions to prevent reoccurrence. Critical incident reporting systems have recently been criticized for their lack of effectiveness in achieving actual patient safety improvements. However, no overview yet exists of the reported incidents' characteristics, their communication within institutions, or actions taken either to correct them or to prevent their recurrence. Our main goals were to systematically describe the reported CIRS events and to assess the actions taken and their learning effects. In this systematic review of studies based on CIRS data, we analyzed the main types of critical incidents (CIs), the severity of their consequences, their contributing factors, and any reported corrective actions.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we queried MEDLINE, Embase, CINAHL, and Scopus for publications on hospital-based CIRS. We classified the consequences of the incidents according to the National Coordinating Council for Medication Error Reporting and Prevention index, the contributing factors according to the Yorkshire Contributory Factors Framework and the Human Factors Classification Framework, and all corrective actions taken according to an action hierarchy model on intervention strengths.

RESULTS

We reviewed 41 studies, which covered 479,483 CI reports from 212 hospitals in 17 countries. The most frequent type of incident was medication related (28.8%); the most frequent contributing factor was labeled "active failure" within health care provision (26.1%). Of all professions, nurses submitted the largest percentage (83.7%) of CI reports. Actions taken to prevent future CIs were described in 15 studies (36.6%). Overall, the analyzed studies varied considerably regarding methodology and focus.

CONCLUSIONS

This review of studies from hospital-based CIRS provides an overview of reported CIs' contributing factors, characteristics, and consequences, as well as of the actions taken to prevent their recurrence. Because only 1 in 3 studies reported on corrective actions within the healthcare facilities, more emphasis on such actions and learnings from CIRS is required. However, incomplete or fragmented reporting and communication cycles may additionally limit the potential value of CIRS. To make a CIRS a useful tool for improving patient safety, the focus must be put on its strength of providing new qualitative insights in unknown hazards and also on the development of tools to facilitate nomenclature and management CIRS events, including corrective actions in a more standardized manner.

[Safety‑II: a systemic approach for an effective clinical risk management]

The healthcare system is an example of a complex sociotechnical system where the goal is the best possible individual treatment together with the cost-effective use of modern technology. Working in anesthesia requires medical knowledge as well as manual skills and the use of specialized technical equipment in an interdisciplinary and interprofessional setting. The susceptibility to errors and adverse events, especially in the care of critically ill patients, is high.In order to avoid unintentional hospital-induced patient harm, the healthcare system has recently taken the path of prescribing the best possible care for a large number of patients with the help of evidence-based guidelines and specific algorithms or instructions for action. Patient safety is defined accordingly as a state in which adverse events occur as rarely as possible (Safety‑I).Following this approach clinical risk management is defined as the purposeful planning, coordination, execution and control of all measures that serve to avoid unintended hospital-induced patient harm or to limit its effects. For this purpose, the focus has recently been placed on instruments such as Critical Incident Reporting Systems (CIRS) or Morbidity and Mortality Conferences (M&MC); however, it is increasingly recognized that adverse events in complex sociotechnical systems such as the healthcare system arise situationally from the interaction of numerous components of the system. The effectiveness of CIRS and M&MC is limited because they do not comprehensively take situational effects into account. Thus, only selective changes are possible which, however, do not imply a sustainable improvement of the system. Newer approaches to strengthening safety in complex sociotechnical systems understand positive as well as negative events as being equally caused by the variable adaptation of behavior to daily practice. They therefore focus on the majority of positive courses of treatment and the necessary adaptations of the health professionals involved in daily practice (Safety‑II). In this way, the adaptability of the system under unexpected conditions should be increased (Resilience Engineering). Taking this systemic approach into account, the Functional Resonance Analysis Method (FRAM) offers a variety of possibilities for the prospective analysis of a complex sociotechnical system or for retrospective incident analysis through modelling of actual everyday actions (work as done). Through interviews with the health professionals involved, document analyses and work inspections, processes and their functions as well as the associated variability are assessed and graphically presented. The FRAM models the collected information of the process as complexes of interconnected functions represented by hexagonal symbols. Each corner of the hexagon represents a given aspect, which together form the properties of the function (input, output, precondition, resource, time, control). Through this visualization and evaluation of the interview results, the actual everyday actions (work as done) can be compared with the predefined ones (work as imagined). The evaluation of the variability found in this way enables the strengths and weaknesses of processes to be uncovered. As a result, specific measures can be derived to strengthen the system. Increased consideration of the Safety‑II approach within clinical risk management can be a valuable addition to existing clinical risk management methods.

Negative emotions experienced by healthcare staff following medication administration errors: a descriptive study using text-mining and content analysis of incident data

BACKGROUND

Medication errors regardless of the degree of patient harm can have a negative emotional impact on the healthcare staff involved. The potential for self-victimization of healthcare staff following medication errors can add to the moral distress of healthcare staff. The stigma associated with errors and their disclosure often haunts healthcare professionals, leading them to question their own professional competence. This paper investigates the negative emotions expressed by healthcare staff in their reported medication administration error incidents along with the immediate responses they received from their seniors and colleagues after the incident.

METHOD

This is a retrospective study using a qualitative descriptive design and text mining. This study includes free-text descriptions of medication administration error incidents (n = 72,390) reported to National Reporting & Learning System in 2016 from England and Wales. Text-mining by SAS text miner and content analysis was used to analyse the data.

