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Griffeth EM, Gajic O, Schueler N, Todd A, Ramar K. Multifaceted Intervention to Improve Patient Safety Incident Reporting in Intensive Care Units. J Patient Saf 2023; 19:422-428. [PMID: 37466643 PMCID: PMC10526728 DOI: 10.1097/pts.0000000000001151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
OBJECTIVES Patient safety incident reporting in our institution's intensive care units (ICUs) had fallen 30% below national benchmarks during the COVID-19 pandemic. Underreporting diminishes awareness of risks and precludes organizational learning from near misses. We aimed to increase the ICU number of patient safety incident reports by 30% from 27 to 35 reports/1000 patient-days without negatively impacting culture of safety as measured by patient-care staff surveys. METHODS Single-institution prospective interventional study with 9 ICUs receiving a multifaceted intervention developed using quality improvement methodology during February-April 2022. Study intervention involved creation of patient safety peer-leadership role, feedback process, interactive dashboards for patient safety data, and education resources accessible via quick response codes. Primary outcome was patient safety incident reports/1000 patient-days. Intensive care unit patient-care staff culture of safety was assessed with surveys. RESULTS Intensive care unit patient safety incident reporting increased by 48% after intervention (40 versus 27 reports/1000 patient-days [ P = 0.136]). Near misses were the most common incident report. Intensive care unit patient-care staff ratings of patient safety did not change; 80% rated patient safety as good or better after intervention versus 78% at baseline ( P = 0.465). However, significant improvement was observed for subcomponents related to learning culture and support for staff involved in patient safety incidents. Most reports (>80%) were submitted by nurses. CONCLUSIONS This multifaceted quality improvement intervention increased patient safety incident reporting in the ICUs. Increases in ratings of learning culture and support for staff underline the importance of a well-functioning patient safety incident reporting system in an institutional culture of safety.
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Affiliation(s)
- Elaine M. Griffeth
- Department of Surgery; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
| | - Nicole Schueler
- Patient Safety; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
| | - Austin Todd
- Department of Quantitative Health Sciences Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
| | - Kannan Ramar
- Division of Pulmonary and Critical Care Medicine; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
- Patient Safety; Mayo Clinic, 200 First St. SW, Rochester, MN, USA 55901
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Seino Y, Sato N, Idei M, Nomura T. The Reduction in Medical Errors on Implementing an Intensive Care Information System in a Setting Where a Hospital Electronic Medical Record System is Already in Use: Retrospective Analysis. JMIR Perioper Med 2022; 5:e39782. [PMID: 35964333 PMCID: PMC9475405 DOI: 10.2196/39782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/01/2022] [Accepted: 08/14/2022] [Indexed: 11/30/2022] Open
Abstract
Background Although the various advantages of clinical information systems in intensive care units (ICUs), such as intensive care information systems (ICISs), have been reported, their role in preventing medical errors remains unclear. Objective This study aimed to investigate the changes in the incidence and type of errors in the ICU before and after ICIS implementation in a setting where a hospital electronic medical record system is already in use. Methods An ICIS was introduced to the general ICU of a university hospital. After a step-by-step implementation lasting 3 months, the ICIS was used for all patients starting from April 2019. We performed a retrospective analysis of the errors in the ICU during the 6-month period before and after ICIS implementation by using data from an incident reporting system, and the number, incidence rate, type, and patient outcome level of errors were determined. Results From April 2018 to September 2018, 755 patients were admitted to the ICU, and 719 patients were admitted from April 2019 to September 2019. The number of errors was 153 in the 2018 study period and 71 in the 2019 study period. The error incidence rates in 2018 and 2019 were 54.1 (95% CI 45.9-63.4) and 27.3 (95% CI 21.3-34.4) events per 1000 patient-days, respectively (P<.001). During both periods, there were no significant changes in the composition of the types of errors (P=.16), and the most common type of error was medication error. Conclusions ICIS implementation was temporally associated with a 50% reduction in the number and incidence rate of errors in the ICU. Although the most common type of error was medication error in both study periods, ICIS implementation significantly reduced the number and incidence rate of medication errors. Trial Registration University Hospital Medical Information Network Clinical Trials Registry UMIN000041471; https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000047345
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Affiliation(s)
- Yusuke Seino
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Nobuo Sato
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Masafumi Idei
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
- Department of Anesthesiology and Intensive Care Medicine, Yokohama City University, Yokohama, Japan
| | - Takeshi Nomura
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
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Tlili MA, Aouicha W, Sahli J, Mtiraoui A, Ajmi T, Laatiri H, Chelbi S, Ben Rejeb M, Mallouli M. An Intervention to Optimize Attitudes Toward Adverse Events Reporting Among Tunisian Critical Care Nurses. J Patient Saf 2022; 18:e872-e876. [PMID: 35044996 DOI: 10.1097/pts.0000000000000961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed at evaluating the impact of a combined-strategies intervention on ICUs nurses' attitudes toward AE reporting. METHODS We conducted a quasi-experimental study from January to October 2020 which consisted of an intervention to improve attitudes toward incident reporting among nurses working in 10 intensive care units at a university hospital using the Reporting of Clinical Adverse Events Scale. The intervention consisted of a 2-hour educational presentation for nurse unit managers and a 30-minute in-units educational training for intensive care unit nurses, which encompassed technical aspects of reporting, the reporting process, a nonpunitive environment, and the importance of submitting reports. The educational presentation was reinforced with distributing posters and brochures and biweekly patient safety rounds that inquired about events, reinforced education, and provided follow-up to incident reports. RESULTS All dimensions were significantly improved. Score increased from 27.4% to 42.1% ( P < 0.01) for perceived blame, from 35.2% to 52.5% for perceived criteria for identifying events that should be reported ( P < 0.01), from 34.3% to 46% for perceptions of colleagues' expectations ( P = 0.04), from 37.1% to 51.4% for perceived benefits of reporting ( P = 0.01), and from 29.2% to 51.4% for perceived clarity of reporting procedures ( P < 0.01). CONCLUSIONS Interventions using a combination of several strategies such as training, safety round, and messaging can be effective and should be considered by hospitals attempting to increase adverse events reporting. Results reinforce the assumption that a nonpunitive environment and the resulting feeling of safety and reassurance are crucial to foster the submission of reports.
