A cross-national comparison of incident reporting systems implemented in German and Swiss hospitals

Development and validation of a short clinical risk management implementation (Short CRiMI) questionnaire

Clinical Risk Management (CRM) is an important instrument to continuously improve safety of health care delivery. In Germany, hospitals are required by law to implement CRM and incidence reporting systems. Since 2010, nation-wide surveys have been conducted periodically to evaluate implementation of CRM in hospitals. The instrument used in these surveys is constantly being updated to reflect previous experiences, as well as to adapt to ongoing trends and developments in CRM practices. The survey instrument used in 2022 consisted of up to 200 items and took up to an hour to complete. In this study, we aimed to develop a short instrument to measure the level of CRM implementation in hospitals, evaluate its psychometric properties, and to offer benchmarking data for health care facilities of different sizes. We used data collected in 2022 as part of KHaSiMiR study, employing a cross-sectional self-reported online survey. The hospital administrations were invited to designate one CRM manager to participate in the study. Out of 1,411 general hospitals invited, 401 responses were collected (response rate of 28%). After removing the cases with excessive missings, we imputed remaining missing values using multiple imputation, and split the resulting sample (n=362) in two halves (i.e., exploratory and testing subsamples). A principal component analysis was applied on the first subsample. We validated the resulting model using confirmatory factor analysis in the testing subsample. We evaluated internal consistency, and tested external validity of the established instrument using correlation analysis with two single-item measures: subjective evaluation of CRM implementation compared to similar organizations and compared to own ideal level. The principal component analysis included 45 items from the full instrument. The analysis resulted in a three-factor model with 26 items. In the confirmatory factor analysis, the model demonstrated acceptable fit with the data according to the commonly used fit indices: Chi2/df=1.36, CFI=0.941, TLI=0.930, RMSEA=0.045 (90% CI=0.032-0.056), SRMR=0.049. Cronbach's alpha of all three factors was good (>0.70). All three factors had statistically significant positive correlations with each other (0.359-0.497) and with the two single items (0.282-0.532). None of the correlations were high enough (>0.7) to indicate multicollinearity. The proposed short clinical risk management implementation (Short CRiMI) questionnaire is psychometrically valid and can be used to rapidly evaluate CRM implementation in hospitals. Further research can provide evidence of its external validity and association with quality and safety outcomes. Benchmarking data can be used to compare the results with the data from the most recent Germany-wide survey.

Implementation of a comprehensive clinical risk management system in a university hospital

BACKGROUND

Adverse events during hospital treatment are common and can lead to serious harm. This study reports the implementation of a comprehensive clinical risk management system in a university hospital and assesses the impact of clinical risk management on patient harms.

METHODS

The clinical risk management system was rolled out over a period of eight years and consisted of a training of interdisciplinary risk management teams, external and internal risk audits, and the implementation of a critical incident reporting system (CIRS). The risks identified during the audits were analyzed according to the type, severity, and implementation of preventive measures. Other key figures of the risk management system were obtained from the annual risk reports. The number of liability cases was used as primary outcome measurement.

RESULTS

Of the 1,104 risks identified during the risk audits, 56.2% were related to organization, 21.3% to documentation, 15.3% to treatment, and 7.2% to patient information and consent. The highest proportion of serious risks was found in the category organization (22.7%), the lowest in the category documentation (13.6%). Critical incident reporting identified between 241 and 370 critical incidents per year, for which in 79.5% to 83% preventive measures were implemented within twelve months. The frequency of incident reports per department correlated with the number of active risk managers and risk team meetings. Compared with the years prior to the introduction of the clinical risk management system, an average annual reduction of harms by 60.1% (95% CI: 57.1; 63.1) was observed two years after the implementation was completed. On average, the rate of harms dropped by 5% per year for each 10% increase in roll-out of the clinical risk management system (incidence rate ratio: 0.95; 95% CI: 0.93; 0.97) .

CONCLUSION

The results of this project demonstrate the effectiveness of clinical risk management in detecting treatment-related risks and in reducing harm to patients.

Indicators for implementation outcome monitoring of reporting and learning systems in hospitals: an underestimated need for patient safety

Objective

We aimed to investigate the perception of the implementation success of reporting and learning systems in German hospitals, the perceived relevance of the implementation outcomes and whether and how these implementation outcomes are monitored. An reporting and learning system is a tool used worldwide for patient safety that identifies and analyses critical events, errors, risks and near misses in healthcare.

Methods

A pretested exploratory cross-sectional online survey was conducted with reporting and learning system experts from 51 acute care hospitals. For communicative validation, the results were discussed in person in an expert panel discussion (N=23).

Results

Fifty-three per cent (n=27) of the participants (N=51) of the online survey perceived that their reporting and learning system was being comprehensively and successfully implemented. However, no service or patient outcomes were reported to ultimately capture the concept of implementation success. Most of the participants reported a (high) relevance of the implementation outcomes’ acceptability and sustainability. In total, 44 measures were provided to monitor implementation outcomes. However, most of the quantitative measures were based on the (relative) number of entered reports. Qualitative measures were reported in relation to the ‘quality of the report’. In general, the measures were poorly specified.

Conclusion

There is an underestimated need to develop validated ‘implementation patient safety indicator(s) (sets)’ to monitor implementation outcomes of reporting and learning systems. We also identified a potential need to facilitate awareness of the concept of implementation success and its relevance for patient safety. Drafts of indicators that could be used as a starting point for the further development of ‘implementation patient safety indicators’ were provided.

Registration and Management of "Never Events" in Swiss Hospitals-The Perspective of Clinical Risk Managers

BACKGROUND

In Switzerland, there is no mandatory reporting of "never events." Little is known about how hospitals in countries with no "never event" policies deal with these incidents in terms of registration and analyses.

OBJECTIVE

The aim of our study was to explore how hospitals outside mandatory "never event" regulations identify, register, and manage "never events" and whether practices are associated with hospital size.

METHODS

Cross-sectional survey data were collected from risk managers of Swiss acute care hospitals.

RESULTS

Clinical risk managers representing 95 hospitals completed the survey (55% response rate). Among responding risk and quality managers, only 45% would be formally notified through a designated reporting channel if a "never event" has happened in their hospital. Averaged over a list of 8 specified events, only half of hospitals could report a systematic count of the number of events. Hospital size was not associated with "never event" management. Respondents reported that their hospital pays "too little attention" to the recording (46%), the analysis (34%), and the prevention (40%) of "never events." All respondents rated the systematic registration and analysis of "never events" as very (81%) or rather important (19%) for the improvement of patient safety.

CONCLUSIONS

A substantial fraction of Swiss hospitals do not have valid data on the occurrence of "never events" available and do not have reliable processes installed for the registration and exam of these events. Surprisingly, larger hospitals do not seem to be better prepared for "never events" management.