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Sells JR, Cole I, Dharmasukrit C, Brown A, Rovinski-Wagner C, Tasseff TL. System planning for modern-day Just Culture to mitigate worker distress and second victim response. BMJ LEADER 2024; 8:149-152. [PMID: 37734904 DOI: 10.1136/leader-2023-000811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/07/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Joanna R Sells
- VA Quality Scholars Program, San Francisco VA Health Care System, San Francisco, California, USA
- Rocky Mountain MIRECC, Aurora, Colorado, USA
| | - Irene Cole
- VA Quality Scholars Program, San Francisco VA Health Care System, San Francisco, California, USA
- School of Nursing, University of California San Francisco, San Francisco, California, USA
| | - Charlie Dharmasukrit
- VA Quality Scholars Program, San Francisco VA Health Care System, San Francisco, California, USA
- Center for Nursing Excellence and Innovation, UCSF Health, San Francisco, California, USA
| | - Amy Brown
- VA Readjustment Counseling Service, District 3, St. Louis, Missouri, USA
- VA Quality Scholars Program, Iowa City VA Medical Center, Iowa City, Iowa, USA
| | - Christine Rovinski-Wagner
- Office of Integrated Veteran Care, VA Health Connect, Veterans Health Administration, Washington, DC, USA
- VA Quality Scholars Program, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Tamara L Tasseff
- VA Quality Scholars Program, Iowa City VA Medical Center, Iowa City, Iowa, USA
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Amberger O, Müller A, Lemke D, Müller H, Schwappach D, Wendt P, Wensing M, Brueckle MS, Müller BS. Patient Safety and the COVID-19 Pandemic in Germany: A Repeated Population-Based Cross-Sectional Survey. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:112. [PMID: 36612434 PMCID: PMC9819909 DOI: 10.3390/ijerph20010112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 12/12/2022] [Accepted: 12/19/2022] [Indexed: 06/17/2023]
Abstract
The coronavirus (COVID-19) has presented Germany with major challenges and has led to concerns about patient safety. We conducted an observational, population-based, nationwide, repeated cross-sectional survey on patient safety in Germany in 2019, 2020, and 2021. Each of the three samples consisted of 1000 randomly recruited adults. Self-reported data via computer-assisted telephone interviews were taken from TK Monitor of Patient Safety. Perceptions, experience, and knowledge relating to patient safety were assessed. The majority of respondents considered medical treatment to involve risks to patient safety. This proportion decreased during the pandemic. The majority also had a high degree of self-efficacy regarding the prevention of medical errors, whereby the percentage that felt well informed with regard to patient safety rose throughout the pandemic. The proportion of persons that suspected they had in the past experienced an error in their treatment remained steady at one third as well as the reported errors. In 2020, 65% of respondents thought health communication with service providers (e.g., extent and comprehensibility of information) remained unchanged during the pandemic, while 35% reported that medical appointments had been cancelled or postponed. This study is the first to assess patient safety from a general population perspective during the coronavirus pandemic in Germany. COVID-19 had a positive impact on perceived patient safety but no impact on suspected and reported errors. Self-efficacy with regard to medical error prevention steadily increased in the general population, and people considered themselves well informed.