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Affiliation(s)
- Mohamed Ayoub Tlili
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
| | - Wiem Aouicha
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
| | - Jihene Sahli
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
| | - Ali Mtiraoui
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
| | - Thouraya Ajmi
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
| | - Houyem Laatiri
- Department of Prevention and Care Safety, Sahloul University Hospital
| | - Souad Chelbi
- Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia
| | - Mohamed Ben Rejeb
- Department of Prevention and Care Safety, Sahloul University Hospital
| | - Manel Mallouli
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
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Danielis M, Bellomo F, Farneti F, Palese A. Critical incidents rates and types in Italian Intensive Care Units: A five-year analysis. Intensive Crit Care Nurs 2020; 62:102950. [PMID: 33131994 DOI: 10.1016/j.iccn.2020.102950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 08/02/2020] [Accepted: 08/07/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe rates and types of critical incidents in Intensive Care Units. RESEARCH METHODOLOGY A retrospective study in four intensive care units of an Academic Hospital located in the North-East of Italy. All critical incidents recorded in an incident reporting system database from 2013 to 2017 were collected. RESULTS 160 critical incidents emerged. The rate was 1.7/100 intensive care-patient admissions, and 2.86/1000 in intensive care-patient days. Nurses reported most of the critical incidents (n = 113, 70.6%). In 2013 there were 19 (11.9%) critical incidents which significantly increased by 2017 (n = 38, 23.7%; p = 0.034). The most frequent critical incidents were medication/intravenous fluids issues (n = 35, 21.9%) and resources and organisational management (n = 35, 21.9%). Less frequently occurring incidents concerned medical devices/equipment (n = 29, 18.1%), clinical processes/procedures (n = 18, 11.3%), documentation (n = 14, 8.8%) and patient accidents (n = 13, 8.1%). Rare incidents included behaviour, clinical administration, nutrition, blood products and healthcare associated infection. CONCLUSION Over a five-year period, documented incidents were steadily increasing in four Italian intensive care units. A voluntary incident reporting system might provide precious information on safety issues occurring in units. at both policy and professional levels.
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Affiliation(s)
- Matteo Danielis
- School of Nursing, Department of Medical Sciences, University of Udine, Viale Ungheria 20, 33100 Udine, Italy.
| | - Fabrizio Bellomo
- Accreditation, Clinical Risk Management and Performance Assessment Unit, Udine University Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
| | - Federico Farneti
- Accreditation, Clinical Risk Management and Performance Assessment Unit, Udine University Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
| | - Alvisa Palese
- School of Nursing, Department of Medical Sciences, University of Udine, Viale Ungheria 20, 33100 Udine, Italy
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Feeser VR, Jackson AK, Savage NM, Layng TA, Senn RK, Dhindsa HS, Santen SA, Hemphill RR. When Safety Event Reporting Is Seen as Punitive: "I've Been PSN-ed!". Ann Emerg Med 2020; 77:449-458. [PMID: 32807540 DOI: 10.1016/j.annemergmed.2020.06.048] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/29/2020] [Accepted: 06/25/2020] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE Reporting systems are designed to identify patient care issues so changes can be made to improve safety. However, a culture of blame discourages event reporting, and reporting seen as punitive can inhibit individual and system performance in patient safety. This study aimed to determine the frequency and factors related to punitive patient safety event report submissions, referred to as Patient Safety Net reports, or PSNs. METHODS Three subject matter experts reviewed 513 PSNs submitted between January and June 2019. If the PSN was perceived as blaming an individual, it was coded as punitive. The experts had high agreement (κ=0.84 to 0.92), and identified relationships between PSN characteristics and punitive reporting were described. RESULTS A total of 25% of PSNs were punitive, 7% were unclear, and 68% were designated nonpunitive. Punitive (vs nonpunitive) PSNs more likely focused on communication (41% vs 13%), employee behavior (38% vs 2%), and patient assessment issues (17% vs 4%). Nonpunitive (vs punitive) PSNs were more likely for equipment (19% vs 4%) and patient or family behavior issues (8% vs 2%). Punitive (vs nonpunitive) PSNs were more common with adverse reactions or complications (21% vs 10%), communication failures (25% vs 16%), and noncategorized events (19% vs 8%), and nonpunitive (vs punitive) PSNs were more frequent in falls (5% vs 0%) and radiology or laboratory events (17% vs 7%). CONCLUSION Punitive reports have important implications for reporting systems because they may reflect a culture of blame and a failure to recognize system influences on behaviors. Nonpunitive wording better identifies factors contributing to safety concerns. Reporting systems should focus on patient outcomes and learning from systems issues, not blaming individuals.
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Affiliation(s)
- V Ramana Feeser
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA
| | - Anne K Jackson
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA
| | - Nastassia M Savage
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA
| | - Timothy A Layng
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA; Department of Emergency Medicine, University of Virginia, Charlottesville, VA (Layng)
| | - Regina K Senn
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA
| | - Harinder S Dhindsa
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA
| | - Sally A Santen
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA; Office of Assessment, Evaluation, and Scholarship, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Robin R Hemphill
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA.
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Mohsin SU, Ibrahim Y, Levine D. Teaching medical students to recognise and report errors. BMJ Open Qual 2019; 8:e000558. [PMID: 31276054 PMCID: PMC6579567 DOI: 10.1136/bmjoq-2018-000558] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 02/26/2019] [Accepted: 03/08/2019] [Indexed: 11/18/2022] Open
Abstract
Background Medical student error reporting can potentially be increased through patient safety education, culture change and by teaching students how to report errors. There is scant literature on what kinds of errors students see during clinical rotations. The authors developed an intervention to better understand what kinds of errors students see and to train them to identify and report errors. Methods A safety curriculum was delivered during the Medicine clerkship for the academic year 2015–2016. Prior to the workshop, students completed a preintervention survey to determine whether they had reported a clinical error. Subsequently, they participated in an educational workshop. Facilitated discussions about conditions contributing to errors, types of errors, prevention of errors and importance of reporting followed. Students were required to submit a simulated error report about an error they personally observed. An end-of-year survey was sent to students who participated in the curriculum to determine clinical error reporting frequency. Results Students submitted 282 reports. Near miss errors were seen in 64% and adverse events in 36%. National Quality Forum serious events were reported in 14%, including one death. Recommendations to prevent similar events were weak (62%). Students correctly categorised 93% near miss, 88% adverse events, 67% diagnostic, 81% treatment and 78% preventative errors. On the preintervention survey, 8.5% stated they submitted an error report to their clinical site. On the end-of-year survey, 18% confirmed submitting a formal error report. Conclusion Training students to recognise and report errors can be successfully integrated into a clinical clerkship and impact clinical error reporting.
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Affiliation(s)
- Syed Umer Mohsin
- Internal Medicine, Wayne State University, Detroit Medical Center, Detroit, Michigan, USA
| | - Yahya Ibrahim
- Internal Medicine, Wayne State University, Detroit Medical Center, Detroit, Michigan, USA
| | - Diane Levine
- Internal Medicine, Wayne State University, Detroit Medical Center, Detroit, Michigan, USA
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Sellers MM, Berger I, Myers JS, Shea JA, Morris JB, Kelz RR. Using Patient Safety Reporting Systems to Understand the Clinical Learning Environment: A Content Analysis. JOURNAL OF SURGICAL EDUCATION 2018; 75:e168-e177. [PMID: 30174144 DOI: 10.1016/j.jsurg.2018.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/05/2018] [Accepted: 08/04/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To examine patient safety event reporting behavior by trainees caring for surgical patients compared to other clinicians. DESIGN Qualitative analysis of a patient safety event reporting system comparing reports entered by trainees to those entered by attending physicians and nurses. Categorical data associated with reports were compared, and free-text event descriptions underwent content analysis focusing on themes related to report completeness and report focus. SETTING The Hospital of the University of Pennsylvania, an academic tertiary care hospital in Philadelphia, Pennsylvania. PARTICIPANTS All patient safety event reports related to surgical patients from a 6-month period (July-December 2016). RESULTS One thousand four hundred twenty-three reports were entered by trainees (T), attendings (A), and nurses (N). Trainees had a lower number of reports entered per reporter compared to nurses (T median [IQR]: 1 [1-2], N: 2 [1-3]), and the highest percentage of reports entered anonymously for any group (T: 28.7%, N: 9.9%, A: 4.6%). The overall distribution of event location and event type differed significantly between groups (p < 0.001). Trainee reports were found to have a broader range of focus, more elements associated with completeness of reports, and more frequent use of blame language. CONCLUSIONS Surgical trainees report a wide variety of issues in the perioperative, floor, and ICU settings. Their reports often include more details than those entered by other clinicians, but feature higher rates of anonymous reporting and use of blame language. Analysis of patient safety event reports by trainees compared with other healthcare professionals can reveal important insights into the clinical learning environment and areas for safety improvement.
