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Adams MA, Bevan C, Booker M, Hartley J, Heazell AE, Montgomery E, Sanford N, Treadwell M, Sandall J. Strengthening open disclosure in maternity services in the English NHS: the DISCERN realist evaluation study. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-159. [PMID: 39185618 DOI: 10.3310/ytdf8015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Abstract
Background There is a policy drive in NHS maternity services to improve open disclosure with harmed families and limited information on how better practice can be achieved. Objectives To identify critical factors for improving open disclosure from the perspectives of families, doctors, midwives and services and to produce actionable evidence for service improvement. Design A three-phased, qualitative study using realist methodology. Phase 1: two literature reviews: scoping review of post-2013 NHS policy and realist synthesis of initial programme theories for improvement; an interview study with national stakeholders in NHS maternity safety and families. Phase 2: in-depth ethnographic case studies within three NHS maternity services in England. Phase 3: interpretive forums with study participants. A patient and public involvement strategy underpinned all study phases. Setting National recruitment (study phases 1 and 3); three English maternity services (study phase 2). Participants We completed n = 142 interviews, including 27 with families; 93 hours of ethnographic observations, including 52 service and family meetings over 9 months; and interpretive forums with approximately 69 people, including 11 families. Results The policy review identified a shift from viewing injured families as passive recipients to active contributors of post-incident learning, but a lack of actionable guidance for improving family involvement. The realist synthesis found weak evidence of the effectiveness of open disclosure interventions in the international maternity literature, but some improvements with organisation-wide interventions. Recent evidence was predominantly from the United Kingdom. The research identified and explored five key mechanisms for open disclosure: meaningful acknowledgement of harm; involvement of those affected in reviews/investigations; support for families' own sense-making; psychological safely of skilled clinicians (doctors and midwives); and knowing that improvements to care have happened. The need for each family to make sense of the incident in their own terms is noted. The selective initiatives of some clinicians to be more open with some families is identified. The challenges of an adversarial medicolegal landscape and limited support for meeting incentivised targets is evidenced. Limitations Research was conducted after the pandemic, with exceptional pressure on services. Case-study ethnography was of three higher performing services: generalisation from case-study findings is limited. No observations of Health Safety Investigation Branch investigations were possible without researcher access. Family recruitment did not reflect population diversity with limited representation of non-white families, families with disabilities and other socially marginalised groups and disadvantaged groups. Conclusions We identify the need for service-wide systems to ensure that injured families are positioned at the centre of post-incident events, ensure appropriate training and post-incident care of clinicians, and foster ongoing engagement with families beyond the individual efforts made by some clinicians for some families. The need for legislative revisions to promote openness with families across NHS organisations, and wider changes in organisational family engagement practices, is indicated. Examination of how far the study's findings apply to different English maternity services, and a wider rethinking of how family diversity can be encouraged in maternity services research. Study registration This study is registered as PROSPERO CRD42020164061. The study has been assessed following RAMESES realist guidelines. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research Programme (NIHR award ref: 17/99/85) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 22. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Mary Ann Adams
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London, UK
| | - Charlotte Bevan
- The Stillbirth and Neonatal Death Charity (SANDS), London, UK
| | | | - Julie Hartley
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London, UK
| | | | - Elsa Montgomery
- The Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Natalie Sanford
- The Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | | | - Jane Sandall
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London, UK
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Finkelstein A, Brezis M, Taub A, Arad D. Disclosure following a medical error: lessons learned from a national initiative of workshops with patients, healthcare teams, and executives. Isr J Health Policy Res 2024; 13:13. [PMID: 38462624 PMCID: PMC10926562 DOI: 10.1186/s13584-024-00599-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 02/27/2024] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND Despite the increase in disclosures of medical errors, transparency remains a challenge. Recognized barriers include shame, fear of litigation, disciplinary actions, and loss of patient trust. In 2018, the Israeli Ministry of Health initiated a series of workshops about disclosure of medical errors. The workshops involved medical center executives, healthcare providers, patients, and family members of patients who had previously been harmed by a medical error. This study presents the lessons learned about perceived challenges in disclosure of errors in 15 such workshops. METHODS Data collection included participant observations in 15 workshops, full audio recordings of all of the workshops, and documentation of detailed field notes. Analysis was performed under thematic analysis guidelines. RESULTS We identified four main themes: "Providers agree on the value of disclosure of a medical error to the patient"; "Emotional challenges of disclosure of medical error to patients"; "The medico-legal discourse challenges transparency"; and "Providers and patients call for a change in the culture regarding disclosure of medical errors". Participant observations indicated that the presence of a patient who had experienced a tragedy in another hospital, and who was willing to share it created an intimate atmosphere that enabled an open conversation between parties. CONCLUSION The study shows the moral, human, and educational values of open discourse in a protective setting after the occurrence of a medical error. We believe that workshops like these may help foster a culture of institutional disclosure following medical errors. We recommend that the Ministry of Health extend such workshops to all healthcare facilities, establish guidelines and mandate training for skills in disclosure for all providers.
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Affiliation(s)
- Adi Finkelstein
- Department of Nursing, Faculty of Life and Health Sciences, Jerusalem College of Technology (JCT), Beit Hadfus 7 St., 9548307, Jerusalem, Israel.
| | - Mayer Brezis
- School of Public Health, Hebrew University Hadassah Medical Center, Ein-Kerem, PO Box 12000, 91120, Jerusalem, Israel
| | - Amiad Taub
- 'Ofek Back to Life' Organization, Sderot H'areches 13, 7178441, Modi'in, Israel
| | - Dana Arad
- Patient Safety Division, Ministry of Health, 39 Yeremiahu, 9101002, Jerusalem, Israel
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Adkins S, Alta'any R, Brar K, Kauser H, Hughbanks S, Rabah K, Flowers S. Medical Error: Using Storytelling and Reflection to Impact Error Response Factors in Family Medicine Residents. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2024; 11:23821205241272358. [PMID: 39149530 PMCID: PMC11325321 DOI: 10.1177/23821205241272358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 07/12/2024] [Indexed: 08/17/2024]
Abstract
I am a healer, yet sometimes I do more harm than good…David Hilfiker, 1984. Objectives Medical error is common and significantly impacts patients, physicians, learners, and public perception of the medical system; however, residents receive little formal training on this topic. Research on error response in practicing physicians is limited, and even more so on medical education interventions to improve this. This study evaluates a curriculum developed to foster the sharing of faculty medical error stories, practice of constructive coping strategies, and growth in resident confidence in managing error. Methods Researchers identified factors related to effective physician error management and recovery to develop a targeted intervention for family medicine residents. The intervention consisted of three one hour didactic sessions in a medium-sized midwestern, urban family medicine residency program over the course of 6 months. Instructional methods included guided reflection after mentor storytelling, small group discussion, role play, and self-reflection. Results Of the 30 residents, 22 (73%) completed the preintervention survey, and 15 (50%) completed the postintervention survey. While most residents reported having experienced error (55%), fewer than half of the residents reported they knew what to do when faced with medical errors (46%). This increased to 93% after intervention. Personal error stories from mentors were the most desired type of training reported by residents preintervention, but this was surpassed by legal and malpractice concerns in the postintervention survey. Rates of reported error story sharing increased after the intervention. Residents reported self-efficacy (I can be honest about errors) and self-awareness (I acknowledge when I am at increased risk for error) also increased with intervention. However, these changes did not reach statistical significance. Conclusions Family medicine residents are receptive to learning from peers and mentors about error management and recovery. A brief intervention can impact the culture around disclosure and support. Future research should focus on the impact of targeted interventions on patient-oriented outcomes related to medical error.
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Affiliation(s)
- Sherry Adkins
- Rural Family Medicine Residency, Wright State University, Greenville, OH, USA
| | - Rahaf Alta'any
- Rural Family Medicine Residency, Wright State University, Greenville, OH, USA
| | - Kewaljit Brar
- Rural Family Medicine Residency, Wright State University, Greenville, OH, USA
| | - Humaira Kauser
- Rural Family Medicine Residency, Wright State University, Greenville, OH, USA
| | - Savannah Hughbanks
- School of Professional Psychology, Wright State University, Dayton, OH, USA
| | - Kelly Rabah
- Department of Faculty Affairs, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Stacy Flowers
- Family Medicine Residency, Wright State University, Dayton, Ohio, USA
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Ituk U, Mueller R. Implementation and evaluation of an event reporting system in an academic anaesthesia department. BMJ Open Qual 2023; 12:e002389. [PMID: 38123473 DOI: 10.1136/bmjoq-2023-002389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Reporting adverse clinical events is essential to a culture of safety in healthcare. However, self-reporting such events is generally not widely prevalent in a typical academic anaesthesia department. METHODS We set out to create a self-reporting tool to securely accept data from multiple anaesthesia service locations, including data linked to our electronic anaesthesia record, and combine them into an accessible database.We created a web-based database module for incident reporting integrated into the department's intranet. The system was also designed to actively prompt anaesthesia providers for reports following each day of clinical work. RESULTS 478 events were recorded in the database in the first year of implementation. There were 33 347 anaesthesia encounters in that period, translating to a reporting rate of 1.43% (95% CI 1.31% to 1.57%). In the second year, which coincided with the second phase of implementation, 608 events were reported out of 45 985 anaesthesia encounters, for a reporting rate of 1.32% (95% CI 1.22% to 1.43%). Approximately 40% of events entered into the database occurred in a non-operating room location. The annual reporting rates for 2014, 2015, 2016, 2017, 2018 and 2019 were 1.26% (95% CI 1.16% to 1.37%), 1.15% (95% CI 1.05% to 1.25%), 1% (95% CI 0.9% to 1.1%), 0.6% (95% CI 0.53% to 0.68%), 0.5% (95% CI 0.44% to 0.57%), 0.4% (95% CI 0.3% to 0.5%), respectively. CONCLUSIONS Our incident reporting system facilitated reporting of events within and outside the operating room. The system captured event data valid for quality improvement within the anaesthesia department.