RESULTS

Analysis of data led to the extraction of 93 initial codes and two categories i.e., 1) negative emotions expressed by healthcare staff which included 4 sub-categories of feelings: (i) fear; (ii) disturbed; (iii) sadness; (iv) guilt and 2) Immediate response from seniors and colleagues which included 2 sub-categories: (i) Reassurance and support and (ii) Guidance on what to do after an error.

CONCLUSION

Negative emotions expressed by healthcare staff when reporting medication errors could be a catalyst for learning and system change. However, negative emotions when internalized as fear, guilt, or self-blame, could have a negative impact on the mental health of individuals concerned, reporting culture, and opportunities for learning from the error. Findings from this study, hence, call for future research to investigate the impact of negative emotions on healthcare staff well-being and identify ways to mitigate these in practice.

The impact of "To Err Is Human" on patient safety in anesthesiology. A bibliometric analysis of 20 years of research

Background

Patient safety gained public notoriety following the 1999 report of the Institute of Medicine: To Err is Human - Building a Safer Health System which summarized a culminated decades' worth of research that had so far been largely ignored. The aim of this study was to analyze the report's impact on patient safety research in anesthesiology.

Methods

A bibliometric analysis was performed on all anesthesiologic publications from 2000 to 2019 that referenced To Err Is Human. In bibliometric literature, references are understood to represent an author's conscious decision to express a relationship between his own manuscript and the cited document.

Results

The anesthesiologic data base contained 1.036 publications. The journal with the most references to the IOM report is Anesthesia & Analgesia. By analyzing author keywords and patterns of collaboration, changes in the patient safety debate and its core themes in anesthesiology over time could be visualized. The generic notion of "error," while initially a central topic in the scientific discourse, was subsequently replaced by terms representing a more granular, team-oriented, and educational approach. Patient safety research in anesthesia, while profiting from a certain intellectual and conceptual head start, showed a discursive shift toward more managerial, quality-management related topics as observed in the health care system as a whole.

Conclusions

Over the last 20 years, the research context expanded from the initial focus set forth by the IOM report, which ultimately led to an underrepresentation of research on critical incident reporting and systemic approaches to safety. Important collaborations with safety researchers from outside of health care dating back to the 1990's were gradually reduced, while previous research within anesthesiology was aligned with a broader, more managerial patient safety agenda.

Developing evaluation capacities in integrated care projects: Lessons from a scientific support mission implemented in Belgium

The capacity of self-assessment, to learn from experience, to make information-based decisions, and to adapt over time are essential drivers of success for any project aiming at healthcare system change. Yet, many of those projects are managed by healthcare providers' teams with little evaluation capacity. In this article, we describe the support mission delivered by an interdisciplinary scientific team to 12 integrated care pilot projects in Belgium, mobilizing a set of tools and methods: a dashboard gathering population health indicators, a significant event reporting method, an annual report, and the development of a sustainable "learning community." The article provides a reflexive return on the design and implementation of such interventions aimed at building organizational evaluation capacity. Some lessons were drawn from our experience, in comparison with the broader evaluation literature: The provided support should be adapted to the various needs and contexts of the beneficiary organizations, and it has to foster experience-based learning and requires all stakeholders to adopt a learning posture. A long-time, secure perspective should be provided for organizations, and the availability of data and other resources is an essential precondition for successful work.

Complication Management and Prevention in Vascular and non-vascular Interventions

PURPOSE

 This overview summarizes key points of complication management in vascular and non-vascular interventions, particularly focusing on complication prevention and practiced safety culture. Flowcharts for intervention planning and implementation are outlined, and recording systems and conferences are explained in the context of failure analysis. In addition, troubleshooting by interventionalists on patient cases is presented.

MATERIAL AND METHODS

 The patient cases presented are derived from our institute. Literature was researched on PubMed.

RESULTS

 Checklists, structured intervention planning, standard operating procedures, and opportunities for error and complication discussion are important elements of complication management and essential for a practiced safety culture.

CONCLUSION

 A systematic troubleshooting and a practiced safety culture contribute significantly to patient safety. Primarily, a rational and thorough error analysis is important for quality improvement.

KEY POINTS

· Establishing a safety culture is essential for high-quality interventions with few complications.. · A rational and careful troubleshooting is essential to increase quality of interventions.. · Checklists and SOPs can structure and optimize the procedure of interventions..

CITATION FORMAT

· Weiss D, Wilms LM, Ivan VL et al. Complication Management and Prevention in Vascular and non-vascular Interventions. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1829-6055.

Training residents in medical incident report writing to improve incident investigation quality and efficiency enables accurate fact gathering

We assessed whether training on writing readable and accurate medical incident reports (IRs) improves the quality of fact description. In this training, 124 residents created fictional IRs. We provided tips, including using When, Where, Who, What, Why, How. We compared the fictional IRs with and without tips, and the trainees' and non-trainees' IRs submitted in the first five months after training. Results indicated that the subject words in IRs were more clarified and the readability was improved. The fictional IRs using tips were more accurate, with increased descriptions of the patient's background, reporter's actions, team members' actions and conversations, safety check procedures, result of the error, and post-incident response. The reporter's actions, work procedures, and environment were more clarified in the trainees' IRs than in the non-trainees' IRs. This training may help analysts comprehend the sequence of and underlying factors for reporter's actions based on IRs.