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Affiliation(s)
- Morgan M Sellers
- Department of Surgery, Center for Surgery Healthcare and Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Ian Berger
- Department of Surgery, Center for Surgery Healthcare and Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer S Myers
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Judy A Shea
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jon B Morris
- Department of Surgery, Center for Surgery Healthcare and Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel R Kelz
- Department of Surgery, Center for Surgery Healthcare and Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Rishoej RM, Hallas J, Juel Kjeldsen L, Thybo Christesen H, Almarsdóttir AB. Likelihood of reporting medication errors in hospitalized children: a survey of nurses and physicians. Ther Adv Drug Saf 2017; 9:179-192. [PMID: 29492247 DOI: 10.1177/2042098617746053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 11/14/2017] [Indexed: 11/16/2022] Open
Abstract
Background Hospitalized children are at risk of medication errors (MEs) due to complex dosage calculations and preparations. Incident reporting systems may facilitate prevention of MEs but underreporting potentially undermines this system. We aimed to examine whether scenarios involving medications should be reported to a national mandatory incident reporting system and the likelihood of self- and peer-reporting these scenarios among paediatric nurses and physicians. Methods Participants' reporting of MEs was explored through a questionnaire involving 20 medication scenarios. The scenarios represented different steps in the medication process, types of error, patient outcomes and medications. Reporting rates and odds ratios with 95% confidence interval [OR, (95% CI)] were calculated. Barriers to and enablers of reporting were identified through content analysis of participants' comments. Results The response rate was 42% (291/689). Overall, 61% of participants reported that scenarios should be reported. The likelihood of reporting was 60% for self-reporting and 37% for peer-reporting. Nurses versus physicians, and healthcare professionals with versus without patient safety responsibilities assessed to a larger extent that the scenarios should be reported [OR = 1.34 (1.05-1.70) and OR = 1.41 (1.12-1.78), respectively]; were more likely to self-report, [OR = 2.81 (1.71-4.62) and OR = 2.93 (1.47-5.84), respectively]; and were more likely to peer-report [OR = 1.89 (1.36-2.63) and OR = 3.61 (2.57-5.06), respectively].Healthcare professionals with versus without management responsibilities were more likely to peer-report [OR = 5.16 (3.44-7.72)]. Participants reported that scenarios resulting in actual injury or incidents considered to have a learning potential should be reported. Conclusion The likelihood of underreporting scenarios was high among paediatric nurses and physicians. Nurses and staff with patient safety responsibilities were more likely to assess that scenarios should be reported and to report. Incidents with actual injury or learning potential were more likely to be reported. The potential for improving reporting rates involving MEs seems high.
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Affiliation(s)
- Rikke Mie Rishoej
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 19, 2., 5000 Odense C, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | | | - Henrik Thybo Christesen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Anna Birna Almarsdóttir
- Social and Clinical Pharmacy, Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
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Abstract
OBJECTIVE To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill. DATA SOURCES PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015. STUDY SELECTION Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system. The committee collectively developed Population, Intervention, Comparator, Outcome questions and quality of evidence statements pertaining to medication errors and adverse drug events addressing the key components. A total of 34 Population, Intervention, Comparator, Outcome questions, five quality of evidence statements, and one commentary on disclosure was developed. DATA EXTRACTION Subcommittee members were assigned selected Population, Intervention, Comparator, Outcome questions or quality of evidence statements. Subcommittee members completed their Grading of Recommendations Assessment, Development, and Evaluation of the question with his/her quality of evidence assessment and proposed strength of recommendation, then the draft was reviewed by the relevant subcommittee. The subcommittee collectively reviewed the evidence profiles for each question they developed. After the draft was discussed and approved by the entire committee, then the document was circulated among all members for voting on the quality of evidence and strength of recommendation. DATA SYNTHESIS The committee followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation system to determine quality of evidence and strength of recommendations. CONCLUSIONS This guideline evaluates the ICU environment as a risk for medication-related events and the environmental changes that are possible to improve safe medication use. Prevention strategies for medication-related events are reviewed by medication use process node (prescribing, distribution, administration, monitoring). Detailed considerations to an active surveillance system that includes reporting, identification, and evaluation are discussed. Also, highlighted is the need for future research for safe medication practices that is specific to critically ill patients.
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Gong Y, Kang H, Wu X, Hua L. Enhancing Patient Safety Event Reporting. A Systematic Review of System Design Features. Appl Clin Inform 2017; 8:893-909. [PMID: 28853766 DOI: 10.4338/aci-2016-02-r-0023] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 06/25/2017] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Electronic patient safety event reporting (e-reporting) is an effective mechanism to learn from errors and enhance patient safety. Unfortunately, the value of e-reporting system (a software or web server based platform) in patient safety research is greatly overshadowed by low quality reporting. This paper aims at revealing the current status of system features, detecting potential gaps in system design, and accordingly proposing suggestions for future design and implementation of the system. METHODS Three literature databases were searched for publications that contain informative descriptions of e-reporting systems. In addition, both online publicly accessible reporting forms and systems were investigated. RESULTS 48 systems were identified and reviewed. 11 system design features and their frequencies of occurrence (Top 5: widgets (41), anonymity or confidentiality (29), hierarchy (20), validator (17), review notification (15)) were identified and summarized into a system hierarchical model. CONCLUSIONS The model indicated the current e-reporting systems are at an immature stage in their development, and discussed their future development direction toward efficient and effective systems to improve patient safety.