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Affiliation(s)
- Olga Amberger
- Institute of General Practice, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany
| | - Angelina Müller
- Institute of General Practice, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany
| | - Dorothea Lemke
- Institute of General Practice, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany
| | - Hardy Müller
- Techniker Krankenkasse, TK, Unternehmenszentrale, 22305 Hamburg, Germany
| | - David Schwappach
- Institute of Social and Preventive Medicine (ISPM), University Bern, 3012 Bern, Switzerland
| | - Peter Wendt
- Techniker Krankenkasse, TK, Unternehmenszentrale, 22305 Hamburg, Germany
| | - Michel Wensing
- Department of General Practice and Health Services Research, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Maria-Sophie Brueckle
- Institute of General Practice, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany
| | - Beate S. Müller
- Institute of General Practice, University of Cologne, 50937 Köln, Germany
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Akinyelure OP, Colvin CL, Sterling MR, Safford MM, Muntner P, Colantonio LD, Kern LM. Frailty, gaps in care coordination, and preventable adverse events. BMC Geriatr 2022; 22:476. [PMID: 35655193 PMCID: PMC9164877 DOI: 10.1186/s12877-022-03164-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 05/16/2022] [Indexed: 11/25/2022] Open
Abstract
Background Older US adults often receive care from multiple ambulatory providers. Seeing multiple providers may be clinically appropriate but creates challenges for communication. Whether frailty is a risk factor for gaps in communication among older adults and subsequent preventable adverse events is unknown. Methods We conducted a cross-sectional analysis of community-dwelling US adults ≥ 65 years of age in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study who attended an in-home study examination in 2013–2016 and completed a survey on experiences with healthcare in 2017–2018 (n = 5,024). Using 5 frailty indicators (low body mass index, exhaustion, slow walk, weakness, and history of falls), we characterized participants into 3 mutually exclusive groups: not frail (0 indicators), intermediate-frail (1–2 indicators), and frail (3–5 indicators). We used survey data on self-reported gaps in care coordination and self-reported adverse events that participants attributed to poor communication among providers (a drug-drug interaction, repeat testing, an emergency department visit, or a hospital admission). Results Overall, 2,398 (47.7%) participants were not frail, 2,436 (48.5%) were intermediate-frail, and 190 (3.8%) were frail. The prevalence of any gap in care coordination was 37.0%, 40.8%, and 51.1% among participants who were not frail, intermediate-frail and frail, respectively. The adjusted prevalence ratio (PR) for any gap in care coordination among intermediate-frail and frail versus not frail participants was 1.09 (95% confidence interval [95%CI] 1.02–1.18) and 1.34 (95%CI 1.15–1.56), respectively. The prevalence of any preventable adverse event was 7.0%, 11.3% and 20.0% among participants who were not frail, intermediate-frail and frail, respectively. The adjusted PR for any preventable adverse event among those who were intermediate-frail and frail versus not frail was 1.47 (95%CI 1.22–1.77) and 2.24 (95%CI 1.60–3.14), respectively. Conclusion Among older adults, frailty is associated with an increased prevalence for self-reported gaps in care coordination and preventable adverse events. Targeted interventions to address patient-reported concerns regarding care coordination among intermediate-frail and frail older adults may be warranted.
Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03164-7.
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Associations between sociodemographic factors, health spending, disease burden, and life expectancy of older adults (70 + years old) in 22 countries in the Western Pacific Region, 1995-2019: estimates from the Global Burden of Disease (GBD) Study 2019. GeroScience 2022; 44:925-951. [PMID: 35000094 PMCID: PMC9135952 DOI: 10.1007/s11357-021-00494-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 11/17/2021] [Indexed: 01/25/2023] Open
Abstract
The needs of the aging populations are putting increasing burden on healthcare particularly in the Western Pacific Region (WPR), which is the home of aging economies such as Hong Kong and Japan alongside rapid increases in older people in low- and middle-income countries (LMICs). However, little is known about the associations between sociodemographic factors, disease burden, and life expectancy in WPR. The current study conducted secondary analysis on the Global Burden of Disease (GBD) estimates of populations aged 70 years and older in WPR countries between 1995 and 2019. Correlation tests, linear mixed regressions and generalized additive mixture models were run to examine the associations of interest. Unsupervised machine learning was conducted to segment the data automatically, at cluster analysis. The sociodemographic development index was found an important factor to the disease burden in terms of Years Lived with Disability (YLD) rate and mortality rate among older adults. YLD rate and mortality rate of non-communicable diseases (NCDs) attributable to different risk groups were significant contributors to higher expectation of Lost Healthy Years (LHE) and shorter life expectancy respectively in the context of rising YLD rate, particularly in LMICs. Three clusters of countries with similar characteristics were identified. NCDs were the most significant contributors to shorter life expectancy within which the time living in poor health did not improve. Better management of NCDs in aging populations should be emphasized in all countries. The country clusters may help in a more regional strategic planning.