A 6-Year Thematic Review of Reported Incidents Associated With Cardiopulmonary Resuscitation Calls in a United Kingdom Hospital

BACKGROUND

Critical incident reporting can be applied to cardiopulmonary resuscitation (CPR) events as a means of reducing further occurrences. We hypothesized that local CPR-related events might follow patterns only seen after a long period of analysis.

DESIGN

We reviewed 6 years of local incidents associated with cardiac arrest calls. The following search terms were used to identify actual or potential resuscitation events: "resuscitation," "cardio-pulmonary," "CPR," "arrest," "heart attack," "DNR," "DNAR," "DNACPR," "Crash," "2222." All identified incidents were independently reviewed and categorized, looking for identifiable patterns.

SETTING

Nottingham University Hospitals is a large UK tertiary referral teaching hospital.

RESULTS

A total of 1017 reports were identified, relating to 1069 categorizable incidents. During the same time, there were approximately 1350 cardiac arrest calls, although it should be noted that many arrest-related incidents were not associated with cardiac arrest call (e.g., failure to have the correct equipment available in the event of a cardiac arrest). Incidents could be broadly classified into 10 thematic areas: no identifiable incident (n = 189; 18%), failure to rescue (n = 133; 12%), staffing concerns (n = 134; 13%), equipment/drug concerns (n = 133; 12%), communication issues (n = 122; 10%), do-not-attempt-CPR decisions (n = 101; 9%), appropriateness of patient location or transfer (n = 96; 9%), concerns that the arrest may have been iatrogenic (n = 76; 7%), patient or staff injury (n = 43; 4%), and miscellaneous (n = 52; 5%). Specific patterns of events were seen within each category.

CONCLUSIONS

By reviewing incidents, we were able to identify patterns only noticeable over a long time frame, which may be amenable to intervention. Our findings may be generalizable to other centers or encourage others to undertake this exercise themselves.

An Analysis of Judicial Cases Concerning Analgesic-Related Medication Errors in the Republic of Korea

OBJECTIVES

Analgesic-related medication errors can be a threat to patient safety. This study aimed to identify and describe medication errors that can cause serious adverse drug events (ADEs) related to analgesic use.

METHODS

This retrospective, observational, medicolegal study analyzed closed cases concerning complications induced by medication errors involving 3 commonly used analgesics: opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen (AAP). Cases closed between 1994 and 2019 that were available in the Korean Supreme Court judgment database system were included. Medication errors were categorized using a classification system (developed by our group) based on the stage of drug administration. Clinical characteristics and judgment statuses were analyzed.

RESULTS

A total of 71 cases were included in the final analysis (opioids, n = 30; NSAIDs, n = 35; AAP, n = 6). Among them, 43 claims (60.6%) resulted in payments to the plaintiffs, with a median payment of $86,607 (interquartile range, $34,554-$193,782). The severity of ADEs was high (National Association of Insurance Commissioners scale ≥6) in 88.7% (n = 63) of claims, with a total of 44 (62%) deaths. The most common types of ADEs associated with opioid, NSAID, and AAP use were respiratory depression, anaphylactic shock, and fulminant hepatitis, respectively. The most common recognized medication errors associated with opioid, NSAIDs, and AAP were inappropriate patient monitoring (n = 10; 33.3%), improper analgesic choice (n = 15; 42.9%), and inappropriate treatment after ADEs (n = 3; 50%), respectively.

CONCLUSIONS

Our findings indicate that efforts should be made to reduce medication errors related to analgesic use to prevent permanent injury and potential malpractice claims.

The use of sugammadex in critical events in anaesthesia: A retrospective review of the webAIRS database

Sugammadex has been used for more than ten years in Australia and New Zealand and has been implicated as an effective treatment, and in some cases a potential cause, of a critical incident. We aimed to identify and analyse critical incidents involving sugammadex reported to webAIRS, a de-identified voluntary online critical incident reporting system in Australia and New Zealand. We identified 116 incidents where the reporter implicated sugammadex as either a cause (23 cases) or a treatment (93 cases) during anaesthesia. There were 17 incidents suggestive of sugammadex anaphylaxis, although not all were confirmed by skin testing. There were six incidents when bradycardia was temporally related to sugammadex administration, although it was not possible to exclude other causes or contributory factors. There were nine incidents in which sugammadex was used to reverse aminosteroid-related neuromuscular blockade successfully in a 'can't intubate, can't oxygenate' (CICO) situation, and a further 67 incidents in which sugammadex was used to reverse aminosteroid neuromuscular blockade as part of the management of other critical incidents. While sugammadex was used during the management of 16 cases of anaphylaxis, there was no clear indication that this altered the course of the anaphylaxis in any of the cases. These reports indicate that sugammadex can be a potential trigger for anaphylaxis and that its use may be associated with the development of significant bradycardia. However, it is not possible to estimate or even speculate on the incidence of these sugammadex-related incidents on the basis of voluntary reporting to a database such as webAIRS. The reports also indicate that sugammadex has been used successfully to reverse residual or deep aminosteroid neuromuscular blockade in critical incident situations and to help rescue CICO scenarios. These findings provide further support for ensuring the ready availability of sugammadex wherever aminosteroid muscle relaxants are used.

