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Bowman CL, De Gorter R, Zaslow J, Fortier JH, Garber G. Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis. BMJ Open Qual 2023; 12:e002264. [PMID: 37364940 PMCID: PMC10314656 DOI: 10.1136/bmjoq-2023-002264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Never events (NEs) are patient safety incidents that are preventable and so serious they should never happen. To reduce NEs, several frameworks have been introduced over the past two decades; however, NEs and their harms continue to occur. These frameworks have varying events, terminology and preventability, which hinders collaboration. This systematic review aims to identify the most serious and preventable events for targeted improvement efforts by answering the following questions: Which patient safety events are most frequently classified as never events? Which ones are most commonly described as entirely preventable? METHODS For this narrative synthesis systematic review we searched Medline, Embase, PsycINFO, Cochrane Central and CINAHL for articles published from 1 January 2001 to 27 October 2021. We included papers of any study design or article type (excluding press releases/announcements) that listed NEs or an existing NE framework. RESULTS Our analyses included 367 reports identifying 125 unique NEs. Those most frequently reported were surgery on the wrong body part, wrong surgical procedure, unintentionally retained foreign objects and surgery on the wrong patient. Researchers classified 19.4% of NEs as 'wholly preventable'. Those most included in this category were surgery on the wrong body part or patient, wrong surgical procedure, improper administration of a potassium-containing solution and wrong-route administration of medication (excluding chemotherapy). CONCLUSIONS To improve collaboration and facilitate learning from errors, we need a single list that focuses on the most preventable and serious NEs. Our review shows that surgery on the wrong body part or patient, or the wrong surgical procedure best meet these criteria.
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Affiliation(s)
- Cara L Bowman
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Ria De Gorter
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Joanna Zaslow
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Jacqueline H Fortier
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Gary Garber
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
- Department of Medicine, and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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2
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Ferorelli D, Benevento M, Vimercati L, Spagnolo L, De Maria L, Caputi A, Zotti F, Mandarelli G, Dell'Erba A, Solarino B. Improving Healthcare Workers' Adherence to Surgical Safety Checklist: The Impact of a Short Training. Front Public Health 2022; 9:732707. [PMID: 35211450 PMCID: PMC8860967 DOI: 10.3389/fpubh.2021.732707] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 12/30/2021] [Indexed: 12/04/2022] Open
Abstract
Background Although surgery is essential in healthcare, a significant number of patients suffer unfair harm while undergoing surgery. Many of these originate from failures in non-technical aspects, especially communication among operators. A surgical safety checklist is a simple tool that helps to reduce surgical adverse events, but even if it is fast to fill out, its compilation is often neglected by the healthcare workers because of unprepared cultural background. The present study aims to value the efficacy of a free intervention, such as a short training about risk management and safety checklist, to improve checklist adherence. Methods In March 2019, the medical and nursing staff of the General Surgical Unit attended a two-lesson theoretical training concerning surgical safety and risk management tools such as the surgical safety checklist. The authors compared the completeness of the surgical checklists after and before the training, considering the same period (2 months) for both groups. Result The surgical safety checklists were present in 198 cases (70.97%) before the intervention and 231 cases (96.25%) after that. After the training, the compilation adherence increased for every different type of healthcare worker of the unit (surgeons, nurses, anesthetists, and scrab nurses). Furthermore, a longer hospitalization was associated with a higher surgical checklist adherence by the operators. Conclusions The results showed that a free and simple intervention, such as a two-lesson training, significantly stimulated the correct use of the surgical safety checklist. Moreover, the checklist adherence increased even for the operators who did not attend the training, maybe because of the positive influence of the colleagues' positive behaviors. As the results were promising with only two theoretical lessons, much more can be done to build a new safety culture in healthcare.