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Error Detection and Reporting in the Intensive Care Unit: Progress, Barriers, and Future Direction. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0228-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Wright J, Lawton R, O’Hara J, Armitage G, Sheard L, Marsh C, Grange A, McEachan RRC, Cocks K, Hrisos S, Thomson R, Jha V, Thorp L, Conway M, Gulab A, Walsh P, Watt I. Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04150] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BackgroundEstimates suggest that, in NHS hospitals, incidents causing harm to patients occur in 10% of admissions, with costs to the NHS of > £2B. About one-third of harmful events are believed to be preventable. Strategies to reduce patient safety incidents (PSIs) have mostly focused on changing systems of care and professional behaviour, with the role that patients can play in enhancing the safety of care being relatively unexplored. However, although the role and effectiveness of patient involvement in safety initiatives is unclear, previous work has identified a general willingness among patients to contribute to initiatives to improve health-care safety.AimOur aim in this programme was to design, develop and evaluate four innovative approaches to engage patients in preventing PSIs: assessing risk, reporting incidents, direct engagement in preventing harm and education and training.Methods and resultsWe developed tools to report PSIs [patient incident reporting tool (PIRT)] and provide feedback on factors that might contribute to PSIs in the future [Patient Measure of Safety (PMOS)]. These were combined into a single instrument and evaluated in the Patient Reporting and Action for a Safe Environment (PRASE) intervention using a randomised design. Although take-up of the intervention by, and retention of, participating hospital wards was 100% and patient participation was high at 86%, compliance with the intervention, particularly the implementation of action plans, was poor. We found no significant effect of the intervention on outcomes at 6 or 12 months. The ThinkSAFE project involved the development and evaluation of an intervention to support patients to directly engage with health-care staff to enhance their safety through strategies such as checking their care and speaking up to staff if they had any concerns. The piloting of ThinkSAFE showed that the approach is feasible and acceptable to users and may have the potential to improve patient safety. We also developed a patient safety training programme for junior doctors based on patients who had experienced PSIs recounting their own stories. This approach was compared with traditional methods of patient safety teaching in a randomised controlled trial. The study showed that delivering patient safety training based on patient narratives is feasible and had an effect on emotional engagement and learning about communication. However, there was no effect on changing general attitudes to safety compared with the control.ConclusionThis research programme has developed a number of novel interventions to engage patients in preventing PSIs and protecting them against unintended harm. In our evaluations of these interventions we have been unable to demonstrate any improvement in patient safety although this conclusion comes with a number of caveats, mainly about the difficulty of measuring patient safety outcomes. Reflecting this difficulty, one of our recommendations for future research is to develop reliable and valid measures to help efficiently evaluate safety improvement interventions. The programme found patients to be willing to codesign, coproduce and participate in initiatives to prevent PSIs and the approaches used were feasible and acceptable. These factors together with recent calls to strengthen the patient voice in health care could suggest that the tools and interventions from this programme would benefit from further development and evaluation.Trial registrationCurrent Controlled Trials ISRCTN07689702.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- John Wright
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Rebecca Lawton
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
- School of Psychology, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Jane O’Hara
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
- Leeds Institute of Medical Education, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Gerry Armitage
- Faculty of Health Studies, University of Bradford, Bradford, UK
| | - Laura Sheard
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Claire Marsh
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Angela Grange
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Rosemary RC McEachan
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Kim Cocks
- York Trials Unit, University of York, York, UK
| | - Susan Hrisos
- Institute of Health & Society, University of Newcastle, Newcastle, UK
| | - Richard Thomson
- Institute of Health & Society, University of Newcastle, Newcastle, UK
| | - Vikram Jha
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Liz Thorp
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | | | - Peter Walsh
- Action against Medical Accidents, Croydon, UK
| | - Ian Watt
- Department of Health Sciences, University of York, York, UK
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13
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Arabi YM, Al Owais SM, Al-Attas K, Alamry A, AlZahrani K, Baig B, White D, Deeb AM, Al-Dozri HD, Haddad S, Tamim HM, Taher S. Learning from defects using a comprehensive management system for incident reports in critical care. Anaesth Intensive Care 2016; 44:210-20. [PMID: 27029653 DOI: 10.1177/0310057x1604400207] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Incident reporting systems are often used without a structured review process, limiting their utility to learn from defects and compromising their impact on improving the healthcare system. The objective of this study is to describe the experience of implementing a Comprehensive Management System (CMS) for incident reports in the ICU. A physician-led multidisciplinary Incident Report Committee was created to review, analyse and manage the department incident reports. New protocols, policies and procedures, and other patient safety interventions were developed as a result. Information was disseminated to staff through multiple avenues. We compared the pre- and post-intervention periods for the impact on the number of incident reports, level of harm, time needed to close reports and reporting individuals. A total of 1719 incidents were studied. ICU-related incident reports increased from 20 to 36 incidents per 1000 patient days (P=0.01). After implementing the CMS, there was an increase in reporting 'no harm' from 14.2 to 28.1 incidents per 1000 patient days (P<0.001). There was a significant decrease in the time needed to close incident report after implementing the CMS (median of 70 days [Q1-Q3: 26-212] versus 13 days [Q1-Q3: 6-25, P<0.001]). A physician-led multidisciplinary CMS resulted in significant improvement in the output of the incident reporting system. This may be important to enhance the effectiveness of incident reporting systems in highlighting system defects, increasing learning opportunities and improving patient safety.
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Affiliation(s)
- Y M Arabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - S M Al Owais
- Quality Management Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - K Al-Attas
- Anesthesia Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - A Alamry
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - K AlZahrani
- Quality Management Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - B Baig
- King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - D White
- King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - A M Deeb
- King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - H D Al-Dozri
- King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - S Haddad
- King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - H M Tamim
- King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - S Taher
- King Abdulaziz Medical City, Riyadh, Saudi Arabia
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14
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Aljeesh YI, Alkariri N, Abusalem S, Myers JA, Alaloul F. Staff-developed infection prevention program decreases health care-associated infection rates in pediatric critical care. J Nurs Care Qual 2016; 30:71-6. [PMID: 25084470 DOI: 10.1097/ncq.0000000000000079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The health care team identified the causes of health care-associated infections (HAI) and developed interventions in a pediatric intensive care unit in Gaza. A quasi-experimental pretest-posttest design was used. All 26 full-time staff members in the pediatric intensive care unit participated. The HAI rate decreased significantly from the first to the second year following the implementation of the intervention (208 vs 120.55, odds ratio: 3.21, 95% confidence interval: 1.87-5.11; P < .001).
