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Hellinger A, Hörscher D, Biber FC, Haasenritter J, Jost K, Kreuzer T, Müller HH, Wächtershäuser EM, Weber J, Weise C, Opitz E. [Safety of patient care on an interprofessional training ward in visceral surgery]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:299-306. [PMID: 38319344 DOI: 10.1007/s00104-024-02034-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Interprofessional training wards (ITW) are increasingly being integrated into teaching and training concepts in visceral surgery clinics. OBJECTIVE How safe is patient care on an ITW in visceral surgery? MATERIAL AND METHODS Data collection took place from November 2021 to December 2022. In this nonrandomized prospective evaluation study the frequency and severity of adverse events (AE) in 3 groups of 100 patients each in a tertiary referral center hospital for visceral surgery were investigated. The groups consisted of patients on the ITW and on the conventional ward before and after implementation of the ITW. The Global Trigger Tool (GTT) was used to search for AE. Simultaneously, a survey of the treatment was conducted according to the Picker method to measure patient reported outcome. RESULTS Baseline characteristics and clinical outcome parameters of the patients in the three groups were comparable. The GTT analysis found 74 nonpreventable and 5 preventable AE in 63 (21%) of the patients and 12 AE occurred before the hospital stay. During the hospital stay 50 AE occurred in the operating theater and 17 on the conventional ward. None of the five preventable AE (in 1.7% of the patients) was caused by the treatment on the ITW. Patients rated the safety on the ITW better than in 90% of the hospitals included in the Picker benchmark cohort and as good as on the normal ward. CONCLUSION The GTT-based data as well as from the patients' point of view show that patient care on a carefully implemented ITW in visceral surgery is safe.
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Affiliation(s)
- A Hellinger
- Klinik für Allgemein‑, Viszeral‑, Endokrine und Onkologische Chirurgie, Klinikum Fulda gAG, Campus Fulda der Universitätsmedizin Marburg, Pacelliallee 4, 36043, Fulda, Deutschland.
| | - D Hörscher
- Klinik für Allgemein‑, Viszeral‑, Endokrine und Onkologische Chirurgie, Klinikum Fulda gAG, Campus Fulda der Universitätsmedizin Marburg, Pacelliallee 4, 36043, Fulda, Deutschland
| | - F C Biber
- Klinik für Allgemein‑, Viszeral‑, Endokrine und Onkologische Chirurgie, Klinikum Fulda gAG, Campus Fulda der Universitätsmedizin Marburg, Pacelliallee 4, 36043, Fulda, Deutschland
| | - J Haasenritter
- Institut für Allgemeinmedizin, Philipps-Universität Marburg, Marburg, Deutschland
| | - K Jost
- Klinik für Allgemein‑, Viszeral‑, Endokrine und Onkologische Chirurgie, Klinikum Fulda gAG, Campus Fulda der Universitätsmedizin Marburg, Pacelliallee 4, 36043, Fulda, Deutschland
| | - T Kreuzer
- Studiendekanat des Fachbereichs Medizin, Philipps-Universität Marburg, Marburg, Deutschland
| | - H-H Müller
- Institut für Medizinische Bioinformatik und Biostatistik, Philipps-Universität Marburg, Marburg, Deutschland
| | - E M Wächtershäuser
- Klinik für Allgemein‑, Viszeral‑, Endokrine und Onkologische Chirurgie, Klinikum Fulda gAG, Campus Fulda der Universitätsmedizin Marburg, Pacelliallee 4, 36043, Fulda, Deutschland
| | - J Weber
- Apotheke, Klinikum Fulda gAG, Campus Fulda der Universitätsmedizin Marburg, Fulda, Deutschland
| | - C Weise
- Medizinische Klinik III - Nephrologie, Klinikum Fulda gAG, Campus Fulda der Universitätsmedizin Marburg, Fulda, Deutschland
| | - E Opitz
- Studiendekanat des Fachbereichs Medizin, Philipps-Universität Marburg, Marburg, Deutschland
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Munkhtogoo D, Liu YP, Hung SH, Chan PT, Ku CH, Shih CL, Wang PC. Trend Analysis of Inpatient Medical Adverse Events in Taiwan (2014-2020): Findings From Taiwan Patient Safety Reporting System. J Patient Saf 2024; 20:171-176. [PMID: 38197910 DOI: 10.1097/pts.0000000000001196] [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: 01/11/2024]
Abstract
OBJECTIVES Medical adverse event (MAE) reporting and management are essential for patient safety campaigns. An epidemiological assessment of MAE trends is crucial for understanding the effectiveness of patient safety improvement efforts. This study analyzed the trends of inpatient MAEs, focusing on MAE incidence and harm severity. METHODS Longitudinal secondary data (over 2014-2020) on MAEs reported by 18 hospitals were retrieved from the Taiwan Patient-safety Reporting system. The numbers and incidence rates (per 1000 inpatient days) of reported MAEs were calculated. The harm severity levels of six major MAE categories were analyzed. Trend and generalized estimating equation analyses were conducted to investigate changes in MAE patterns. RESULTS Trend analyses revealed significant decreasing trends in the number (4763-3107 per year; Jonckheere-Terpstra test = -1.952, P = 0.05) and incidence rates (0.92-0.62 per 1000 inpatient days; β = -0.5017, P = 0.00) of harmful MAEs over 7-year study period. Among the most frequently reported MAEs, tube-related events exhibited the most significant decreasing trend (28%-23.8%; Jonckheere-Terpstra test = -2.854, P = 0.00). The reported numbers, incidence rates, and severity of falls and tube-related events dropped significantly. CONCLUSIONS By analyzing representative longitudinal MAE data, this study demonstrated the effectiveness of nationwide patient safety improvement campaigns in Taiwan. Our data reveal significant reductions in the reported numbers, incidence rates, and severity of several major MAEs. Specifically, our data indicate significant reductions in the incidence and severity of tube-related events, which can be beneficial for patient safety improvement efforts.
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Affiliation(s)
- Dulmaa Munkhtogoo
- From the Division of Quality Improvement, Joint Commission of Taiwan, New Taipei City, Taiwan, Republic of China
| | - Yueh-Ping Liu
- Department of Medical Affairs, Ministry of Health and Welfare, Taipei, Taiwan, Republic of China
| | - Sheng-Hui Hung
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan, Republic of China
| | - Pi-Tuan Chan
- From the Division of Quality Improvement, Joint Commission of Taiwan, New Taipei City, Taiwan, Republic of China
| | | | - Chung-Liang Shih
- National Health Insurance Administration, Ministry of Health and Welfare, Taipei, Taiwan, Republic of China
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Barbosa IDS, Jaques AE, Radovanovic CAT, Andrade LD, Dermatte LPG, Souza CMD, Tonon MM. Development of a mobile application for emergency shift handovers using the National Early Warning Score. Rev Gaucha Enferm 2023; 44:e20220130. [PMID: 37729267 DOI: 10.1590/1983-1447.2023.20220130.en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 03/08/2023] [Indexed: 09/22/2023] Open
Abstract
OBJECTIVE To develop and validate a prototype of a mobile application shift handover between nurses in the emergency room using a severity scale. METHOD This is a technological tool carried out at the Universidade Estadual de Maringá using design thinking, divided into four phases: discovering, defining, developing, and delivering. To structure the information, a checklist was used based on the Situation Background Assessment Recommendation, and to categorize patients in terms of severity, the National Early Warning Score was used. The validation of the sample was carried out by 10 nurses, specialized in the field of urgency and emergency, using the System Usability Scale questionnaire to assess usability. The content validity coefficient was used for analysis. RESULTS The application scored 75.75 in usability and had a content validity coefficient of 0.8. CONCLUSION The prototype obtained an excellent evaluation of usability and agreement between evaluators. Future studies are needed for implementation in practice, evaluating the practicality, applicability, efficiency and time savings in shift information transfer.
