The Irish National Adverse Event Study-2 (INAES-2): longitudinal trends in adverse event rates in the Irish healthcare system

Patients' and doctors' views and experiences of the patient safety trajectory of breast cancer care

INTRODUCTION

Successful breast cancer outcomes can be jeopardised by adverse events. Understanding and integrating patients' and doctors' perspectives into care trajectories could improve patient safety. This study assessed their views on, and experiences of, medical error and patient safety.

METHODS

A cross-sectional, quantitative 20-40 item questionnaire for patients attending Cork University Hospital Cancer Centre and breast cancer doctors in the Republic of Ireland was developed. Domains included demographics, medical error experience, patient safety opinions and concerns.

RESULTS

184 patients and 116 doctors completed the survey. Of the doctors, 41.4% felt patient safety had deteriorated over the previous five years and 54.3% felt patient safety measures were inadequate compared to 13.0% and 27.7% of patients respectively. Of the 30 patients who experienced medical errors/negligence claims, 18 reported permanent or long-term physical and emotional effects. Forty-two of 48 (87.5%) doctors who experienced medical errors/negligence claims reported emotional health impacts. Almost half of doctors involved in negligence claims considered early retirement. Forty-four patients and 154 doctors didn't experience errors but reported their patient safety concerns. Doctors were more concerned about communication and administrative errors, staffing and organisational factors compared to patients. Multiple barriers to error reporting were highlighted.

CONCLUSION

This is the first study to assess patients' and doctors' patient safety views and medical error/negligence claims experiences in breast cancer care in Ireland. Experience of medical error/negligence claims had long-lasting implications for both groups. Doctors were concerned about a multitude of errors and causative factors. Failure to embed these findings is a missed opportunity to improve safety.

Trend Analysis of Inpatient Medical Adverse Events in Taiwan (2014-2020): Findings From Taiwan Patient Safety Reporting System

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.

Current Irish medicolegal landscape: an unsustainable trajectory

A number of outstanding clinical claims that are yet to be resolved as well as their associated estimated costs are at a record high in Ireland. By the end of 2022, the Irish government face 3875 active clinical claims which are expected to cost €3.85 billion in total. This does not account for future claims yet to be brought. The financial burden will be borne by the Irish healthcare system which is already facing unprecedented pressures on its services and staff. If current trends continue, the opportunity costs of the current medicolegal landscape will impact the future provision of healthcare. Aside from the financial consequences, clinical claims have numerous negative impacts on all parties involved. Gaining an understanding as to why claims and costs continue to increase relies on access to, and analysis of high-quality patient safety data, including learning from previous litigation. Addressing the causal and perpetuating factors requires efficient implementation of evidence-based recommendations through engagement with stakeholders, including the public. It is necessary to continuously assess the implementation of recommendations as well as measure their impact. This is to ensure that novel efforts from this point onwards do not suffer the same fate as many previous recommendations that, because of a lack of follow-on research, appear to go no further than the page of the report they are written. Action is required now to change the course of the currently unsustainable trajectory of the Irish medicolegal landscape.

Occurrence and preventability of adverse events in hospitals: a retrospective study

OBJECTIVES

to analyze the incidence of preventable adverse events related to health care in adult patients admitted to public hospitals in Brazil.

METHODS

observational, analytical, retrospective study based on medical records review.

RESULTS

medical records from 370 patients were evaluated, 58 of whom had at least one adverse event. The incidence of adverse events corresponded to 15.7%. Adverse events were predominantly related to healthcare-related infection (47.1%) and procedures (24.5%). Regarding the adverse event severity, 13.7% were considered mild, 51.0% moderate, and 35.3% severe. 99% of adverse events were classified as preventable. Patients admitted to the emergency room had a 3.73 times higher risk for adverse events.

CONCLUSIONS

this study's results indicate a high incidence of avoidable adverse events and highlight the need for interventions in care practice.

Videos of simulated after action reviews: a training resource to support social and inclusive learning from patient safety events

Innovation in the education and training of healthcare staff is required to support complementary approaches to learning from patient safety and everyday events in healthcare. Debriefing is a commonly used learning tool in healthcare education but not in clinical practice. Little is known about how to implement debriefing as an approach to safety learning across a health system. After action review (AAR) is a debriefing approach designed to help groups come to a shared mental model about what happened, why it happened and to identify learning and improvement. This paper describes a digital-based implementation strategy adapted to the Irish healthcare system to promote AAR uptake. The digital strategy aims to assist implementation of national level incident management policies and was collaboratively developed by the RCSI University of Medicine and Health Sciences and the National Quality and Patient Safety Directorate of the Health Service Executive. During the COVID-19 pandemic, a well-established in-person AAR training programme was disrupted and this led to the development of a series of open access videos on AAR facilitation skills (which accompany the online version of this paper). These provide: (1) an introduction to the AAR facilitation process; (2) a simulation of a facilitated formal AAR; (3) techniques for handling challenging situations that may arise in an AAR and a (4) reflection on the benefits of the AAR process. These have the potential to be used widely to support learning from patient safety and everyday events including excellent care.

