Improving patient safety reporting systems

The Well-Defined Pediatric ICU: Active Surveillance Using Nonmedical Personnel to Capture Less Serious Safety Events

BACKGROUND

Adverse events, diverse and often costly, commonly occur in pediatric intensive care units (PICUs). Serious safety events (SSEs) are captured through well-developed systems, typically by voluntary reporting. Less serious safety events (LSSEs), including close calls, however, occur at a higher frequency than those that result in immediate harm or death but are underestimated by standard reporting systems. LSSEs can reveal system defects and precede serious events resulting in patient or provider harm.

METHODS

A unique active surveillance program was created at Children's Hospitals and Clinics of Minnesota to quantify and categorize, and, ultimately reduce, LSSEs, in PICUs. Premedical college graduates without formal health care training daily canvassed the PICUs and facilitated reporting of LSSEs at the point of care. Events were recorded on a Web application and stored in a relational database management system. Events were enumerated and categorized according to distinctive characteristics (Theme Index) and real or potential harm (Harm Index).

RESULTS

Some 1,980 PICU patients, representing 10,766 PICU patient-days in a 15-month period (June 1, 2013- August 31, 2014) experienced 2,465 LSSEs-5.4 LSSEs/ day or 0.23 LSSEs/patient-day. Such events resulted in a patient intervention 38% of the time. Some 158 quality/safety improvement projects were initiated during the observation period, 74 of which have been completed. Quality/safety information was broadcasted to providers, local leadership, and hospital management.

CONCLUSIONS

LSSEs occur frequently in our PICUs. Non-health care providers can cost-effectively facilitate reporting by actively canvassing PICU providers on a daily basis and can contribute to quality/safety improvement projects and local safety culture. Reported events can serve as a focus for quality/safety improvement projects. A Web application and mobile tablet interfaces are efficient tools to record events.

Physician Attitudes and Practices Related to Voluntary Error and Near-Miss Reporting

Physicians are less likely to report events than other colleagues. There are barriers to physician reporting that need to be addressed to encourage reporting and create a fair culture around reporting.

Medication errors reported in a pediatric intensive care unit for oncologic patients

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.

Quality management and benchmarking in emergency medicine

PURPOSE OF REVIEW

Being critical in terms of time and complexity, emergency medicine is exposed to an emerging imperative for quality improvement strategies. We review current concepts and recent advances in the management of quality in emergency medicine.

RECENT FINDINGS

There is a strong interdependence between quality of emergency healthcare provision and the education of emergency healthcare providers. Introduction of emergency medical residencies and highly qualified triage liaison physicians helps prevent the overcrowding of emergency departments, accelerate access to emergency medical care and improve patient satisfaction. New advances in detecting and reducing patient management errors include the collection of healthcare provider complaints and the classification of unpreventable and preventable deaths of patients within 1 week of admission via the emergency department. Medical record review and video recording have revealed that frequent patient management problems relate to shortcomings in the diagnostic process, clinical tasks, patient factors, and poor teamwork. Communication skills and patient data/documentation systems may effectively resolve these problems.

SUMMARY

According to the available evidence, more performance improvement strategies need to be tested to delineate which process changes would be most effective in improving patient outcome in emergency medicine.

How safe is my intensive care unit? Methods for monitoring and measurement

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?