Voluntary patient safety incidents reporting in forensic psychiatry-What do the reports tell us?

WHAT IS KNOWN ON THE SUBJECT?: Patient safety incident reporting has been recognized as a key process for organizational learning and safety culture; however, there is limited knowledge about patient safety in forensic psychiatric care. There are distinct patient safety issues in psychiatric nursing, associated (inter alia) with the self-harm, violence, seclusion/restrain and restrictions. Many adverse events are preventable. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: No harm was caused to patients in less than half (51%) of all reported incidents (in a Finnish forensic psychiatric hospital during a six-year period) considered in this study. The most common location of violent incidents was corridors (31%), followed by day rooms (20%), and patient rooms (15%). The most common patient safety incidence type was violence against another patient (38%), which typically occurred in corridors (36%), dayrooms (25%) and patient rooms (15%), and was usually related to daily activities in the afternoon (1,400-1,600 hr) and evening (1,800-2,000 hr). Typically, recommendations for improving patient safety focus on human behaviours. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is a need to notify and report all patient safety incidents (following staff training), learn from previous incidents (also learn for success), prevent typical incidents, learn for success, promote patient participation in incident prevention, share development measures outside the ward to enable exploitation by others and strengthen safety culture. In forensic psychiatry, conversation with patients regarding safety measures is strongly recommended to prevent patient safety incidents related to violence. The perspective should be extended from patient-specific factors to general factors such as patient treatment and general comfort and privacy.

ABSTRACT

INTRODUCTION: Patient safety incident reporting has been recognized as a key process for organizational learning and safety culture, but there is limited knowledge about patient safety in forensic psychiatric care.

AIMS

To characterize the types and frequencies of incidents in forensic psychiatric care and assess the implications for practice.

METHODS

Data were collected from a patient safety incident reporting system (PSiRS) database of one forensic psychiatry hospital in Finland and analysed using descriptive statistics.

RESULTS

No harm was caused in more than half of the 2,521 reported incidents examined (51%, n = 1,260). The most frequently recorded incident type was violence (38%), which typically occurred in corridors (31%) or dayrooms (20%). The most frequently recommended action to prevent violent events was that potential risks should be discussed (77%).

DISCUSSION

Patient safety incidents related to violence are common in forensic psychiatric hospitals. Although very few adverse events were classified as causing serious harm to patients, many cases of violence could be prevented by identifying potential circumstances that lead to violence.

IMPLICATIONS FOR PRACTICE

Staff need encouragement and training to detect and report all patient safety incidents. Safety culture is strengthened by learning and sharing development measures to improve patient safety.

Medication Errors in Anesthesiology: Is It Time to Train by Example? Vignettes Can Assess Error Awareness, Assessment of Harm, Disclosure, and Reporting Practices

BACKGROUND

Perioperative medication errors (MEs) are complex, multifactorial, and a significant source of in-hospital patient morbidity. Anesthesiologists' awareness of error and the potential for harm is not well understood, nor is their attitude to reporting and disclosure. Anesthesiologists are not routinely exposed to medication safety training.

METHODS

Ten clinical vignettes, describing an ME or a near miss, were developed using eDelphi consensus. An online survey instrument presented these vignettes to anesthesiologists along with a series of questions assessing error awareness, potential harm severity, the likelihood of reporting, and the likelihood of open disclosure to the patient. The study also explored the influence of prior medication safety training.

RESULTS

Eighty-nine anesthesiologists from 14 hospitals across Ireland (53.9% were residents, and 46.1% were attendings) completed the survey. Just 35.6% of anesthesiologists recalled having had medication safety training, more commonly among residents than attendings, although this failed to reach significance (P < 0.081). Medication error awareness varied with the vignette presented. Harm severity assessment was positively associated with error awareness. The likelihood of patient disclosure and incident reporting was both low and independent of harm severity assessment.

CONCLUSIONS

Perioperative ME awareness and assessment of potential harm by anesthesiologists is variable. Self-reported rates of incident reporting and error disclosure fall short of the standards that might apply in an environment focused on candor and safety. An extensive education program is required to raise awareness of error and embed appropriate reporting and disclosure behaviors. Vignettes, designed by consensus, may be valuable in the delivery of such a curriculum.

106 How the COVID-19 Pandemic has Changed Departmental Teaching in a Tertiary Hospital

Pressure from the COVID-19 pandemic on healthcare has had a detrimental effect on the delivery of teaching to junior doctors. During a time when teaching is needed more than ever the constraints of a pandemic have made this challenging. Parallel to this patient safety remains a cause for concern in healthcare systems worldwide

The aim of the study was to create an educational programme for the acute medical unit to allow flexibility of learning whilst incorporating key lessons from significant incidents.

Our initial approach was to gain an understanding of the problem by consulting the multi-disciplinary team. We spoke with a range of healthcare professionals working on the acute medical unit to identify concerns relating to SIs: in particular, the governance lead was key in this. Following this, we consulted junior doctors using questionnaires to explore the challenges they faced working on AMU. The design of the scenarios is based around two SIs per scenario for a total of five scenarios and all scenarios were based around the management of common conditions seen on AMU. We opted for an interactive ward round style teaching with a particular focus on key skills such as prescribing and taking bloods. With the help of our colleagues at Hull Institute of Learning & Simulation (HILS) the scenarios were filmed in 1 day and later edited to produce a short video.