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Affiliation(s)
- Iran Dos Santos Barbosa
- Universidade Estadual de Maringá (UEM), Programa de Mestrado Profissional em Gestão, Tecnologia e Inovação em Urgência e Emergência. Maringá, Paraná, Brasil
| | - André Estevam Jaques
- Universidade Estadual de Maringá (UEM), Programa de Pós-Graduação em Enfermagem. Maringá, Paraná, Brasil
| | | | - Luciano de Andrade
- Universidade Estadual de Maringá (UEM), Programa de Pós-Graduação em Ciências da Saúde. Maringá, Paraná, Brasil
| | | | - Carla Moretti de Souza
- Universidade Estadual de Maringá (UEM), Programa de Pós-Graduação em Enfermagem. Maringá, Paraná, Brasil
| | - Martina Mesquita Tonon
- Universidade Estadual de Maringá (UEM), Programa de Pós-Graduação em Enfermagem. Maringá, Paraná, Brasil
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Kannukene A, Orrego C, Lember M, Uusküla A, Põlluste K. Estonian adverse events study for multimorbid patients using Estonian Trigger Tool (MUPETT-MUltimorbid Patients-Estonian Trigger Tool). Development of Estonian trigger tool for multimorbid patients. A study protocol for mixed-methods study. PLoS One 2023; 18:e0280200. [PMID: 36928658 PMCID: PMC10019657 DOI: 10.1371/journal.pone.0280200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/21/2022] [Indexed: 03/18/2023] Open
Abstract
INTRODUCTION It is widely recognized that providing healthcare may produce harm to the patient. Different approaches have been developed to measure the burden of adverse events (AEs) to plan and measure the effects of interventions. One of the most widely used instruments is the Trigger Tool, which has previously been modified to be used on various settings and translated into many languages. Multimorbidity complicates care and may increase the number of AEs patients experience. Currently there is no instrument designed to measure AEs in multimorbid patients. In Estonia, there is currently no validated instrument to measure the burden of AEs. AIMS The aim of this study will be evaluating the characteristics and ocurrence of AEs in multimorbid patients in hospitalised internal medicine patients of Estonia, and describes the development of a trigger tool for this purpose. METHODS AND ANALYSIS We will search for the evidence on measuring AEs in the population of multimorbid patients focusing on trigger tools, and synthesize the data. Data collection of the triggers from the literature will be followed by translating triggers from English to Estonian. An expert multidisciplinary panel will select the suitable triggers for this population. Trigger tool will be pre-tested to assess agreement among professionals and usability of the tool. Validation will be done using 90 medical records. A cross-sectional study in internal medicine departments of two Estonian tertiary care hospitals will be performed to identify the frequency and characteristics of AEs in 960 medical records. We will also provide preventability potential and influencing factors. DISSEMINATION Results will be disseminated to healthcare providers and stakeholders at national and international conferences, and as a doctoral medical thesis.
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Affiliation(s)
- Angela Kannukene
- Department of Medicine, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- * E-mail:
| | - Carola Orrego
- Avedis Donabedian Research Institute (FAD), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Margus Lember
- Department of Medicine, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Clinic of Internal Medicine, Tartu University Hospital, Tartu, Estonia
| | - Anneli Uusküla
- Department of Medicine, Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
- Clinic of Dermatology, Tartu Univeristy Hospital, Tartu, Estonia
| | - Kaja Põlluste
- Department of Medicine, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
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Eggenschwiler LC, Rutjes AWS, Musy SN, Ausserhofer D, Nielen NM, Schwendimann R, Unbeck M, Simon M. Variation in detected adverse events using trigger tools: A systematic review and meta-analysis. PLoS One 2022; 17:e0273800. [PMID: 36048863 PMCID: PMC9436152 DOI: 10.1371/journal.pone.0273800] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 08/15/2022] [Indexed: 11/19/2022] Open
Abstract
Background Adverse event (AE) detection is a major patient safety priority. However, despite extensive research on AEs, reported incidence rates vary widely. Objective This study aimed: (1) to synthesize available evidence on AE incidence in acute care inpatient settings using Trigger Tool methodology; and (2) to explore whether study characteristics and study quality explain variations in reported AE incidence. Design Systematic review and meta-analysis. Methods To identify relevant studies, we queried PubMed, EMBASE, CINAHL, Cochrane Library and three journals in the patient safety field (last update search 25.05.2022). Eligible publications fulfilled the following criteria: adult inpatient samples; acute care hospital settings; Trigger Tool methodology; focus on specialty of internal medicine, surgery or oncology; published in English, French, German, Italian or Spanish. Systematic reviews and studies addressing adverse drug events or exclusively deceased patients were excluded. Risk of bias was assessed using an adapted version of the Quality Assessment Tool for Diagnostic Accuracy Studies 2. Our main outcome of interest was AEs per 100 admissions. We assessed nine study characteristics plus study quality as potential sources of variation using random regression models. We received no funding and did not register this review. Results Screening 6,685 publications yielded 54 eligible studies covering 194,470 admissions. The cumulative AE incidence was 30.0 per 100 admissions (95% CI 23.9–37.5; I2 = 99.7%) and between study heterogeneity was high with a prediction interval of 5.4–164.7. Overall studies’ risk of bias and applicability-related concerns were rated as low. Eight out of nine methodological study characteristics did explain some variation of reported AE rates, such as patient age and type of hospital. Also, study quality did explain variation. Conclusion Estimates of AE studies using trigger tool methodology vary while explaining variation is seriously hampered by the low standards of reporting such as the timeframe of AE detection. Specific reporting guidelines for studies using retrospective medical record review methodology are necessary to strengthen the current evidence base and to help explain between study variation.
