1
|
Alalaween MA, Karia N. The predictive power of electronic reporting system utilization on voluntary reporting of near-miss incidents among nurses: A PLS-SEM approach. BELITUNG NURSING JOURNAL 2024; 10:15-22. [PMID: 38425684 PMCID: PMC10900056 DOI: 10.33546/bnj.2805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/07/2023] [Accepted: 12/15/2023] [Indexed: 03/02/2024] Open
Abstract
Background Patient safety is crucial in healthcare, with incident reporting vital for identifying and addressing errors. Near-miss incidents, common yet underreported, serve as red flags requiring attention. Nurses' underreporting, influenced by views and system usability, inhibits learning opportunities. The Electronic Reporting System (ERS) is a modern solution, but its effectiveness remains unclear. Objective This study aimed to investigate the role of the ERS in enhancing the voluntary reporting of near-miss (VRNM) incidents among nurses. Methods A cross-sectional study was conducted in the Al Dhafra region of the United Arab Emirates, involving 247 nurses from six hospitals. Data were collected using a questionnaire between April 2022 and August 2022. Structural Equation Modelling Partial Least Square (SEM-PLS) was employed for data analysis. Results The average variance extracted for the ERS construct was 0.754, indicating that the common factor accounted for 75.4% of the variation in the ERS scores. The mean ERS score was 4.093, with a standard deviation of 0.680. For VRNM, the mean was 4.104, and the standard deviation was 0.688. There was a positive correlation between ERS utilization and nurses' willingness to report near-miss incidents. Additionally, our research findings suggest a 66.7% relevance when applied to various hospital settings within the scope of this study. Conclusion The findings suggest that adopting a user-friendly reporting system and adequate training on the system's features can increase reporting and improve patient safety. Additionally, these systems should be designed to be operated by nursing staff with minimal obstacles.
Collapse
Affiliation(s)
| | - Noorliza Karia
- School of Management, Universiti Sains Malaysia, Penang, Malaysia
| |
Collapse
|
2
|
Goekcimen K, Schwendimann R, Pfeiffer Y, Mohr G, Jaeger C, Mueller S. Addressing Patient Safety Hazards Using Critical Incident Reporting in Hospitals: A Systematic Review. J Patient Saf 2023; 19:e1-e8. [PMID: 35985209 PMCID: PMC9788933 DOI: 10.1097/pts.0000000000001072] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Critical incident reporting systems (CIRS) are in use worldwide. They are designed to improve patient care by detecting and analyzing critical and adverse patient events and by taking corrective actions to prevent reoccurrence. Critical incident reporting systems have recently been criticized for their lack of effectiveness in achieving actual patient safety improvements. However, no overview yet exists of the reported incidents' characteristics, their communication within institutions, or actions taken either to correct them or to prevent their recurrence. Our main goals were to systematically describe the reported CIRS events and to assess the actions taken and their learning effects. In this systematic review of studies based on CIRS data, we analyzed the main types of critical incidents (CIs), the severity of their consequences, their contributing factors, and any reported corrective actions. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we queried MEDLINE, Embase, CINAHL, and Scopus for publications on hospital-based CIRS. We classified the consequences of the incidents according to the National Coordinating Council for Medication Error Reporting and Prevention index, the contributing factors according to the Yorkshire Contributory Factors Framework and the Human Factors Classification Framework, and all corrective actions taken according to an action hierarchy model on intervention strengths. RESULTS We reviewed 41 studies, which covered 479,483 CI reports from 212 hospitals in 17 countries. The most frequent type of incident was medication related (28.8%); the most frequent contributing factor was labeled "active failure" within health care provision (26.1%). Of all professions, nurses submitted the largest percentage (83.7%) of CI reports. Actions taken to prevent future CIs were described in 15 studies (36.6%). Overall, the analyzed studies varied considerably regarding methodology and focus. CONCLUSIONS This review of studies from hospital-based CIRS provides an overview of reported CIs' contributing factors, characteristics, and consequences, as well as of the actions taken to prevent their recurrence. Because only 1 in 3 studies reported on corrective actions within the healthcare facilities, more emphasis on such actions and learnings from CIRS is required. However, incomplete or fragmented reporting and communication cycles may additionally limit the potential value of CIRS. To make a CIRS a useful tool for improving patient safety, the focus must be put on its strength of providing new qualitative insights in unknown hazards and also on the development of tools to facilitate nomenclature and management CIRS events, including corrective actions in a more standardized manner.
