Validating the Danish adaptation of the World Health Organization's International Classification for Patient Safety classification of patient safety incident types

Patient safety classifications, taxonomies and ontologies, part 2: A systematic review on content coverage

BACKGROUND

Content coverage of patient safety ontology and classification systems should be evaluated to provide a guide for users to select appropriate ones for specific applications. In this review, we identified and compare content coverage of patient safety classifications and ontologies.

METHODS

We searched different databases and ontology/classification repositories to identify these classifications and ontologies. We included patient safety-related taxonomies, ontologies, classifications, and terminologies. We identified and extracted different concepts covered by these systems and mapped these concepts to international classification for patient safety (ICPS) and finally compared the content of these systems.

RESULTS

Finally, 89 papers (77 classifications or ontologies) were analyzed. Thirteen classifications have been developed to cover all medical domains. Among specific domain systems, most systems cover medication (16), surgery (8), medical devices (3), general practice (3), and primary care (3). The most common patient safety-related concepts covered in these systems include incident types (41), contributing factors/hazards (31), patient outcomes (29), degree of harm (25), and action (18). However, stage/phase (6), incident characteristics (5), detection (5), people involved (5), organizational outcomes (4), error type (4), and care setting (3) are some of the less covered concepts in these classifications/ontologies.

CONCLUSION

Among general systems, ICPS, World Health Organization's Adverse Reaction Terminology (WHO-ART), and Ontology of Adverse Events (OAE) cover most patient safety concepts and can be used as a gold standard for all medical domains. As a result, reporting systems could make use of these broad classifications, but the majority of their covered concepts are related to patient outcomes, with the exception of ICPS, which covers other patient safety concepts. However, the ICPS does not cover specialized domain concepts. For specific medical domains, MedDRA, NCC MERP, OPAE, ADRO, PPST, OCCME, TRTE, TSAHI, and PSIC-PC provide the broadest coverage of concepts. Many of the patient safety classifications and ontologies are not formally registered or available as formal classification/ontology in ontology repositories such as BioPortal. This study may be used as a guide for choosing appropriate classifications for various applications or expanding less developed patient safety classifications/ontologies. Furthermore, the same concepts are not represented by the same terms; therefore, the current study could be used to guide a harmonization process for existing or future patient safety classifications/ontologies.

Challenges to the Implementation of the World Health Organization's International Classification for Patient Safety in Slovenia

BACKGROUND AND OBJECTIVES

Slovenia lags behind international recommendations for reporting and learning from patient safety incidents and risk management in health care. To counter this, the country established the SenSys project, which receives technical support from the European Commission's Structural Reform Support Service, in cooperation with the Danish Patient Safety Authority, and pertains to an initiative to improve health care. A subproject of the SenSys project works to adapt and implement the International Classification for Patient Safety of the World Health Organization (ICPS-WHO). This article presents a case study of the national research process to identify the necessary Slovenian national adaptation and upgrade of the ICPS-WHO, the ICPS-SL, particularly regarding types of patient safety incidents. Our aim was to reflect on how we used the insights from different research elements and learned from different aspects of our project/system development.

METHODS

We used the SQUIRE 2.0 (Standards of Quality Improvement Reporting Excellence) to present our case study. The methods used to collect information on the necessary adaptations to establish an optimal ICPS-SL included a literature review, qualitative analysis of national consultation meetings, and a 2-cycle Delphi study. This process took place between January 2018 and August 2019, and we found 18 useful articles. Participants such as providers, users, and national bodies from national consultation meetings were all key stakeholders.

RESULTS

The relevant stakeholders agreed upon changes to the ICPS-WHO to implement in the ICPS-SL as an integrated part of a Slovenia's incident reporting and learning system. Notably, they implemented changes in terminology in the translation of some English terms. They also added or hierarchically reordered some patient safety incident types: for example, they added the nation-specific point "treatment of pain" as a type of patient safety incident. The stakeholders will also partially integrate the following indicators: monitoring systems, vigilance systems, and complaint systems.

CONCLUSION

Different research elements contributed to the ICPS-SL's new knowledge and more reliable development. We emphasized a cooperative process with a consensus-building approach while linking the knowledge, experience, and needs of various stakeholders. All interested parties adopted this process, aiming to establish conditions for national learning from patient safety incidents and better preventive action for health care quality and safety. Vertical and horizontal multidisciplinary teamwork was a focal point as well. Technical assistance proved especially useful. It is now necessary to clinically test the ICPS-SL classification framework as Slovenia's internationally harmonized standard, and have the Health Council adopt it for use both online and in practice.

Patient safety classification, taxonomy and ontology systems: A systematic review on development and evaluation methodologies

INTRODUCTION

Patient safety classifications/ontologies enable patient safety information systems to receive and analyze patient safety data to improve patient safety. Patient safety classifications/ontologies have been developed and evaluated using a variety of methods. The purpose of this review was to discuss and analyze the methodologies for developing and evaluating patient safety classifications/ontologies.