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Affiliation(s)
- Unyime Ituk
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Rashmi Mueller
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Menang O, Kuemmerle A, Maigetter K, Burri C. Strategies and interventions to strengthen pharmacovigilance systems in low-income and middle-income countries: a scoping review. BMJ Open 2023; 13:e071079. [PMID: 37709326 PMCID: PMC10503375 DOI: 10.1136/bmjopen-2022-071079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 07/27/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVES The slow progress of pharmacovigilance (PV) in low-income and middle-income countries (LMIC) raises questions about core challenges on the growth of PV, and the appropriateness of strategies used so far to develop PV. Therefore, this scoping review aims to describe strategies and interventions to strengthen PV in LMIC and to propose recommendations for future investments in PV capacity building. INCLUSION CRITERIA Publications included were primary studies, articles, policy and guideline papers, describing interventions to strengthen PV in LMIC. METHODS The review was conducted following the Joanna Briggs Institute (JBI) guidelines on conducting scoping reviews. Literature searches were performed in MEDLINE, EMBASE, Web of Science, PDQ-evidence, CINAHL and other relevant websites from January 1990 to January 2021. Two reviewers independently screened titles, abstracts and full texts. One reviewer performed data extraction and descriptive analysis, which were reviewed by two other reviewers. RESULTS 10 922 unique titles were screened and 152 were eligible for full text review. Of these, 57 and an additional 13 reports from grey literature fulfilled eligibility criteria for inclusion in the review. These were grouped into two categories: (1) Interventions aimed at increasing PV knowledge and adverse drug reactions (ADR) reporting (45 papers), primarily education of healthcare professionals (HCP), alone or in combination with other interventions such as mobile and electronic reporting and (2) Interventions aimed at strengthening various components of the national PV system (25 papers), describing strategies or mixed interventions implemented at the national level, targeting different components of the national PV system. CONCLUSIONS Results of this review suggest that educating HCP on ADR reporting is the most common approach to build PV capacity in LMIC. Though important, education alone is insufficient and should ideally be organised within the holistic framework of strengthening national PV systems, with a focus on also building capacity for advanced activities such as signal detection.
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Affiliation(s)
- Olga Menang
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Andrea Kuemmerle
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Karen Maigetter
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Christian Burri
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
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Lee S, Roh H, Kim M, Park JK. Evaluating medical students' ability to identify and report errors: finding gaps in patient safety education. MEDICAL EDUCATION ONLINE 2022; 27:2011604. [PMID: 35129092 PMCID: PMC8823682 DOI: 10.1080/10872981.2021.2011604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/17/2021] [Accepted: 11/23/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Although there are frequent complaints of medical students' incompetence in reporting errors, few studies have examined their error-reporting abilities in the real world. OBJECTIVES Three sub-functions of self-regulation theory were used to evaluate medical students' ability to identify errors (self-monitoring), analyse root causes (self-judgment), and devise improvement plans (self-reactions). In addition, whether students reacted differently to their errors and those of others (three sub-functions) was also examined. METHODS A total of 952 patient safety reports were reviewed retrospectively, submitted by third-year medical students between 2016 and 2018. Data were quantitatively and qualitatively analysed to investigate who committed the error, to identify the type of error and its root causes, and to find suggested improvement plans. Chi-square and Fisher's exact tests were used to compare students' responses to error origins. RESULTS Students reported other errors more frequently than their own (67.6% vs. 32.4%). They reported common critical medical errors, including errors related to engaging with patients (34.5%), invasive procedures (20.2%), and infection (18.5%). The root causes identified were more precise than the improvement plans by the students (75.5% vs. 18.4%, respectively). The students' improvement plans were not practical, especially at the patient level (25.8%). When students committed errors, they considered human factors such as fatigue, scheduling, and training as the most common root cause, focussing on improvement plans at the individual level. CONCLUSIONS The results suggest that students were good at self-judgment, but not at self-monitoring and self-reactions. They reacted differently, based on who committed the error. To enhance self-regulated learning, Educators should encourage students to confront their errors, reflect on their self-reactions towards errors, develop well-being with time management, and think about the meaning of patient-centredness. Finally, active participation in clinical clerkship longitudinally may provide students with opportunities to learn from their errors.
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Affiliation(s)
- Sungjoon Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - HyeRin Roh
- Department of Medical Education and the Institute for Medical Humanities, Inje University College of Medicine, Busan, Korea
| | - Myounghun Kim
- Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Ji Kyoung Park
- Department of Pediatrics, Busan Paik Hospital, inje University College of Medicine, Busan, Korea
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Building organisations, setting minds: exploring how boards of Dutch medical specialist companies address physicians’ professional performance. BMC Health Serv Res 2022; 22:155. [PMID: 35123458 PMCID: PMC8818234 DOI: 10.1186/s12913-022-07512-6] [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: 02/25/2021] [Accepted: 01/11/2022] [Indexed: 11/15/2022] Open
Abstract
Background Governments worldwide are reforming healthcare systems to achieve high quality and safe patient care while maintaining costs. Self-employed physicians reorganise into novel organisations to meet reconfiguration demands, impacting their work environment and practice. This study explores what strategies these novel organisations use to address physicians’ professional performance and what they encounter when executing these strategies to achieve high quality and safe care. Methods This constructivist exploratory qualitative study used focus groups to answer our research question. Between October 2018 and May 2019, we performed eight focus group sessions with purposively sampled Medical Specialist Companies (MSCs), which are novel physician-led organisations in the Netherlands. In each session, board members of an MSC participated (n = 33). Results MSCs used five strategies to address physicians’ professional performance: 1) actively managing and monitoring performance, 2) building a collective mindset, 3) professionalising selection and onboarding, 4) improving occupational well-being, and 5) harmonising working procedures. The MSC’s unique context determined which strategies and quality and safety topics deserved the most attention. Physicians’ support, trusting relationships with hospital administrators, and the MSC’s organisational maturity seem critical to the quality of the strategies’ execution. Conclusions The five strategies have clear links to physicians’ professional performance and quality and safety. Insight into whether an MSC’s strategies together reflect medical professional or organisational values seems crucial to engage physicians and collaboratively achieve high quality and safe care. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07512-6.
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Myren BJ, de Hullu JA, Bastiaans S, Koksma JJ, Hermens RPMG, Zusterzeel PLM. Disclosing Adverse Events in Clinical Practice: The Delicate Act of Being Open. HEALTH COMMUNICATION 2022; 37:191-201. [PMID: 33045852 DOI: 10.1080/10410236.2020.1830550] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Practicing a "safe" disclosure of adverse events remains challenging for healthcare professionals. In addition, knowledge on how to deliver a disclosure is still limited. This review focuses on how disclosure communication may be practiced based on the perspectives of patients and healthcare professionals. Empirical studies conducted between September 2008 and October 2019 were included from the databases PubMed, Web of Science and Psychinfo. After full text analysis and quality appraisal this scoping review included a total of 23 studies out of 2537 studies. As a first step, the needs of patients and the challenges of healthcare professionals with the practice of providing an effective disclosure were extracted from the empirical literature. Based on these findings, the review demonstrates that specific disclosure communication strategies on the level of interpersonal skills, organization, and supportive factors may facilitate healthcare professionals to provide optimal disclosure of adverse events. These may be relevant to provide patients with a tailored approach that accompanies their preferences for information and recognition. In conclusion, healthcare professionals may need training in interpersonal (verbal and nonverbal) communication skills. Furthermore, it is important to develop an open (organizational) culture that supports the communication of adverse events and disclosure as a standard practice.
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Affiliation(s)
- B J Myren
- Department of Gynaecology, Radboud University Medical Center
| | - J A de Hullu
- Department of Gynaecology, Radboud University Medical Center
| | - S Bastiaans
- Department of Gynaecology, Radboud University Medical Center
| | - J J Koksma
- Health Academy, Radboud University Medical Center
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Gu X, Deng M. The Impacts of Disclosure and a Proactive Compensation Offer on Chinese Patients' Actions After Medical Errors. J Patient Saf 2021; 17:e745-e751. [PMID: 34009870 DOI: 10.1097/pts.0000000000000855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study aims to obtain evidence of the impacts of error disclosure and the impacts of a proactive compensation offer on Chinese patients' actions after medical errors. METHODS A total of 915 responses were collected from a questionnaire survey. Two fictitious cases (entailed moderate and severe harm) that involved error disclosure were described. One of 5 disclosure and compensation types was randomly provided to each participant. The 5 types were combinations of 3 disclosure types (no disclosure, partial disclosure, and full disclosure) and 2 proactive compensation offer categories (no offer and an offer), with the exception of no disclosure but a proactive compensation offer. The respondents were asked about their willingness to take actions if they were the affected patient. RESULTS The generalized ordinal logit regression model showed that error disclosure did not increase the likelihood of the patients taking action, such as changing physicians, complaining, or filing lawsuits. A proactive compensation offer decreased the patients' willingness to file lawsuits but had no significant influence on the other action choices. In addition, the patients' actions were affected by other factors, such as the severity of the error, age, sex, education level, being religious, prior error experience, and health insurance. CONCLUSIONS We suggest that "disclosure and compensation" programs are developed in China. To ensure their implementation, it is recommended that appropriate training is provided and that the disclosure culture in health care organizations is improved. Furthermore, laws or regulations are required that govern error disclosure and provide support for health care professionals and organizations.