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Affiliation(s)
- Luisa C. Eggenschwiler
- Institute of Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Anne W. S. Rutjes
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Sarah N. Musy
- Institute of Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Dietmar Ausserhofer
- Institute of Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Basel, Switzerland
- College of Health Care-Professions Claudiana, Bozen-Bolzano, Italy
| | - Natascha M. Nielen
- Institute of Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Basel, Switzerland
| | - René Schwendimann
- Institute of Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Basel, Switzerland
- Patient Safety Office, University Hospital Basel, Basel, Switzerland
| | - Maria Unbeck
- School of Health and Welfare, Dalarna University, Falun, Sweden
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Michael Simon
- Institute of Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Basel, Switzerland
- * E-mail:
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Brösterhaus M, Hammer A, Gruber R, Kalina S, Grau S, Roeth AA, Ashmawy H, Groß T, Binnebösel M, Knoefel WT, Manser T. Using the Global Trigger Tool in surgical and neurosurgical patients: A feasibility study. PLoS One 2022; 17:e0272853. [PMID: 35972977 PMCID: PMC9380916 DOI: 10.1371/journal.pone.0272853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/28/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The Global Trigger Tool (GTT) has become a worldwide used method for estimating adverse events through a retrospective patient record review. However, little is known about the facilitators and the challenges in the GTT-implementation process. Thus, this study followed two aims: First, to apply a comprehensive set of feasibility criteria to qualitatively and systematically assess the GTT-implementation process in three departments of German university hospitals. Second, to identify the facilitators and the obstacles met in the GTT-implementation process and to derive recommendations for supporting other hospitals in implementing the GTT in clinical practice. METHODS The study used a qualitative documentary method based on process documentation, with written and verbal feedback from the reviewer, as well as evaluating the study sites during the implementation process. The study was conducted in three departments, each in a different German university hospital. The authors applied a comprehensive set of 22 feasibility criteria assessing the level of challenge in GTT implementation. The results were synthesized and they focused on the facilitators and the challenges. RESULTS Of these 22 feasibility criteria, nine were assessed as a low-level challenge, eleven regarded as a moderate-level challenge, and two with a problematic level of challenge. In particular, the lack of time and staff resources, the quality of the information in the patient records, organizational procedures, and local issues, posed major challenges in the implementation process. By contrast, the use of local coordinators and an external expert made important contributions to the GTT implementation. CONCLUSIONS Considering the facilitators and the obstacles beforehand may help with the implementation of the GTT in routine practice. In particular, early and effective planning can reduce or prevent critical challenges in terms of time, staff resources, and organizational aspects.
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Affiliation(s)
| | - Antje Hammer
- Institute for Patient Safety, University Hospital Bonn, Bonn, Germany
| | - Rosalie Gruber
- Institute for Patient Safety, University Hospital Bonn, Bonn, Germany
| | - Steffen Kalina
- Central Division Medical Synergies, University Hospital of Cologne, Cologne, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Stefan Grau
- Center of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Anjali A. Roeth
- Department of General, Visceral, and Transplantation Surgery, University Hospital Aachen, Aachen, Germany
| | - Hany Ashmawy
- Heinrich-Heine-Universität und Universitätsklinikum Düsseldorf, Duesseldorf, Germany
| | - Thomas Groß
- Central Division Medical Synergies, University Hospital of Cologne, Cologne, Germany
| | - Marcel Binnebösel
- Department of General, Visceral, and Transplantation Surgery, University Hospital Aachen, Aachen, Germany
| | - Wolfram Trudo Knoefel
- Heinrich-Heine-Universität und Universitätsklinikum Düsseldorf, Duesseldorf, Germany
| | - Tanja Manser
- FHNW School of Applied Psychology, University of Applied Sciences and Arts, Northwestern Switzerland, Olten, Switzerland
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Kim MJ, Seo HJ, Koo HM, Ock M, Hwang JI, Lee SI. The Korea National Patient Safety Incidents Inquiry Survey: Feasibility of Medical Record Review for Detecting Adverse Events in Regional Public Hospitals. J Patient Saf 2022; 18:389-395. [PMID: 35067623 PMCID: PMC9329038 DOI: 10.1097/pts.0000000000000964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We aimed to examine the Korea National Patient Safety Incidents Inquiry conducted in the Republic of Korea; specifically, we assessed the validity of screening criteria, interreviewer reliability, quality of medical records, and the time required for reviewing medical records. METHODS A 3-stage retrospective medical record review was performed. The sensitivity and positive predictive value of the screening criteria for the adverse events were calculated, and interreviewer reliability was verified using the overall agreement rate and κ value. In addition, the results of medical record quality assessment and time required for review were analyzed. RESULTS There were a total of 4159 patients (55.5%) with at least 1 of the 41 screening criteria. In stage 1, the overall percent of agreement was 81.9% when all negatives from the 2 reviewers were included, and the κ value was 0.64 (95% confidence interval [CI], 0.61-0.66). In stage 2, 84.6% of cases were a perfect match, and 87.4% were a partial match. The κ values were 0.159 (95% CI, 0.12-0.20) and 0.389 (95% CI, 0.35-0.43), respectively. The mean quality assessment scores were 3.18 of 4 points in stage 1 and 3.05 of 4 points in stage 2. In stage 1, it took an average of 13.02 minutes to asses each patient file; in stage 2, it took an average of 5.06 minutes. CONCLUSIONS To increase the feasibility of medical record review for detecting adverse events, it is important not only to improve the reliability between reviewers but also to monitor the quality of medical records and the time required for review.
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Affiliation(s)
- Min Ji Kim
- From the Korea Institute for Healthcare Accreditation, Seoul
| | - Hee Jung Seo
- From the Korea Institute for Healthcare Accreditation, Seoul
| | - Hong Mo Koo
- From the Korea Institute for Healthcare Accreditation, Seoul
| | - Minsu Ock
- Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan
- Department of Preventive Medicine, University of Ulsan College of Medicine
| | - Jee-In Hwang
- Department of Nursing Management, College of Nursing Science, Kyung Hee University, Seoul, Republic of Korea
| | - Sang-Il Lee
- Department of Preventive Medicine, University of Ulsan College of Medicine
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Zhang P, Liao X, Luo J. Effect of Patient Safety Training Program of Nurses in Operating Room. J Korean Acad Nurs 2022; 52:378-390. [PMID: 36117300 DOI: 10.4040/jkan.22017] [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: 02/14/2022] [Revised: 07/11/2022] [Accepted: 08/11/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE This study developed an in-service training program for patient safety and aimed to evaluate the impact of the program on nurses in the operating room (OR). METHODS A pretest-posttest self-controlled survey was conducted on OR nurses from May 6 to June 14, 2020. An in-service training program for patient safety was developed on the basis of the knowledge-attitude-practice (KAP) theory through various teaching methods. The levels of safety attitude, cognition, and attitudes toward the adverse event reporting of nurses were compared to evaluate the effect of the program. Nurses who attended the training were surveyed one week before the training (pretest) and two weeks after the training (posttest). RESULTS A total of 84 nurses participated in the study. After the training, the scores of safety attitude, cognition, and attitudes toward adverse event reporting of nurses showed a significant increase relative to the scores before the training (p < .001). The effects of safety training on the total score and the dimensions of safety attitude, cognition, and attitudes toward nurses' adverse event reporting were above the moderate level. CONCLUSION The proposed patient safety training program based on KAP theory improves the safety attitude of OR nurses. Further studies are required to develop an interprofessional patient safety training program. In addition to strength training, hospital managers need to focus on the aspects of workflow, management system, department culture, and other means to promote safety culture.