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Müller A, Sawicki OA, Müller H, Schwappach D, Wendt P, Ploeger C, Brückle MS, Müller BS. [Patient perspectives on patient safety: Results of a population-based survey in Germany]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2021; 165:13-20. [PMID: 34412979 DOI: 10.1016/j.zefq.2021.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 07/06/2021] [Accepted: 07/09/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The growing number of people with multimorbidity and polypharmacy in Germany has led to increasing complexity in health care and risks to patient safety. A high priority should therefore be placed on identifying and preventing avoidable adverse events. The patient perspective plays an important role in improving patient safety. In this study, we conducted a representative, population-based survey of knowledge, perceptions and experiences of patient safety, especially of subjectively experienced errors in health care. Our aim was, in particular, to assess patient safety from the patients' point of view, and to analyze differences in assessments of risk and preventability between persons that felt well or poorly informed about patient safety topics. METHODS In 2019, computer-assisted telephone interviews were conducted nationwide as part of the "TK-Monitor Patient Safety" project. Recruitment was carried out by using multistage selection and forming a stratified random sample. Adults (18 years and older) with sufficient knowledge of German were included. The survey was conducted using a structured guideline containing 21 questions concerning perceptions and experiences of patient safety, and 12 questions on sociodemographic factors. The results were analyzed both descriptively and using inferential statistical methods. RESULTS Of a total of 1,000 respondents (51% female), approx. half (52%) were gainfully employed, and 57% rated their state of health as "very good" or "good". The patients regarded data protection, medication errors, hospital infections and diagnostic (un)certainty as of major relevance to patient safety. Overall, 55% of the respondents rated their knowledge of patient safety as "very good" or "good". The results showed that subjective knowledge was negatively associated with important outcome parameters such as having experience of medication errors or suspecting errors had been made in a medical examination or treatment. Patients that considered themselves well-informed also reckoned they could contribute towards increasing safety in health care. DISCUSSION The respondents considered diagnostic uncertainty to be one of the greatest risks to their person. This shows that they recognized a need for further information and felt this need was inadequately satisfied in the German research landscape. With regard to the correlation between subjective knowledge and outcome parameters, it is also necessary to analyze whether the respondents' subjective knowledge reflects their actual knowledge, as this would be necessary for preventive measures to be effective. This question will be the subject of further studies. CONCLUSION The patient perspective is an important addition to the study of the safety of medical care in Germany. Factors influencing subjective knowledge should be investigated. Furthermore, regular surveys would be desirable in order to gain greater insight into the topic.
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Affiliation(s)
- Angelina Müller
- Institut für Allgemeinmedizin, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
| | - Olga A Sawicki
- Institut für Allgemeinmedizin, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
| | - Hardy Müller
- Techniker Krankenkasse, TK, Unternehmenszentrale, Hamburg, Deutschland
| | - David Schwappach
- Stiftung für Patientensicherheit, Zürich, Schweiz; Institut für Sozial- und Präventivmedizin (ISPM), Universität Bern, Bern, Schweiz
| | - Peter Wendt
- Techniker Krankenkasse, TK, Unternehmenszentrale, Hamburg, Deutschland
| | - Cornelia Ploeger
- Institut für Allgemeinmedizin, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
| | - Maria-Sophie Brückle
- Institut für Allgemeinmedizin, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland
| | - Beate S Müller
- Institut für Allgemeinmedizin, Goethe-Universität Frankfurt, Frankfurt am Main, Deutschland.
