How different countries respond to adverse events whilst patients' rights are protected

Patient safety is high on the policy agenda internationally. Learning from safety incidents is a core component in achieving the important goal of increasing patient safety. This study explores the legal frameworks in the countries to promote reporting, disclosure, and supporting healthcare professionals (HCPs) involved in safety incidents. A cross-sectional online survey was conducted to ascertain an overview of the legal frameworks at national level, as well as relevant policies. ERNST (The European Researchers' Network Working on Second Victims) group peer-reviewed data collected from countries was performed to validate information. Information from 27 countries was collected and analyzed, giving a response rate of 60%. A reporting system for patient safety incidents was in place in 85.2% (N = 23) of countries surveyed, though few (37%, N = 10) were focused on systems-learning. In about half of the countries (48.1%, N = 13) open disclosure depends on the initiative of HCPs. The tort liability system was common in most countries. No-fault compensation schemes and alternative forms of redress were less common. Support for HCPs involved in patient safety incidents was extremely limited, with just 11.1% (N = 3) of participating countries reporting that supports were available in all healthcare institutions. Despite progress in the patient safety movement worldwide, the findings suggest that there are considerable differences in the approach to the reporting and disclosure of patient safety incidents. Additionally, models of compensation vary limiting patients' access to redress. Finally, the results highlight the need for comprehensive support for HCPs involved in safety incidents.

Improving the Quality of Maternity Care: Learning From Malpractice

OBJECTIVE

This study aimed to depict the characteristics, injury outcomes, and payment of obstetric malpractice lawsuits to better understand the medicolegal burden in obstetrics and categorize the causes of obstetric malpractice lawsuits using The National Health Service Litigation Authority coding taxonomy for further quality improvement in maternity care.

METHODS

We reviewed and retrieved key information on court records of legal trials from China Judgment Online between 2013 and 2021.

RESULTS

A total of 3441 obstetric malpractice lawsuits successfully claimed were reviewed in this study, with a total indemnity payment of $139,875,375. After peaking in 2017, the number of obstetric malpractice claims begins to decline. Of the 2424 hospitals that were sued, 8.3% (201/2424) were referred to as "repeat defendant" because they were involved in multiple lawsuits. Death and injury were the outcomes in 53.4% and 46.6% of the cases, respectively. The most common outcome type was neonatal death, which made up 29.8% of all cases. The median indemnity payment for death was higher compared with injury (P < 0.05). In terms of detailed injury outcomes, the major neonatal injury had higher median indemnity payments than neonatal death and fetal death (P < 0.05). The median indemnity payment of the major maternal injury was higher than that of maternal death (P < 0.05). The leading causes of obstetric malpractice were the management of birth complications and adverse events (23.3%), management of labor (14.4%), career decision making (13.7%), fetal surveillance (11.0%), and cesarean section management (9.5%). The cause for 8.7% of cases was high payment (≥$100, 000). As indicated by the results of the multivariate analysis, the hospitals in the midland of China (odds ratio [OR], 0.476; 95% confidence interval [CI], 0.348-0.651), the hospitals in the west of China (OR, 0.523; 95% CI, 0.357-0.767), and the secondary hospitals (OR, 0.587; 95% CI, 0.356-0.967) had lower risks of high payment. Hospitals with ultimate liability (OR, 9.695; 95% CI, 4.072-23.803), full liability (OR, 16.442; 95% CI, 6.231-43.391), major neonatal injury (OR, 12.326; 95% CI, 5.836-26.033), major maternal injury (OR, 20.885; 95% CI, 7.929-55.011), maternal death (OR, 18.783; 95% CI, 8.887-39.697), maternal death with child injury (OR, 54.682; 95% CI, 10.900-274.319), maternal injury with child death (OR, 6.935; 95% CI, 2.773-17.344), and deaths of both mother and child (OR, 12.770; 95% CI, 5.136-31.754) had higher risks of high payment. In the causative domain, only anesthetics had a higher risk of high payment (OR, 5.605; 95% CI, 1.347-23.320), but anesthetic-related lawsuits made up just 1.4% of all cases.

CONCLUSIONS

The healthcare systems had to pay a significant amount as a result of obstetric malpractice lawsuits. Greater efforts are required to minimize serious injury outcomes and improve obstetric quality in the risky domains.