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Affiliation(s)
- Xiuzhu Gu
- From the Department of Industrial Engineering and Economics, School of Engineering, Tokyo Institute of Technology, Tokyo, Japan
| | - Mingming Deng
- School of Management, Xi'an Jiaotong University, Xi'an, Shaanxi, China
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Gu X, Deng M. Medical Error Disclosure: Developing Evidence-Based Guidelines for Chinese Hospitals. J Patient Saf 2021; 17:e738-e744. [PMID: 32740131 DOI: 10.1097/pts.0000000000000760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study aims to investigate Chinese individuals' expectations regarding the disclosure of errors that vary in level of harm severity and to develop guidelines for error disclosure. METHODS A total of 947 valid responses were collected from a questionnaire survey in 2019, and 220 respondents or their family members had experienced medical errors. The respondents were required to indicate their preferences regarding the disclosure of errors that entail moderate and severe harm. Based on their responses and interviews conducted with several patient safety managers, guidelines for medical error disclosure were developed. RESULTS Similar preferences were reported for the disclosure of errors that entail moderate and severe harm. They expected a formal disclosure. Furthermore, they wished to be informed about the error through face-to-face communication in a meeting room immediately after error detection. Moreover, they wanted to be provided with all details about the incident. The health care provider who was involved in the incident, the leader of his/her department/team, the patient safety manager, and top management member were expected to attend the meeting. However, there was a significant difference in who was expected to disclose errors that entail moderate (i.e., the health care provider involved in the incident) and severe (i.e., the leader, top management member) harm. CONCLUSIONS Medical error disclosure is not commonly practiced in Chinese hospitals. Therefore, the proposed guidelines could be the first step toward disclosure supporting. In addition, the present findings underscore the importance of cultural sensitivity and error severity in international error disclosure research and practice.
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Affiliation(s)
- Xiuzhu Gu
- From the Department of Industrial Engineering and Economics, School of Engineering, Tokyo Institute of Technology, Tokyo, Japan
| | - Mingming Deng
- School of Management, Xi'an Jiaotong University, Xi'an, China
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Mohamed MFH, Abubeker IY, Al-Mohanadi D, Al-Mohammed A, Abou-Samra AB, Elzouki AN. Perceived Barriers of Incident Reporting Among Internists: Results from Hamad Medical Corporation in Qatar. Avicenna J Med 2021; 11:139-144. [PMID: 34646790 PMCID: PMC8500080 DOI: 10.1055/s-0041-1734386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background
Adverse events (AE) are responsible for annual deaths that exceed deaths due to motor vehicle accidents, breast cancer, and AIDS. Many AE are considered preventable. Thus, AE needs to be detected and analyzed. Incident reporting systems (IRS) are crucial in identifying AE. Nevertheless, the incident report (IR) process is flawed with underreporting, especially from the physicians' side. This limits its efficiency in detecting AE. Therefore, we aimed to assess the practice and identify the barriers associated with incident reporting among internal medicine physicians in a large tertiary hospital through a survey.
Methods
A cross-sectional descriptive study. We distributed an online survey to physicians working in the Internal Medicine Department of Qatar's largest tertiary academic institute. The questionnaire was validated and piloted ahead of the start of the trial. The response rate was 53%.
Results
A total of 115 physicians completed the survey; 59% acknowledged the availability of an institutional IRS. However, only 29% knew how to submit an online IR, and 20% have ever submitted an IR. The survey revealed that participants were less likely to submit an IR when they or a colleague is involved in the incident; 46% and 63%, respectively. The main barriers of reporting incidents were unawareness about the IRS (36%) and the perception that IR will not bring a system change (13%); moreover, there exists the fear of retaliation (13%). When asked about solutions, 57% recommended training and awareness, and 22% recommended sharing learnings and actions from previous IR.
Conclusions
IRS is underutilized by internal medicine physicians. The main barrier at the time of the survey is the lack of training and awareness. Promoting awareness and sharing previous learning and actions may improve the utilization of the IRS.
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Affiliation(s)
- Mouhand F H Mohamed
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ibrahim Y Abubeker
- Department of Medicine, Brown Internal Medicine Residency, Brown University, Providence, Rhode Island, United States
| | - Dabia Al-Mohanadi
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Al-Mohammed
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Abdul-Badi Abou-Samra
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Department of Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Abdel-Naser Elzouki
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Department of Medicine, Weill Cornell Medical College, Doha, Qatar.,Department of Medicine, College of Medicine, Qatar University, Doha, Qatar
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Samuels A, Broome ME, McDonald TB, Peterson CH, Thompson JA. Improving self-reported empathy and communication skills through harm in healthcare response training. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2021. [DOI: 10.1177/25160435211047643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objective Communication and Resolution Programs (CRP) were developed to equip healthcare organizations with tools to respond when physical and psychological harm occurs. Our objective was to assess development of empathic behaviors and communication skills through CRP training based upon the Agency for Healthcare Research and Quality (AHRQ) CANDOR toolkit to assess the ability to develop and improve empathic behaviors and communication skills. Methods The Jefferson Scale of Empathy, the CANDOR Communication Assessment Questionnaire and a self-assessment were used pre- and post-intervention to analyze development of empathy, growth of communication, and improvement in confidence and knowledge through 6 h of virtual education over a six-week course. Results Self-reported communication, confidence and knowledge improved with statistical significance and small to moderate effect size in both men and women. A statistically significant improvement of self-reported empathy scores t (22) = 2.23, p = .037; (95% CI = 0.41 to 11.5) for women only represented a small to moderate effect size (Cohen’s d = 0.46). While there was no improvement in Cognitive Complexity, (Cohen’s d = 0.065) mean pre-post .42 (SD = 6.52); Message Design Logic improved with statistical significance in paired pre-and post-assessment (Z = -3.28, p = .001). Notably, previous attendance at CANDOR classes demonstrated no impact on improvement of scores. Conclusions Our findings demonstrate improvement in self-reported empathy and communication skills through harm in healthcare response training. Healthcare organizations should carefully consider investing in CANDOR training for the benefit of patients, their families, and healthcare workforce members.
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Affiliation(s)
- Aimee Samuels
- Samaritan Health Services, Department of Patient Safety and Clinical Risk
| | | | - Timothy B. McDonald
- Chief Patient Safety and Risk Officer, RLDatix, Loyola University, Beazley Institute for Health Law and Policy
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Welsh D, Zephyr D, Pfeifle AL, Carr DE, Fink JL, Jones M. Development of the Barriers to Error Disclosure Assessment Tool. J Patient Saf 2021; 17:363-374. [PMID: 28671908 PMCID: PMC5748022 DOI: 10.1097/pts.0000000000000331] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES An interprofessional group of health colleges' faculty created and piloted the Barriers to Error Disclosure Assessment tool as an instrument to measure barriers to medical error disclosure among health care providers. METHODS A review of the literature guided the creation of items describing influences on the decision to disclose a medical error. Local and national experts in error disclosure used a modified Delphi process to gain consensus on the items included in the pilot. After receiving university institutional review board approval, researchers distributed the tool to a convenience sample of physicians (n = 19), pharmacists (n = 20), and nurses (n = 20) from an academic medical center. Means and SDs were used to describe the sample. Intraclass correlation coefficients were used to examine test-retest correspondence between the continuous items on the scale. Factor analysis with varimax rotation was used to determine factor loadings and examine internal consistency reliability. Cronbach α coefficients were calculated during initial and subsequent administrations to assess test-retest reliability. RESULTS After omitting 2 items with intraclass correlation coefficient of less than 0.40, intraclass correlation coefficients ranged from 0.43 to 0.70, indicating fair to good test-retest correspondence between the continuous items on the final draft. Factor analysis revealed the following factors during the initial administration: confidence and knowledge barriers, institutional barriers, psychological barriers, and financial concern barriers to medical error disclosure. α Coefficients of 0.85 to 0.93 at time 1 and 0.82 to 0.95 at time 2 supported test-retest reliability. CONCLUSIONS The final version of the 31-item tool can be used to measure perceptions about abilities for disclosing, impressions regarding institutional policies and climate, and specific barriers that inhibit disclosure by health care providers. Preliminary evidence supports the tool's validity and reliability for measuring disclosure variables.