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Giannini O, Rizza N, Pironi M, Parlato S, Waldispühl Suter B, Borella P, Pagnamenta A, Fishman L, Ceschi A. Prevalence, clinical relevance and predictive factors of medication discrepancies revealed by medication reconciliation at hospital admission: prospective study in a Swiss internal medicine ward. BMJ Open 2019; 9:e026259. [PMID: 31133583 PMCID: PMC6538074 DOI: 10.1136/bmjopen-2018-026259] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Medication reconciliation (MedRec) is a relevant safety procedure in medication management at transitions of care. The aim of this study was to evaluate the impact of MedRec, including a best possible medication history (BPMH) compared with a standard medication history in patients admitted to an internal medicine ward. DESIGN Prospective interventional study. Data were analysed using descriptive statistics followed by univariate and multivariate Poisson regression models and a zero-inflated Poisson regression model. SETTING Internal medicine ward in a secondary care hospital in Southern Switzerland. PARTICIPANTS The first 100 consecutive patients admitted in an internal medicine ward. PRIMARY AND SECONDARY OUTCOME MEASURES Medication discrepancies between the medication list obtained by the physician and that obtained by a pharmacist according to a systematic approach (BPMH) were collected, quantified and assessed by an expert panel that assigned a severity score. The same procedure was applied to discrepancies regarding allergies. Predicting factors for medication discrepancies were identified. RESULTS The median of medications per patient was 8 after standard medication history and 11 after BPMH. Total admission discrepancies were 524 (5.24 discrepancies per patient) with at least 1 discrepancy per patient. For 47 patients, at least one discrepancy was classified as clinically relevant. Discrepancies were classified as significant and serious in 19% and 2% of cases, respectively. Furthermore, 67% of the discrepancies were detected during the interview conducted by the pharmacist with the patients and/or their caregivers. The number of drugs used and the autonomous management of home therapy were associated with an increased number of clinically relevant discrepancies in a multivariable Poisson regression model. CONCLUSION Even in an advanced healthcare system, a standardised MedRec process including a BPMH represents an important strategy that may contribute to avoid a notable number of clinically relevant discrepancies and potential adverse drug events.
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Affiliation(s)
- Olivier Giannini
- Department of Internal Medicine, Ospedale Regionale di Mendrisio, Ente Ospedaliero Cantonale, Mendrisio, Ticino, Switzerland
| | - Nicole Rizza
- Hospital Pharmacy Service, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Michela Pironi
- Hospital Pharmacy Service, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Saida Parlato
- Hospital Pharmacy Service, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | | | - Paola Borella
- Department of Internal Medicine, Ospedale Regionale di Mendrisio, Ente Ospedaliero Cantonale, Mendrisio, Ticino, Switzerland
| | - Alberto Pagnamenta
- Unit of Clinical Epidemiology, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Division of Pneumology, University of Geneva, Geneva, Switzerland
| | | | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
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Sahlström M, Partanen P, Turunen H. Patient-reported experiences of patient safety incidents need to be utilized more systematically in promoting safe care. Int J Qual Health Care 2019; 30:778-785. [PMID: 29668942 DOI: 10.1093/intqhc/mzy074] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 04/07/2018] [Indexed: 11/13/2022] Open
Abstract
Objective To analyze patient safety incidents (PSIs) reported by patients and their use in Finnish healthcare organizations. Study Design Cross-sectional study. Setting About 15 Finnish healthcare organizations ranging from specialized hospital care to home care, outpatient and inpatient clinics, and geographically diverse areas of Finland. Participants The study population included all Finnish patients who had voluntarily reported PSI via web-based system in 2009-15. Main Outcome Measure(s) Quantitative analysis of patients' safety reports, inductive content analysis of patients' suggestions to prevent the reoccurrence incidents and how those suggestions were used in healthcare organizations. Results Patients reported 656 PSIs, most of which were classified by the healthcare organizations' analysts as problems associated with information flow (32.6%) and medications (18%). Most of the incidents (65%) did not cause any harm to patients. About 76% of the reports suggested ways to prevent reoccurrence of PSIs, most of which were feasible, system-based amendments of processes for reviewing or administering treatment, anticipating risks or improving diligence in patient care. However, only 6% had led to practical implementation of corrective actions in the healthcare organizations. Conclusions The results indicate that patients report diverse PSIs and suggest practical systems-based solutions to prevent their reoccurrence. However, patients' reports rarely lead to corrective actions documented in the registering system, indicating that there is substantial scope to improve utilization of patients' reports. There is also a need for strong patient safety management, including willingness and commitment of HCPs and leaders to learn from safety incidents.