Collapse
Affiliation(s)
| | - René Schwendimann
- Patient Safety Office, University Hospital Basel
- Department Public Health, Institute of Nursing Science, University of Basel, Basel
| | - Yvonne Pfeiffer
- Research Department, Patient Safety Foundation, Zurich, Switzerland
| | - Giulia Mohr
- Patient Safety Office, University Hospital Basel
| | | | | |
Collapse
|
3
|
Al Meslamani AZ. Underreporting of Adverse Drug Events: a Look into the Extent, Causes, and Potential Solutions. Expert Opin Drug Saf 2023; 22:351-354. [PMID: 37300402 DOI: 10.1080/14740338.2023.2224558] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/08/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Ahmad Z Al Meslamani
- College of Pharmacy, Al Ain University, Abu Dhabi, United Arab Emirates
- AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, United Arab Emirates
| |
Collapse
|
4
|
Höcherl A, Lüttel D, Schütze D, Blazejewski T, González-González AI, Gerlach FM, Müller BS. Characteristics of Critical Incident Reporting Systems in Primary Care: An International Survey. J Patient Saf 2022; 18:e85-e91. [PMID: 32209949 DOI: 10.1097/pts.0000000000000708] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to support the development of future critical incident reporting systems (CIRS) in primary care by collecting information on existing systems. Our focus was on processes used to report and analyze incidents, as well as strategies used to overcome difficulties. METHODS Based on literature from throughout the world, we identified existing CIRS in primary care. We developed a questionnaire and sent it to operators of a purposeful sample of 17 CIRS in primary care. We used cross-case analysis to compare the answers and pinpoint important similarities and differences in the CIRS in our sample. RESULTS Ten CIRS operators filled out the questionnaire, and 9 systems met our inclusion criteria. The sample of CIRS came from 8 different countries and was rather heterogeneous. The reporting systems invited a broad range of professions to report, with some also including reports by patients. In most cases, reporting was voluntary and conducted via an online reporting form. Reports were analyzed locally, centrally, or both. The various CIRS used interesting ideas to deal with barriers. Some, for example, used confidential reporting modes as a compromise between anonymity and the need for follow-up investigations, whereas others used smartphone applications and call centers to speed up the reporting process. CONCLUSIONS We found multiple CIRS that have operated in primary care for many years and have received a high number of reports. They were largely developed in accordance with recommendations found in literature. Developers of future systems may find this overview useful.
Collapse
Affiliation(s)
- Andreas Höcherl
- From the Institute of General Practice, Goethe University Frankfurt, Frankfurt
| | - Dagmar Lüttel
- Aktionsbündnis Patientensicherheit e.V., Berlin, Germany
| | - Dania Schütze
- From the Institute of General Practice, Goethe University Frankfurt, Frankfurt
| | - Tatjana Blazejewski
- From the Institute of General Practice, Goethe University Frankfurt, Frankfurt
| | | | - Ferdinand M Gerlach
- From the Institute of General Practice, Goethe University Frankfurt, Frankfurt
| | - Beate S Müller
- From the Institute of General Practice, Goethe University Frankfurt, Frankfurt
| |
Collapse
|
5
|
Al-Rayes SA, Aldar FA, Al Nasif NS, Alkhadrawi ZI, Al-Fayez A, Alumran A. The use of electronic incident reporting system: Influencing factors. INFORMATICS IN MEDICINE UNLOCKED 2020. [DOI: 10.1016/j.imu.2020.100477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
6
|
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.
Collapse
|
7
|
Liang C, Gong Y. Knowledge Representation in Patient Safety Reporting: An Ontological Approach. JOURNAL OF DATA AND INFORMATION SCIENCE 2016; 1:75-91. [PMID: 38770358 PMCID: PMC11104324 DOI: 10.20309/jdis.201615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
Purpose The current development of patient safety reporting systems is criticized for loss of information and low data quality due to the lack of a uniformed domain knowledge base and text processing functionality. To improve patient safety reporting, the present paper suggests an ontological representation of patient safety knowledge. Design/methodology/approach We propose a framework for constructing an ontological knowledge base of patient safety. The present paper describes our design, implementation, and evaluation of the ontology at its initial stage. Findings We describe the design and initial outcomes of the ontology implementation. The evaluation results demonstrate the clinical validity of the ontology by a self-developed survey measurement. Research limitations The proposed ontology was developed and evaluated using a small number of information sources. Presently, US data are used, but they are not essential for the ultimate structure of the ontology. Practical implications The goal of improving patient safety can be aided through investigating patient safety reports and providing actionable knowledge to clinical practitioners. As such, constructing a domain specific ontology for patient safety reports serves as a cornerstone in information collection and text mining methods. Originality/value The use of ontologies provides abstracted representation of semantic information and enables a wealth of applications in a reporting system. Therefore, constructing such a knowledge base is recognized as a high priority in health care.
