Rate of avoidable deaths in a Norwegian hospital trust as judged by retrospective chart review

Frequency, Prognosis, and Clinical Features of Unexpected versus Expected Cardiac Arrest in the Emergency Department: A Retrospective Analysis

Background: Though out-of-hospital CA (OHCA) is widely reported, data on in-hospital CA (IHCA) and especially cardiac arrest (CA) in the emergency department (CAED) are scarce. This study aimed to determine the frequency, prevalence, and clinical features of unexpected CAED and compare the data with those of expected CAED. Methods: We defined unexpected CAED as CA occurring in patients in non-critical ED-care areas; classified as not requiring strict monitoring. This classification was the modified Japanese Triage and Acuity Scale and physician assessment. A retrospective analysis of cases from 2016 to 2018 was performed, in comparison to other patients experiencing CAED. Results: The 38 cases of unexpected CA in this study constituted 34.5% of CA diagnosed in the ED and 8.4% of all CA treated in the ED. This population did not differ significantly from other CAED regarding demographics, comorbidities, and survival rates. The commonest symptoms were dyspnoea, disorders of consciousness, generalised weakness, and chest pain. The commonest causes of death were acute myocardial infarction, malignant neoplasms with metastases, septic shock, pulmonary embolism, and heart failure. Conclusions: Unexpected CAED represents a group of potentially avoidable CA and deaths. These patients should be analysed, and ED management should include measures aimed at reducing their incidence.

Leveraging artificial intelligence and decision support systems in hospital-acquired pressure injuries prediction: A comprehensive review

BACKGROUND

Hospital-acquired pressure injuries (HAPIs) constitute a significant challenge harming thousands of people worldwide yearly. While various tools and methods are used to identify pressure injuries, artificial intelligence (AI) and decision support systems (DSS) can help to reduce HAPIs risks by proactively identifying patients at risk and preventing them before harming patients.

OBJECTIVE

This paper comprehensively reviews AI and DSS applications for HAPIs prediction using Electronic Health Records (EHR), including a systematic literature review and bibliometric analysis.

METHODS

A systematic literature review was conducted through PRISMA and bibliometric analysis. In February 2023, the search was performed using four electronic databases: SCOPIS, PubMed, EBSCO, and PMCID. Articles on using AI and DSS in the management of PIs were included.

RESULTS

The search approach yielded 319 articles, 39 of which have been included and classified into 27 AI-related and 12 DSS-related categories. The years of publication varied from 2006 to 2023, with 40% of the studies taking place in the US. Most studies focused on using AI algorithms or DSS for HAPIs prediction in inpatient units using various types of data such as electronic health records, PI assessment scales, and expert knowledge-based and environmental data to identify the risk factors associated with HAPIs development.

CONCLUSIONS

There is insufficient evidence in the existing literature concerning the real impact of AI or DSS on making decisions for HAPIs treatment or prevention. Most studies reviewed are solely hypothetical and retrospective prediction models, with no actual application in healthcare settings. The accuracy rates, prediction results, and intervention procedures suggested based on the prediction, on the other hand, should inspire researchers to combine both approaches with larger-scale data to bring a new venue for HAPIs prevention and to investigate and adopt the suggested solutions to the existing gaps in AI and DSS prediction methods.

Psychometric properties of the full and short version Nursing Home Survey on Patient Safety Culture (NHSOPSC) instrument: a cross-sectional study assessing patient safety culture in Norwegian homecare services

OBJECTIVES

Measure patient safety culture in homecare services; test the psychometric properties of the Nursing Home Survey on Patient Safety Culture (NHSOPSC) instrument; and propose a short-version Homecare Services Survey on Patient Safety Culture instrument for use in homecare services.

DESIGN

Cross-sectional survey with psychometric testing.

SETTING

Twenty-seven publicly funded homecare units in eight municipalities (six counties) in Norway.

PARTICIPANTS

Five-hundred and forty health personnel working in homecare services.

INTERVENTIONS

Not applicable.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary: Patient safety culture assessed using the NHSOPSC instrument. Secondary: Overall perception of service users' safety, service safety and overall care.