METHODS

Studies that developed or evaluated patient safety classifications, terminologies, taxonomies, or ontologies were searched through Google Scholar, Google search engines, National Center for Biomedical Ontology (NCBO) BioPortal, Open Biological and Biomedical Ontology (OBO) Foundry and World Health Organization (WHO) websites and Scopus, Web of Science, PubMed, and Science Direct. We updated our search on 30 February 2021 and included all studies published until the end of 2020. Studies that developed or evaluated classifications only for patient safety and provided information on how they were developed or evaluated were included. Systems with covered patient safety terms (such as ICD-10) but are not specifically developed for patient safety were excluded. The quality and the risk of bias of studies were not assessed because all methodologies and criteria were intended to be covered. In addition, we analyzed the data through descriptive narrative synthesis and compared and classified the development and evaluation methods and evaluation criteria according to available development and evaluation approaches for biomedical ontologies.

RESULTS

We identified 84 articles that met all of the inclusion criteria, resulting in 70 classifications/ontologies, nine of which were for the general medical domain. The most papers were published in 2010 and 2011, with 8 and 7 papers, respectively. The United States (50) and Australia (23) have the most studies. The most commonly used methods for developing classifications/ontologies included the use of existing systems (for expanding or mapping) (44) and qualitative analysis of event reports (39). The most common evaluation methods were coding or classifying some safety report samples (25), quantitative analysis of incidents based on the developed classification (24), and consensus among physicians (16). The most commonly applied evaluation criteria were reliability (27), content and face validity (9), comprehensiveness (6), usability (5), linguistic clarity (5), and impact (4), respectively.

CONCLUSIONS

Because of the weaknesses and strengths of the development/evaluation methods, it is advised that more than one method for development or evaluation, as well as evaluation criteria, should be used. To organize the processes of developing classification/ontologies, well-established approaches such as Methontology are recommended. The most prevalent evaluation methods applied in this domain are well fitted to the biomedical ontology evaluation methods, but it is also advised to apply some evaluation approaches such as logic, rules, and Natural language processing (NLP) based in combination with other evaluation approaches. This research can assist domain researchers in developing or evaluating domain ontologies using more complete methodologies. There is also a lack of reporting consistency in the literature and same methods or criteria were reported with different terminologies.

Patients Own Safety Incidents Reports to the Danish Patient Safety Database Possess a Unique but Underused Learning Potential in Patient Safety

OBJECTIVE

The aim of the study was to analyze how patients' own reports of safety incidents to the Danish Patient Safety Database can contribute to patient safety.

BACKGROUND

Patient involvement enhances patient safety; however, there is a shortage of tools capable of systematically capturing and usage of patients' own reports. Since 2012, the Danish Patient Safety Database (DPSD) has comprised such a tool.

METHODS

A total of 209,263 incident reports were compared across the following four reporting groups: patients, relatives, doctors, and nurses. Using thematic comparison, 300 narratives from each group were compared with respect to differences and similarities in the wording of the safety incident.

RESULTS

Only a tiny proportion of safety incidents were reported by patients' themselves (1.4%). Most of these (86%) were accepted for processing in the DPSD. Almost 90% of the accepted incidents were classified successfully. Patients' own reports were longer, more often "less severe incidents," and more often reported by female patients. Thematic content analyses revealed incident descriptions from health professionals as terse, unemotional, and extensively using medical terminology and abbreviations. In contrast patients' reports were lengthy, emotional, and focused on relations to health personal, health consequences, and communication errors.

CONCLUSIONS

Despite the very low ratio of patients reporting an observed incident to DPSD, the finding that most patients own reports are accepted and classified makes the DPSD a promising, comprehensive tool to capture patients' own reports. However, the rich, contextualized descriptions seem insufficiently captured by established nomenclature.

Drug change: 'a hassle like no other'. An in-depth investigation using the Danish patient safety database and focus group interviews with Danish hospital personnel

Background:

Drug change (DC) is a common challenge in Danish hospitals. It affects the work of hospital personnel and has potentially serious patient safety consequences. Focus on medication safety is becoming increasingly important in the prevention of adverse events. The aim of this study is to identify and describe patient safety challenges related to DCs, and to explore potential facilitators to improve patient safety in the medication process in Danish hospital setting.

Method:

Two qualitative methods were combined. Data were obtained from the Danish Patient Safety Database (DPSD) containing incidents reports of adverse events related to DCs. Additionally, five semi-structured focus group interviews with hospital personnel (doctors, nurses, pharmacists and pharmacy technicians) from the five regions of Denmark were held.