A scoping review of patient safety research carried out in the Republic of Ireland

Maintaining the highest levels of patient safety is a priority of healthcare organisations. However, although considerable resources are invested in improving safety, patients still suffer avoidable harm. The aims of this study are: (1) to examine the extent, range, and nature of patient safety research activities carried out in the Republic of Ireland (RoI); (2) make recommendations for future research; and (3) consider how these recommendations align with the Health Service Executive's (HSE) patient safety strategy. A five-stage scoping review methodology was used to synthesise the published research literature on patient safety carried out in the RoI: (1) identify the research question; (2) identify relevant studies; (3) study selection; (4) chart the data; and (5) collate, summarise, and report the results. Electronic searches were conducted across five electronic databases. A total of 31 papers met the inclusion criteria. Of the 24 papers concerned with measuring and monitoring safety, 12 (50%) assessed past harm, 4 (16.7%) the reliability of safety systems, 4 (16.7%) sensitivity to operations, 9 (37.5%) anticipation and preparedness, and 2 (8.3%) integration and learning. Of the six intervention papers, three (50%) were concerned with education and training, two (33.3%) with simplification and standardisation, and one (16.7%) with checklists. One paper was concerned with identifying potential safety interventions. There is a modest, but growing, body of patient safety research conducted in the RoI. It is hoped that this review will provide direction to researchers, healthcare practitioners, and health service managers, in how to build upon existing research in order to improve patient safety.

'What effect do safety culture interventions have on health care workers in hospital settings?' A systematic review of the international literature

Introduction: Interventions designed to improve safety culture in hospitals foster organisational environments that prevent patient safety events and support organisational and staff learning when events do occur. A safety culture supports the required health workforce behaviours and norms that enable safe patient care, and the well-being of patients and staff. The impact of safety culture interventions on staff perceptions of safety culture and patient outcomes has been established. To-date, however, there is no common understanding of what staff outcomes are associated with interventions to improve safety culture and what staff outcomes should be measured. Objectives: The study seeks to examine the effect of safety culture interventions on staff in hospital settings, globally. Methods and Analysis: A mixed methods systematic review will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches will be conducted using the electronic databases of MEDLINE, EMBASE, CINAHL, Health Business Elite, and Scopus. Returns will be screened in Covidence according to inclusion and exclusion criteria. The mixed-methods appraisal tool (MMAT) will be used as a quality assessment tool. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials and non-randomised studies of interventions will be employed to verify bias. Synthesis will follow the Joanna Briggs Institute methodological guidance for mixed methods reviews, which recommends a convergent approach to synthesis and integration. Discussion: This systematic review will contribute to the international evidence on how interventions to improve safety culture may support staff outcomes and how such interventions may be appropriately designed and implemented.

Gender differences in medical errors among older patients and inequalities in medical compensation compared with younger adults

Background

Despite growing evidence focusing on health inequalities in older adults, inequalities in medical compensation compared with younger adults and gender disparities of medical errors among older patients have received little attention. This study aimed to disclose the aforementioned inequalities and examine the disparities in medical errors among older patients.

Methods

First, available litigation documents were searched on "China Judgment Online" using keywords including medical errors. Second, we compiled a database with 5,072 disputes. After using systematic random sampling to retain half of the data, we removed 549 unrelated cases. According to the age, we identified 424 and 1,563 cases related to older and younger patients, respectively. Then, we hired two frontline physicians to review the documents and independently judge the medical errors and specialties involved. A third physician further considered the divergent results. Finally, we compared the medical compensation between older and younger groups and medical errors and specialties among older patients.

Results

Older patients experienced different medical errors in divergent specialties. The medical error rate of male older patients was over 4% higher than that of females in the departments of general surgery and emergency. Female older patients were prone to adverse events in respiratory medicine departments and primary care institutes. The incidence of insufficient implementation of consent obligation among male older patients was 5.18% higher than that of females. However, females were more likely to suffer adverse events at the stages of diagnosis, therapy, and surgical operation. The total amount of medical compensation obtained by younger patients was 41.47% higher than that of older patients.

Conclusions

Except for the common medical errors and departments involved, additional attention should be paid to older patients of different genders according to the incidence of medical errors. Setting up the department of geriatrics or specialist hospitals is also an important alternative to improve patient safety for older people. Furthermore, there may be inequality in medical compensation in older patients due to the tort liability law of China.