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Affiliation(s)
- Peijia Zhang
- Department of Operating Room Nursing, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Xin Liao
- Department of Operating Room Nursing, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China.
| | - Jie Luo
- Department of Operating Room Nursing, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
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Kim MJ, Seo HJ, Koo HM, Ock M, Hwang JI, Lee SI. The Korea National Patient Safety Incidents Inquiry Survey: Characteristics of Adverse Events Identified Through Medical Records Review in Regional Public Hospitals. J Patient Saf 2022; 18:382-388. [PMID: 35948288 PMCID: PMC9329043 DOI: 10.1097/pts.0000000000000944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In 2019, the Korean National Patient Safety Incidents Inquiry was conducted in the Republic of Korea to identify the national-level incidence of adverse events. This study determined the incidence and detailed the characteristics of adverse events at 15 regional public hospitals in the Republic of Korea. METHODS Medical records data of 500 randomly selected patients (discharged in 2016) were extracted from each of the 15 studied hospitals and reviewed in 3 stages. First, for each hospital, 2 nurses independently reviewed the medical records, using 41 screening criteria. Second, 2 physicians independently reviewed the records of those patients with at least 1 screening criterion from the first stage for adverse events occurrence and their characteristics. Third, a 9-member committee conducted a final review and compiled the final adverse event report. RESULTS Among 7500 patients, 4159 (55.5%) had at least 1 screening criterion; 745 (9.9%) experienced 901 adverse events (incidence, 12.0%). By type of institution, adverse event incidence varied widely from 1.2% to 45.6%. In 1032 adverse events, the majority (33.5%) were "patient care-related." By severity, the majority (638; 70.8%) were temporary, requiring intervention, whereas 38 (4.2%) resulted in death. The preventability score was high for "patient care-related" and "diagnosis-related" adverse events. Duration of hospitalization was extended for 463 (44.9%) adverse events, with "diagnosis-related" (30.8%) and "surgery/procedural-related" (30.1%) types extended by at least 21 days. CONCLUSIONS A review of medical records aids in identifying adverse events in medical institutions with varying characteristics, thus helping prioritize interventions to reduce their incidence.
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Affiliation(s)
- Min Ji Kim
- From the Korea Institute for Healthcare Accreditation, Seoul
| | - Hee Jung Seo
- From the Korea Institute for Healthcare Accreditation, Seoul
| | - Hong Mo Koo
- From the Korea Institute for Healthcare Accreditation, Seoul
| | - Minsu Ock
- Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan
- Department of Preventive Medicine, University of Ulsan College of Medicine
| | - Jee-In Hwang
- Department of Nursing Management, College of Nursing Science, Kyung Hee University, Seoul, Republic of Korea
| | - Sang-Il Lee
- Department of Preventive Medicine, University of Ulsan College of Medicine
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Deilkås ET, Haugen M, Risberg MB, Narbuvold H, Flesland Ø, Nylén U, Rutberg H. Longitudinal rates of hospital adverse events that contributed to death in Norway and Sweden from 2013 to 2018. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2021. [DOI: 10.1177/25160435211026125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives In this paper, we explore and compare types and longitudinal trends of hospital adverse events in Norway and Sweden in the years 2013–2018 with special reference to AEs that contributed to death. Design Acute care hospitals in both countries performed medical record reviews on randomly selected medical records from all eligible admissions. Analysis: Comparison between Norway and Sweden of linear trends from 2013–2018, and percentage rates of admissions with at least one AE according to types and severities. Setting Norway and Sweden have similar socio-economic and demographic characteristics, which constitutes a relevant context for cooperation, comparison and mutual learning. This setting has promoted the use of GTT to monitor national rates of AEs in hospital care in the two countries. Participants 53 367 medical records in Norway and 88 637 medical records in Sweden were reviewed. Results 13.2% of hospital admissions in Norway and 13.1% in Sweden were associated with an AE of all severities (E-I). 0.23% of hospital admissions in Norway and 0.26% in Sweden were associated with an AE that contributed to death (I). The differences between the two countries were not statistically significant. Conclusions There were no significant differences in overall rates (E-I) of AEs in Norway and Sweden, nor in rates of AEs that contributed to death (I). There was no significant change in AEs or fatal AEs in either country over the six-year time period.
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Affiliation(s)
- Ellen Tveter Deilkås
- Department for Quality Improvement and Patient Safety, Norwegian Directorate of Health, Oslo, Norway
- Health Services Research Center, Akershus University Hospital, Lørenskog, Norway
| | | | | | - Hanne Narbuvold
- Department for Quality Improvement and Patient Safety, Norwegian Directorate of Health, Oslo, Norway
| | - Øystein Flesland
- Department for Quality Improvement and Patient Safety, Norwegian Directorate of Health, Oslo, Norway
| | - Urban Nylén
- National Board of Health and Welfare, Stockholm, Sweden
| | - Hans Rutberg
- Swedish Association of Local Authorities and Regions, Stockholm, Sweden
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Connolly W, Li B, Conroy R, Hickey A, Williams DJ, Rafter N. National and Institutional Trends in Adverse Events Over Time: A Systematic Review and Meta-analysis of Longitudinal Retrospective Patient Record Review Studies. J Patient Saf 2021; 17:141-148. [PMID: 33395019 PMCID: PMC7908854 DOI: 10.1097/pts.0000000000000804] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study aimed to determine if the implementation of large-scale patient safety initiatives have been successful in reducing overall and preventable adverse event rates in hospital inpatients. DESIGN The design used in this study was systematic review and meta-analysis. DATA RESOURCES We followed our published protocol (PROSPERO [CRD42019140058]) and searched the following databases: PubMed, CINAHL, PsycINFO, Cochrane Library, and Embase from inception to February 2020. The reference lists of eligible studies were also searched. ELIGIBILITY All longitudinal retrospective record review studies that examined adverse event rates before and after the introduction of patient safety initiatives in hospital inpatients were included. DATA EXTRACTION Data extraction, quality, and risk of bias assessment were carried out by 2 independent reviewers. Information on study design, setting, demographics, interventions, and safety outcome measures was extracted. RESULTS A total of 3894 articles were screened, and 7 articles met the eligibility criteria for our systematic review with 5 of these providing sufficient information for inclusion in the meta-analysis. The degree of heterogeneity was high among studies. The meta-analysis demonstrated a minimal risk reduction in overall adverse event rates of 0.017 (95% confidence interval, 0.002-0.032) when the lower-quality studies were excluded, with one adverse event being prevented for every 59 hospital admissions. CONCLUSIONS These findings are significant when the large numbers of admissions to a hospital every year are considered. Given the low numbers of large-scale implementation studies, there is a need for more research on the effectiveness of patient safety initiatives to further assess the impact of such initiatives on adverse events.
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Affiliation(s)
| | - Brian Li
- Division of Population Health Science, Department of Epidemiology and Public Health
| | | | - Anne Hickey
- Division of Population Health Science, Department of Psychology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Natasha Rafter
- Division of Population Health Science, Department of Epidemiology and Public Health
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12
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Abstract
The aim of the study was to assess the feasibility and potential of the Global Trigger Tool (GTT) for identifying adverse events (AEs) in different specialties in German hospitals.