We have designed and created a VR360 teaching programme that combines with departmental induction allowing junior doctors to access learning from anywhere in the world and immerse themselves on AMU. Feedback has been positive so far and we hope to expand this simulation-based learning to allow to include additional topics.

The Perceptions and Experience of Surgical Trainees Related to Patient Safety Improvement and Incident Reporting: Structured Interviews With 612 Surgical Trainees

Background We undertook a prospective qualitative study to ascertain the perceptions and experience of trainee doctors in the first two years of formal core surgical training related to patient safety improvement and incident reporting. We sought to explore the beliefs, knowledge and opinions of core surgical trainees related to patient safety improvement, their understanding of existing patient safety initiatives and their experience and attitudes to incident reporting. Methods We identified 1133 doctors in formal core surgical training posts in the United Kingdom at this time, and we contacted these doctors to invite them to participate in our study. We received responses from 687 (60.6%) core surgical trainees, and 612 trainees (54%) agreed to participate. The study participants underwent an interview using structured questions asked by trained assessors with an opportunity to explore any particular themes identified by the trainee in more detail. Qualitative data related to the knowledge, experience and perceptions of safety improvement and incident reporting were collected. Results Overall, 163 surgical trainees (26.6%) reported that they felt that they could impact patient safety positively. A total of 222 trainees (36.3%) had been involved in or witnessed an adverse patient safety event, while 509 trainees (83.2%) reported that they had witnessed a 'near-miss' event. Only 81 trainees (13.2%) had submitted a patient safety report at some point in their career. In addition, 536 trainees (87.6%) reported that they considered a patient safety or incident report to be 'negative' or 'seriously negative' and that they would be discouraged from making these because of the negative connotations associated with them. Of the 81 core surgical trainees who had submitted a patient safety report, only nine trainees (11.1%) reported that they had received a meaningful reply and update following their report. Several themes were identified during the interviews in response to open questions. These included a perception that patient safety improvement is the responsibility of senior surgeons and managers and that surgical trainees did not feel empowered to influence patient safety improvement. Trainees expressed the view that incident reporting reflected negatively on clinicians and the standard of care provided, and there were reports of culture based on blame and the fear of litigation or complaints. Surgical trainees did not feel that incident reporting was an effective tool for patient safety improvement, and those trainees who had made patient safety reports felt that these did not result in change and that they often received no feedback. Conclusions Core surgical trainees report that they are not well engaged in patient safety improvement and that their perceptions and experience of incident reporting are not positive. This represents a missed opportunity. We suggest that in order to recruit the surgical workforce to the improvement work and learning associated with patient safety, opportunities for focused education, training and culture change are needed from the early years of surgical training. In addition, improvements to the processes and systems that allow trainees to engage with safety improvement are needed in order to make these more user-friendly and accessible.

A cross-sectional overview of the second 4000 incidents reported to webAIRS, a de-identified web-based anaesthesia incident reporting system in Australia and New Zealand

This cross-sectional overview of the second 4000 incidents reported to webAIRS has findings that are very similar to the previous overview of the first 4000 incidents. The distribution of patient age, body mass index and American Society of Anesthesiologists physical status was similar, as was anaesthetist gender, grade, location and time of day of incidents. About 35% of incidents occurred during non-elective procedures (vs. 33% in the first 4000 incidents). The proportion of incidents in the various main categories was also similar, with respiratory/airway being most common, followed by cardiovascular, medication-related and medical device or equipment-related incidents. Together these categories made up about 78% of all incidents in both overviews. The immediate outcome was comparable with reports of harm in about a quarter of incidents and a similar rate of deaths (4.7% vs. 4.2%). However, the proportion of patients who had received total intravenous anaesthesia was higher (17.6% vs. 7.7%) and the proportion of patients who received combined intravenous and inhalational anaesthesia was lower (52.3% vs. 58.4%), as was the proportion receiving local anaesthesia alone (1.6% vs. 6.7%). There was a small increase in the number of incidents resulting in unplanned admission to a high dependency or intensive care unit (18.1% vs. 13.5%). It is not clear whether these differences represent trends or random observations. About 48% of incidents were considered preventable by the reporters (vs. 52% in the first 4000). These findings support continued emphasis on human and system factors to promote and improve patient safety in anaesthesia care.

Clinical incident reporting behaviors and associated factors among health professionals in Dessie comprehensive specialized hospital, Amhara Region, Ethiopia: a mixed method study

Background

Understanding the type and causes of errors are necessary for the prevention of occurrence or reoccurrence. Therefore addressing the behavior of health professionals on reporting clinical incidents is crucial to create spontaneous knowledge from mistakes and enhance patient safety.

Method

A mixed type institution-based cross-sectional study design was conducted from March 1 - 30, 2020 in Dessie comprehensive specialized hospital among 319 and 18 participants for the quantitative and qualitative study, respectively. The professions and participants with their assigned proportions were selected using a simple random sampling technique. For quantitative and qualitative data, semi structured questionnaires and interviewer-guided questions were used to collect data, respectively. Finally, qualitative findings were used to supplement the quantitative result.