Collapse
Affiliation(s)
- Chen Liang
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston 77030, USA
| | - Yang Gong
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston 77030, USA
| |
Collapse
|
8
|
Howell AM, Burns EM, Hull L, Mayer E, Sevdalis N, Darzi A. International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process. BMJ Qual Saf 2016; 26:150-163. [PMID: 26902254 DOI: 10.1136/bmjqs-2015-004456] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 01/10/2016] [Accepted: 01/24/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Patient safety incident reporting systems (PSRS) have been established for over a decade, but uncertainty remains regarding the role that they can and ought to play in quantifying healthcare-related harm and improving care. OBJECTIVE To establish international, expert consensus on the purpose of PSRS regarding monitoring and learning from incidents and developing recommendations for their future role. METHODS After a scoping review of the literature, semi-structured interviews with experts in PSRS were conducted. Based on these findings, a survey-based questionnaire was developed and subsequently completed by a larger expert panel. Using a Delphi approach, consensus was reached regarding the ideal role of PSRSs. Recommendations for best practice were devised. RESULTS Forty recommendations emerged from the Delphi procedure on the role and use of PSRS. Experts agreed reporting system should not be used as an epidemiological tool to monitor the rate of harm over time or to appraise the relative safety of hospitals. They agreed reporting is a valuable mechanism for identifying organisational safety needs. The benefit of a national system was clear with respect to medication error, device failures, hospital-acquired infections and never events as these problems often require solutions at a national level. Experts recommended training for senior healthcare professionals in incident investigation. Consensus recommendation was for hospitals to take responsibility for creating safety solutions locally that could be shared nationally. CONCLUSIONS We obtained reasonable consensus among experts on aims and specifications of PSRS. This information can be used to reflect on existing and future PSRS, and their role within the wider patient safety landscape. The role of PSRS as instruments for learning needs to be elaborated and developed further internationally.
Collapse
Affiliation(s)
- Ann-Marie Howell
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Elaine M Burns
- Department of Biosurgery and Surgical Technology, Imperial College London, London, UK
| | - Louise Hull
- Division of Surgery, Imperial College London, London, UK
| | - Erik Mayer
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Nick Sevdalis
- Department of Surgery and Cancer, Imperial College London, London, UK.,Health Service and Population Research, Centre for Implementation Science, King's College, London, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, London, UK
| |
Collapse
|
9
|
McElroy LM, Daud A, Lapin B, Ross O, Woods DM, Skaro AI, Holl JL, Ladner DP. Detection of medical errors in kidney transplantation: a pilot study comparing proactive clinician debriefings to a hospital-wide incident reporting system. Surgery 2014; 156:1106-15. [PMID: 25444312 DOI: 10.1016/j.surg.2014.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Accepted: 05/08/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Rates of medical errors and adverse events remain high for patients who undergo kidney transplantation; they are particularly vulnerable because of the complexity of their disease and the kidney transplantation procedure. Although institutional incident-reporting systems are used in hospitals around the country, they often fail to capture a substantial proportion of medical errors. The goal of this study was to assess the ability of a proactive, web-based clinician safety debriefing to augment the information about medical errors and adverse events obtained via traditional incident reporting systems. METHODS Debriefings were sent to all individuals listed on operating room personnel reports for kidney transplantation surgeries between April 2010 and April 2011, and incident reports were collected for the same time period. The World Health Organization International Classification for Patient Safety was used to classify all issues reported. RESULTS A total of 270 debriefings reported 334 patient safety issues (179 safety incidents, 155 contributing factors), and 57 incident reports reported 92 patient safety issues (56 safety incidents, 36 contributing factors). Compared with incident reports, more attending physicians completed the debriefings (32.0 vs 3.5%). DISCUSSION The use of a proactive, web-based debriefing to augment an incident reporting system in assessing safety risks in kidney transplantation demonstrated increased information, more perspectives of a single safety issue, and increased breadth of participants.