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Affiliation(s)
- Merja Sahlström
- Department of Nursing Science, University of Eastern Finland, Kuopio Campus, Finland.,Ylä-Savo SOTE Joint Municipal Authority, Finland
| | - Pirjo Partanen
- Department of Nursing Science, University of Eastern Finland, Kuopio Campus, Finland
| | - Hannele Turunen
- Department of Nursing Science, University of Eastern Finland, Kuopio Campus, Finland.,Department of Nursing Science, University of Eastern Finland, Kuopio Campus, Kuopio University Hospital, Kuopio, Finland
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[Medication safety in Switzerland: Where are we today?]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:1152-1158. [PMID: 30043087 DOI: 10.1007/s00103-018-2794-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Empirical research shows that medication safety is an urgent area of concern in the Swiss healthcare system. Adverse drug events and medication errors are common and risks such as polypharmacy are widespread. No comprehensive national strategy explicitly dedicated to medication safety exists in Switzerland. The federalist system of government with relative autonomy of the cantons relating to healthcare laws influences the implementation of national healthcare reforms, also to the disadvantage of medication safety. Direct dispensing of drugs by the prescribing physician is permitted in almost all German-speaking cantons. This special feature of the Swiss system implies specific challenges for medication safety. Nonetheless, there is an increasing number of national activities dealing with various aspects of medication safety, such as the "progress!" programmes within the National Quality Strategy. Within the National Research Programme "Smarter Health Care" (NRP 74) of the Swiss National Science Foundation, several research projects are currently focusing on medication safety. Clinical pharmacy activities in hospitals are relatively widespread. In the primary care sector, pharmaceutical care practice and the corresponding competencies for pharmacists are being further developed. However, a comprehensive strategy, priority-setting and effectiveness studies involving all stakeholders are required in order for the Swiss healthcare system, to meet the challenges facing medication safety in a forward-looking manner.
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Schwendimann R, Blatter C, Dhaini S, Simon M, Ausserhofer D. The occurrence, types, consequences and preventability of in-hospital adverse events - a scoping review. BMC Health Serv Res 2018; 18:521. [PMID: 29973258 PMCID: PMC6032777 DOI: 10.1186/s12913-018-3335-z] [Citation(s) in RCA: 164] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 06/27/2018] [Indexed: 11/19/2022] Open
Abstract
Background Adverse events (AEs) seriously affect patient safety and quality of care, and remain a pressing global issue. This study had three objectives: (1) to describe the proportions of patients affected by in-hospital AEs; (2) to explore the types and consequences of observed AEs; and (3) to estimate the preventability of in-hospital AEs. Methods We applied a scoping review method and concluded a comprehensive literature search in PubMed and CINAHL in May 2017 and in February 2018. Our target was retrospective medical record review studies applying the Harvard method–or similar methods using screening criteria–conducted in acute care hospital settings on adult patients (≥18 years). Results We included a total of 25 studies conducted in 27 countries across six continents. Overall, a median of 10% patients were affected by at least one AE (range: 2.9–21.9%), with a median of 7.3% (range: 0.6–30%) of AEs being fatal. Between 34.3 and 83% of AEs were considered preventable (median: 51.2%). The three most common types of AEs reported in the included studies were operative/surgical related, medication or drug/fluid related, and healthcare-associated infections. Conclusions Evidence regarding the occurrence of AEs confirms earlier estimates that a tenth of inpatient stays include adverse events, half of which are preventable. However, the incidence of in-hospital AEs varied considerably across studies, indicating methodological and contextual variations regarding this type of retrospective chart review across health care systems. For the future, automated methods for identifying AE using electronic health records have the potential to overcome various methodological issues and biases related to retrospective medical record review studies and to provide accurate data on their occurrence.