METHODS

Psychometric testing of the NHSOPSC instrument using factor analysis and optimal test assembly with generalised partial credit model to develop a short-version instrument proposal.

RESULTS

Most healthcare personnel rated patient safety culture in homecare services positively. A 19-item short-version instrument for assessing patient safety culture had high internal consistency, and was considered to have sufficient concurrent and convergent validity. It explained a greater proportion of variance (59%) than the full version (50%). Short-version factors included safety improvement actions, teamwork, information flow and management support.

CONCLUSION

This study provides a first proposal for a short-version Homecare Services Survey on Patient Safety Culture instrument to assess patient safety culture within homecare services. It needs further improvement, but provides a starting point for developing an improved valid and reliable short-version instrument as part of assessment of patient safety and quality improvement processes.

NHS 'Learning from Deaths' reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme

OBJECTIVES

To review how National Health Service (NHS) Secondary Care Trusts (NSCTs) are using the Learning from Deaths (LfDs) programme to learn from and prevent, potentially preventable deaths.

INTRODUCTION

Potentially preventable deaths occur worldwide within healthcare organisations. In England, inconsistencies in how NSCTs reviewed, investigated and shared LfDs, resulted in the introduction of national guidance on 'LfDs' in 2017. This guidance provides a 'framework for identifying, reporting, investigating and LfDs'. Amendments to NHS Quality Account regulations, legally require NSCTs in England to report quantitative and qualitative information relating to patient deaths annually. The programme intended NSCTs would share this learning and take measurable action to prevent future deaths.

METHOD

We undertook qualitative and quantitative secondary data, document analysis of all NSCTs LfDs reports within their 2017/2018 Quality Accounts (n=222).

RESULTS

All statutory elements of LfDs reporting were reported by 98 out of 222 (44%) NSCTs. The percentage of deaths judged more likely than not due to problems in healthcare was between 0% and 13%. The majority of NSCTs (89%) reported lessons learnt; the most common learning theme was poor communication. 106 out of 222 NSCTs (48%) have shared or plan to share the learning within their own organisation. The majority of NSCTs (86%) reported actions taken and 47% discussed or had a plan for assessment of impact. 37 out of 222 NSCTs (17%) mentioned involvement of bereaved families.

CONCLUSIONS

The wide variation in reporting demonstrates that some NSCTs have engaged fully with LfDs, while other NSCTs appear to have disengaged with the programme. This may reveal a disparity in organisational learning and patient safety culture which could result in inequity for bereaved families. Many themes identified from the LfDs reports have previously been identified by national and international reports and inquiries.

Problems in care and avoidability of death after discharge from intensive care: a multi-centre retrospective case record review study

BACKGROUND

Over 138,000 patients are discharged to hospital wards from intensive care units (ICUs) in England, Wales and Northern Ireland annually. More than 8000 die before leaving hospital. In hospital-wide populations, 6.7-18% of deaths have some degree of avoidability. For patients discharged from ICU, neither the proportion of avoidable deaths nor the reasons underlying avoidability have been determined. We undertook a retrospective case record review within the REFLECT study, examining how post-ICU ward care might be improved.

METHODS

A multi-centre retrospective case record review of 300 consecutive post-ICU in-hospital deaths, between January 2015 and March 2018, in 3 English hospitals. Trained multi-professional researchers assessed the degree to which each death was avoidable and determined care problems using the established Structured Judgement Review method.

RESULTS

Agreement between reviewers was good (weighted Kappa 0.77, 95% CI 0.64-0.88). Discharge from an ICU for end-of-life care occurred in 50/300 patients. Of the remaining 250 patients, death was probably avoidable in 20 (8%, 95% CI 5.0-12.1) and had some degree of avoidability in 65 (26%, 95% CI 20.7-31.9). Common problems included out-of-hours discharge from ICU (168/250, 67.2%), suboptimal rehabilitation (167/241, 69.3%), absent nutritional planning (76/185, 41.1%) and incomplete sepsis management (50/150, 33.3%).