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Affiliation(s)
- Yousef I Aljeesh
- School of Nursing, Islamic University of Gaza, Gaza, Palestinian NA (Dr Aljeesh and Mr Alkariri); and School of Nursing, University of Louisville, Louisville, Kentucky (Drs Abusalem, Myers, and Alaloul)
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15
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Brunsveld-Reinders AH, Arbous MS, De Vos R, De Jonge E. Incident and error reporting systems in intensive care: a systematic review of the literature. Int J Qual Health Care 2015; 28:2-13. [DOI: 10.1093/intqhc/mzv100] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2015] [Indexed: 01/19/2023] Open
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16
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Lipshutz AKM, Caldwell JE, Robinowitz DL, Gropper MA. An analysis of near misses identified by anesthesia providers in the intensive care unit. BMC Anesthesiol 2015; 15:93. [PMID: 26082147 PMCID: PMC4468961 DOI: 10.1186/s12871-015-0075-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 06/09/2015] [Indexed: 11/23/2022] Open
Abstract
Background Learning from adverse events and near misses may reduce the incidence of preventable errors. Current literature on adverse events and near misses in the ICU focuses on errors reported by nurses and intensivists. ICU near misses identified by anesthesia providers may reveal critical events, causal mechanisms and system weaknesses not identified by other providers, and may differ in character and causality from near misses in other anesthesia locations. Methods We analyzed events reported to our anesthesia near miss reporting system from 2009 to 2011. We compared causative mechanisms of ICU near misses with near misses in other anesthesia locations. Results A total of 1,811 near misses were reported, of which 22 (1.2 %) originated in the ICU. Five causal mechanisms explained over half of ICU near misses. Compared to near misses from other locations, near misses from the ICU were more likely to occur while on call (45 % vs. 19 %, p = 0.001), and were more likely to be associated with airway management (50 % vs. 12 %, p < 0.001). ICU near misses were less likely to be associated with equipment issues (23 % vs. 48 %, p = 0.02). Conclusions A limited number of causal mechanisms explained the majority of ICU near misses, providing targets for quality improvement. Errors associated with airway management in the ICU may be underappreciated. Specialist consultants can identify systems weaknesses not identified by critical care providers, and should be engaged in the ICU patient safety movement.
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Affiliation(s)
- Angela K M Lipshutz
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - James E Caldwell
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - David L Robinowitz
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - Michael A Gropper
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA.
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17
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Chillingworth S, Slater B, Simpson G. A Prospective Observational Study of Significant Airway Events in Intensive Care. J Intensive Care Soc 2014. [DOI: 10.1177/175114371401500408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This is a single-centre, prospective, observational study that aimed to establish the incidence of airway events and the interventions required to manage these events in a 9-bedded general intensive care unit. During the 30-day study period there were 278 significant airway events requiring 332 interventions. Forty-six (16.5%) events were associated with hypoxia, and medical intervention was required for 25 events (9%) with the remainder managed by trained nurses or physiotherapists. The most frequent events were tube blockage due to secretions (47.8%) and circuit disconnection (14.3%). Events occurred more frequently in those ventilated with tracheostomy compared to endotracheal tube (event rate per ventilator day 1.76 vs 1), but these were less likely to lead to hypoxia (OR 2.93). We have found a rate of airway events of 1.22 per ventilator day and conclude that access to appropriately skilled and trained staff is required to manage these intensive care airway problems.
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Affiliation(s)
- Simon Chillingworth
- Specialty Trainee, South East Scotland School of Anaesthesia
- Department of Anaesthesia and Intensive Care, Victoria Hospital, Kirkcaldy
| | - Ben Slater
- Consultant in Anaesthetics and Intensive Care Medicine
- Department of Anaesthesia and Intensive Care, Victoria Hospital, Kirkcaldy
| | - Gavin Simpson
- Consultant in Anaesthetics and Intensive Care Medicine
- Department of Anaesthesia and Intensive Care, Victoria Hospital, Kirkcaldy
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18
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Sommella L, de Waure C, Ferriero AM, Biasco A, Mainelli MT, Pinnarelli L, Ricciardi W, Damiani G. The incidence of adverse events in an Italian acute care hospital: findings of a two-stage method in a retrospective cohort study. BMC Health Serv Res 2014; 14:358. [PMID: 25164708 PMCID: PMC4155122 DOI: 10.1186/1472-6963-14-358] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 08/20/2014] [Indexed: 12/04/2022] Open
Abstract
Background The promotion of safer healthcare interventions in hospitals is a relevant public health topic. This study is aimed to investigate predictors of Adverse Events (AEs) taking into consideration the Charlson Index in order to control for confounding biases related to comorbidity. Methods The study was a retrospective cohort study based on a two-stage assessment tool which was used to identify AEs. In stage 1, two physicians reviewed a random sample of patient records from 2008 discharges. In stage 2, reviewers independently assessed each screened record to confirm the presence of AEs. A univariable and multivariable analysis was conducted to identify prognostic factors of AEs; socio-demographic and some main organizational variables were taken into consideration. Charlson comorbidity Index was calculated using the algorithm developed by Quan et al. Results A total of 1501 records were reviewed; mean patients age was 60 (SD: 19) and 1415 (94.3%) patients were Italian. Forty-six (3.3%) AEs were registered; they most took place in medical wards (33, 71.7%), followed by surgical ones (9, 19.6%) and intensive care unit (ICU) (4, 8.7%). According to the logistic regression model and controlling for Charlson Index, the following variables were associated to AEs: type of admission (emergency vs elective: OR 3.47, 95% CI: 1.60-7.53), discharge ward (surgical and ICU vs medical wards: OR 2.29, 95% CI: 1.00-5.21 and OR 4.80, 95% CI: 1.47-15.66 respectively) and length of stay (OR 1.03, 95% CI 1.01-1.04). Among patients experiencing AEs a higher frequency of elderly (≥65 years) was shown (58.7% vs 49.3% among patients without AEs) but this difference was not statistically significant. Interestingly, a higher percentage of patients admitted through emergency department was found among patients experiencing AEs (69.7% vs 55.1% among patients without AEs). Conclusions The incidence of AEs was associated with length of stay, type of admission and unit of discharge, independently by comorbidity. On the basis of our results, it appears that organizational characteristics, taking into account the adjustment for comorbidity, are the main factors responsible for AEs while patient vulnerability played a minor role. Electronic supplementary material The online version of this article (doi:10.1186/1472-6963-14-358) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | | | | | | | | | - Gianfranco Damiani
- Department of Public Health, Catholic University of Sacred Heart, L,go Francesco Vito 1, Rome 00168, Italy.
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19
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Thomas AN, Taylor RJ. An analysis of patient safety incidents associated with medications reported from critical care units in the North West of England between 2009 and 2012. Anaesthesia 2014; 69:735-45. [PMID: 24810765 DOI: 10.1111/anae.12670] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2014] [Indexed: 11/28/2022]
Abstract
Incident reporting is promoted as a key tool for improving patient safety in healthcare. We analysed 2238 patient safety incidents involving medications submitted from up to 29 critical care units each year in the North West of England between 2009 and 2012; 452 (20%) of these incidents led to harm to patients. Although 1461 (65%) incidents were judged to have been preventable, there was no reduction in the rate of incidents per 1000 days between 2009 and 2012 (5.9 in 2009, 6.6 in 2012). Furthermore, in the 2012 data, there were wide variations in the incident rates between units, the median (IQR [range]) rate per 1000 patient days for individual units being 6.8 (3.8-11.0 [1.3-37.1]). The variation in the percentage that could have been avoided was narrower, with a median (IQR [range]) of 70% (61-80% [38-100%]). The most commonly reported drugs were noradrenaline (161 incidents, 92 with harm), heparins (153 incidents, 29 with harm), morphine (131 incidents, 14 with harm) and insulin (111 incidents, 54 with harm). The administration of drugs was the stage in the process where incidents were most commonly reported; it was also the stage most likely to harm patients. We conclude that the wide range in reported rates between units, and the scope for preventing many incidents, suggest that quality improvement initiatives could improve medication safety in the units studied.