Collapse
Affiliation(s)
- Lisa M McElroy
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Amna Daud
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Brittany Lapin
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Olivia Ross
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Donna M Woods
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Anton I Skaro
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Jane L Holl
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Daniela P Ladner
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| |
Collapse
|
10
|
McKaig D, Collins C, Elsaid KA. Impact of a Reengineered Electronic Error-Reporting System on Medication Event Reporting and Care Process Improvements at an Urban Medical Center. Jt Comm J Qual Patient Saf 2014; 40:398-407. [DOI: 10.1016/s1553-7250(14)40052-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
11
|
Elliott P, Martin D, Neville D. Electronic clinical safety reporting system: a benefits evaluation. JMIR Med Inform 2014; 2:e12. [PMID: 25600569 PMCID: PMC4288083 DOI: 10.2196/medinform.3316] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 04/20/2014] [Accepted: 05/15/2014] [Indexed: 11/22/2022] Open
Abstract
Background Eastern Health, a large health care organization in Newfoundland and Labrador (NL), started a staged implementation of an electronic occurrence reporting system (used interchangeably with “clinical safety reporting system”) in 2008, completing Phase One in 2009. The electronic clinical safety reporting system (CSRS) was designed to replace a paper-based system. The CSRS involves reporting on occurrences such as falls, safety/security issues, medication errors, treatment and procedural mishaps, medical equipment malfunctions, and close calls. The electronic system was purchased from a vendor in the United Kingdom that had implemented the system in the United Kingdom and other places, such as British Columbia. The main objective of the new system was to improve the reporting process with the goal of improving clinical safety. The project was funded jointly by Eastern Health and Canada Health Infoway. Objective The objectives of the evaluation were to: (1) assess the CSRS on achieving its stated objectives (particularly, the benefits realized and lessons learned), and (2) identify contributions, if any, that can be made to the emerging field of electronic clinical safety reporting. Methods The evaluation involved mixed methods, including extensive stakeholder participation, pre/post comparative study design, and triangulation of data where possible. The data were collected from several sources, such as project documentation, occurrence reporting records, stakeholder workshops, surveys, focus groups, and key informant interviews. Results The findings provided evidence that frontline staff and managers support the CSRS, identifying both benefits and areas for improvement. Many benefits were realized, such as increases in the number of occurrences reported, in occurrences reported within 48 hours, in occurrences reported by staff other than registered nurses, in close calls reported, and improved timelines for notification. There was also user satisfaction with the tool regarding ease of use, accessibility, and consistency. The implementation process encountered challenges related to customizing the software and the development of the classification system for coding occurrences. This impacted on the ability of the managers to close-out files in a timely fashion. The issues that were identified, and suggestions for improvements to the form itself, were shared with the Project Team as soon as they were noted. Changes were made to the system before the rollout. Conclusions There were many benefits realized from the new system that can contribute to improved clinical safety. The participants preferred the electronic system over the paper-based system. The lessons learned during the implementation process resulted in recommendations that informed the rollout of the system in Eastern Health, and in other health care organizations in the province of Newfoundland and Labrador. This study also informed the evaluation of other health organizations in the province, which was completed in 2013.
Collapse
|
12
|
Galt KA, Fuji KT, Faber J. Patient safety problem identification and solution sharing among rural community pharmacists. J Am Pharm Assoc (2003) 2013; 53:584-94. [DOI: 10.1331/japha.2013.12176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
13
|
Colvin C, Baird P, Easty T, Trbovich P. Human factors and medical IT systems: complex incident reporting systems and multiple IV infusions. Biomed Instrum Technol 2013; Suppl:59-63. [PMID: 24111773 DOI: 10.2345/0899-8205-47.s2.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
14
|
Mandavia R, Yassin G, Dhar V, Jacob T. Completing the audit cycle: the impact of an electronic reporting system on the feedback loop in surgical specialties. J Healthc Qual 2013; 35:16-23. [PMID: 24033547 DOI: 10.1111/jhq.12040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The feedback loop of incident reporting is essential in improving patient care. Few studies have followed the loop around its cycle and little data are available concerning the impact of interventions. We investigated the feedback loop before and after the implementation of an electronic reporting system. METHOD Data were collected before and after our intervention. Data were analyzed in terms of the percentage of incidents evaluated, the percentage of incidents resulting in action, whether correlations demonstrated an increased rate of action taken as incident risk score increased. RESULTS Prior to our intervention, 43% and 40% of incidents reported were evaluated and acted upon, respectively. Postintervention, the number of incidents reported increased by 198%. All incidents were evaluated and 66% were acted upon. Both pre- and postintervention, no correlations demonstrated an increase in action taken as incident severity increased. CONCLUSION Our intervention resulted in a considerable increase in the number of incidents reported, evaluated, and acted upon. Such an effect would be expected to improve patient safety, although further studies are needed to definitively confirm this. We therefore recommend the use of electronic systems and further studies to evaluate their impact on patient safety.