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Affiliation(s)
| | - Dominique Zephyr
- Applied Statistics Laboratory, University of Kentucky, Lexington, KY
| | | | - Douglas E Carr
- Division of General Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Joseph L Fink
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY
| | - Mandy Jones
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY
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Bryant J, Carey M, Sanson-Fisher R, Turon H, Wei A, Kuss B. The Patients' Perspective: Hematological Cancer Patients' Experiences of Adverse Events as Part of Care. J Patient Saf 2021; 17:e387-e392. [PMID: 28306611 DOI: 10.1097/pts.0000000000000347] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe in a sample of patients with a confirmed diagnosis of a hematological cancer: (a) the proportion who self-report experiencing an unexpected adverse event as part of their care; (b) how the adverse event was handled by the health-care organization; and (c) the sociodemographic, disease, and treatment characteristics associated with experiencing an adverse event. DESIGN Cross sectional survey. SETTING Three Australian hematological oncology treatment centers. PARTICIPANTS Individuals with a confirmed diagnosis of a hematological cancer. MAIN OUTCOME MEASURES Participants were asked if they had ever experienced an adverse event in their cancer care. Those who did were asked about their perceptions concerning what the adverse event was related to, how much harm the event caused, who identified the adverse event, and how the health-care organization responded to the adverse event. RESULTS Forty-two participants (26.4%) perceived that they had experienced an unexpected adverse event as part of their care. Most were told about the event as soon as it happened (62%) and were given an explanation about why the event occurred (75%). Fewer were given information about how to take the matter further if they wished (43%). Participants who were unemployed, retired, disabled, or performed home duties and those whose employment status was "other" had higher odds of reporting an adverse event than those in full- or part-time employment. CONCLUSIONS There is a need for routinely querying patients during their treatment regarding the occurrence of unexpected adverse events. In addition, there is a need for improvement in the responses of health-care providers and the health-care system to these events in regard to full disclosure, apology, and options available to the patient for resolution.
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Affiliation(s)
- Jamie Bryant
- From the Health Behaviour Research Group, Priority Research Centre in Health Behaviour and Hunter Medical Research Institute, University of Newcastle, New South Wales
| | - Mariko Carey
- From the Health Behaviour Research Group, Priority Research Centre in Health Behaviour and Hunter Medical Research Institute, University of Newcastle, New South Wales
| | - Rob Sanson-Fisher
- From the Health Behaviour Research Group, Priority Research Centre in Health Behaviour and Hunter Medical Research Institute, University of Newcastle, New South Wales
| | - Heidi Turon
- From the Health Behaviour Research Group, Priority Research Centre in Health Behaviour and Hunter Medical Research Institute, University of Newcastle, New South Wales
| | - Andrew Wei
- Department of Haematology, Alfred Hospital and Monash University, Melbourne, Victoria
| | - Bryone Kuss
- Haematology and Molecular Medicine, Flinders Medical Centre and Flinders University, Flinders Centre for Innovation in Cancer, South Australia, Australia
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15
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Kaldjian LC. Communication about medical errors. PATIENT EDUCATION AND COUNSELING 2021; 104:989-993. [PMID: 33280965 DOI: 10.1016/j.pec.2020.11.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/24/2020] [Accepted: 11/26/2020] [Indexed: 06/12/2023]
Abstract
Communication about medical errors with patients and families demonstrates respect, compassion, and commitment by providing information, acknowledging harm, and maintaining trust through a process of dialogue that involves multiple conversations. This communication requires knowledge, skills, and attitudes that allow healthcare professionals to discuss facts transparently, take responsibility for what happened, and express regret and (as appropriate) apologize; these abilities also allow professionals to describe what will happen next for the patient and explain what will be done to prevent the error from happening to others in the future. Communication about medical errors also encompasses two other contexts: reporting information about errors to healthcare organizations through data collection systems designed to improve patient safety, and discussing errors with fellow healthcare professionals to promote professional learning and receive emotional support. Communication about errors in these three contexts depends on healthcare professionals who are honest, reflective, compassionate, courageous, accountable, reassuring, and willing to acknowledge and engage their own feelings of sadness, fear, and guilt. Healthcare organizations should promote a systems approach to patient safety and cultivate a culture of transparency and learning in which healthcare professionals are supported as they cope with the distress they experience after an error. Communication about errors should be incorporated into all healthcare practice settings (medical, surgical, in-patient, out-patient), and can be taught to medical students and residents using didactic, role-playing, or simulation methodologies.
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Affiliation(s)
- Lauris Christopher Kaldjian
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA; Program in Bioethics and Humanities, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.
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16
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Afolalu OO, Jordan S, Kyriacos U. Medical error reporting among doctors and nurses in a Nigerian hospital: A cross-sectional survey. J Nurs Manag 2021; 29:1007-1015. [PMID: 33346942 DOI: 10.1111/jonm.13238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/04/2020] [Accepted: 12/15/2020] [Indexed: 12/29/2022]
Abstract
AIM To compare doctors' and nurses' perceptions of factors influencing medical error reporting. BACKGROUND In Nigeria, there is limited information on determinants of error reporting and systems. METHODS From the total workforce (N = 600), 140 nurses and 90 doctors were selected by random sampling and completed the questionnaire February to March 2017. RESULTS All 140 nurses and 90 doctors approached responded. Inter-professional differences in response to sentinel events showed that 55/140, 39.3% nurses and 48/90, 53.3% doctors would never report wrong medicines administered and 49/138, 35.5% nurses and 35/90, 38.9% doctors would never report a haemolytic transfusion error. Some respondents (72/140, 51.4% nurses vs. 29/90, 32.2% doctors) were unaware of reporting systems. Most (77/140, 55% nurses vs. 48/90, 53.3% doctors) considered these to be ineffective and confounded by a 'blame culture'. Perceived barriers included lack of confidentiality; facilitators included clear guidelines about protection from litigation. CONCLUSIONS Error reporting is suboptimal. Nurses and doctors have a minimal common understanding of barriers to error reporting and demonstrate inconsistent practice. IMPLICATIONS FOR NURSING MANAGEMENT Suboptimal reporting of serious adverse events has implications for patient safety. Managers need to prioritize education in adverse events, clarify reporting procedures and divest the organisation of a 'blame culture'.
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Affiliation(s)
- Olamide O Afolalu
- Division of Nursing and Midwifery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sue Jordan
- School of Human and Health Sciences, Swansea University, Wales, UK
| | - Una Kyriacos
- Division of Nursing and Midwifery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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17
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Mansour R, Ammar K, Al-Tabba A, Arawi T, Mansour A, Al-Hussaini M. Disclosure of medical errors: physicians' knowledge, attitudes and practices (KAP) in an oncology center. BMC Med Ethics 2020; 21:74. [PMID: 32819353 PMCID: PMC7439528 DOI: 10.1186/s12910-020-00513-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 07/29/2020] [Indexed: 12/04/2022] Open
Abstract
Background Between the need for transparency in healthcare, widely promoted by patient’s safety campaigns, and the fear of negative consequences and malpractice threats, physicians face challenging decisions on whether or not disclosing medical errors to patients and families is a valid option. We aim to assess the knowledge, attitudes and practices (KAP) of physicians in our center regarding medical error disclosure. Methods This is a cross-sectional self-administered questionnaire study. The questionnaire was piloted and no major modifications were made. A day-long training workshop consisting of didactic lectures, short and long case scenarios with role playing and feedback from the instructors, were conducted. Physicians who attended these training workshops were invited to complete the questionnaire at the end of the training, and physicians who did not attend any training were sent a copy of the questionnaire to their offices to complete. To assure anonymity and transparency of responses, we did not query names or departments. Descriptive statistics were used to present demographics and KAP. The differences between response\s of physicians who received the training and those who did not were analyzed with t-test and descriptive statistics. The 0.05 level of significance was used as a cutoff measure for statistical significance. Results Eighty-eight physicians completed the questionnaire (55 attended training (62.50%), and 33 did not (37.50%)). Sixty Five percent of physicians were males and the mean number of years of experience was 16.5 years. Eighty-Seven percent (n = 73) of physicians were more likely to report major harm, compared to minor harm or no harm. Physicians who attended the workshop were more knowledgeable of articles of Jordan’s Law on Medical and Health Liability (66.7% vs 45.5%, p-value = 0.017) and the Law was more likely to affect their decision on error disclosure (61.8% vs 36.4%, p-value = 0.024). Conclusion Formal training workshops on disclosing medical errors have the power to positively influence physicians’ KAP toward disclosing medical errors to patients and possibly promoting a culture of transparency in the health care system.
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Affiliation(s)
- Razan Mansour
- University of Jordan, School of Medicine, Amman, Jordan
| | - Khawlah Ammar
- Office of Scientific Affair and Research, King Hussein Cancer Center, Amman, Jordan
| | - Amal Al-Tabba
- Office of Human Research Protection Program, King Hussein Cancer Center, Amman, Jordan
| | - Thalia Arawi
- Salim EL Hoss Bioethics and Professionalism Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Asem Mansour
- Office of Human Research Protection Program, King Hussein Cancer Center, Amman, Jordan
| | - Maysa Al-Hussaini
- Office of Human Research Protection Program, King Hussein Cancer Center, Amman, Jordan. .,Chair, Institutional Review Board Office, King Hussein Cancer Center, Amman, Jordan.