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Affiliation(s)
- A N Thomas
- Salford Royal NHS Foundation Trust, Salford, UK
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20
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Carayon P, Wetterneck TB, Cartmill R, Blosky MA, Brown R, Kim R, Kukreja S, Johnson M, Paris B, Wood KE, Walker J. Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units. BMJ Qual Saf 2013; 23:56-65. [PMID: 24050986 DOI: 10.1136/bmjqs-2013-001828] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To examine medication safety in two intensive care units (ICU), and to assess the complexity of medication errors and adverse drug events (ADE) in ICUs across the stages of the medication-management process. METHODS Four trained nurse data collectors gathered data on medication errors and ADEs between October 2006 and March 2007. Patient care documents (eg, medication order sheets, notes) and incident reports were used to identify medication errors and ADEs in a 24-bed adult medical/surgical ICU and an 18-bed cardiac ICU in a tertiary care, community teaching hospital. In this cross-sectional study, a total of 630 consecutive ICU patient admissions were assessed to produce data on the number, rates and types of potential and preventable ADEs across stages of the medication-management process. RESULTS An average of 2.9 preventable or potential ADEs occurred in each admission, that is, 0.4 events per patient-day. Preventable or potential ADEs occurred in 2.6% of the medication orders. The rate of potential ADEs per 1000 patient-days was 276, whereas the rate of preventable ADEs per 1000 patient-days was 9.2. Most medication errors occur at the ordering (32%) and administration stages (39%). In 16-24% of potential and preventable ADEs, clusters of errors occurred either as a sequence of errors (eg, delay in medication dispensing leading to delay in medication administration) or grouped errors (eg, route and frequency errors in the order for a medication). Many of the sequences led to administration errors that were caused by errors earlier in the medication-management process. CONCLUSIONS Understanding the complexity of the vulnerabilities of the medication-management process is important to devise solutions to improve patient safety. Electronic health record technology with computerised physician order entry may be one step necessary to improve medication safety in ICUs. Solutions that target multiple stages of the medication-management process are necessary to address sequential errors.
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Affiliation(s)
- Pascale Carayon
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, , Madison, Wisconsin, USA
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21
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Chamberlain JM, Shaw KN, Lillis KA, Mahajan PV, Ruddy RM, Lichenstein R, Olsen CS, Dean JM. Creating an infrastructure for safety event reporting and analysis in a multicenter pediatric emergency department network. Pediatr Emerg Care 2013; 29:125-30. [PMID: 23364372 DOI: 10.1097/pec.0b013e31828043a5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Hospital incident reporting is widely used but has had limited effectiveness for improving patient safety nationally. We describe the process of establishing a multi-institutional safety event reporting system. METHODS A descriptive study in The Pediatric Emergency Care Applied Research Network of 22 hospital emergency departments was performed. An extensive legal analysis addressed investigators' concerns about sharing confidential incident reports (IRs): (1) the ability to identify sites and (2) potential loss of peer review statute protection. Of the 22 Pediatric Emergency Care Applied Research Network sites, 19 received institutional approval to submit deidentified IRs to the data center. Incident reports were randomly assigned to independent review; discordance was resolved by consensus. Incident reports were categorized by type, subtype, severity, staff involved, and contributing factors. RESULTS A total of 3,106 IRs were submitted by 18 sites in the first year. Reporting rates ranged more than 50-fold from 0.12 to 6.13 per 1000 patients. Data were sufficient to determine type of error (90% of IRs), severity (79%), staff involved (82%), and contributing factors (82%). However, contributing factors were clearly identified in only 44% of IRs and required extrapolation by investigators in 38%. The most common incidents were related to laboratory specimens (25.5%), medication administration (19.3%), and process variance, such as delays in care (14.4%). CONCLUSIONS Incident reporting provides qualitative data concerning safety events. Perceived legal barriers to sharing confidential data can be addressed. Large variability in reporting rates and low rates of providing contributing factors suggest a need for standardization and improvement of safety event reporting.
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Affiliation(s)
- James M Chamberlain
- Division of Emergency Medicine, Children's National Medical Center, Washington, DC 20010, USA.
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22
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Wang SC, Li YC, Huang HC. The effect of a workflow-based response system on hospital-wide voluntary incident reporting rates. Int J Qual Health Care 2012; 25:35-42. [DOI: 10.1093/intqhc/mzs078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Adverse event reporting in adult intensive care units and the impact of a multifaceted intervention on drug-related adverse events. Ann Intensive Care 2012; 2:47. [PMID: 23174137 PMCID: PMC3526522 DOI: 10.1186/2110-5820-2-47] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 10/30/2012] [Indexed: 11/17/2022] Open
Abstract
Background Adverse events (AEs) frequently occur in intensive care units (ICUs) and affect negatively patient outcomes. Targeted improvement strategies for patient safety are difficult to evaluate because of the intrinsic limitations of reporting crude AE rates. Single interventions influence positively the quality of care, but a multifaceted approach has been tested only in selected cases. The present study was designed to evaluate the rate, types, and contributing factors of emerging AEs and test the hypothesis that a multifaceted intervention on medication might reduce drug-related AEs. Methods This is a prospective, multicenter, before-and-after study of adult patients admitted to four ICUs during a 24-month period. Voluntary, anonymous, self-reporting of AEs was performed using a detailed, locally designed questionnaire. The temporal impact of a multifaceted implementation strategy to reduce drug-related AEs was evaluated using the risk-index scores methodology. Results A total of 2,047 AEs were reported (32 events per 100 ICU patient admissions and 117.4 events per 1,000 ICU patient days) from 6,404 patients, totaling 17,434 patient days. Nurses submitted the majority of questionnaires (n = 1,781, 87%). AEs were eye-witnessed in 49% (n = 1,003) of cases and occurred preferentially during an elective procedure (n = 1,597, 78%) and on morning shifts (n = 1,003, 49%), with a peak rate occurring around 10 a.m. Drug-related AEs were the most prevalent (n = 984, 48%), mainly as a consequence of incorrect prescriptions. Poor communication among caregivers (n = 776) and noncompliance with internal guidelines (n = 525) were the most prevalent contributing factors for AE occurrence. The majority of AEs (n = 1155, 56.4%) was associated with minimal, temporary harm. Risk-index scores for drug-related AEs decreased from 10.01 ± 2.7 to 8.72 ± 3.52 (absolute risk difference 1.29; 95% confidence interval, 0.88-1.7; p < 0.01) following the introduction of the intervention. Conclusions AEs occurred in the ICU with a typical diurnal frequency distribution. Medication-related AEs were the most prevalent. By applying the risk-index scores methodology, we were able to demonstrate that our multifaceted implementation strategy focused on medication-related adverse events allowed to decrease drug related incidents.
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Abstract
Improving the quality and safety of intensive care unit (ICU) care in the United States is a significant challenge for the future. Obtaining improvement in systems of care is difficult given the reactionary mode physicians tend to enter when dealing with moment-to-moment crises. It will be important to implement quality and safety measures that are already supported by evidence. Improvement of device safety will be critical to reducing the large number of device-related complications that occur in US ICUs. Prospective collection of adverse events with rigorous analysis will be important to allow systematic errors to be exposed and corrected.