Result

The finding showed that the proportion of clinical incident reporting behavior among health professionals was 12.4%. Having training (AOR=3.6, 95% CI, 1.15-11.45), incident reporting help to minimize errors (AOR=2.8, 95% CI, 1.29-6.02), fear of legal penalty (AOR= 0.3, 95% CI, 0.13-0.82), and lack of feedback (AOR=0.3, 95% CI, 0.11-0.90) were identified as significant factors for clinical incident reporting behavior of the health professionals.

Conclusions

This study showed that the clinical incident reporting behavior of the health professionals was very low. Therefore health professionals should get training on clinical incident reporting and the hospital should have an incident reporting system and guideline.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07350-y.

Analysis of medication errors during anaesthesia in the first 4000 incidents reported to webAIRS

Medication error is a well-recognised cause of harm to patients undergoing anaesthesia. From the first 4000 reports in the webAIRS anaesthetic incident reporting system, we identified 462 reports of medication errors. These reports were reviewed iteratively by several reviewers paying particular attention to their narratives. The commonest error category was incorrect dose (29.4%), followed by substitution (28.1%), incorrect route (7.6%), omission (6.5%), inappropriate choice (5.8%), repetition (5.4%), insertion (4.1%), wrong timing (3.5%), wrong patient (1.5%), wrong side (1.5%) and others (6.5%). Most (58.9%) of the errors resulted in at least some harm (20.8% mild, 31.0% moderate and 7.1% severe). Contributing factors to the medication errors included the presence of look-alike medications, storage of medications in the incorrect compartment, inadequate labelling of medications, pressure of time, anaesthetist fatigue, unfamiliarity with the medication, distraction, involvement of multiple people and poor communication. These data add to current evidence suggesting a persistent and concerning failure effectively to address medication safety in anaesthesia. The wide variation in the nature of the errors and contributing factors underline the need for increased systematic and multifaceted efforts underpinned by a strengthening of the current focus on safety culture to improve medication safety in anaesthesia. This will require the concerted and committed engagement of all concerned, from practitioners at the clinical workface, to those who fund and manage healthcare.

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.

Patient safety education in anesthesia: current state and future directions

PURPOSE OF REVIEW

Although patient safety is a core component of education in anesthesiology, approaches to implementation of education programs are less well defined. The goal of this review is to describe the current state of education in anesthesia patient safety and the ideal patient safety curriculum.

RECENT FINDINGS

Anesthesiology has been a pioneer in patient safety for decades, with efforts amongst national organizations, such as the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation to disseminate key standards and guidelines in patient safety. However, few, if any strategies for implementation of a patient safety curriculum in anesthesiology exist.

SUMMARY

Patient safety education is crucial to the field of anesthesiology, particularly with the advancement of surgical and anesthesia technologies and increasing complexity of patients and procedures. The ideal patient safety curriculum in anesthesiology consists of simulation, adverse event investigation and analysis, and participation in process improvement. Efforts in education must adapt with changing technology, shifts in the way anesthesia care is delivered, and threats to physician wellness. Future efforts in education should harness emerging platforms, such as social media, podcasts, and wikis.

Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis

BACKGROUND

Increasing demand on emergency healthcare systems has prompted introduction of new healthcare service models including the provision of GP services in or alongside emergency departments. In England this led to a policy proposal and £100million (US$130million) of funding for all emergency departments to have co-located GP services. However, there is a lack of evidence for whether such service models are effective and safe. We examined diagnostic errors reported in patient safety incident reports to develop theories to explain how and why they occurred to inform potential priority areas for improvement and inform qualitative data collection at case study sites to further refine the theories.

METHODS

We used a mixed-methods design using exploratory descriptive analysis to identify the most frequent and harmful sources of diagnostic error and thematic analysis, incorporating realist methodology to refine theories from an earlier rapid realist review, to describe how and why the events occurred and could be mitigated, to inform improvement recommendations. We used two UK data sources: Coroners' reports to prevent future deaths (30.7.13-14.08.18) and National Reporting and Learning System (NRLS) patient safety incident reports (03.01.05-30.11.15).

RESULTS

Nine Coroners' reports (from 1347 community and hospital reports, 2013-2018) and 217 NRLS reports (from 13 million, 2005-2015) were identified describing diagnostic error related to GP services in or alongside emergency departments. Initial theories to describe potential priority areas for improvement included: difficulty identifying appropriate patients for the GP service; under-investigation and misinterpretation of diagnostic tests; and inadequate communication and referral pathways between the emergency and GP services. High-risk presentations included: musculoskeletal injury, chest pain, headache, calf pain and sick children.

CONCLUSION

Initial theories include the following topics as potential priority areas for improvement interventions and evaluation to minimise the risk of diagnostic errors when GPs work in or alongside emergency departments: a standardised initial assessment with streaming guidance based on local service provision; clinical decision support for high-risk conditions; and standardised computer systems, communication and referral pathways between emergency and GP services. These theories require refinement and testing with qualitative data collection from case study (hospital) sites.