Civil Lawsuits as an Indicator of Adverse Outcomes in Healthcare

The financial burden of adverse healthcare outcomes in Poland still remains unknown. The objective of the study was to estimate the cost of adverse healthcare outcomes in the Polish healthcare system. Cost calculation was performed on the basis of civil cases completed in Polish courts against doctors and healthcare entities. The research material consisted of 183 civil cases completed by a final judgment in 2011-2013. The case study was conducted in five out of forty-five district courts across the country. Out of 183 reviewed cases, 73 complaints ended up with favorable judgments (39.9%). The average value of the subject matter of the dispute was USD 78,675. The total expected value of lawsuits in the 183 reviewed cases was USD 11,299,020. The total amount awarded in 73 judgments from medical facilities to injured patients was USD 2,653,595, which on average means USD 36,351 per case. The average amount of awarded compensation was USD 33,317 per case. The average compensation amount in the analyzed cases was USD 11,724. The average one-time annuity for a patient was USD 11,788. The estimated costs of negative healthcare outcomes amounted to USD 8,000,000 per year.

Implementing a Robust Process Improvement Program in the Neonatal Intensive Care Unit to Reduce Harm

INTRODUCTION

Preventable harm continues to occur with critically ill neonates despite efforts by hospital neonatal intensive care units (NICUs) to improve processes and reduce harm. Attaining significant and sustainable improvements will require training including leadership support, mentoring, and patient family engagement to improve care processes. This paper describes the implementation of a robust process improvement (RPI) program in the NICU to reduce harm.

METHODS

Leaders, staff, and parents were trained in RPI concepts and tools. Multidisciplinary teams including parent members applied the training and received regular mentorship for their improvement initiatives.

RESULTS

Participants (N = 67) completed pretraining and post-training surveys. Training scores (0-10 scale) improved from an average of 4.45-7.60 (p < .001) for confidence in leading process improvement work, 2.36 to 7.49 (p < .001) for RPI knowledge, and 2.19 to 7.30 (p < .001) for confidence in using RPI tools; relative improvement of 71%, 217%, and 233% respectively. Participants applied their RPI training on improvement initiatives that resulted in improvements of central line blood stream infections, very low birth weight infant nutrition, and unplanned extubations.

CONCLUSIONS

Implementing an RPI program in the NICU to reduce harm resulted in significant and sustainable improvements on their improvement initiatives.

A Systematic Review and Meta-analysis of the Medical Error Rate in Iran: 2005-2019

BACKGROUND AND OBJECTIVES

Medical errors (MEs) are one of the main factors affecting the quality of hospital services and reducing patient safety in health care systems, especially in developing countries. The aim of this study was to determine the rate of ME in Iran.

METHODS

This is a systematic literature review and meta-analysis of extracted data. The databases MEDLINE, EMBASE, Scopus, Cochrane, SID, Magiran, and Medlib were searched in Persian and English, using a combination of medical subject heading terms ("Medical Error" [Mesh] OR "Medication error" [Mesh] OR "Hospital Error" AND ("Iran" [Mesh]) for observational and interventional studies that reported ME rate in Iran from January 1995 to April 2019. We followed the STROBE checklist for the purpose of this review.

RESULTS

The search yielded a total of 435 records, of which 74 articles were included in the systematic review. The rate of MEs in Iran was determined as 0.35%. The rates of errors among physicians and nurses were 31% and 37%, respectively. The error rates during the medication process, including prescription, recording, and administration, were 31%, 27%, and 35%, respectively. Also, incidence of MEs in night shifts was higher than in any other shift (odds ratio [OR] = 38%; 95% confidence interval [CI]: 31%-45%). Moreover, newer nurses were responsible for more errors within hospitals than other nurses (OR = 57%; 95% CI: 41%-80%). The rate of reported error after the Health Transformation Plan was higher than before the Health Transformation Plan (OR = 40%; CI: 33%-49% vs OR = 30%; CI: 25%-35%).

CONCLUSION

This systematic review has demonstrated the high ME rate in Iranian hospitals. Based on the error rate attributed solely to night shifts, more attention to the holistic treatment process is required. Errors can be decreased through a variety of strategies, such as training clinical and support staff regarding safe practices and updating and adapting systems and technologies.

Investigating medical malpractice victim compensation: micro-level evidence from a professional liability insurer's files

We examine micro-level data on medical incidents recorded by a major Belgian professional liability insurer to identify the predictors of medical malpractice victim compensation. The data allow us to track each instance of suspect medical malpractice from the moment of insurer's knowledge about the incident to file closure. We are, therefore, able to investigate the determinants of both the incidence and amount of indemnity payment while addressing the associated sample selection concerns. Conditional on some indemnity having been paid, provider specialty risk predicts the indemnity payment amount, but only via the effect of sustained injury type. We find little evidence of vertical or horizontal inequities in indemnity payment. Our results highlight previously overlooked features of the incident resolution process as quantitatively important predictors of victim compensation.