‘What effect do safety culture interventions have on health care workers in hospital settings?’ A systematic review of the international literature

Introduction: Interventions designed to improve safety culture in hospitals foster organisational environments that prevent patient safety events and support organisational and staff learning when events do occur. A safety culture supports the required health workforce behaviours and norms that enable safe patient care, and the well-being of patients and staff. The impact of safety culture interventions on staff perceptions of safety culture and patient outcomes has been established. To-date, however, there is no common understanding of what staff outcomes are associated with interventions to improve safety culture and what staff outcomes should be measured. Objectives: The study seeks to examine the effect of safety culture interventions on staff in hospital settings, globally. The research questions are: 1) what effects do interventions to improve safety culture have on staff? 2) What intervention features, safety culture domains or other factors explain these effects? 3) What staff outcomes and experiences are identified? Methods and Analysis: A mixed methods systematic review will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches will be conducted using the electronic databases of MEDLINE, EMBASE, CINAHL, Health Business Elite, and Scopus. Returns will be screened in Covidence according to inclusion and exclusion criteria. The mixed-methods appraisal tool (MMAT) will be used as a quality assessment tool. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials and non-randomised studies of interventions will be employed to verify bias. Synthesis will follow the Joanna Briggs Institute methodological guidance for mixed methods reviews, which recommends a convergent approach to synthesis and integration. Discussion: This systematic review will contribute to the international evidence on how interventions to improve safety culture may support staff outcomes and how such interventions may be appropriately designed and implemented.

Implementation of the Frailty Care Bundle (FCB) to promote mobilisation, nutrition and cognitive engagement in older people in acute care settings: protocol for an implementation science study

Background: Older people are among the most vulnerable patients in acute care hospitals. The hospitalisation process can result in newly acquired functional or cognitive deficits termed hospital associated decline (HAD).  Prioritising fundamental care including mobilisation, nutrition, and cognitive engagement can reduce HAD risk. Aim: The Frailty Care Bundle (FCB) intervention aims to implement and evaluate evidence-based principles on early mobilisation, enhanced nutrition and increased cognitive engagement to prevent functional decline and HAD in older patients. Methods: A hybrid implementation science study will use a pragmatic prospective cohort design with a pre-post mixed methods evaluation to test the effect of the FCB on patient, staff, and health service outcomes.  The evaluation will include a description of the implementation process, intervention adaptations, and economic costs analysis. The protocol follows the Standards for Reporting Implementation Studies (StaRI). The intervention design and implementation strategy will utilise the behaviour change theory COM-B (capability, motivation, opportunity) and the Promoting Action on Research Implementation in Health Services (i-PARIHS). A clinical facilitator will use a co-production approach with staff. All patients will receive care as normal, the intervention is delivered at ward level and focuses on nurses and health care assistants (HCA) normative clinical practices. The intervention will be delivered in three hospitals on six wards including rehabilitation, acute trauma, medical and older adult wards. Evaluation: The evaluation will recruit a volunteer sample of 180 patients aged 65 years or older (pre 90; post 90 patients). The primary outcomes are measures of functional status (modified Barthel Index (MBI)) and mobilisation measured as average daily step count using accelerometers. Process data will include ward activity mapping, staff surveys and interviews and an economic cost-impact analysis. Conclusions: This is a complex intervention that involves ward and system level changes and has the potential to improve outcomes for older patients.

Effect of after action review on safety culture and second victim experience and its implementation in an Irish hospital: A mixed methods study protocol

Background

After Action Review is a form of facilitated team learning and review of events. The methodology originated in the United States Army and forms part of the Incident Management Framework in the Irish Health Services. After Action Review has been hypothesized to improve safety culture and the effect of patient safety events on staff (second victim experience) in health care settings. Yet little direct evidence exists to support this and its implementation has not been studied.

Aim

To investigate the effect of After Action Review on safety culture and second victim experience and to examine After Action Review implementation in a hospital setting.

Methods

A mixed methods study will be conducted at an Irish hospital. To assess the effect on safety culture and second victim experience, hospital staff will complete surveys before and twelve months after the introduction of After Action Review to the hospital (Hospital Survey on Safety Culture 2.0 and Second Victim Experience and Support Tool). Approximately one in twelve staff will be trained as After Action Review Facilitators using a simulation based training programme. Six months after the After Action Review training, focus groups will be conducted with a stratified random sample of the trained facilitators. These will explore enablers and barriers to implementation using the Theoretical Domains Framework. At twelve months, information will be collected from the trained facilitators and the hospital to establish the quality and resource implications of implementing After Action Review.

Discussion

The results of the study will directly inform local hospital decision-making and national and international approaches to incorporating After Action Review in hospitals and other healthcare settings.