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13
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Connolly W, Rafter N, Conroy RM, Stuart C, Hickey A, Williams DJ. The Irish National Adverse Event Study-2 (INAES-2): longitudinal trends in adverse event rates in the Irish healthcare system. BMJ Qual Saf 2021; 30:547-558. [PMID: 33436402 PMCID: PMC8237194 DOI: 10.1136/bmjqs-2020-011122] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 12/09/2020] [Accepted: 12/16/2020] [Indexed: 12/22/2022]
Abstract
Objectives To quantify the prevalence and nature of adverse events in acute Irish hospitals in 2015 and to assess the impact of the National Clinical Programmes and the National Clinical Guidelines on the prevalence of adverse events by comparing these results with the previously published data from 2009. Design and methods A retrospective chart review of 1605 admissions to eight Irish hospitals in 2015, using identical methods to those used in 2009. Results The percentage of admissions associated with one or more adverse events was unchanged (p=0.48) at 14% (95% CI=10.4% to 18.4%) in 2015 compared with 12.2% (95% CI=9.5% to 15.5%) in 2009. Similarly, the prevalence of preventable adverse events was unchanged (p=0.3) at 7.4% (95% CI=5.3% to 10.5%) in 2015 compared with 9.1% (95% CI=6.9% to 11.9%) in 2009. The incidence densities of preventable adverse events were 5.6 adverse events per 100 admissions (95% CI=3.4 to 8.0) in 2015 and 7.7 adverse events per 100 admissions (95% CI=5.8 to 9.6) in 2009 (p=0.23). However, the percentage of preventable adverse events due to hospital-associated infections decreased to 22.2% (95% CI=15.2% to 31.1%) in 2015 from 33.1% (95% CI=25.6% to 41.6%) in 2009 (p=0.01). Conclusion Adverse event rates remained stable between 2009 and 2015. The percentage of preventable adverse events related to hospital-associated infection decreased, which may represent a positive impact of the related national programmes and guidelines.
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Affiliation(s)
- Warren Connolly
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Natasha Rafter
- Division of Population Health Sciences, Department of Epidemiology and Public Health, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ronan M Conroy
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Anne Hickey
- Division of Population Health Sciences, Department of Psychology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - David J Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
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14
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Chen Y, Broman AT, Priest G, Landrigan CP, Rahman SA, Lockley SW. The Effect of Blue-Enriched Lighting on Medical Error Rate in a University Hospital ICU. Jt Comm J Qual Patient Saf 2020; 47:165-175. [PMID: 33341396 DOI: 10.1016/j.jcjq.2020.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 11/05/2020] [Accepted: 11/11/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Fatigue-related errors that occur during patient care impose a tremendous socioeconomic impact on the health care system. Blue-enriched light has been shown to promote alertness and attention. The present study tested whether blue-enriched light can help to reduce medical errors in a university hospital adult ICU. METHODS In this interventional study, a blue-enriched white light emitting diode was used to enhance traditional fluorescent light at the nurse workstation and common areas in the ICU. Medical errors were identified retrospectively using an established two-step surveillance process. Suspected incidents of potential errors detected on nurse chart review were subsequently reviewed by two physicians blinded to lighting conditions, who made final classifications. Error rates were compared between the preintervention fluorescent and postintervention blue-enriched lighting conditions using Poisson regression. RESULTS The study included a total of 1,073 ICU admissions, 522 under traditional and 551 under interventional lighting (age range 17-97 years, mean age ± standard deviation 58.5 ± 15.8). No difference was found in overall medical error rate (harmful and non-harmful) pre- vs. postintervention, 45.5 vs. 42.7 per 1,000 patient-days (rate ratio: 0.94, 95% confidence interval = 0.71-1.23, p = 0.64). CONCLUSION Interventional lighting did not have an effect on overall medical error rate. The study was likely underpowered to detect the 25% error reduction predicted. Future studies are required that are powered to assess more modest effects for lighting to reduce the risk of fatigue-related medical errors and errors of differing severity.
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Zanetti ACB, Gabriel CS, Dias BM, Bernardes A, Moura AAD, Gabriel AB, Lima Júnior AJD. Assessment of the incidence and preventability of adverse events in hospitals: an integrative review. Rev Gaucha Enferm 2020; 41:e20190364. [PMID: 32667424 DOI: 10.1590/1983-1447.2020.20190364] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 02/12/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To highlight the scientific production related to the use of the retrospective chart review methods to assess the incidence and preventability of adverse events in hospitals. METHOD An integrative review in the MEDLINE, LILACS, SCOPUS, Web of Science and EMBASE databases conducted in May 2019 with the following guiding question: What is known about the retrospective chart review methods to assess the incidence and preventability of adverse events in hospitals? Subsequently, the categorization, synthesis, and classification of the evidence levels of the included publications were performed. RESULTS In the 13 selected studies, the instruments adopted to assess the occurrence of adverse events were the Harvard Medical Practice Study, the Canadian Adverse Event Study, the Quality in Australian Health Care Study, and the Global Trigger Tool. Incidence ranged from 5.7 to 14.2%, while preventability ranged from 31 to 83%. CONCLUSION Differences in incidence and preventability were found, showing different results in the quality of care provided, the information registered in medical records, the screening criteria used, and the assessments of the reviewers.
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Affiliation(s)
- Ariane Cristina Barboza Zanetti
- Departamento de Enfermagem Geral e Especializada, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brasil
| | - Carmen Silvia Gabriel
- Departamento de Enfermagem Geral e Especializada, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brasil
| | - Bruna Moreno Dias
- Departamento de Enfermagem Geral e Especializada, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brasil
| | - Andrea Bernardes
- Departamento de Enfermagem Geral e Especializada, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brasil
| | - André Almeida de Moura
- Departamento de Enfermagem Geral e Especializada, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brasil
| | - Andréia Boldrini Gabriel
- Departamento de Enfermagem Geral e Especializada, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brasil
| | - Antônio José de Lima Júnior
- Departamento de Enfermagem Geral e Especializada, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brasil
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Between a rock and a hard place: Registered nurses' accounts of their work situation in cancer care in Swedish acute care hospitals. Eur J Oncol Nurs 2020; 47:101778. [PMID: 32563048 DOI: 10.1016/j.ejon.2020.101778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 05/27/2020] [Accepted: 06/03/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE Hospital organizational features related to registered nurses' (RNs') practice environment are often studied using quantitative measures. These are however unable to capture nuances of experiences of the practice environment from the perspective of individual RNs. The aim of this study is therefore to investigate individual RNs' experiences of their work situation in cancer care in Swedish acute care hospitals. METHODS This study is based on a qualitative framework analysis of data derived from an open-ended question by 200 RNs working in specialized or general cancer care hospital units, who responded to the Swedish RN4CAST survey on nurse work environment. Antonovsky's salutogenic concepts "meaningfulness", "comprehensibility", and "manageability" were applied post-analysis to support interpretation of results. RESULTS RNs describe a tension between expectations to uphold safe, high quality care, and working in an environment where they are unable to influence conditions for care delivery. A lacking sense of agency, on individual and collective levels, points to organizational factors impeding RNs' use of their competence in clinical decision-making and in governing practice within their professional scope. CONCLUSIONS RNs in this study appear to experience work situations which, while often described as meaningful, generally appear neither comprehensible nor manageable. The lack of an individual and collective sense of agency found here could potentially erode RNs' sense of meaningfulness and readiness to invest in their work.