Association between measured teamwork and medical errors: an observational study of prehospital care in the USA

OBJECTIVES

The goal of this study was to examine the relationship between measured teamwork and adverse safety events in the prehospital emergency care of children using high-fidelity simulation. We posit that non-technical skills such as leadership, teamwork, situation awareness and decision-making are associated with the clinical success of teams.

DESIGN

Observational study.

SETTING

Emergency medical services (EMS) responders were recruited from public fire and private transport agencies in Oregon State to participate in four simulations of paediatric emergencies using high-fidelity patient simulators, scene design, and professional actors playing parents and bystanders.

PARTICIPANTS

Forty-four fire/transport teams consisting of 259 EMS professionals consented to participate and completed simulations.

PRIMARY AND SECONDARY OUTCOME MEASURES

Teams were assessed using the Clinical Teamwork Scale (CTS), a validated instrument that measures overall teamwork and 15 specific elements in five overarching domains: communication, decision-making, role responsibility (leadership and followership), situational awareness/resource management and patient-friendliness. We used generalised estimating equations to estimate the odds of error with increasing overall CTS teamwork score while adjusting for clinical scenario and potential clustering by team.

RESULTS

Across 176 simulations, the mean overall score on the CTS was 6.04 (SD 2.10; range 1=poor to 10=perfect) and was normally distributed. The distribution of scores was similar across the four clinical scenarios. At least one error was observed in 82% of the simulations. In simulations with at least one observed error, the mean CTS score was 5.76 (SD 2.04) compared with 7.16 (SD 1.95) in scenarios with no observed error. Logistic regression analysis accounting for clustering at the team level revealed that the odds of an error decreased 28% with each unit increase in CTS (OR 0.72, 95% CI 0.59 to 0.88).

CONCLUSIONS

This study found that overall teamwork among care delivery teams was strongly associated with the risk of serious adverse events in simulated scenarios of caring for critically ill and injured children.

Incidence and mortality from adverse effects of medical treatment in the UK, 1990-2013: levels, trends, patterns and comparisons

Objective

To present an update on incidence and mortality from adverse effects (AEs) of medical treatment in the UK, its four countries and nine English regions between 1990 and 2013.

Design

Descriptive epidemiological study on AEs of medical treatment. AEs are shown as a single cause-of-injury category from the Global Burden of Disease (GBD) 2013 study.

Data sources

The GBD 2013 interactive data visualisation tools ‘Epi Visualisation’ and ‘GBD Compare’.

Outcome measures

The means of incidence and mortality rates with 95% uncertainty intervals (UIs). The estimates are age-standardised.

Results

Incidence rate was 175 and 176 cases per 100 000 men, 173 and 174 cases per 100 000 women in 1990 and 2013, in the UK (UI 170–180). The mortality from AEs declined from 1.33 deaths (UI 0.99–1.5) to 0.92 deaths (UI 0.75–1.2) per 100 000 individuals in the UK between 1990 and 2013 (30.8% change). Although mortality trends were descending in every region of the UK, they varied by geography and gender. Mortality rates in Scotland, North East England and West Midlands were highest. Mortality rates in South England and Northern Ireland were lowest. In 2013, age-specific mortality rates were higher in males in all 20 age groups compared with females.

Conclusions

Despite gains in reducing mortality from AEs of medical treatment in the UK between 1990 and 2013, the incidence of AEs remained the same. The results of this analysis suggest revising healthcare policies and programmes aimed to reduce incidence of AEs in the UK.

Data-Driven Approach to Improving the Risk Assessment Process of Medical Failures

In recent decades, many researchers have focused on the issue of medical failures in the healthcare industry. A variety of techniques have been employed to assess the risk of medical failure and to generate strategies to reduce the frequency of medical failures. Considering the limitations of the traditional method—failure mode and effects analysis (FMEA)—for risk assessment and quality improvement, this paper presents two models developed using data envelopment analysis (DEA). One is called the slacks-based measure DEA (SBM-DEA) model, and the other is a novel data-driven approach (NDA) that combines FMEA and DEA. The relative advantages of the three models are compared. In this paper, an infant security case consisting of 16 failure modes at Western Wake Medical Center in Raleigh, North Carolina, U.S., was employed. The results indicate that both SBM-DEA and NDA may improve the discrimination and accuracy of detection compared to the traditional method of FMEA. However, NDA was found to have a relative advantage over SBM-DEA due to its risk assessment capability and precise detection of medical failures.

Physicians as second victims after a malpractice claim: An important issue in need of attention

OBJECTIVE

Being sued for malpractice is extremely stressful and potentially traumatizing. We aim to identify claims' consequences on the physicians' well-being and medical practice.

MATERIAL AND METHODS

We administered a confidential telephonic survey to those physicians with a claim closed during 2014, among those insured by the main professional liability insurance company in the region. The questionnaire addressed several topics: symptoms and well-being changes, needs, impairments and practice changes. We used descriptive statistics as well as Chi-square and T-Student tests.