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Zarrabi K, Cummings K, Lum N, Taub E, Goolsarran N. A resident-led initiative to improve patient safety event reporting in an internal medicine residency program. J Community Hosp Intern Med Perspect 2020; 10:111-116. [PMID: 32850045 PMCID: PMC7425618 DOI: 10.1080/20009666.2020.1740507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Background Despite the Clinical Learning Environment Review's recommendations of their use, patient safety event reporting systems are underutilized by residents. Objective We aimed to identify perceived barriers to event reporting amongst internal medicine residents and implement a targeted quality improvement initiative to address the identified barriers and increase overall resident event report rates. Methods A total of 94 Internal Medicine (IM) residents participated in the educational intervention in 2018. We measured residents' perception of barriers to event reporting and employed the results of the questionnaire to create a skill-based educational workshop. We conducted the plan-do-study-act model to test a structured educational intervention and its effectiveness on pre-post IM residents' event report rates and compared it to report rates of Non-Internal Medicine (Non-IM) residents. Additionally, we assessed pre-post intervention knowledge, skills, and attitudes in event reporting. Results 94/94 (100%) of IM residents had a significantly higher median percent of patient safety event reporting when compared to pre-intervention (23.6% compared to 5.88%, p-value = 0.0030) and when compared to Non-IM residents (23.6% compared to 5.31%, p-value = 0.0002). Residents performed better on the post-test compared to the pre-test (90% compared to 30%, p-value = 0.0001) for knowledge. 100% of the critical action items were completed and 90% of participants reported their perception of the event reporting process improved. Conclusions By elucidating common reasons why residents are not reporting patient safety events, a specific intervention can be created to target the identified impediments and improve resident event reporting. Abbreviations IM: Internal Medicine IM; Non-IM: Non-Internal Medicine; IOM: Institute of Medicine I; ACGME CLER: Accreditation Council for Graduate Medical Education Clinical Learning Environment Review; GME: Graduate Medical Education; IRB: Institutional Review Board; PDSA: Plan, Do, Study, Act.
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Affiliation(s)
- Kevin Zarrabi
- Department of Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Kelly Cummings
- Department of Geriatrics and Palliative Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicole Lum
- Department of Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Erin Taub
- Department of Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Nirvani Goolsarran
- Department of Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
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Geuijen P, de Rond M, Kuppens J, Atsma F, Schene A, de Haan H, de Jong C, Schellekens A. Physicians' norms and attitudes towards substance use in colleague physicians: A cross-sectional survey in the Netherlands. PLoS One 2020; 15:e0231084. [PMID: 32243472 PMCID: PMC7122818 DOI: 10.1371/journal.pone.0231084] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 03/17/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Substance use disorders (SUD) in physicians often remain concealed for a long time. Peer monitoring and open discussions with colleagues are essential for identifying SUD. However, physicians often feel uncomfortable discussing substance use with a colleague. We explored physicians' attitudes and norms about substance use (disorders) and their (intended) approach upon a presumption of substance use in a colleague. MATERIALS AND METHODS An online cross-sectional survey concerning "Addiction in physicians" was administered by the Royal Dutch Medical Association physician panel. Overall, 1685 physicians (47%) responded. Data were analyzed by logistic regression to explore factors associated with taking action upon a substance use presumption. RESULTS Most physicians agreed that SUD can happen to anyone (67%), is not a sign of weakness (78%) and that it is a disease that can be treated (83%). Substance use in a working context was perceived as unacceptable (alcohol at work: 99%, alcohol during a standby duty: 91%, alcohol in the eight hours before work: 77%, and illicit drugs in the eight hours before work: 97%). Almost all respondents (97%) intend to act upon a substance use presumption in a colleague. Of the 29% who ever had this presumption, 65% took actual action. Actual action was associated with male gender and older age (OR = 1.81; 95% CI = 1.20-2.74 and OR = 1.03; 95% CI = 1.01-1.05, respectively). CONCLUSIONS About one-third of physicians reported experience with a presumption of substance use in a colleague. Whilst most physicians intend to take action upon such a presumption, two-thirds actually do act upon a presumption. To bridge this intention-behavior gap continued medical education on signs and symptoms of SUD and instructions on how to enter a supportive dialogue with a colleague about personal issues, may enhance physicians' knowledge, confidence, and ethical responsibility to act upon a presumption of substance use or other concerns in a colleague.
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Affiliation(s)
- Pauline Geuijen
- Department of Psychiatry, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Nijmegen, the Netherlands
- Physician Health Program ABS-doctors, Royal Dutch Medical Association (RDMA), Utrecht, the Netherlands
- * E-mail:
| | - Marlies de Rond
- Physician Health Program ABS-doctors, Royal Dutch Medical Association (RDMA), Utrecht, the Netherlands
| | - Joanneke Kuppens
- Physician Health Program ABS-doctors, Royal Dutch Medical Association (RDMA), Utrecht, the Netherlands
| | - Femke Atsma
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Aart Schene
- Department of Psychiatry, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hein de Haan
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Nijmegen, the Netherlands
- Tactus Addiction Treatment, Deventer, the Netherlands
| | - Cornelis de Jong
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Nijmegen, the Netherlands
- Behavioral Science Institute, Radboud University, Nijmegen, the Netherlands
| | - Arnt Schellekens
- Department of Psychiatry, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Nijmegen, the Netherlands
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Waller A, Turon H, Bryant J, Shepherd J, Hobden B, Sanson-Fisher R. Nurses perspectives on healthcare errors in oncology care: A cross-sectional study. Eur J Oncol Nurs 2020; 45:101741. [PMID: 32163860 DOI: 10.1016/j.ejon.2020.101741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/05/2020] [Accepted: 02/25/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Recognition and responses of the health system to healthcare errors are key areas for improvement in oncology. Despite their role in direct patient care, nurses' perceptions of errors have rarely been explored. The aim of this study was to determine oncology nurses' direct experience of healthcare errors in the previous six months; the circumstances surrounding the error; and ensuing actions by the healthcare system. METHODS Cross-sectional survey of nurses who were members of an oncology nursing society and/or registered or enrolled nurses employed in an oncology setting. Participants indicated whether they had direct experience (i.e. direct involvement or witnessing) of error(s) in the previous six months. Those who experienced an error indicated their perceptions of the: cause; location and phase of care; how the error was identified, who was responsible, level of harm and action(s) taken. RESULTS 67% (n = 65/97) of nurses who completed the survey had direct experience with at least one error in the previous six months. According to these nurses, most occurred during treatment (n = 48, 74%), happened in outpatient clinics (n = 28, 43%) and were related to chemotherapy (n = 15, 23%). Nurses perceived errors were primarily caused by nurses (n = 36, 55%) and doctors (n = 27, 42%); and 54% (n = 35) were deemed 'near-miss'. Nurses perceived errors were recorded (n = 40, 62%), explained to patients (n = 33, 51%) and an apology provided (n = 32, 49%). CONCLUSION Two-thirds of oncology nurses in this study had direct experience with an error in the previous six months. Nurses perceived response to errors as inconsistent with open disclosure standards. Strategies to improve accuracy of measures of error and response of the health system, including adherence to open disclosure processes, are required.
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Affiliation(s)
- Amy Waller
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health, University of Newcastle, Callaghan, Australia; Hunter Medical Research Institute, New Lambton Heights, Australia; Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia.
| | - Heidi Turon
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health, University of Newcastle, Callaghan, Australia; Hunter Medical Research Institute, New Lambton Heights, Australia; Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Jamie Bryant
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health, University of Newcastle, Callaghan, Australia; Hunter Medical Research Institute, New Lambton Heights, Australia; Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Jan Shepherd
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health, University of Newcastle, Callaghan, Australia; Hunter Medical Research Institute, New Lambton Heights, Australia; Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Bree Hobden
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health, University of Newcastle, Callaghan, Australia; Hunter Medical Research Institute, New Lambton Heights, Australia; Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Rob Sanson-Fisher
- Health Behaviour Research Collaborative, School of Medicine and Public Health, Faculty of Health, University of Newcastle, Callaghan, Australia; Hunter Medical Research Institute, New Lambton Heights, Australia; Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia
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Mahdaviazad H, Askarian M, Kardeh B. Medical Error Reporting: Status Quo and Perceived Barriers in an Orthopedic Center in Iran. Int J Prev Med 2020; 11:14. [PMID: 32175054 PMCID: PMC7050265 DOI: 10.4103/ijpvm.ijpvm_235_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 04/30/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Medical error reporting is fundamental for improving patient safety. We surveyed healthcare professionals to evaluate their experience of adverse events witness and reporting, knowledge about adverse events, attitude toward own and colleagues' errors, and perceived barriers in reporting errors. Methods: This cross-sectional study was conducted on healthcare professionals from May to October 2017 at Chamran hospital, which is the largest referral orthopedic center in southern Iran. The self-administered questionnaire comprised 32 items covering five domains: (1) demographic and professional characteristics, (2) medical error witness and reporting, (3) actual and perceived knowledge regarding type of events and the status of completed training courses, (4) attitude toward reporting one's own and colleagues' errors, and (5) perceived barriers in error reporting. Questionnaire validity and reliability was proven in our previous study. Results: From a total of 210 participants, 164 returned completed questionnaires (response rate = 78.1%); 87 (53%) were physicians and 77 (47%) were nurses. Underreporting was common, particularly among physicians. Out of physicians and nurses, 57.1% and 49.4% had poor knowledge, respectively. Participants reported their own or colleagues' errors alike, but physicians tended to only provide verbal warning to their colleagues (36.8%), and nurses stated they would report the colleagues' errors, if it was serious (32.4%). Fear of blame and punishment and fear of legal ramification were the most important perceived barriers. Conclusions: Improvements in current medical error registry system, implementing effective educational courses, and modifying the curricula for students seem to be necessary to resolve the problem of underreporting and poor knowledge level.