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Pettersson PK, Sköldenberg O, Samuelsson B, Stark A, Muren O, Unbeck M. The identification of adverse events in hip fracture patients using the Global Trigger Tool: A prospective observational cohort study. Int J Orthop Trauma Nurs 2020; 38:100779. [PMID: 32439319 DOI: 10.1016/j.ijotn.2020.100779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/26/2020] [Accepted: 04/07/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Hip fracture is common in the elderly and is associated with high comorbidity, mortality and complication rates. There has been an increase in the investigation of healthcare-related adverse events (AEs) in some patient groups but there is limited knowledge about hip fracture patients. The aim was to explore the incidence, preventability and nature of AEs in hip fracture patients. METHODS One hundred and sixty three hip fracture patients participated. A record review was conducted of prospectively collected data using Global Trigger Tool methodology to identify AEs up to 90 days after surgery. RESULTS Sixty two (38.0%) of 163 patients had at least one AE (range 1-7). One hundred and two AEs were identified and 62 (60.8%) were deemed preventable. Healthcare-associated infections e.g. pneumonia, urinary tract infections and pressure ulcers were common. AEs were more common in older patients and those with pre-existing health conditions. Fifty eight (56.9%) AEs caused temporary harm and 4 (3.9%) contributed to patient death. CONCLUSION AEs are common in hip fracture patients and most are preventable. If the focus is on improving healthcare for these patients, we should be concentrating our efforts on reducing the number of these preventable AEs, with a particular emphasis on improving the care of older patients with pre-existing health conditions.
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Affiliation(s)
- Paula Kelly Pettersson
- Department of Orthopaedics, Danderyd Hospital, Stockholm, Sweden; Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - Olof Sköldenberg
- Department of Orthopaedics, Danderyd Hospital, Stockholm, Sweden; Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Bodil Samuelsson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; Acute and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Andreas Stark
- Department of Orthopaedics, Danderyd Hospital, Stockholm, Sweden; Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Olav Muren
- Department of Orthopaedics, Danderyd Hospital, Stockholm, Sweden; Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Maria Unbeck
- Acute and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden; Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
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Lindblad M, Unbeck M, Nilsson L, Schildmeijer K, Ekstedt M. Identifying no-harm incidents in home healthcare: a cohort study using trigger tool methodology. BMC Health Serv Res 2020; 20:289. [PMID: 32252755 PMCID: PMC7137226 DOI: 10.1186/s12913-020-05139-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/23/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Patient safety in home healthcare is largely unexplored. No-harm incidents may give valuable information about risk areas and system failures as a source for proactive patient safety work. We hypothesized that it would be feasible to retrospectively identify no-harm incidents and thus aimed to explore the cumulative incidence, preventability, types, and potential contributing causes of no-harm incidents that affected adult patients admitted to home healthcare. METHODS A structured retrospective record review using a trigger tool designed for home healthcare. A random sample of 600 home healthcare records from ten different organizations across Sweden was reviewed. RESULTS In the study, 40,735 days were reviewed. In all, 313 no-harm incidents affected 177 (29.5%) patients; of these, 198 (63.2%) no-harm incidents, in 127 (21.2%) patients, were considered preventable. The most common no-harm incident types were "fall without harm," "deficiencies in medication management," and "moderate pain." The type "deficiencies in medication management" was deemed to have a preventability rate twice as high as those of "fall without harm" and "moderate pain." The most common potential contributing cause was "deficiencies in nursing care and treatment, i.e., delayed, erroneous, omitted or incomplete treatment or care." CONCLUSION This study suggests that it is feasible to identify no-harm incidents and potential contributing causes such as omission of care using record review with a trigger tool adapted to the context. No-harm incidents and potential contributing causes are valuable sources of knowledge for improving patient safety, as they highlight system failures and indicate risks before an adverse event reach the patient.
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Affiliation(s)
- Marléne Lindblad
- School of Engineering Sciences in Chemistry, Biotechnology and Health, Royal Institute of Technology, Stockholm, Sweden
- Department of Healthcare Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden
| | - Maria Unbeck
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Acute and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lena Nilsson
- Department of Anesthesiology and Intensive Care, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Kristina Schildmeijer
- Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden
| | - Mirjam Ekstedt
- Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden.
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
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Nilsson L, Borgstedt-Risberg M, Brunner C, Nyberg U, Nylén U, Ålenius C, Rutberg H. Adverse events in psychiatry: a national cohort study in Sweden with a unique psychiatric trigger tool. BMC Psychiatry 2020; 20:44. [PMID: 32019518 PMCID: PMC7001519 DOI: 10.1186/s12888-020-2447-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 01/21/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The vast majority of patient safety research has focused on somatic health care. Although specific adverse events (AEs) within psychiatric healthcare have been explored, the overall level and nature of AEs is sparsely investigated. METHODS Cohort study using a retrospective record review based on a two-step trigger tool methodology in the charts of randomly selected patients 18 years or older admitted to the psychiatric acute care departments in all Swedish regions from January 1 to June 30, 2017. Hospital care together with corresponding outpatient care were reviewed as a continuum, over a maximum of 3 months. The AEs were categorised according to type, severity and preventability. RESULTS In total, the medical records of 2552 patients were reviewed. Among the patients, 50.4% were women and 49.6% were men. The median (range) age was 44 (18-97) years for women and 44.5 (18-93) years for men. In 438 of the reviewed records, 720 AEs were identified, corresponding to the AEs identified in 17.2% [95% confidence interval, 15.7-18.6] of the records. The majority of AEs resulted in less or moderate harm, and 46.2% were considered preventable. Prolonged disease progression and deliberate self-harm were the most common types of AEs. AEs were significantly more common in women (21.5%) than in men (12.7%) but showed no difference between age groups. Severe or catastrophic harm was found in 2.3% of the records, and the majority affected were women (61%). Triggers pointing at deficient quality of care were found in 78% of the records, with the absence of a treatment plan being the most common. CONCLUSIONS AEs are common in psychiatric care. Aside from further patient safety work, systematic interventions are also warranted to improve the quality of psychiatric care.