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Affiliation(s)
- René Schwendimann
- University Hospital Basel, Patient Safety Office, Spitalstr. 22, 4031, Basel, Switzerland. .,Department Public Health Institute of Nursing Science, University of Basel, Basel, Switzerland.
| | - Catherine Blatter
- Department Public Health Institute of Nursing Science, University of Basel, Basel, Switzerland
| | - Suzanne Dhaini
- Department Public Health Institute of Nursing Science, University of Basel, Basel, Switzerland.,American University of Beirut, School of Nursing, Beirut, Lebanon
| | - Michael Simon
- Department Public Health Institute of Nursing Science, University of Basel, Basel, Switzerland.,Inselspital Bern University Hospital, Nursing Research Unit, Bern, Switzerland
| | - Dietmar Ausserhofer
- Department Public Health Institute of Nursing Science, University of Basel, Basel, Switzerland.,College of Health Care-Professions Claudiana, Bozen, Italy
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Walsh JN, Knight M, Lee AJ. Diagnostic Errors: Impact of an Educational Intervention on Pediatric Primary Care. J Pediatr Health Care 2018; 32:53-62. [PMID: 28916249 DOI: 10.1016/j.pedhc.2017.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 07/11/2017] [Accepted: 07/17/2017] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The purpose of our study was to determine the impact of an educational program on a provider's knowledge related to diagnostic errors and diagnostic reasoning strategies. METHODS A quasi-experimental interventional study with a multimedia approach, case study discussion, and trigger-generated medical record review at two time points was conducted. Measurement tools included a test developed by the National Patient Safety Foundation, Reducing Diagnostic Errors: Strategies for Solutions Quiz, additional diagnostic reasoning questions, and a trigger-generated process to analyze medical records. RESULTS Knowledge related to diagnostic errors statistically improved from the pretest to posttest scores with sustained 60-day differences (p < .025). Although there was a decline in the proportion of patients returning with the same chief complaint within 14 days, this was not statistically significant (p < .15). When providers were confronted with an unrecognizable clinical presentation, they reported an increased use of a "diagnostic timeout" (p < .038). DISCUSSION Providers developed an increased awareness of the presence of diagnostic errors in the primary care setting, the contributing risk factors for a diagnostic error, and possible strategies to reduce diagnostic errors. These factors had an unexpected impact on changing the primary care practice model to enhance the continuity of patient care.
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Christiansen AH, Lipczak H, Knudsen JL, Kejs AMT. Risk factors for patient-reported errors during cancer follow-up: Results from a national survey in Denmark. Cancer Epidemiol 2017; 49:38-45. [DOI: 10.1016/j.canep.2017.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 03/31/2017] [Accepted: 05/09/2017] [Indexed: 11/29/2022]
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Restelli V, Taylor A, Cochrane D, Noble MA. Medical laboratory associated errors: the 33-month experience of an on-line volunteer Canadian province wide error reporting system. Diagnosis (Berl) 2017. [DOI: 10.1515/dx-2017-0013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractBackground:This article reports on the findings of 12,278 laboratory related safety events that were reported through the British Columbia Patient Safety & Learning System Incident Reporting System.Methods:The reports were collected from 75 hospital-based laboratories over a 33-month period and represent approximately 4.9% of all incidents reported.Results:Consistent with previous studies 76% of reported incidents occurred during the pre-analytic phase of the laboratory cycle, with twice as many associated with collection problems as with clerical problems. Eighteen percent of incidents occurred during the post-analytic reporting phase. The remaining 6% of reported incidents occurred during the actual analytic phase. Examination of the results suggests substantial under-reporting in both the post-analytic and analytic phases. Of the reported events, 95.9% were reported as being associated with little or no harm, but 0.44% (55 events) were reported as having severe consequences.Conclusions:It is concluded that jurisdictional reporting systems can provide valuable information, but more work needs to be done to encourage more complete reporting of events.