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Affiliation(s)
- Hamideh Mahdaviazad
- Department of Family Medicine, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehrdad Askarian
- Department of Community Medicine, Medicinal and Natural Products Chemistry Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Bahareh Kardeh
- Bone and Joint Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Jung JJ, Elfassy J, Jüni P, Grantcharov T. Adverse Events in the Operating Room: Definitions, Prevalence, and Characteristics. A Systematic Review. World J Surg 2019; 43:2379-2392. [PMID: 31197439 DOI: 10.1007/s00268-019-05048-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Adverse events occur commonly in the operating room (OR) and often contribute to morbidity, mortality, and increased healthcare spending. Validated frameworks to measure and report postoperative outcomes have long existed to facilitate exchanges of structured information pertaining to postoperative complication rates in order to improve patient safety. However, systematic evidence regarding measurement and reporting of intraoperative adverse events (iAE) is still lacking. METHODS We searched Ovid Medline, Embase, and Cochrane databases for articles published up to June 2016 that measured and reported iAE. We presented the terms and definitions used to describe iAE. We identified the types of reported iAE and summarized them into discrete categories. We reported frequencies of iAE by detection methods. RESULTS Of the 47 included studies, 30 were cross-sectional, 14 were case-series, and 3 were cohort studies. The studies used 16 different terms and 22 unique definitions to describe 74 types of iAE. Frequencies of iAE appeared to vary depending on the detection methods, with higher numbers reported when direct observation in the OR was used to detect iAE. Twenty studies assessed severity of iAE, which were mostly based on whether they resulted in postoperative outcomes. CONCLUSIONS This study systematically reviewed the current evidence on prevalence and characteristics of iAE that were detected by direct observation, reviews of patient charts, administrative data and incident reports, and surveys and interviews of healthcare providers. Our findings suggest that direct observation method has the most potential to identify and characterize iAE in detail.
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Affiliation(s)
- James J Jung
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, 8th Floor East, Toronto, ON, M5B 1T8, Canada.
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
| | - Jonah Elfassy
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, 8th Floor East, Toronto, ON, M5B 1T8, Canada
| | - Peter Jüni
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Teodor Grantcharov
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, 8th Floor East, Toronto, ON, M5B 1T8, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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Assessment of Patient Safety Culture in Iranian Academic Hospitals: Strengths and Weaknesses. J Patient Saf 2019; 14:213-226. [PMID: 26192488 DOI: 10.1097/pts.0000000000000199] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In the relevant literature, the establishment of a patient safety culture (PSC) is a vital step in providing quality service to patients. The goal of this study was to establish a baseline for PSC in Iranian academic hospitals and to determine its strength and weaknesses. METHODS A survey was distributed in 26 academic hospitals linked to the Iran and Tehran Universities of Medical Sciences, of which 18 participated. The questionnaire, the Hospital Survey on Patient Safety Culture (HSOPSC), was used to collect the data. The questionnaire contained 14 dimensions and 43 items, and the questions were scored using a 5-point Likert scale in which 1 = strongly disagree and 5 = strongly agree.The results were expressed in the percentage of positive responses (%), or the percentage of positive responses (e.g., agree, strongly agree) to positively worded items (e.g., "Hospital units work well together to provide the best care for patients") in relation to the percentage of negative responses (e.g., disagree, strongly disagree) to negatively worded items (e.g., "When an event is reported, it feels like the person is being written up, not the problem"). To score each item, the following formula was applied: % of Positive Responses = [(No. of Agree + No. of Totally Agree) / Total No. of Subjects Responding to the Question)] × 100). For the negatively worded items, the answers were reversed. To score each dimension, a composite mean score of positive responses were estimated. The same methodology was applied to the scoring of the PSC of each hospital. (i.e., the composite mean score of positive responses on 12 dimensions was obtained). Note that the data reported in the tables of this manuscript represent percentages, and for ease of communication, (%) are omitted from the stated tables. In the text, however, we have used percent wherever needed.To categorize the hospitals' safety culture from very weak to very strong, a range of 0.0% to 100% positive responses on the PSC questionnaire was divided by 5 ((100% - 0.0%) / 5 = 20%), and 5 equally spaced intervals were defined (i.e., 0.0%-20.0%, very weak; 21.0%-40.0%, weak; 41.0%-60.0%, intermediate; 61.0%-80.0%, strong; 81.0%-100.0%, very strong).The convenience sampling method was used to select the samples. For the purpose of this research, 35 questionnaires were randomly distributed in each hospital: 15 among nurses and assistant nurses (as the frontline personnel having the most direct contact with patients) and 20 among other clinical and paraclinical personnel as well as other groups (physicians, residents, interns, ward secretaries, laboratory personnel, radiology personnel, and managers). The questionnaires were distributed and collected by the hospitals' head nurses. The data were analyzed using a one-sample and independent t test. RESULTS The mean score of the hospitals on the PSC ranged from 42.74 to 67.22, 12 of 18 hospitals obtained an "intermediate" ranking position, and 6 obtained a "strong" ranking position on the PSC. The overall mean (SD) score for the entire hospital for PSC was 56.74 (18.41). No significant difference was observed between the Iran and Tehran universities of medical sciences hospitals for the PSC. However, significant differences were observable at the dimension and item levels.A hospital's strengths lie in the "organizational learning-continuous improvement," "teamwork within hospital units," and "hospital management support for patient safety" dimensions. Dimensions including "feedback and communication concerning errors," "communication openness," "staffing," and "nonpunitive response to error" were shown to be weak points of all of the hospitals in this study. CONCLUSIONS The PSC of the investigated hospitals is not at an ideal level and is in need of serious improvement, particularly in the dimensions of feedback and communication regarding errors, communication openness, staffing, and nonpunitive response to error. The same conditions hold true for other Iranian hospitals (i.e., the Afshar and Sadoughi hospitals in the city of Yazd, Iran), and American hospitals were used for comparison purposes in this paper.
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Choi EY, Pyo J, Ock M, Lee SI. Nurses' Perceptions Regarding Disclosure of Patient Safety Incidents in Korea: A Qualitative Study. Asian Nurs Res (Korean Soc Nurs Sci) 2019; 13:200-208. [DOI: 10.1016/j.anr.2019.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 05/26/2019] [Accepted: 05/27/2019] [Indexed: 10/26/2022] Open
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Jung JJ, Adams-McGavin RC, Grantcharov TP. Underreporting of Veress Needle Injuries: Comparing Direct Observation and Chart Review Methods. J Surg Res 2018; 236:266-270. [PMID: 30694765 DOI: 10.1016/j.jss.2018.11.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 10/11/2018] [Accepted: 11/20/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Adverse events in surgery occur frequently, increase likelihood of postoperative morbidity, and mostly take place in the operating rooms. Several surgeons have advocated for learning from adverse events and near misses to help improve patient safety. To do so, one must first understand how to accurately identify and report intraoperative events. MATERIALS AND METHODS Consecutive laparoscopic cases performed in a referral center were included in the cohort. Veress needle (VN) injuries were characterized according to a priori established criteria. Two methods were used to identify VN injuries: direct observation and patient chart review. For direct observation, trained surgeon assessors identified the outcomes using a comprehensive data capture platform called the operating room black box. On the other hand, operative reports and patient charts were reviewed by trained assessors to identify reported VN injuries. RESULTS Hundred thirty-one cases were analyzed. There were 12 (9%) VN injuries identified by direct observation compared to 3 (2%) identified in patient chart review method. Injuries to the liver and stomach were identified by both methods, whereas injuries to the omentum were not reported in patient charts even if they required rectification. There were seven VN injuries that required rectification, lasting up to 12% of the operating time. There were 47 (35%) near misses identified through direct observation, whereas none was reported in patient charts. CONCLUSIONS Direct observation enables characterization of VN injury and near misses with far greater detail and accuracy than patient chart review.
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Affiliation(s)
- James J Jung
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Robert Chris Adams-McGavin
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Teodor P Grantcharov
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Danielsson M, Nilsen P, Rutberg H, Carlfjord S. The professional culture among physicians in Sweden: potential implications for patient safety. BMC Health Serv Res 2018; 18:543. [PMID: 29996832 PMCID: PMC6042365 DOI: 10.1186/s12913-018-3328-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 06/26/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Patient safety culture, i.e. a subset of an organization's culture, has become an important focus of patient safety research. An organization's culture consists of many cultures, underscoring the importance of studying subcultures. Professional subcultures in health care are potentially important from a patient safety point of view. Physicians have an important role to play in the effort to improve patient safety. The aim was to explore physicians' shared values and norms of potential relevance for patient safety in Swedish health care. METHODS Data were collected through group and individual interviews with 28 physicians in 16 semi-structured interviews, which were recorded and transcribed verbatim before being analysed with an inductive approach. RESULTS Two overarching themes, "the competent physician" and "the integrated yet independent physician", emerged from the interview data. The former theme consists of the categories Infallible and Responsible, while the latter theme consists of the categories Autonomous and Team player. The two themes and four categories express physicians' values and norms that create expectations for the physicians' behaviours that might have relevance for patient safety. CONCLUSIONS Physicians represent a distinct professional subculture in Swedish health care. Several aspects of physicians' professional culture may have relevance for patient safety. Expectations of being infallible reduce their willingness to talk about errors they make, thus limiting opportunities for learning from errors. The autonomy of physicians is associated with expectations to act independently, and they use their decisional latitude to determine the extent to which they engage in patient safety. The physicians perceived that organizational barriers make it difficult to live up to expectations to assume responsibility for patient safety. Similarly, expectations to be part of multi-professional teams were deemed difficult to fulfil. It is important to recognize the implications of a multi-faceted perspective on the culture of health care organizations, including physicians' professional culture, in efforts to improve patient safety.