Collapse
|
15
|
Tariq A, Georgiou A, Westbrook J. Medication incident reporting in residential aged care facilities: limitations and risks to residents' safety. BMC Geriatr 2012; 12:67. [PMID: 23122411 PMCID: PMC3547703 DOI: 10.1186/1471-2318-12-67] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 09/04/2012] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Medication incident reporting (MIR) is a key safety critical care process in residential aged care facilities (RACFs). Retrospective studies of medication incident reports in aged care have identified the inability of existing MIR processes to generate information that can be used to enhance residents' safety. However, there is little existing research that investigates the limitations of the existing information exchange process that underpins MIR, despite the considerable resources that RACFs' devote to the MIR process. The aim of this study was to undertake an in-depth exploration of the information exchange process involved in MIR and identify factors that inhibit the collection of meaningful information in RACFs. METHODS The study was undertaken in three RACFs (part of a large non-profit organisation) in NSW, Australia. A total of 23 semi-structured interviews and 62 hours of observation sessions were conducted between May to July 2011. The qualitative data was iteratively analysed using a grounded theory approach. RESULTS The findings highlight significant gaps in the design of the MIR artefacts as well as information exchange issues in MIR process execution. Study results emphasized the need to: a) design MIR artefacts that facilitate identification of the root causes of medication incidents, b) integrate the MIR process within existing information systems to overcome key gaps in information exchange execution, and c) support exchange of information that can facilitate a multi-disciplinary approach to medication incident management in RACFs. CONCLUSIONS This study highlights the advantages of viewing MIR process holistically rather than as segregated tasks, as a means to identify gaps in information exchange that need to be addressed in practice to improve safety critical processes.
Collapse
Affiliation(s)
- Amina Tariq
- Centre for Health Systems and Safety Research, University of New South Wales, Kensington, Sydney, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, University of New South Wales, Kensington, Sydney, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, University of New South Wales, Kensington, Sydney, Australia
| |
Collapse
|
16
|
Wu RL, Aufses AH. Characteristics and costs of surgical scheduling errors. Am J Surg 2012; 204:468-73. [DOI: 10.1016/j.amjsurg.2012.01.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 12/20/2011] [Accepted: 01/03/2012] [Indexed: 10/27/2022]
|
17
|
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.
Collapse
|
18
|
Whitehurst JM, Schroder J, Leonard D, Horvath MM, Cozart H, Ferranti J. Towards the creation of a flexible classification scheme for voluntarily reported transfusion and laboratory safety events. J Biomed Semantics 2012; 3:4. [PMID: 22607821 PMCID: PMC3431246 DOI: 10.1186/2041-1480-3-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 05/11/2012] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Transfusion and clinical laboratory services are high-volume activities involving complicated workflows across both ambulatory and inpatient environments. As a result, there are many opportunities for safety lapses, leading to patient harm and increased costs. Organizational techniques such as voluntary safety event reporting are commonly used to identify and prioritize risk areas across care settings. Creation of functional, standardized safety data structures that facilitate effective exploratory examination is therefore essential to drive quality improvement interventions. Unfortunately, voluntarily reported adverse event data can often be unstructured or ambiguously defined. RESULTS To address this problem, we sought to create a "best-of-breed" patient safety classification for data contained in the Duke University Health System Safety Reporting System (SRS). Our approach was to implement the internationally recognized World Health Organization International Classification for Patient Safety Framework, supplemented with additional data points relevant to our organization. Data selection and integration into the hierarchical framework is discussed, as well as placement of the classification into the SRS. We evaluated the impact of the new SRS classification on system usage through comparisons of monthly average report rates and completion times before and after implementation. Monthly average inpatient transfusion reports decreased from 102.1 ± 14.3 to 91.6 ± 11.2, with the proportion of transfusion reports in our system remaining consistent before and after implementation. Monthly average transfusion report rates in the outpatient and homecare environments were not significantly different. Significant increases in clinical lab report rates were present across inpatient and outpatient environments, with the proportion of lab reports increasing after implementation. Report completion times increased modestly but not significantly from a practical standpoint. CONCLUSIONS A common safety vocabulary can facilitate integration of information from disparate systems and processes to permit meaningful measurement and interpretation of data to improve safety within and across organizations. Formation of a "best-of-breed" classification for voluntary reporting necessitates an internal examination of localized data needs and workflow in order to design a product that enables comprehensive data capture. A team of clinical, safety, and information technology experts is necessary to integrate the data structures into the reporting system. We have found that a "best-of-breed" patient safety classification provides a solid, extensible model for adverse event analysis, healthcare leader communication, and intervention identification.