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Affiliation(s)
- Davide Ferorelli
- Section of Legal Medicine, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Marcello Benevento
- Section of Legal Medicine, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Luigi Vimercati
- Section of Occupational Medicine, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Lorenzo Spagnolo
- Section of Legal Medicine, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Luigi De Maria
- Section of Occupational Medicine, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Antonio Caputi
- Section of Occupational Medicine, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Fiorenza Zotti
- Section of Clinical Risk Management, Policlinico University Hospital of Bari, Bari, Italy
| | - Gabriele Mandarelli
- Section of Criminology and Forensic Psychiatry, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Alessandro Dell'Erba
- Section of Legal Medicine, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Biagio Solarino
- Section of Legal Medicine, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
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Wood DP, Robinson CA, Nathan R, McPhillips R. A study of the implementation of patient safety policies in the NHS in England since 2000: what can we learn? J Health Organ Manag 2022; ahead-of-print. [PMID: 35298879 DOI: 10.1108/jhom-02-2021-0073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Despite repeated policy initiatives, progress in improving patient safety in the National Health Service (NHS) in England over the past two decades has been slow. The NHS Patient Safety Strategy (NHS England and NHS Improvement, 2019), which is being implemented currently, aims to address this problem. The purpose of this study is to identify learning from the implementation of past patient safety policies and thereby suggest means of supporting the NHS in delivering the current policy initiative successfully. DESIGN/METHODOLOGY/APPROACH The authors identified key health policies in the domain of patient safety, published since 2000, by searching the United Kingdom (UK) government website. Discussion papers from the research literature concerning these policies were collated and reviewed. The authors then used a thematic analysis approach to identify themes discussed within these papers. These themes represent factors that support the effective delivery of patient safety policy initiatives. FINDINGS Within the discussion papers the authors collated, concerning 11 patient safety policies implemented between 2000 and 2017, five inter-related core themes of capability, culture, systems, candour and leadership were identified. By evaluating these themes and identifying composite sub-themes, a conceptual framework is presented that can be used to support the delivery of patient safety policy initiatives to maximise their impact. ORIGINALITY/VALUE The conceptual framework the authors illustrate, arising from this new contribution to the body of knowledge, can be translated into a novel self-assessment for individual NHS trusts to understand organisational development areas in the domain of patient safety improvement.
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Affiliation(s)
- David Phillip Wood
- The University of Manchester, Manchester, UK.,Cheshire and Wirral Partnership NHS Foundation Trust, Chester, UK
| | | | - Rajan Nathan
- Cheshire and Wirral Partnership NHS Foundation Trust, Chester, UK
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4
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Schwappach DLB, Pfeiffer Y. Registration and Management of "Never Events" in Swiss Hospitals-The Perspective of Clinical Risk Managers. J Patient Saf 2021; 17:e1019-e1025. [PMID: 32590527 PMCID: PMC8612887 DOI: 10.1097/pts.0000000000000741] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In Switzerland, there is no mandatory reporting of "never events." Little is known about how hospitals in countries with no "never event" policies deal with these incidents in terms of registration and analyses. OBJECTIVE The aim of our study was to explore how hospitals outside mandatory "never event" regulations identify, register, and manage "never events" and whether practices are associated with hospital size. METHODS Cross-sectional survey data were collected from risk managers of Swiss acute care hospitals. RESULTS Clinical risk managers representing 95 hospitals completed the survey (55% response rate). Among responding risk and quality managers, only 45% would be formally notified through a designated reporting channel if a "never event" has happened in their hospital. Averaged over a list of 8 specified events, only half of hospitals could report a systematic count of the number of events. Hospital size was not associated with "never event" management. Respondents reported that their hospital pays "too little attention" to the recording (46%), the analysis (34%), and the prevention (40%) of "never events." All respondents rated the systematic registration and analysis of "never events" as very (81%) or rather important (19%) for the improvement of patient safety. CONCLUSIONS A substantial fraction of Swiss hospitals do not have valid data on the occurrence of "never events" available and do not have reliable processes installed for the registration and exam of these events. Surprisingly, larger hospitals do not seem to be better prepared for "never events" management.