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Affiliation(s)
- Marita Danielsson
- Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, SE-581 83 Linköping, Sweden
- Head Office, County Council of Östergötland, SE-581 91 Linköping, Sweden
| | - Per Nilsen
- Department of Medical and Health Sciences, Division of Community Medicine, Linköping University, SE-581 83 Linköping, Sweden
| | - Hans Rutberg
- Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, SE-581 83 Linköping, Sweden
| | - Siw Carlfjord
- Department of Medical and Health Sciences, Division of Community Medicine, Linköping University, SE-581 83 Linköping, Sweden
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Effects of Shame and Guilt on Error Reporting Among Obstetric Clinicians. J Obstet Gynecol Neonatal Nurs 2018; 47:468-478. [PMID: 29678432 DOI: 10.1016/j.jogn.2018.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To understand how the experiences of shame and guilt, coupled with organizational factors, affect error reporting by obstetric clinicians. DESIGN Descriptive cross-sectional. SETTING AND PARTICIPANTS A sample of 84 obstetric clinicians from three maternity units in Washington State. METHODS In this quantitative inquiry, a variant of the Test of Self-Conscious Affect was used to measure proneness to guilt and shame. In addition, we developed questions to assess attitudes regarding concerns about damaging one's reputation if an error was reported and the choice to keep an error to oneself. Both assessments were analyzed separately and then correlated to identify relationships between constructs. Interviews were used to identify organizational factors that affect error reporting. RESULTS As a group, mean scores indicated that obstetric clinicians would not choose to keep errors to themselves. However, bivariate correlations showed that proneness to shame was positively correlated to concerns about one's reputation if an error was reported, and proneness to guilt was negatively correlated with keeping errors to oneself. Interview data analysis showed that Past Experience with Responses to Errors, Management and Leadership Styles, Professional Hierarchy, and Relationships With Colleagues were influential factors in error reporting. CONCLUSION Although obstetric clinicians want to report errors, their decisions to report are influenced by their proneness to guilt and shame and perceptions of the degree to which organizational factors facilitate or create barriers to restore their self-images. Findings underscore the influence of the organizational context on clinicians' decisions to report errors.
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Moffatt-Bruce S, Clark S, DiMaio M, Fann J. Leadership Oversight for Patient Safety Programs: An Essential Element. Ann Thorac Surg 2018; 105:351-356. [DOI: 10.1016/j.athoracsur.2017.11.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/15/2017] [Indexed: 10/18/2022]
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Investigating Physicians' Views on Soft Signals in the Context of Their Peers' Performance. J Healthc Qual 2017; 40:310-317. [PMID: 29189435 DOI: 10.1097/jhq.0000000000000120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Physicians are responsible for delivering high quality of care. In cases of underperformance, hindsight knowledge indicates forewarning being potentially available in terms of concerns, signs, or signals. It is not known how the physicians involved perceive such signals. PURPOSE To openly explore how physicians perceive soft signals and react on them. METHODS In-depth interviews with 12 hospital-based physicians from various specialties and institutions following the interpretative phenomenological analysis approach. RESULTS Physicians perceive soft signals as an observable deviation from a colleague's normal behavior, appearance, or communication. Once observed, they evaluate the signal by reflecting on it personally and/or by consulting others, resulting in either an active (i.e., speaking up) or passive (i.e., avoidance) reaction. Observer sensitivity, closeness to the peer, and cohesion of the physician group influence this observation-evaluation-reaction process. CONCLUSIONS AND IMPLICATIONS Physicians perceive soft signals as indicators of well-being and collegiality, not as concerns about performance or patient safety. They feel it is their responsibility to be sensitive to and deal with expressed signals. Creating a psychological safe culture could foster such an environment. Because a threat to physicians' well-being may indirectly affect their professional performance, soft signals require serious follow-up.
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Bourne RS, Shulman R, Tomlin M, Borthwick M, Berry W, Mills GH. Reliability of clinical impact grading by healthcare professionals of common prescribing error and optimisation cases in critical care patients. Int J Qual Health Care 2017; 29:250-255. [PMID: 28453820 DOI: 10.1093/intqhc/mzx003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 01/12/2017] [Indexed: 11/12/2022] Open
Abstract
Objective To identify between and within profession-rater reliability of clinical impact grading for common critical care prescribing error and optimisation cases. To identify representative clinical impact grades for each individual case. Design Electronic questionnaire. Setting 5 UK NHS Trusts. Participants 30 Critical care healthcare professionals (doctors, pharmacists and nurses). Intervention Participants graded severity of clinical impact (5-point categorical scale) of 50 error and 55 optimisation cases. Main Outcome Measures Case between and within profession-rater reliability and modal clinical impact grading. Methods Between and within profession rater reliability analysis used linear mixed model and intraclass correlation, respectively. Results The majority of error and optimisation cases (both 76%) had a modal clinical severity grade of moderate or higher. Error cases: doctors graded clinical impact significantly lower than pharmacists (-0.25; P < 0.001) and nurses (-0.53; P < 0.001), with nurses significantly higher than pharmacists (0.28; P < 0.001). Optimisation cases: doctors graded clinical impact significantly lower than nurses and pharmacists (-0.39 and -0.5; P < 0.001, respectively). Within profession reliability grading was excellent for pharmacists (0.88 and 0.89; P < 0.001) and doctors (0.79 and 0.83; P < 0.001) but only fair to good for nurses (0.43 and 0.74; P < 0.001), for optimisation and error cases, respectively. Conclusions Representative clinical impact grades for over 100 common prescribing error and optimisation cases are reported for potential clinical practice and research application. The between professional variability highlights the importance of multidisciplinary perspectives in assessment of medication error and optimisation cases in clinical practice and research.
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Affiliation(s)
- Richard S Bourne
- Departments of Pharmacy and Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield S5 7 AU, UK
| | - Rob Shulman
- Pharmacy Department, University College Hospital NHS Foundation Trust, 235 Euston Road, London NW1 2BU, UK
| | - Mark Tomlin
- Departments of Pharmacy and Critical Care, University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Tremona Rd, Southampton SO16 6YD, UK
| | - Mark Borthwick
- Departments of Pharmacy and Critical Care, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK
| | - Will Berry
- Pharmacy Department, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7 EH, UK
| | - Gary H Mills
- Departments of Critical Care and Anaesthesia, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield S5 7 AU, UK
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Williams GD, Muffly MK, Mendoza JM, Wixson N, Leong K, Claure RE. Reporting of Perioperative Adverse Events by Pediatric Anesthesiologists at a Tertiary Children's Hospital: Targeted Interventions to Increase the Rate of Reporting. Anesth Analg 2017; 125:1515-1523. [PMID: 28678071 DOI: 10.1213/ane.0000000000002208] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Incident reporting systems (IRSs) are important patient safety tools for identifying risks and opportunities for improvement. A major IRS limitation is underreporting of incidents. Perioperative anesthesia IRSs have been established at multiple pediatric institutions and a national pediatric anesthesia IRS for perioperative serious adverse events (SAEs) is maintained by Wake Up Safe (WUS), a patient safety organization dedicated to pediatric anesthesia quality improvement. A confidential, electronic, perioperative IRS was instituted at our tertiary children's hospital, which is a WUS member. The primary study aim was to increase the rate of incident reporting by anesthesiologists at our institution through a series of interventions. The secondary aim was to characterize our reporting behavior relative to national practice by referencing SAE data from WUS. METHODS Perioperative adverse events reported over a 71-month period (November 2010 to September 2016) were categorized and the monthly reporting rates determined. Effects of 6 interventions targeted to increase the reporting rate were analyzed using control charts. Intervention 5 involved interviewing pediatric anesthesiologists to ascertain incident reporting barriers and motivators. A key driver diagram was developed and used to guide an improvement initiative. Incidents that fulfilled WUS criteria for SAEs were identified and categorized. SAE reporting rates over a 27-month period for 12 WUS member institutions were determined. RESULTS 2689 perioperative adverse events were noted in 1980 of 72,384 anesthetics. Mean monthly adverse event case rate was 273 (95% confidence interval, 250-297) per 10,000 anesthetics. A subgroup involving 54,469 cases had 529 SAEs in 440 anesthetics; a mean monthly SAE case rate of 80 (95% confidence interval, 69-91) per 10,000 anesthetics. Cardiac, respiratory, and airway events predominated. Relative to WUS peer members, our institution is a high-reporting outlier. The rate of incident reporting per 10,000 anesthetics was sustainably increased from 149 ± 35 to 387 ± 73 (mean ± SD) after implementing mandatory IRS data entry and Intervention 5 quality improvement initiative. Barriers to reporting included concern for punitive repercussions, feelings of incompetence, poor education about what constitutes an event, lack of feedback, and the perception that reporting had no value. These were addressed by IRS education, cultivation of a culture of safety where reporting is encouraged, reporter feedback, and better inclusion of anesthesiologists in patient safety work. CONCLUSIONS Electronic mandatory IRS data entry and an initiative to understand and address reporting barriers and motivators were associated with sustained increases in the adverse event reporting rate. These strategies to minimize underreporting enhance IRS value for learning and may be generalizable.