Results:

The DPSD search identified 88 incidents related to DCs due to tender or drug shortage. The incidents were linked to prescribing errors, incorrect dose being dispensed/administered, and delayed/omitted treatment. Four themes from the interviews emerged: (1) challenges related to the drug itself; (2) situational challenges; (3) challenges related to the organization/IT systems/personnel; (4) facilitators/measures to ensure patient safety.

Conclusion:

DC is as a complex challenge, especially related to drug shortage. The results allow for a deeper understanding of the challenges and possible facilitators of DCs on the individual and organizational level. Pharmacy personnel were identified to play a key role in ensuring patient safety of DCs in hospitals. Indeed, this emphasizes that pharmacy personnel should be engaged in developing patient safety strategies and support hospital personnel around drug changes.

Measuring patient safety culture in maternal and child health institutions in China: a qualitative study

INTRODUCTION

Patient safety culture (PSC) plays a critical role in ensuring safe and quality care. Extensive PSC studies have been undertaken in hospitals. However, little is known about PSC in maternal and child health (MCH) institutions in China, which provide both population-based preventive services as well as individual care for patients.

OBJECTIVES

This study aimed to develop a theoretical framework for conceptualising PSC in MCH institutions in China.

METHODS

The study was undertaken in six MCH institutions (three in Hebei and three in Beijing). Participants (n=118) were recruited through stratified purposive sampling: 20 managers/administrators, 59 care providers and 39 patients. In-depth interviews were conducted with the participants. The interview data were coded using both inductive (based on the existing PSC theory developed by the Agency for Healthcare Research and Quality) and deductive (open coding arising from data) approaches. A PSC framework was formulated through axial coding that connected initial codes and selective coding that extracted a small number of themes.

RESULTS

The interviewees considered patient safety in relation to six aspects: safety and security in public spaces, safety of medical services, privacy and information security, financial security, psychological safety and gap in services. A 12-dimensional PSC framework was developed, containing 69 items. While the existing PSC theory was confirmed by this study, some new themes emerged from the data. Patients expressed particular concerns about psychological safety and financial security. Defensive medical practices emerged as a PSC dimension that is associated with not only medical safety but also financial security and psychological safety. Patient engagement was also valued by the interviewees, especially the patients, as part of PSC.

CONCLUSIONS

Although there are some common features in PSC across different healthcare delivery systems, PSC can also be context specific. In MCH settings in China, the meaning of 'patient safety' goes beyond the traditional definition of patients. General well-being, health and disease prevention are important anchor points for defining PSC in such settings.

Applying the WHO conceptual framework for the International Classification for Patient Safety to a surgical population

OBJECTIVE

Efforts to improve patient safety are challenged by the lack of universally agreed upon terms. The International Classification for Patient Safety (ICPS) was developed by the World Health Organization for this purpose. This study aimed to test the applicability of the ICPS to a surgical population.

DESIGN

A web-based safety debriefing was sent to clinicians involved in surgical care of abdominal organ transplant patients. A multidisciplinary team of patient safety experts, surgeons and researchers used the data to develop a system of classification based on the ICPS. Disagreements were reconciled via consensus, and a codebook was developed for future use by researchers.

RESULTS

A total of 320 debriefing responses were used for the initial review and codebook development. In total, the 320 debriefing responses contained 227 patient safety incidents (range: 0-7 per debriefing) and 156 contributing factors/hazards (0-5 per response). The most common severity classification was 'reportable circumstance,' followed by 'near miss.' The most common incident types were 'resources/organizational management,' followed by 'medical device/equipment.' Several aspects of surgical care were encompassed by more than one classification, including operating room scheduling, delays in care, trainee-related incidents, interruptions and handoffs.

CONCLUSIONS

This study demonstrates that a framework for patient safety can be applied to facilitate the organization and analysis of surgical safety data. Several unique aspects of surgical care require consideration, and by using a standardized framework for describing concepts, research findings can be compared and disseminated across surgical specialties. The codebook is intended for use as a framework for other specialties and institutions.

No-fault compensation for treatment injuries in Danish public hospitals 2006-12

OBJECTIVE

We aimed to determine the incidence rate and time trend of approved treatment injuries in Danish public hospitals from 2006 to 2012 and also to identify independent predictors of severe treatment injuries among patient and system factors and characterize the injuries.

DESIGN AND SETTING

We performed a nationwide, historical observational study on data from the Danish Patient Compensation Association, which receives all compensation claims from Danish health care. All approved closed claims of treatment injuries occurring in public hospitals 2006-12 were included. Health care activity information was obtained through Statistics Denmark.

MAIN OUTCOME MEASURES

Incidence rates were determined as treatment injuries per year by population and by public hospital contacts. By using a multivariable logistic regression model, we calculated mutually adjusted odds ratios to assess the association between potential predictors and severe injuries among approved claims.