Barriers and enablers in implementing an electronic incident reporting system in a teaching hospital: A case study from Saudi Arabia

BACKGROUND

Widespread recognition of the impact of healthcare adverse events has triggered incident reporting system implementation to promote patient safety. The aim was to assess the effectiveness, usability, enablers, and barriers of the Electronic Occurrence Variance Reporting System (eOVR) in addition to end user satisfaction.

METHODS

This study comprised a cross-sectional survey two years after implementation of the eOVR. Secondary data analysis evaluated the volume of incident reporting before and after implementing the eOVR.

OUTCOME MEASURES

Primary outcome measures: satisfaction and system usability, system security, workplace safety culture, training, and reporting trends. An overall satisfaction was collected. Secondary outcome: rate of reported OVRs per 1000 admissions. Furthermore, barriers and enablers to the reporting process were explored.

RESULTS

Study findings indicate that the eOVR has been successful in terms of high satisfaction according to respondents. Most of the respondents found the system easy to access, maintained patient confidentiality and reporting anonymity. Around half the respondents indicated having a non-punitive culture of reporting in their hospital. Physicians had significantly lower scores in all primary outcomes Incident reporting increased by 33.6% (p < 0.0001) after implementing the eOVR.

CONCLUSION

Successful incident reporting systems should be easy and simple to use, accessible and include features that guarantee anonymity and confidentiality. End-users should be trained prior to launching such a system. The implementation of such systems needs to be combined with promoting a just culture in the organization, timely feedback, more involvement and focus on physicians and junior staff which will improve user satisfaction and reporting rates.

Patient Safety Silence and Safety Nursing Activities: Mediating Effects of Moral Sensitivity

Among the factors that threaten patient safety and quality of care due to the diversification and complication of hospital environments, nurses play a pivotal role regarding patient safety in the clinical setting. This study investigates the mediating effects of moral sensitivity on the relationship between nurses’ patient safety silence and safety nursing activities and contributes to developing strategies. Nurses (n = 120) employed for at least one year in two university hospitals in Korea between 1 September and 30 October 2020 participated in the study. Data were analyzed using t-test, Pearson’s correlation coefficients, and multiple regression using the SPSS/WIN 22.0 program. Additionally, the mediating effects were analyzed using Baron and Kenny’s method and bootstrapping. Safety nursing activities were significantly negatively correlated with patient safety silence and significantly positively correlated with moral sensitivity. Patient safety silence was significantly negatively correlated with moral sensitivity. Moral sensitivity partially mediated the relationship between patient safety silence and safety nursing activities. There is a need to develop and implement individualized ethical programs that enhance moral sensitivity in nurses to promote patient safety nursing activities.

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.

Sins of Omission: Are junior doctors failing to report clinical incidents, and if so, how can we better support them to do so?

Objectives

University Hospitals Birmingham's (UHB) Foundation Doctors should log clinical incidents via the Trust's incident reporting system. Anecdotal reports suggest under-reporting is commonplace. It is therefore important to identify the proportion of Foundation Year 1 (FY1s) who witnessed but did not report incidents and identify and weigh perceived barriers to reporting. We can then suggest strategies to address these barriers and repeat our data collection.

Methodology

We performed an analysis of anonymised data from the Trust's Datix Incident Reporting system alongside an anonymised survey to determine the proportion of FY1s witnessing reportable clinical incidents, and the proportion successfully reporting an incident in the 2017/18 academic year. The survey also gathered data on FY1 perceptions of barriers to reporting. We went on to discuss our results with UHB management and suggested several strategies to improve reporting, prior to repeating data collection for the 2019–20 academic year.

Results

36.4% FY1 doctors surveyed in 2017–18 reported witnessing at least one clinical incident that they did not report. 37.0% FY1 doctors surveyed in 2019–20 reported the same. Respondents felt time taken to complete forms and system complexity were the key barriers to reporting.

Conclusion

Results show that over a third of FY1s at UHB had witnessed but not reported at least one clinical incident each year. The evidence-based strategies suggested to the trust in 2018 and 2020 included FY1 education on incident reporting, early senior clinician involvement in the reporting pathway, and a streamlined reporting system integrated with existing infrastructure. These have not been implemented.

Perspective on reducing errors in research

Efforts to ensure research integrity has mostly focused on research misconduct. However, the complexity of research operations and processes makes research work also prone to unintentional errors. To safeguard against errors and their consequences, strategies for error reduction, detection, and mitigation can be applied to research work. Nurturing a scientific culture that encourages error disclosure and rectification is essential to reduce the negative consequences of errors. Creating repositories where errors can be reported can enable learning from errors and creation of more robust research processes.

Impact of the Norwegian National Patient Safety Program on implementation of the WHO Surgical Safety Checklist and on perioperative safety culture

Objectives

Our primary objective was to study the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture. Secondary objective was associations between SSC fidelity and safety culture. We hypothesised that the programme influenced on SSC use and operating theatre personnel’s safety culture perceptions.

Setting

A longitudinal cross-sectional study was conducted in a large Norwegian tertiary teaching hospital.

Participants

We invited 1754 operating theatre personnel to participate in the study, of which 920 responded to the surveys at three time points in 2009, 2010 and 2017.

Primary and secondary outcome measures

Primary outcome was the results of the patient safety culture measured by the culturally adapted Norwegian version of the Hospital Survey on Patient Safety Culture. Our previously published results from 2009/2010 were compared with new data collected in 2017. Secondary outcome was correlation between SSC fidelity and safety culture. Fidelity was electronically recorded.