RESULTS

A total of 99 physicians responded to the questionnaire (response rate of 64.7%). Most of them (80.8%) acknowledged having suffered a significant emotional distress, no matter the claim's outcome (p=0.958) or the kind of procedure (p=0.928). Anger and mood cluster of symptoms were frequent, and the experience frequently affected their personal, family or social life and professional conduct. Practice changes correlated significantly and positively with the number of symptoms reported (p=0.010), but not with the outcome of the claim (p=0.338) or the kind of procedure (p=0.552).

CONCLUSIONS

Most claimed physicians suffer a significant emotional distress after a malpractice claim, which affects their professional performance. According to our results, they should be assessed and assisted in order to minimize the negative consequences on their well-being and their praxis.

Rate of avoidable deaths in a Norwegian hospital trust as judged by retrospective chart review

BACKGROUND

The proportion of avoidable hospital deaths is challenging to estimate, but has great implications for quality improvement and health policy. Many studies and monitoring tools are based on selected high-risk populations, which may overestimate the proportion. Mandatory reporting systems, however, under-report. We hypothesise that a review of an unselected sample of hospital deaths will provide an estimate of avoidability in-between the estimates from these methods.

METHODS

A retrospective case record review of an unselected population of 1000 consecutive non-psychiatric hospital deaths in a Norwegian hospital trust was conducted. Reviewers evaluated to what degree each death could have been avoided, and identified problems in care.

RESULTS

We found 42 (4.2%) of deaths to be at least probably avoidable (more than 50% chance of avoidability). Life expectancy was shortened by at least 1 year among 34 of the 42 patients with an avoidable death. Patients whose death was found to be avoidable were less functionally dependent compared with patients in the non-avoidable death group. The surgical department had the greatest proportion of such deaths. Very few of the avoidable deaths were reported to the hospital's report system.

CONCLUSIONS

Avoidable hospital deaths occur less frequently than estimated by the national monitoring tool, but much more frequently than reported through mandatory reporting systems. Regular reviews of an unselected sample of hospital deaths are likely to provide a better estimate of the proportion of avoidable deaths than the current methods.

Creating a comprehensive, unit-based approach to detecting and preventing harm in the neonatal intensive care unit

Background

Error detection and analysis alone cannot create or sustain a culture of safe, high-quality, compassionate care for patients. Some experts have endorsed a unit-based approach to improving quality, but there are few examples and those rarely focus on reducing all preventable harms and engaging frontline clinicians, patients, and families. Approach: We implemented a unit-based approach comprising seven building blocks for creating a comprehensive approach to detect and prevent harm at the unit level within a hospital: (1) unit quality council and stakeholder buy-in, (2) parent engagement and advisory council, (3) frontline clinician and parent quality improvement training, (4) measurement of organizational contextual factors, (5) electronic health record trigger development and synthesis of harm measures, (6) subcommittees to review harm, and (7) quality improvement teams. Challenges and Lessons Learned: Challenges include conceptualizing triggers for a unit unfamiliar with this methodology, establishing unit resources for collecting and analyzing data, and creating processes to integrate parents in unit quality efforts. The seven essential building blocks helped overcome these challenges and could be adopted by other healthcare organizations.

Conclusion

These building blocks create a generalizable foundation for establishing a unit-based approach to detecting and preventing harm.

Lessons learned for reducing the negative impact of adverse events on patients, health professionals and healthcare organizations

Purpose

To summarize the knowledge about the aftermath of adverse events (AEs) and develop a recommendation set to reduce their negative impact in patients, health professionals and organizations in contexts where there is no previous experiences and apology laws are not present.

Data sources

Review studies published between 2000 and 2015, institutional websites and experts' opinions on patient safety.

Study selection

Studies published and websites on open disclosure, and the second and third victims' phenomenon. Four Focus Groups participating 27 healthcare professionals.

Data extraction

Study characteristic and outcome data were abstracted by two authors and reviewed by the research team.

Results of data synthesis

Fourteen publications and 16 websites were reviewed. The recommendations were structured around eight areas: (i) safety and organizational policies, (ii) patient care, (iii) proactive approach to preventing reoccurrence, (iv) supporting the clinician and healthcare team, (v) activation of resources to provide an appropriate response, (vi) informing patients and/or family members, (vii) incidents' analysis and (viii) protecting the reputation of health professionals and the organization.

Conclusion

Recommendations preventing aftermath of AEs have been identified. These have been designed for the hospital and the primary care settings; to cope with patient's emotions and for tacking the impact of AE in the second victim's colleagues. Its systematic use should help for the establishment of organizational action plans after an AE.