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Hincapie AL, Slack M, Malone DC, MacKinnon NJ, Warholak TL. Relationship Between Patients' Perceptions of Care Quality and Health Care Errors in 11 Countries: A Secondary Data Analysis. Qual Manag Health Care 2016; 25:13-21. [PMID: 26783863 PMCID: PMC4721215 DOI: 10.1097/qmh.0000000000000079] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients may be the most reliable reporters of some aspects of the health care process; their perspectives should be considered when pursuing changes to improve patient safety. The authors evaluated the association between patients' perceived health care quality and self-reported medical, medication, and laboratory errors in a multinational sample. The analysis was conducted using the 2010 Commonwealth Fund International Health Policy Survey, a multinational consumer survey conducted in 11 countries. Quality of care was measured by a multifaceted construct developed using Rasch techniques. After adjusting for potentially important confounding variables, an increase in respondents' perceptions of care coordination decreased the odds of self-reporting medical errors, medication errors, and laboratory errors (P < .001). As health care stakeholders continue to search for initiatives that improve care experiences and outcomes, this study's results emphasize the importance of guaranteeing integrated care.
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Affiliation(s)
- Ana L. Hincapie
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio (Drs Hincapie and MacKinnon); and College of Pharmacy, University of Arizona, Tucson (Drs Slack, Malone, and Warholak)
| | - Marion Slack
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio (Drs Hincapie and MacKinnon); and College of Pharmacy, University of Arizona, Tucson (Drs Slack, Malone, and Warholak)
| | - Daniel C. Malone
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio (Drs Hincapie and MacKinnon); and College of Pharmacy, University of Arizona, Tucson (Drs Slack, Malone, and Warholak)
| | - Neil J. MacKinnon
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio (Drs Hincapie and MacKinnon); and College of Pharmacy, University of Arizona, Tucson (Drs Slack, Malone, and Warholak)
| | - Terri L. Warholak
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio (Drs Hincapie and MacKinnon); and College of Pharmacy, University of Arizona, Tucson (Drs Slack, Malone, and Warholak)
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Schwappach DLB. Nach dem Behandlungsfehler. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2014; 58:80-6. [DOI: 10.1007/s00103-014-2083-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Letarte N, Gabay MP, Bressler LR, Long KE, Stachnik JM, Villano JL. Analyzing temozolomide medication errors: potentially fatal. J Neurooncol 2014; 120:111-5. [PMID: 25026995 DOI: 10.1007/s11060-014-1523-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 06/28/2014] [Indexed: 11/27/2022]
Abstract
The EORTC-NCIC regimen for glioblastoma requires different dosing of temozolomide (TMZ) during radiation and maintenance therapy. This complexity is exacerbated by the availability of multiple TMZ capsule strengths. TMZ is an alkylating agent and the major toxicity of this class is dose-related myelosuppression. Inadvertent overdose can be fatal. The websites of the Institute for Safe Medication Practices (ISMP), and the Food and Drug Administration (FDA) MedWatch database were reviewed. We searched the MedWatch database for adverse events associated with TMZ and obtained all reports including hematologic toxicity submitted from 1st November 1997 to 30th May 2012. The ISMP describes errors with TMZ resulting from the positioning of information on the label of the commercial product. The strength and quantity of capsules on the label were in close proximity to each other, and this has been changed by the manufacturer. MedWatch identified 45 medication errors. Patient errors were the most common, accounting for 21 or 47% of errors, followed by dispensing errors, which accounted for 13 or 29%. Seven reports or 16% were errors in the prescribing of TMZ. Reported outcomes ranged from reversible hematological adverse events (13%), to hospitalization for other adverse events (13%) or death (18%). Four error reports lacked detail and could not be categorized. Although the FDA issued a warning in 2003 regarding fatal medication errors and the product label warns of overdosing, errors in TMZ dosing occur for various reasons and involve both healthcare professionals and patients. Overdosing errors can be fatal.