Collapse
Affiliation(s)
- Julie M Whitehurst
- Duke Health Technology Solutions, Duke University Health System, 2424 Erwin Road, Suite 1201, Durham, NC, 27705, USA
| | - John Schroder
- Duke Health Technology Solutions, Duke University Health System, 2424 Erwin Road, Suite 1201, Durham, NC, 27705, USA
| | - Dave Leonard
- Duke Health Technology Solutions, Duke University Health System, 2424 Erwin Road, Suite 1201, Durham, NC, 27705, USA
| | - Monica M Horvath
- Duke Health Technology Solutions, Duke University Health System, 2424 Erwin Road, Suite 1201, Durham, NC, 27705, USA
| | - Heidi Cozart
- Duke Health Technology Solutions, Duke University Health System, 2424 Erwin Road, Suite 1201, Durham, NC, 27705, USA
| | - Jeffrey Ferranti
- Duke Health Technology Solutions, Duke University Health System, 2424 Erwin Road, Suite 1201, Durham, NC, 27705, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
19
|
Tourtier JP, Mangouka L, Bordier E, Carmoi T. Under-reporting of errors: an information technology perspective. J Telemed Telecare 2011; 17:54. [DOI: 10.1258/jtt.2010.100702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Jean-Pierre Tourtier
- Department of Anaesthesia and Intensive Care, Military Hospital Val de Grâce, Paris, France
| | - Laurette Mangouka
- Department of Anaesthesia and Intensive Care, Military Hospital Val de Grâce, Paris, France
| | - Emmanuel Bordier
- Department of Anaesthesia and Intensive Care, Military Hospital Val de Grâce, Paris, France
| | - Thierry Carmoi
- Department of Internal Medicine, Military Hospital Val de Grâce, Paris, France
| |
Collapse
|
20
|
Levtzion-Korach O, Frankel A, Alcalai H, Keohane C, Orav J, Graydon-Baker E, Barnes J, Gordon K, Puopulo AL, Tomov EI, Sato L, Bates DW. Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant. Jt Comm J Qual Patient Saf 2010; 36:402-10. [PMID: 20873673 DOI: 10.1016/s1553-7250(10)36059-4] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND A study was conducted to examine and compare information gleaned from five different reporting systems within one institution: incident reporting, patient complaints, risk management, medical malpractice claims, and executive walk rounds. These data sources vary in the timing of the reporting (retrospective or prospective), severity of the events, and profession of the reporters. METHODS A common methodology was developed for classifying incidents. Data specific to each incident were abstracted from each system and then categorized using the same framework into one of 23 categories. RESULTS Overall, there was little overlap, although each reporting system identified important safety issues. Communication problems were common among patient complaints and malpractice claims; malpractice claims' leading category was clinical judgement. Walk rounds identified issues with equipment and supplies. Adverse event reporting systems highlighted identification issues, especially mislabelled specimens. The frequency of contributions of reports by provider group varied substantially by system. Physicians accounted for 50% of risk management reports, but in adverse event reporting, where nurses were the main reporters, physicians accounted for only 2.5% of reports. Complaints and malpractice claims come primarily from patients. CONCLUSIONS The five reporting systems each identified different yet complementary patient safety issues. To obtain a comprehensive picture of their patient safety problems and to develop priorities for improving safety, hospitals should use a broad portfolio of approaches and then synthesize the messages from all individual approaches into a collated and cohesive whole.
Collapse
|
21
|
Jones DN, Benveniste KA, Schultz TJ, Mandel CJ, Runciman WB. Establishing National Medical Imaging Incident Reporting Systems: Issues and Challenges. J Am Coll Radiol 2010; 7:582-92. [DOI: 10.1016/j.jacr.2010.03.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Accepted: 03/17/2010] [Indexed: 10/19/2022]
|