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Affiliation(s)
- Lena Nilsson
- Department of Anaesthesiology and Intensive Care, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden. .,Department of Anaesthesiology and Intensive Care, University Hospital, 583 81, Linköping, Sweden.
| | - Madeleine Borgstedt-Risberg
- 0000 0001 2162 9922grid.5640.7Centre for Organisational Support and Development (CVU), Region Östergötland, Linköping University, Linköping, Sweden
| | - Charlotta Brunner
- 0000 0001 0597 1373grid.466900.dDepartment of Psychiatry, Kalmar County Council, Kalmar, Sweden
| | - Ullakarin Nyberg
- 0000 0004 1937 0626grid.4714.6Stockholm Centre for Psychiatric Research and Education, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Urban Nylén
- 0000 0004 0511 9852grid.416537.2National Board of Health and Welfare, Stockholm, Sweden
| | - Carina Ålenius
- 0000 0001 2106 9080grid.452053.5Swedish Association of Local Authorities and Regions, Stockholm, Sweden
| | - Hans Rutberg
- 0000 0001 2106 9080grid.452053.5Swedish Association of Local Authorities and Regions, Stockholm, Sweden
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Patient-related factors associated with an increased risk of being a reported case of preventable harm in first-line health care: a case-control study. BMC FAMILY PRACTICE 2020; 21:20. [PMID: 31996137 PMCID: PMC6990540 DOI: 10.1186/s12875-020-1087-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 01/14/2020] [Indexed: 11/10/2022]
Abstract
Background Patient safety issues in primary health care and in emergency departments have not been as thoroughly explored as patient safety issues in the hospital setting. Knowledge is particularly sparse regarding which patients have a higher risk of harm in these settings. The objective was to evaluate which patient-related factors were associated with risk of harm in patients with reports of safety incidents. Methods A case–control study performed in primary health care and emergency departments in Sweden. In total, 4536 patients (cases) and 44,949 controls were included in this study. Cases included patients with reported preventable harm in primary health care and emergency departments from January 1st, 2011 until December 31st, 2016. Results Psychiatric disease, including all psychiatric diagnoses regardless of severity, nearly doubled the risk of being a reported case of preventable harm (odds ratio, 1.96; p < 0.001). Adjusted for income and education there was still an increased risk (odds ratio, 1.69; p < 0.001). The preventable harm in this group was to 46% diagnostic errors of somatic disease. Conclusion Patients with psychiatric illness are at higher risk of preventable harm in primary care and the emergency department. Therefore, this group needs extra attention to prevent harm.
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Hommel A, Magnéli M, Samuelsson B, Schildmeijer K, Sjöstrand D, Göransson KE, Unbeck M. Exploring the incidence and nature of nursing-sensitive orthopaedic adverse events: A multicenter cohort study using Global Trigger Tool. Int J Nurs Stud 2019; 102:103473. [PMID: 31810021 DOI: 10.1016/j.ijnurstu.2019.103473] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND For decades, patient safety has been recognized as a critical global healthcare issue. However, there is a gap of knowledge of all types of adverse events sensitive to nursing care within hospitals in general and within orthopaedic care specifically. OBJECTIVES The aim of this study is to explore the incidence and nature of nursing-sensitive adverse events following elective or acute hip arthroplasty at a national level. DESIGN A retrospective multicenter cohort study. OUTCOME VARIABLES Nursing-sensitive adverse events, preventability, severity and length of stay. METHODS All patients, 18 years or older, who had undergone an elective (degenerative joint disease) or acute (fractures) hemi or total hip arthroplasty surgery at 24 hospitals were eligible for inclusion. Retrospective reviews of weighted samples of 1998 randomly selected patient records were carried out using the Swedish version of the Global Trigger Tool. The patients were followed for readmissions up to 90 days postoperatively throughout the whole country regardless of index hospital. RESULTS A total of 1150 nursing-sensitive adverse events were identified in 728 (36.4%) of patient records, and 943 (82.0%) of the adverse events were judged preventable in the study cohort. The adjusted cumulative incidence regarding nursing-sensitive adverse events for the study population was 18.8%. The most common nursing-sensitive adverse event types were different kinds of healthcare-associated infections (40.9%) and pressure ulcers (16.5%). Significantly higher proportions of nursing-sensitive adverse events were found among female patients compared to male, p < 0.001, and patients with acute admissions compared to elective patients, p < 0.001. Almost half (48.5%) of the adverse events were temporary and of a less severe nature. On the other hand, 592 adverse events were estimated to have contributed to 3351 extra hospital days. CONCLUSIONS This study shows the magnitude of nursing-sensitive adverse events. We found that nursing-sensitive adverse events were common, in most cases deemed preventable and were associated with different kinds of adverse events and levels of severity in orthopaedic care. Registered nurses play a vital role within the interdisciplinary team as they are the largest group of healthcare professionals, work 24/7 and spend much time at the bedside with patients. Therefore, nursing leadership at all hospital levels must assume responsibility for patient safety and authorize bedside registered nurses to deliver high-quality and sustainable care to patients.
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Affiliation(s)
- Ami Hommel
- Department of Care Science, Faculty of Health and Society, Malmö University, SE-205 06 Malmö, Sweden; Department of Orthopaedics, Skåne University Hospital, 221 85 Lund, Sweden.
| | - Martin Magnéli
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, SE-182 88 Stockholm, Sweden; Department of Orthopedics, Danderyd Hospital, SE-182 88 Stockholm, Sweden
| | - Bodil Samuelsson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, SE-182 88 Stockholm, Sweden; Trauma and Reparative Medicine Theme, Karolinska University Hospital, SE-171 79 Stockholm, Sweden
| | - Kristina Schildmeijer
- School of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, SE-391 82 Kalmar, Sweden
| | - Desirée Sjöstrand
- Education Unit, Skånevård Kryh, Region Skåne, SE-291 89 Kristianstad, Sweden
| | - Katarina E Göransson
- Department of Medicine, Solna, Karolinska Institutet, SE-171 77 Stockholm, Sweden; Functional Area of Emergency Medicine Solna, Karolinska University Hospital, SE-171 79 Stockholm, Sweden
| | - Maria Unbeck
- Trauma and Reparative Medicine Theme, Karolinska University Hospital, SE-171 79 Stockholm, Sweden; Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, SE-171 77 Stockholm, Sweden
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Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, Bower P, Campbell S, Haneef R, Avery AJ, Ashcroft DM. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ 2019; 366:l4185. [PMID: 31315828 PMCID: PMC6939648 DOI: 10.1136/bmj.l4185] [Citation(s) in RCA: 260] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2019] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To systematically quantify the prevalence, severity, and nature of preventable patient harm across a range of medical settings globally. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline, PubMed, PsycINFO, Cinahl and Embase, WHOLIS, Google Scholar, and SIGLE from January 2000 to January 2019. The reference lists of eligible studies and other relevant systematic reviews were also searched. REVIEW METHODS Observational studies reporting preventable patient harm in medical care. The core outcomes were the prevalence, severity, and types of preventable patient harm reported as percentages and their 95% confidence intervals. Data extraction and critical appraisal were undertaken by two reviewers working independently. Random effects meta-analysis was employed followed by univariable and multivariable meta regression. Heterogeneity was quantified by using the I2 statistic, and publication bias was evaluated. RESULTS Of the 7313 records identified, 70 studies involving 337 025 patients were included in the meta-analysis. The pooled prevalence for preventable patient harm was 6% (95% confidence interval 5% to 7%). A pooled proportion of 12% (9% to 15%) of preventable patient harm was severe or led to death. Incidents related to drugs (25%, 95% confidence interval 16% to 34%) and other treatments (24%, 21% to 30%) accounted for the largest proportion of preventable patient harm. Compared with general hospitals (where most evidence originated), preventable patient harm was more prevalent in advanced specialties (intensive care or surgery; regression coefficient b=0.07, 95% confidence interval 0.04 to 0.10). CONCLUSIONS Around one in 20 patients are exposed to preventable harm in medical care. Although a focus on preventable patient harm has been encouraged by the international patient safety policy agenda, there are limited quality improvement practices specifically targeting incidents of preventable patient harm rather than overall patient harm (preventable and non-preventable). Developing and implementing evidence-based mitigation strategies specifically targeting preventable patient harm could lead to major service quality improvements in medical care which could also be more cost effective.