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Affiliation(s)
- Nathalie Letarte
- Faculte de pharmacie, Université de Montreal, Montreal, QC, Canada
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Wu AW, Boyle DJ, Wallace G, Mazor KM. Disclosure of adverse events in the United States and Canada: an update, and a proposed framework for improvement. J Public Health Res 2013; 2:e32. [PMID: 25170503 PMCID: PMC4147741 DOI: 10.4081/jphr.2013.e32] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 11/01/2013] [Indexed: 11/24/2022] Open
Abstract
There is consensus that physicians, health professionals and health care organizations should discuss harm that results from health care delivery (adverse events), including the reasons for harm, with patients and their families. Thought leaders and policy makers in the USA and Canada support this goal. However, there are gaps in both countries between patients and physicians in their attitudes about how errors should be handled, and between disclosure policies and their implementation in practice. This paper reviews the state of disclosure policy and practice in the two countries, and the barriers to full disclosure. Important barriers include fear of consequences, attitudes about disclosure, lack of skill and role models, and lack of peer and institutional support. The paper also describes the problem of the second victim, a corollary of disclosure whereby health care workers are also traumatized by the same events that harm patients. The presence of multiple practical and personal barriers to disclosure suggests the need for a comprehensive solution directed at multiple levels of the health care system, including health departments, institutions, local managers, professional staff, patients and families, and including legal, health system and local institutional support. At the local level, implementation could be based on a translating-evidence-into-practice framework. Applying this framework would involve the formation of teams, training, measurement and identification of local barriers to achieving universal disclosure of adverse events. Significance for public health It is inevitable that some patients will be harmed rather than helped by health care. There is consensus that patients and their families must be told about these harmful events. However, there are gaps between patient and physician attitudes about how errors should be handled, and between disclosure policies and their implementation. There are important barriers that impede disclosure, including fear of consequences, attitudes about disclosure, lack of skill, and lack of institutional support. A related problem is that of the second victim, whereby health care workers are traumatized by the same harmful events. This can impair their performance and further compromise safety. The problem is unlikely to be solved by focusing solely on increasing disclosure. A comprehensive solution is needed, directed at multiple levels of the health care system, including health departments, institutions, local managers, professional staff, patients and families, and including legal, health system and local institutional support.
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Affiliation(s)
- Albert W Wu
- Johns Hopkins University, Bloomberg School of Public Health , Baltimore, MD, USA
| | - Dennis J Boyle
- University of Colorado School of Medicine, Denver Health Medical Center Denver , CO, USA
| | - Gordon Wallace
- Canadian Medical Protective Association , Ottawa, Canada
| | - Kathleen M Mazor
- Meyers Primary Care Institute and the University of Massachusetts Medical School , Worcester, MA, USA
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Frequency of patient-reported infections among sicker adults in high-income countries: an international perspective. Am J Infect Control 2013; 41:174-6. [PMID: 22750038 DOI: 10.1016/j.ajic.2012.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 02/06/2012] [Accepted: 02/06/2012] [Indexed: 11/23/2022]
Abstract
The frequency of patient-reported health care-associated infections across several high-income countries was analyzed in representative population samples based on data from "The Commonwealth Fund's 2011 International Survey of Sicker Adults in Eleven countries." Across countries, 8.9% of patients who were hospitalized and/or had surgery reported an infection, but this rate varied considerably from 5.3% in the United States to 11.9% in New Zealand. Patients who reported infection were more likely to rate the quality of medical care received as fair or poor (odds ratio [OR], 2.4; 95% confidence interval [CI]: 1.9-3.1, P < .001). Female sex (OR, 1.2; 95% CI: 1.0-1.5, P = .027), reporting 2 or more chronic conditions (OR, 1.5; 95% CI: 1.1-2.0, P = .004), poor health (OR, 1.6; 95% CI: 1.2-2.1, P < .001), and surgery (OR, 1.8; 95% CI: 1.4-2.3, P < .001) were significant predictors for health care-associated infection across countries. Being above 64 years of age (OR, 0.78; 95% CI: 0.64-0.95, P = .013) and day-surgery (OR, 0.62; 95% CI: 0.48-0.79, P < .001) decreased the likelihood for reporting infection.
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