RESULTS

We identified 10,959 approved treatment injury claims in 2006-12. The total payout was USD 339 million. The mean incidence rate medians were 27.9 injuries/100,000 inhabitants/year and 0.21 injuries/1000 public hospital contacts/year. These did not increase overtime. Severe injuries and preventable cases comprised 11.0 and 41.0%, respectively. Predictors of severe injury included age 0 and above 40 years, male gender and higher level of comorbidity.

CONCLUSION

The incidence rate of approved closed claims at Danish public hospitals appears stable. A high proportion of injuries are preventable and both patient- and system-related factors may predict severe injuries.

Detection of medical errors in kidney transplantation: a pilot study comparing proactive clinician debriefings to a hospital-wide incident reporting system

BACKGROUND

Rates of medical errors and adverse events remain high for patients who undergo kidney transplantation; they are particularly vulnerable because of the complexity of their disease and the kidney transplantation procedure. Although institutional incident-reporting systems are used in hospitals around the country, they often fail to capture a substantial proportion of medical errors. The goal of this study was to assess the ability of a proactive, web-based clinician safety debriefing to augment the information about medical errors and adverse events obtained via traditional incident reporting systems.

METHODS

Debriefings were sent to all individuals listed on operating room personnel reports for kidney transplantation surgeries between April 2010 and April 2011, and incident reports were collected for the same time period. The World Health Organization International Classification for Patient Safety was used to classify all issues reported.

RESULTS

A total of 270 debriefings reported 334 patient safety issues (179 safety incidents, 155 contributing factors), and 57 incident reports reported 92 patient safety issues (56 safety incidents, 36 contributing factors). Compared with incident reports, more attending physicians completed the debriefings (32.0 vs 3.5%).

DISCUSSION

The use of a proactive, web-based debriefing to augment an incident reporting system in assessing safety risks in kidney transplantation demonstrated increased information, more perspectives of a single safety issue, and increased breadth of participants.

Validity of and interrater agreement on the LINNEAUS Euro-PC medication safety incident classification system in primary care in Poland

INTRODUCTION

Medication safety incidents occur in all health care sectors and cause considerable morbidity and mortality, with 8.5% of all related incidents reported estimated to occur in primary care. A common incident classification system could facilitate collective learning from the analysis of medication-related errors and improve patient safety

OBJECTIVE

The objective of this study was to assess the validity of a new classification system of medication safety incidents in primary care in Poland.

METHODS

Analysis of data from a descriptive, cross-sectional, self-reported survey on the Learning from International Networks about Errors and Understanding Safety in Primary Care (LINNEAUS Euro-PC) medication safety incident classification for primary care with assessment of 10 case-based clinical scenarios done by doctors and pharmacists form community-based family medicine clinics and pharmacies in Lodz.

MAIN OUTCOME MEASURES

The percentages of overall agreement on judgements and a fixed-marginal multirater kappa (κ) coefficient as statistical measures of interrater agreement for categorical items.

RESULTS

The overall agreement levels were: category 1 - 86.3%; category 2 - 85.6%; category 3 - 72.1%; category 4 - 71.8%; and category 5 - 70.4%. The interrater agreement between the 15 evaluators varied as follows: category 1 fixed-marginal κ = 0.144; category 5 fixed-marginal κ = 0.565; category 3 fixed-marginal κ = 0.607; category 4 fixed-marginal κ = 0.634; and category 2 fixed-marginal κ = 0.807.

CONCLUSIONS

This is the first known study on levels of agreement on the perception of medication safety incidents and assessment of the validity of a related classification system in primary health care in Poland. Interrater agreement in this study was surprisingly high, but still leaves room for improvement.

An error taxonomy system for analysis of haemodialysis incidents

OBJECTIVES

This paper describes the development of a haemodialysis error taxonomy system for analysing incidents and predicting the safety status of a dialysis organisation.

METHODS

The error taxonomy system was developed by adapting an error taxonomy system which assumed no specific specialty to haemodialysis situations. Its application was conducted with 1,909 incident reports collected from two dialysis facilities in Japan.

RESULTS

Over 70% of haemodialysis incidents were reported as problems or complications related to dialyser, circuit, medication and setting of dialysis condition. Approximately 70% of errors took place immediately before and after the four hours of haemodialysis therapy. Error types most frequently made in the dialysis unit were omission and qualitative errors. Failures or complications classified to staff human factors, communication, task and organisational factors were found in most dialysis incidents. Device/equipment/materials, medicine and clinical documents were most likely to be involved in errors. Haemodialysis nurses were involved in more incidents related to medicine and documents, whereas dialysis technologists made more errors with device/equipment/materials.

CONCLUSIONS

This error taxonomy system is able to investigate incidents and adverse events occurring in the dialysis setting but is also able to estimate safety-related status of an organisation, such as reporting culture.