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Affiliation(s)
- David L. B. Schwappach
- From the Swiss Patient Safety Foundation, Zurich
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
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5
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Hegarty J, Flaherty SJ, Saab MM, Goodwin J, Walshe N, Wills T, McCarthy VJ, Murphy S, Cutliffe A, Meehan E, Landers C, Lehane E, Lane A, Landers M, Kilty C, Madden D, Tumelty M, Naughton C. An International Perspective on Definitions and Terminology Used to Describe Serious Reportable Patient Safety Incidents: A Systematic Review. J Patient Saf 2021; 17:e1247-e1254. [PMID: 32271529 PMCID: PMC8612884 DOI: 10.1097/pts.0000000000000700] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Patients are unintentionally, yet frequently, harmed in situations that are deemed preventable. Incident reporting systems help prevent harm, yet there is considerable variability in how patient safety incidents are reported. This may lead to inconsistent or unnecessary patterns of incident reporting and failures to identify serious patient safety incidents. This systematic review aims to describe international approaches in relation to defining serious reportable patient safety incidents. METHODS Multiple electronic and gray literature databases were searched for articles published between 2009 and 2019. Empirical studies, reviews, national reports, and policies were included. A narrative synthesis was conducted because of study heterogeneity. RESULTS A total of 50 articles were included. There was wide variation in the terminology used to represent serious reportable patient safety incidents. Several countries defined a specific subset of incidents, which are considered sufficiently serious, yet preventable if appropriate safety measures are taken. Terms such as "never events," "serious reportable events," or "always review and report" were used. The following dimensions were identified to define a serious reportable patient safety incident: (1) incidents being largely preventable; (2) having the potential for significant learning; (3) causing serious harm or have the potential to cause serious harm; (4) being identifiable, measurable, and feasible for inclusion in an incident reporting system; and (5) running the risk of recurrence. CONCLUSIONS Variations in terminology and reporting systems between countries might contribute to missed opportunities for learning. International standardized definitions and blame-free reporting systems would enable comparison and international learning to enhance patient safety.
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Affiliation(s)
| | | | | | - John Goodwin
- From the Catherine McAuley School of Nursing and Midwifery
| | - Nuala Walshe
- From the Catherine McAuley School of Nursing and Midwifery
| | - Teresa Wills
- From the Catherine McAuley School of Nursing and Midwifery
| | | | - Siobhan Murphy
- From the Catherine McAuley School of Nursing and Midwifery
| | - Alana Cutliffe
- From the Catherine McAuley School of Nursing and Midwifery
| | - Elaine Meehan
- From the Catherine McAuley School of Nursing and Midwifery
| | - Ciara Landers
- From the Catherine McAuley School of Nursing and Midwifery
| | - Elaine Lehane
- From the Catherine McAuley School of Nursing and Midwifery
| | - Aoife Lane
- From the Catherine McAuley School of Nursing and Midwifery
| | | | - Caroline Kilty
- From the Catherine McAuley School of Nursing and Midwifery
| | | | - Mary Tumelty
- School of Law, University College Cork, Cork, Ireland
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Anderson JE, Watt AJ. Using Safety-II and resilient healthcare principles to learn from Never Events. Int J Qual Health Care 2020; 32:196-203. [PMID: 32175571 DOI: 10.1093/intqhc/mzaa009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/09/2019] [Accepted: 02/05/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Conduct a secondary analysis of root cause analysis (RCA) reports of Never Events to determine whether and how Safety-II/resilient healthcare principles could contribute to improving the quality of investigation reports and therefore preventing future Never Events. DESIGN Qualitative and quantitative retrospective analysis of RCA reports. SETTING A large acute healthcare Trust in London. PARTICIPANTS None. INTERVENTIONS None. MAIN OUTCOME MEASURE Quality of RCA reports, robustness of actions proposed. RESULTS RCA reports had low-to-moderate effectiveness ratings and low resilience ratings. Reports identified many system vulnerabilities that were not addressed in the actions proposed. Using a Safety-II/resilient healthcare lens to examine work-as-done and misalignments between demand and capacity would strengthen analysis of Never Events. CONCLUSION Safety-II/Resilient Healthcare concepts can increase the quality of RCA reports and focus attention on prospectively strengthening systems. Recommendations for incorporating Safety-II concepts into RCA processes are provided.