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Affiliation(s)
- Glyn D Williams
- From the *Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California; and †Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital Stanford, Palo Alto, California
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Hamilton EC, Pham DH, Minzenmayer AN, Austin MT, Lally KP, Tsao K, Kawaguchi AL. Are we missing the near misses in the OR?-underreporting of safety incidents in pediatric surgery. J Surg Res 2017; 221:336-342. [PMID: 29229148 DOI: 10.1016/j.jss.2017.08.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/28/2017] [Accepted: 08/01/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Electronic hospital variance reporting systems used to report near misses and adverse events are plagued by underreporting. The purpose of this study is to prospectively evaluate directly observed variances that occur in our pediatric operating room and to correlate these with the two established variance reporting systems in our hospital. MATERIALS AND METHODS Trained individuals directly observed pediatric perioperative patient care for 6 wk to identify near misses and adverse events. These direct observations were compared to the established handwritten perioperative variance cards and the electronic hospital variance reporting system. All observations were analyzed and categorized into an additional six safety domains and five variance categories. The chi-square test was used, and P-values < 0.05 were considered statistically significant. RESULTS Out of 830 surgical cases, 211 were audited by the safety observers. During this period, 137 (64%) near misses were identified by direct observation, while 57 (7%) handwritten and 8 (1%) electronic variance were reported. Only 1 of 137 observed events was reported in the handwritten variance system. Five directly observed adverse events were not reported in either of the two variance reporting systems. Safety observers were more likely to recognize time-out and equipment variances (P < 0.001). Both variance reporting systems and direct observation identified numerous policy and process issues. CONCLUSIONS Despite multiple reporting systems, near misses and adverse events remain underreported. Identifying near misses may help address system and process issues before an adverse event occurs. Efforts need to be made to lessen barriers to reporting in order to improve patient safety.
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Affiliation(s)
- Emma C Hamilton
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Dean H Pham
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Andrew N Minzenmayer
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Mary T Austin
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas
| | - Akemi L Kawaguchi
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
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Appelbaum NP, Appelbaum EN. Getting real: preparing medical students and physicians for error disclosure. MEDICAL EDUCATION 2017; 51:984-986. [PMID: 28901651 DOI: 10.1111/medu.13391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Pitts SI, Maruthur NM, Luu NP, Curreri K, Grimes R, Nigrin C, Sateia HF, Sawyer MD, Pronovost PJ, Clark JM, Peairs KS. Implementing the Comprehensive Unit-Based Safety Program (CUSP) to Improve Patient Safety in an Academic Primary Care Practice. Jt Comm J Qual Patient Saf 2017; 43:591-597. [PMID: 29056179 DOI: 10.1016/j.jcjq.2017.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 04/24/2017] [Accepted: 06/12/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND While there is growing awareness of the risk of harm in ambulatory health care, most patient safety efforts have focused on the inpatient setting. The Comprehensive Unit-based Safety Program (CUSP) has been an integral part of highly successful safety efforts in inpatient settings. In 2014 CUSP was implemented in an academic primary care practice. METHODS As part of CUSP implementation, staff and clinicians underwent training on the science of safety and completed a two-question safety assessment survey to identify safety concerns in the practice. The concerns identified by team members were used to select two initial safety priorities. The impact of CUSP on safety climate and teamwork was assessed through a pre-post comparison of results on the validated Safety Attitudes Questionnaire. RESULTS Ninety-six percent of staff completed science of safety training as part of CUSP implementation, and 100% of staff completed the two-question safety assessment. The most frequently identified safety concerns were related to medications (n = 11, 28.2), diagnostic testing (n = 9, 25), and communication (n = 5, 14). The CUSP team initially prioritized communication and infection control, which led to standardization of work flows within the practice. Six months following CUSP implementation, large but nonstatistically significant increases were found for the percentage of survey respondents who reported knowledge of the proper channels for questions about patient safety, felt encouraged to report safety concerns, and believed that the work setting made it easy to learn from the errors of others. CONCLUSION CUSP is a promising tool to improve safety climate and to identify and address safety concerns within ambulatory health care.
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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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Ock M, Lee SI. Disclosure of patient safety incidents: implications from ethical and quality of care perspectives. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2017. [DOI: 10.5124/jkma.2017.60.5.417] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Minsu Ock
- Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Sang-Il Lee
- Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul, Korea
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Patient Safety: Disclosure of Medical Errors and Risk Mitigation. Ann Thorac Surg 2016; 102:358-62. [DOI: 10.1016/j.athoracsur.2016.06.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 06/16/2016] [Indexed: 11/18/2022]
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Shu Q, Cai M, Tao HB, Cheng ZH, Chen J, Hu YH, Li G. What Does a Hospital Survey on Patient Safety Reveal About Patient Safety Culture of Surgical Units Compared With That of Other Units? Medicine (Baltimore) 2015; 94:e1074. [PMID: 26166083 PMCID: PMC4504589 DOI: 10.1097/md.0000000000001074] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The objective of this study was to examine the strengths and weaknesses of surgical units as compared with other units, and to provide an opportunity to improve patient safety culture in surgical settings by suggesting targeted actions using Hospital Survey on Patient Safety Culture (HSOPSC) investigation.A Hospital Survey on Patient Safety questionnaire was conducted to physicians and nurses in a tertiary hospital in Shandong China. 12 patient safety culture dimensions and 2 outcome variables were measured.A total of 23.5% of respondents came from surgical units, and 76.5% worked in other units. The "overall perceptions of safety" (48.1% vs 40.4%, P < 0.001) and "frequency of events reported" (63.7% vs 60.7%, P = 0.001) of surgical units were higher than those of other units. However, the communication openness (38.7% vs 42.5%, P < 0.001) of surgical units was lower than in other units. Medical workers in surgical units reported more events than those in other units, and more respondents in the surgical units assess "patient safety grade" to be good/excellent. Three dimensions were considered as strengths, whereas 5 other dimensions were considered to be weaknesses in surgical units. Six dimensions have potential to aid in improving events reporting and patient safety grade. Appropriate working times will also contribute to ensuring patient safety. Medical staff with longer years of experience reported more events.Surgical units outperform the nonsurgical ones in overall perception of safety and the number of events reported but underperform in the openness of communication. Four strategies, namely deepening the understanding about patient safety of supervisors, narrowing the communication gap within and across clinical units, recruiting more workers, and employing the event reporting system and building a nonpunitive culture, are recommended to improve patient safety in surgical units in the context of 1 hospital.
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Affiliation(s)
- Qin Shu
- From the Department of Health Administration (QS, MC, HT, ZC, JC, YH), School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology; and Tongji Hospital (GL), Tongji Medical college, Huazhong University of Science and Technology, Wuhan, Hubei Province, P.R. China
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Stacey S, Coombes I, Wainwright C, Klee B, Miller H, Whitfield K. Characteristics of adverse medication events in a children's hospital. J Paediatr Child Health 2014; 50:966-71. [PMID: 25049060 DOI: 10.1111/jpc.12684] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2014] [Indexed: 11/29/2022]
Abstract
AIM To compare adverse medication events (AMEs) reported in children, via the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) coding with events reported via other data sources. METHOD AME reports were retrieved using codes Y40-Y59 and X40-X44 over 6 months. Patients' charts were manually reviewed to identify events associated with error and/or harm with medicines during a hospital admission. Medication name, group, error, harm and alert documentation were recorded. Clinical incidents and pharmacist interventions were reviewed for the same period. RESULTS Two hundred sixty-three events from January to June 2011 were recorded by ICD-10 coding in 180 patients. After duplicated, missing or unrelated events were excluded and 146 AMEs remained. In the same period, 117 AMEs were reported as incidents and 190 as pharmacist interventions. In total, 276 children with 447 events were reported via all sources. Little duplication between data sources was evident. In total, 158 events involved harm, with 135 of these from ICD-10 coding, 16 from incident reports and 2 pharmacist interventions (including 6 events from multiple sources). Error was involved in 3% of ICD10 reports, 97% of incidents and 100% of interventions. Only 14% of harm-related events from ICD-10 were documented on the medical record clinical alert. Chemotherapy accounted for 31% of harm-related events, antimicrobials 18%, corticosteroids 14% and narcotics 12%. CONCLUSION Of the harm-related events, 85% were documented via ICD-10 coding with few documented in other databases. Review of ICD-10-coded AMEs can provide valuable information to improve patient safety and quality.
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Affiliation(s)
- Sonya Stacey
- Queensland Children's Medical Research Institute, The University of Queensland, Brisbane, Queensland, Australia; School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia; Royal Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
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