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Affiliation(s)
- Peter J Rossi
- Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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25
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Abstract
OBJECTIVE This study aimed to examine the rates and categories of incident reports in an academic tertiary care center in Saudi Arabia both hospital-wide and in the intensive care unit (ICU). Such information would help in redesigning systems and in planning and developing strategies with the goal of improving patient safety and quality of care. METHODS In this descriptive study, we evaluated all incident reports submitted through the paper-based reporting system in the hospital and the ICU for the year 2008. Incident report rates were calculated as the number of incident reports per 1000 patient days. We also reviewed the major and minor categories of the generated reports. RESULTS A total of 3041 incident reports were submitted from all hospital areas; yielding a rate of 5.8 per 1000 patient days. Sixty-two incident reports were reported from the ICU, yielding a rate of 5.8 per 1000 patient days. The most frequent type of incident reports was procedural variances (37%), followed by behavior and communication incidents (34%), hazardous and safety incidents (9.5%), and medication errors (7.4%). In the ICU, the most frequently reported type of incidents was behavior and communication incidents (30.6%), followed by procedural variances (21%) and medication errors (13%). CONCLUSIONS Rates of incident reports at a tertiary care center in Saudi Arabia were low compared with reported international rates. The main categories of incident reports were related to procedural variances and behavior and communication incidents. These findings suggest that patient safety initiatives should focus primarily on these 2 domains. Additional prospective research is needed in this important area to further understand patient safety challenges and reporting practice and culture in the country.
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Bandari J, Schumacher K, Simon M, Cameron D, Goeschel CA, Holzmueller CG, Makary MA, Welsh RJ, Berenholtz SM. Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center. Jt Comm J Qual Patient Saf 2012; 38:154-60. [PMID: 22533127 DOI: 10.1016/s1553-7250(12)38020-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Briefings and debriefings, previously shown to be a practical and feasible strategy to improve interdisciplinary communication and teamwork in the operating room (OR), was then assessed as a strategy to prospectively surface clinical and operational defects in surgical care--and thereby prevent patient harm. METHODS A one-page, double-sided briefing and debriefing tool was used by surgical teams during cases at the William Beaumont Hospital Royal Oak (Royal Oak, Michigan) campus to surface clinical and operational defects during the study period (October 2006-May 2010). Defects were coded into six categories (with each category stratified by briefing or debriefing period) during the first six months, and refinement of coding resulted in expansion to 16 defect categories and no further stratification. A provider survey was used in January 2008 to interview a sample of 40 caregivers regarding the perceived effectiveness of the tool in surfacing defects. FINDINGS The teams identified a total of 6,202 defects--an average of 141 defects per month--during the entire study period. Of 2,760 defects identified during the six-defect coding period, 1,265 (46%) surfaced during briefings, and the remaining 1,495 (54%) during debriefings. Equipment (48%) and communication (31%) issues were most prominent. Of 3,442 defects identified during the 16-defect coding period, the most common were Central Processing Department (CPD) instrumentation (22%) and Communication/Safety (15%). Overall, 70 (87%) of the 80 responses were in agreement that briefings were effective for surfacing defects, as were 59 (76%) of the 78 responses for debriefings. CONCLUSIONS Briefings and debriefings were a practical and effective strategy to surface potential surgical defects in the operating rooms of a large medical center.
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Affiliation(s)
- Jathin Bandari
- Johns Hopkins University School of Medicine, Baltimore, USA
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Abstract
BACKGROUND Considering all sources of errors that may occur during healthcare, medication errors are the most common and also the most frequent cause of adverse events. OBJECTIVE The objective of the study was to describe the medication errors reported in a pediatric intensive care unit for oncologic patients. METHODS This is a descriptive and exploratory study. The errors were reported by the professionals involved in the medication system in a medication error report form developed for the study. RESULTS The sample consisted of 110 medication errors reported on 71 forms. The omission error was the most common error type reported (22.7%), followed by administration error (18.2%). No harm to patients was reported in 83.1% of the notifications. CONCLUSION The analysis of the110 medication errors provides evidence of the context of their occurrence and the need to implement measures that can prevent or intercept these errors. IMPLICATIONS FOR PRACTICE In an institution without adverse events report and a formal system to patient safety analysis, the implementation of a local nonpunitive approach to medication errors notification represented an important tool to patient safety promotion.
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Aranaz-Andres JM, Aibar C, Limon R, Mira JJ, Vitaller J, Agra Y, Terol E. A study of the prevalence of adverse events in primary healthcare in Spain. Eur J Public Health 2011. [DOI: 10.1093/eurpub/ckr168] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ilan R, Squires M, Panopoulos C, Day A. Increasing patient safety event reporting in 2 intensive care units: a prospective interventional study. J Crit Care 2010; 26:431.e11-8. [PMID: 21129913 DOI: 10.1016/j.jcrc.2010.10.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Revised: 09/13/2010] [Accepted: 10/03/2010] [Indexed: 11/19/2022]
Abstract
PURPOSE The aims of this study were to increase the reporting of patient safety events and to enhance report analysis and responsive action. MATERIALS AND METHODS A prospective, interventional study in 2 adult intensive care units (ICUs) in an academic center was used. A paper-based reporting system, adapted from a previously reported intervention, was introduced. A multifaceted approach, including education, reminders, regular updates, personal and group feedback, and weekly leadership rounds, was led by a patient safety committee. Committee members reviewed the reports and initiated solutions as required. RESULTS During the first year, a total of 332 safety events were reported using the new system, reflecting a significant increase in total reporting (10.3/1000 patient days preintervention to 34.5/1000 patient days postintervention; rate ratio, 3.35; 95% confidence interval, 2.23-5.04). Most reports were submitted by nurses (nurses, 75.3%; physicians, 10.5%; other workers, 7.8%). Overall reported events per 1000 patient days differed by unit (level 3 ICU, 44.1; level 2 ICU, 24.9; P < .001). Several system-based interventions were initiated in the ICUs to address reported safety hazards. CONCLUSIONS After the introduction of this new approach, reporting rates have increased significantly throughout the first year. Differences in reporting rates among workers and units may reveal priorities and barriers to reporting. The integrated approach facilitated prompt response to selected reports.
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Affiliation(s)
- Roy Ilan
- Department of Medicine, Queen's University, Kingston General Hospital, Kingston, ON, Canada K7L 3N6.
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Data consistency in a voluntary medical incident reporting system. J Med Syst 2009; 35:609-15. [PMID: 20703528 DOI: 10.1007/s10916-009-9398-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Accepted: 11/09/2009] [Indexed: 10/20/2022]
Abstract
Voluntary medical incident reporting systems are a valuable source for studying adverse events and near misses. Unfortunately, such systems usually contain a large amount of incomplete and inaccurate reports which negatively affect their utility for medical error research. To investigate the reporting quality and propose solutions towards quality voluntary reports, we employed a content analysis method to examine one-year voluntary medical incident reports of a University Hospital. Results indicate that there is a large amount of inconsistent records within the reports. About 25% of the reports were labeled as "miscellaneous" and "other". Through an in-depth analysis, those "miscellaneous" and "other" were substituted by their real incident types or error descriptions. Analysis shows that the pre-defined reporting categories serve well in general for the voluntary reporting need. In some cases, human factors play a key role in selecting accurate categories since reporters lack time or information to complete the report. We suggest that a human-centered, ontology based system design for voluntary reporting is feasible. Such a design could help improve the completeness and accuracy, and interoperability among national and international standards.