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Affiliation(s)
- Janet E Anderson
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Centre for Applied Resilience in Healthcare, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK
| | - Alison J Watt
- Human Factors and Complex Systems, Loughborough Design School, Loughborough University, Leicestershire LE11 3TU, UK
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7
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Albolino S, Bellandi T, Cappelletti S, Di Paolo M, Fineschi V, Frati P, Offidani C, Tanzini M, Tartaglia R, Turillazzi E. New Rules on Patient's Safety and Professional Liability for the Italian Health Service. Curr Pharm Biotechnol 2020; 20:615-624. [PMID: 30961486 DOI: 10.2174/1389201020666190408094016] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/27/2018] [Accepted: 12/16/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND The phenomenon of clinical negligence claims has rapidly spread to United States, Canada and Europe assuming the dimensions and the severity of a pandemia. Consequently, the issues related to medical malpractice need to be studied from a transnational perspective since they raise similar problems in different legal systems. METHODS Over the last two decades, medical liability has become a prominent issue in healthcare policy and a major concern for healthcare economics in Italy. The failures of the liability system and the high cost of healthcare have led to considerable legislative activity concerning medical malpractice liability, and a law was enacted in 2012 (Law no. 189/2012), known as the "Balduzzi Law". RESULTS The law tackles the mounting concern over litigation related to medical malpractice and calls for Italian physicians to follow guidelines. Briefly, the law provided for the decriminalisation of simple negligence of a physician on condition that he/she followed the guidelines and "good medical practice" while carrying out his/her duties, whilst the obligation for compensation, as defined by the Italian Civil Code, remained. Judges had to consider that the physician followed the provisions of the guidelines but nevertheless caused injury to the patient. CONCLUSION However, since the emission of the law, thorny questions remain which have attracted renewed interest and criticism both in the Italian courts and legal literature. Since then, several bills have been presented on the topic and these have been merged into a single text entitled "Regulations for healthcare and patient safety and for the professional responsibility of healthcare providers".
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Affiliation(s)
- Sara Albolino
- Regional Centre for Clinical Risk Management and Patient Safety, Florence, Italy
| | - Tommaso Bellandi
- Regional Centre for Clinical Risk Management and Patient Safety, Florence, Italy
| | - Simone Cappelletti
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Marco Di Paolo
- Section of Legal Medicine, Department of Surgical Pathology, Medical, Molecular and Critical Area, University of Pisa, Pisa, Italy
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli, Italy
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli, Italy
| | - Caterina Offidani
- Unit of Legal Medicine, Bambino Gesu Children's Hospital, IRCCS, P.za Sant'Onofrio 4, Rome, Italy
| | - Michela Tanzini
- Regional Centre for Clinical Risk Management and Patient Safety, Florence, Italy
| | - Riccardo Tartaglia
- Regional Centre for Clinical Risk Management and Patient Safety, Florence, Italy
| | - Emanuela Turillazzi
- Section of Legal Medicine, Department of Surgical Pathology, Medical, Molecular and Critical Area, University of Pisa, Pisa, Italy
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Klein LW, Harjai KJ, Resnic F, Weintraub WS, Vernon Anderson H, Yeh RW, Feldman DN, Gigliotti OS, Rosenfeld K, Duffy P. 2016 Revision of the SCAI position statement on public reporting. Catheter Cardiovasc Interv 2016; 89:269-279. [PMID: 27755653 DOI: 10.1002/ccd.26818] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 10/08/2016] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - Fred Resnic
- Lahey Hospital and Medical Center, Burlington, Massachusetts.,Tufts University School of Medicine, Boston, Massachusetts
| | | | - H Vernon Anderson
- University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas
| | - Robert W Yeh
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Dmitriy N Feldman
- New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | | | - Kenneth Rosenfeld
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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