CONCLUSIONS

The proportion of deaths in hospital with some degree of avoidability is higher in patients discharged from an ICU than reported in hospital-wide populations. Extrapolating our findings suggests around 550 probably avoidable deaths occur annually in hospital following ICU discharge in England, Wales and Northern Ireland. This avoidability occurs in an elderly frail population with complex needs that current strategies struggle to meet. Problems in post-ICU care are rectifiable but multi-disciplinary.

TRIAL REGISTRATION

ISRCTN14658054.

Rate of Preventable Mortality in Hospitalized Patients: a Systematic Review and Meta-analysis

BACKGROUND

The number of preventable inpatient deaths in the USA is commonly estimated as between 44,000 and 98,000 deaths annually. Because many inpatient deaths are believed to be preventable, mortality rates are used for quality measures and reimbursement. We aimed to estimate the proportion of inpatient deaths that are preventable.

METHODS

A systematic literature search of Medline, Embase, Web of Science, and the Cochrane Library through April 8, 2019, was conducted. We included case series of adult patients who died in the hospital and were reviewed by physicians to determine if the death was preventable. Two reviewers independently performed data extraction and study quality assessment. The proportion of preventable deaths from individual studies was pooled using a random-effects model.

RESULTS

Sixteen studies met inclusion criteria. Eight studies of consecutive or randomly selected cohorts including 12,503 deaths were pooled. The pooled rate of preventable mortality was 3.1% (95% CI 2.2-4.1%). Two studies also reported rates of preventable mortality limited to patients expected to live longer than 3 months, ranging from 0.5 to 1.0%. In the USA, these estimates correspond to approximately 22,165 preventable deaths annually and 7150 deaths for patients with greater than 3-month life expectancy.

DISCUSSION

The number of deaths due to medical error is lower than previously reported and the majority occur in patients with less than 3-month life expectancy. The vast majority of hospital deaths are due to underlying disease. Our results have implications for the use of hospital mortality rates for quality reporting and reimbursement.

STUDY REGISTRATION

PROSPERO registration number CRD42018095140.

Ten years of the Helsinki Declaration on patient safety in anaesthesiology: An expert opinion on peri-operative safety aspects

: Patient safety is an activity to mitigate preventable patient harm that may occur during the delivery of medical care. The European Board of Anaesthesiology (EBA)/European Union of Medical Specialists had previously published safety recommendations on minimal monitoring and postanaesthesia care, but with the growing public and professional interest it was decided to produce a much more encompassing document. The EBA and the European Society of Anaesthesiology (ESA) published a consensus on what needs to be done/achieved for improvement of peri-operative patient safety. During the Euroanaesthesia meeting in Helsinki/Finland in 2010, this vision was presented to anaesthesiologists, patients, industry and others involved in health care as the 'Helsinki Declaration on Patient Safety in Anaesthesiology'. In May/June 2020, ESA and EBA are celebrating the 10th anniversary of the Helsinki Declaration on Patient Safety in Anaesthesiology; a good opportunity to look back and forward evaluating what was achieved in the recent 10 years, and what needs to be done in the upcoming years. The Patient Safety and Quality Committee (PSQC) of ESA invited experts in their fields to contribute, and these experts addressed their topic in different ways; there are classical, narrative reviews, more systematic reviews, political statements, personal opinions and also original data presentation. With this publication we hope to further stimulate implementation of the Helsinki Declaration on Patient Safety in Anaesthesiology, as well as initiating relevant research in the future.

Strengthening the Medical Error "Meme Pool"

The exact number of patients in the USA who die from preventable medical errors each year is highly debated. Despite uncertainty in the underlying science, two very large estimates have spread rapidly through both the academic and popular media. We utilize Richard Dawkins' concept of the "meme" to explore why these imprecise estimates remain so compelling, and examine what potential harms can occur from their dissemination. We conclude by suggesting that instead of simply providing more precise estimates, physicians should encourage nuance in public medical error discussions, and strive to provide narrative context about the reality of the complex biological and social systems in which we practice medicine.