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Thomas AN, Panchagnula U, Taylor RJ. Review of patient safety incidents submitted from Critical Care Units in England & Wales to the UK National Patient Safety Agency. Anaesthesia 2009; 64:1178-85. [PMID: 19825051 DOI: 10.1111/j.1365-2044.2009.06065.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We reviewed and classified all patient safety incidents submitted from critical care units in England and Wales to the National Patient Safety Agency for the first quarter of 2008. A total of 6649 incidents were submitted from 141 organisations (median (range) 23 (1-268 incidents)); 786 were unrelated to the critical care episode and 248 were repeat entries. Of the remaining 5615 incidents, 1726 occurred in neonates or babies, 1298 were associated with temporary harm, 15 with permanent harm and 59 required interventions to maintain life or may have contributed to the patient's death. The most common main incident groups were medication (1450 incidents), infrastructure and staffing (1289 incidents) and implementation of care (1047 incidents). There were 2789 incidents classified to more than one main group. The incident analysis highlights ways to improve patient safety and to improve the classification of incidents.
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Affiliation(s)
- A N Thomas
- Intensive Care Unit, Salford Royal Hospitals NHS Foundation Trust, Salford, UK.
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Dückers M, Faber M, Cruijsberg J, Grol R, Schoonhoven L, Wensing M. Safety and Risk Management Interventions in Hospitals. Med Care Res Rev 2009; 66:90S-119S. [PMID: 19759391 DOI: 10.1177/1077558709345870] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this systematic review was (a) to synthesize the evidence on the effectiveness of detection, mitigation, and actions to reduce risks in hospitals and (b) to identify and describe components of interventions responsible for effectiveness. Thirteen literature databases were explored using a structured search and data extraction strategy. All included studies dealing with incident reporting described positive effects. Evidence regarding the effectiveness and efficiency of safety analysis is scarce. No studies on mitigation were included. The collected evidence on risk reduction concerns a variety of interventions to reduce medication errors, fall incidents, diagnostic errors, and adverse events in general. Most studies reported positive effects; however, interventions were often multifaceted, and it was difficult to disentangle their impact. This made it difficult to draw generic lessons from this body of research. More rigorous evaluations are needed, in particular, of continuous learning and safety analysis techniques.
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Affiliation(s)
- Michel Dückers
- Radboud University Nijmegen Medical Centre, the Netherlands
| | - Marjan Faber
- Radboud University Nijmegen Medical Centre, the Netherlands,
| | | | - Richard Grol
- Radboud University Nijmegen Medical Centre, the Netherlands
| | | | - Michel Wensing
- Radboud University Nijmegen Medical Centre, the Netherlands
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Thomas AN, McGrath BA. Patient safety incidents associated with airway devices in critical care: a review of reports to the UK National Patient Safety Agency. Anaesthesia 2009; 64:358-65. [PMID: 19187391 DOI: 10.1111/j.1365-2044.2008.05784.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We used key words and letter sequences to identify airway-associated patient safety incidents submitted to the UK National Patient Safety Agency from critical care units in England and Wales. We identified 1085 such airway incidents submitted in the two years from October 2005 to September 2007. Three hundred and twelve incidents (28.8%) involved neonates or babies. Of the total 1085 incidents, 200 (18.4%) were associated with tracheal intubation, 53 (4.9%) with tracheostomy and 893 (82.3%) were post-procedure problems. One hundred and ten incidents (10.1%) were associated with more than temporary harm. Eighty-eight intubation incidents were associated with equipment problems. Partial displacement of tubes resulted in more than temporary harm to the patient more frequently than complete tube displacement (15.7% vs 3.8%). Capnography was not described in any cases of displacement or blockage of tracheal or tracheostomy tubes. Recommendations concerning minimum standards for capnography, availability and checking of equipment and tracheostomy placement are made.
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Affiliation(s)
- A N Thomas
- Intensive Care Unit, Hope Hospital, Salford, UK.
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Kilbridge PM, Classen DC. The informatics opportunities at the intersection of patient safety and clinical informatics. J Am Med Inform Assoc 2008; 15:397-407. [PMID: 18436896 PMCID: PMC2442268 DOI: 10.1197/jamia.m2735] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Accepted: 04/06/2008] [Indexed: 11/10/2022] Open
Abstract
Health care providers have a basic responsibility to protect patients from accidental harm. At the institutional level, creating safe health care organizations necessitates a systematic approach. Effective use of informatics to enhance safety requires the establishment and use of standards for concept definitions and for data exchange, development of acceptable models for knowledge representation, incentives for adoption of electronic health records, support for adverse event detection and reporting, and greater investment in research at the intersection of informatics and patient safety. Leading organizations have demonstrated that health care informatics approaches can improve safety. Nevertheless, significant obstacles today limit optimal application of health informatics to safety within most provider environments. The authors offer a series of recommendations for addressing these challenges.
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Affiliation(s)
- Peter M Kilbridge
- Department of Pediatrics, Washington University School of Medicine, USA.
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Abstract
PURPOSE OF REVIEW Patient safety is attracting increasing attention. How we monitor and measure safety, however, is not well defined. In this review we describe a conceptual model for monitoring and measuring safety, describe the development of a safety scorecard, and provide an example of how this scorecard is used in the ICU. RECENT FINDINGS Our safety scorecard stratifies measures into two categories. One category uses valid rate-based measures to evaluate: How often do we provide the interventions that patients should receive? (process measure); and How often do we harm patients? (outcome measure). The second category includes measures that cannot be expressed as valid rates: How do we know we learned from defects? (structural measure); and How well have we created a culture of safety? (context measure). Measures within each domain should be important and valid, and organizations should be able to use the measures to improve patient safety. SUMMARY We present a framework for a patient safety scorecard to measure and monitor patient safety. This safety scorecard is a valid and practical tool for ICUs to track progress of efforts to improve patient safety and answer the question, how safe is my ICU?
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Affiliation(s)
- Elizabeth A. Henneman
- Elizabeth A. Henneman is an assistant professor in the school of nursing at the University of Massachusetts, Amherst
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Sterling J. Hospital Pharmacy Pulse - Recent Publications on Medications and Pharmacy. Hosp Pharm 2007. [DOI: 10.1310/hpj4206-578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest will be abstracted monthly regarding a broad scope of topics. Suggestions or comments may be addressed to: Jacyntha Sterling, Drug Information Specialist at Saint Francis Hospital, 6161 S Yale Ave., Tulsa, OK 74136 or e-mail: jasterling@saintfrancis.com .
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