Results

Survey response rates were 61% (349/575), 51% (292/569) and 46% (279/610) in 2009, 2010 and 2017, respectively. Eight of the 12 safety culture dimensions significantly improved over time with the largest increase being ‘Hospital managers’ support to patient safety’ from a mean score of 2.82 at baseline in 2009 to 3.15 in 2017 (mean change: 0.33, 95% CI 0.21 to 0.44). Fidelity in use of the SSC averaged 88% (26 741/30 426) in 2017. Perceptions of safety culture dimensions in 2009 and in 2017 correlated significantly though weakly with fidelity (r=0.07–0.21).

Conclusion

The National Patient Safety Program, fostering engagement from trust boards, hospital managers and frontline operating theatre personnel enabled effective implementation of the SSC. As part of a wider strategic safety initiative, implementation of SSC coincided with an improved safety culture.

Comparison of Patient Safety Incident Reporting Systems in Taiwan, Malaysia, and Indonesia

OBJECTIVES

Incident reporting is one of the tools used to improve patient safety that has been widely used in health facilities in many countries. Incident reporting systems provide functionality to collect, analyze, and disseminate lessons learned to the wider community, whether at the hospital or national level. The aim of this study was to compare the patient safety incident reporting systems of Taiwan, Malaysia, and Indonesia to identify similarities, differences, and areas for improvement.

METHODS

We searched the official Web sites and homepages of the responsible leading patient safety agencies of the three countries. We reviewed all publicly available guidelines, regulatory documents, government reports that included policies, guidelines, strategy papers, reports, evaluation programs, as well as scientific articles and gray literature related to the incident reporting system. We used the World Health Organization components of patient safety reporting system as the guidelines for comparison and analyzed the documents using descriptive comparative analysis.

RESULTS

Taiwan had the most incidents reported, followed by Malaysia and Indonesia. Taiwan Patient Safety Reporting (TPR) and the Malaysian Reporting and Learning System had similar attributes and followed the World Health Organization components for incident reporting. We found differences between the Indonesian system and both of TPR and the Malaysian system. Indonesia did not have an external reporting deadline, analysis and learning were conducted at the national level, and there was a lack of transparency and public access to data and reports. All systems need to establish a clear and structured incident reporting evaluation framework if they are to be successful.

CONCLUSIONS

Compared with TPR and Malaysian system, the Indonesian patient safety incident reporting system seemed to be ineffective because it failed to acquire adequate national incident reporting data and lacked transparency; these deficiencies inhibited learning at the national level. We suggest further research on the implementation at the hospital level to see how far national guidelines and policy have been implemented in each country.

Education and training of nurses in the use of advanced medical technologies in home care related to patient safety: A cross-sectional survey

BACKGROUND

To use advanced medical technologies (AMTs) correctly and safely requires both specialist knowledge and skills, and an awareness of risks and how those can be minimized. Reporting safety concerns about AMTs in home care can contribute to an improved quality of care. The extent to which a health care organization has integrated the reporting, evaluation and learning from incidents is a key element of that organization's patient safety culture.

OBJECTIVES

To explore nurses' experiences regarding the education followed in the use of AMTs in the home setting, and their organizations' systems of reporting.

DESIGN

Descriptive cross-sectional design.

METHODS

209 home care nurses from across the Netherlands who worked with infusion therapy, parenteral nutrition and/or morphine pumps responded to the online questionnaire between July 2018 and February 2019. The analysis of the data was mainly descriptive.

RESULTS

Educational interventions that are most often used to learn how to use AMTs were, as an average over the three AMTs, instruction by a nurse (71%), practical training in the required skills (71%) and acquiring information to increase theoretical knowledge (69%). Considerable attention is paid to patient safety (88%) and the home setting (89%). However, a substantial proportion of the nurses (up to 29%) use AMTs even though they had not been tested on their skills. 95% of the respondents were well acquainted with the incident reporting protocol of their organization, but only 49% received structural or regular feedback on any actions taken as a result of event reporting.

CONCLUSIONS

This study revealed aspects of nurses' education that imply risk factors for patient safety. Practical training is not always given, additional or retraining is often voluntary, and the required skills are not always tested. However, the results show that nurses do have a good awareness of patient safety. Incidents are mainly discussed within the team, but less at the organizational level.

A study on the feasibility of delivering a psychologically informed ward-based intervention on an acute mental health ward

Acute mental health inpatient wards have been criticized for being nontherapeutic. The study aimed to test the feasibility of delivering a psychologically informed intervention in these settings. This single-arm study evaluated the feasibility of clinical psychologists delivering a ward-based psychological service model over a 6-month period on two acute mental health wards. Data were gathered to assess trial design parameters and the feasibility of gathering patient/staff outcome data. Psychologists were able to deliver key elements of the intervention. Baseline staff and patient participant recruitment targets were met. However, there was significant patient attrition at follow-up, with incorrect contact details on discharge being the primary reason. Implementation of a ward-based psychological intervention appears feasible when implemented flexibly. It is feasible to recruit staff and patient participants and to collect staff outcome measures over a 6-month period. However, greater efforts need to be taken to trace patient movement following discharge.