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Affiliation(s)
- Maria Panagioti
- NIHR Greater Manchester Patient Safety Translational Research Centre, NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester M13 9PL, UK
| | - Kanza Khan
- NIHR Greater Manchester Patient Safety Translational Research Centre, NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester M13 9PL, UK
| | - Richard N Keers
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, University of Manchester, Manchester, UK
| | - Aseel Abuzour
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, University of Manchester, Manchester, UK
| | - Denham Phipps
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, University of Manchester, Manchester, UK
| | - Evangelos Kontopantelis
- NIHR Greater Manchester Patient Safety Translational Research Centre, NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester M13 9PL, UK
| | - Peter Bower
- NIHR Greater Manchester Patient Safety Translational Research Centre, NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester M13 9PL, UK
| | - Stephen Campbell
- NIHR Greater Manchester Patient Safety Translational Research Centre, NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester M13 9PL, UK
| | - Razaan Haneef
- Lancashire Teaching Hospitals NHS Foundation Trust, Manchester, UK
| | - Anthony J Avery
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Darren M Ashcroft
- NIHR Greater Manchester Patient Safety Translational Research Centre, NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester M13 9PL, UK
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23
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Fernholm R, Pukk Härenstam K, Wachtler C, Nilsson GH, Holzmann MJ, Carlsson AC. Diagnostic errors reported in primary healthcare and emergency departments: A retrospective and descriptive cohort study of 4830 reported cases of preventable harm in Sweden. Eur J Gen Pract 2019; 25:128-135. [PMID: 31257959 PMCID: PMC6713141 DOI: 10.1080/13814788.2019.1625886] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Background: Diagnostic errors are a major patient safety concern in primary healthcare and emergency care. These settings involve a high degree of uncertainty regarding patients' diagnoses and appear to be those most prone to diagnostic errors. Diagnostic errors comprise missed, delayed, or incorrect diagnoses preventing the patient from receiving correct and timely treatment. Data regarding which diagnoses are affected in these settings are scarce. Objectives: To understand the distribution of diagnoses among reported diagnostic errors in primary health and emergency care as a step towards creating countermeasures for safer care. Methods: A retrospective and descriptive cohort study investigating reported diagnostic errors. A nationwide cohort was collected from two databases. The study was performed in Sweden from 1 January 2011 until 31 December 2016. The setting was primary healthcare and emergency departments. Results: In total, 4830 cases of preventable harm were identified. Of these, 2208 (46%) were due to diagnostic errors. Diagnoses affected in primary care were cancer (37% and 23%, respectively, in the two databases; mostly colon and skin), fractures (mostly hand), heart disease (mostly myocardial infarction), and rupture of tendons (mostly Achilles). Of the diagnostic errors in the emergency department, fractures constituted 24% (mostly hand and wrist, 29%). Rupture/injury of muscle/tendon constituted 19% (mostly finger tendons, rotator cuff tendons, and Achilles tendon). Conclusion: Our findings show that the most frequently missed diagnoses among reported harm were cancers in primary care and fractures in the emergency departments.
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Affiliation(s)
- Rita Fernholm
- a Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet , Huddinge , Sweden
| | - Karin Pukk Härenstam
- b Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet , Stockholm , Sweden
| | - Caroline Wachtler
- a Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet , Huddinge , Sweden
| | - Gunnar H Nilsson
- a Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet , Huddinge , Sweden
| | - Martin J Holzmann
- c Department of Medicine, Karolinska Institutet , Stockholm , Sweden.,d Functional area of Emergency Medicine, Karolinska University Hospital , Huddinge, Stockholm , Sweden
| | - Axel C Carlsson
- a Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet , Huddinge , Sweden
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24
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Parrinello V, Grasso E, Saglimbeni G, Patanè G, Scalia A, Murolo G, Lachman P. Assessing the development and implementation of the Global Trigger Tool method across a large health system in Sicily. F1000Res 2019; 8:263. [PMID: 32595936 PMCID: PMC7308947 DOI: 10.12688/f1000research.18025.4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2020] [Indexed: 11/21/2022] Open
Abstract
Background: The Institute for Healthcare Improvement (IHI) has proposed a new method, the Global Trigger Tool (IHI GTT), to detect and monitor adverse events (AEs) and provide information to implement improvement. In 2015, the Sicilian Health System adopted IHI GTT to assess the number, types and severity levels of AEs. The GTT was implemented in 44 of 73 Sicilian public hospitals and 18,008 clinical records (CRs) were examined. Here we present the standardized application of the GTT and the preliminary results of 14,706 reviews of CRs. Methods: IHI GTT was adapted, developed and implemented to the local context. Reviews of CRs were conducted by 199 professionals divided into 71 review teams consisting of three individuals: two of whom had clinical knowledge and expertise, and a physician to authenticate the AE. The reviewers entered data into a dedicated IT-platform. All 44 of the public hospitals were included, with approximately 300,000 yearly inpatient admissions out of a population of approximately 5 million. In total, 14,706 randomized CRs of inpatients from medicine, surgery, obstetric and ICU wards, from June 2015 to June 2018 were reviewed. Results: In 975 (6.6%) CRs at least one AE was found. Approximately 20,000 patients of the 300,000 discharged each year in Sicily have at least one AE. In 5,574 (37.9%) CRs at least one trigger was found. A total of 1,542 AEs were found. The analysis of ROC curve shows that the presence of two triggers in a CR indicates with high probability the presence of an AE. The most frequent type of AE was in-hospital related infection. Conclusions: The GTT is an efficient method to identify AEs and to track improvement of care. The analysis and monitoring of some triggers is important to prevent AEs. However, it is a labor-intensive method, particularly if the CRs are paper-based.
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Affiliation(s)
- Vincenzo Parrinello
- U.O. Qualità e Rischio Clinico, Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele, Catania, 95129, Italy
| | - Elena Grasso
- U.O. Qualità e Rischio Clinico, Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele, Catania, 95129, Italy
| | - Giuseppe Saglimbeni
- U.O. Qualità e Rischio Clinico, Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele, Catania, 95129, Italy
| | - Gabriella Patanè
- U.O. Qualità e Rischio Clinico, Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele, Catania, 95129, Italy
| | - Alma Scalia
- U.O. Qualità e Rischio Clinico, Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele, Catania, 95129, Italy
| | - Giuseppe Murolo
- Servizio 8 "Qualità, Governo Clinico e Sicurezza del Paziente", Assessorato della Salute, Regione Siciliana, Palermo, 90145, Italy
| | - Peter Lachman
- International Society for Quality in Healthcare, Dublin, D02NY63, Ireland
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