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Šimunović A, Kranjčec K, Pekas M, Tomić S. Analysis of health care professionals' incident reports on medical devices in Croatia. Croat Med J 2023; 64:265-271. [PMID: 37654038 PMCID: PMC10509688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 07/24/2023] [Indexed: 09/02/2023] Open
Abstract
AIM To assess the quantity and quality of incident reports on medical devices by health care professionals from 2012 to 2021 and evaluate the effect of reporting on manufacturers' post-market surveillance. METHODS Eighty-five incident reports were scored according to a self-developed evaluation system, and categorized as excellent, good, medium, qualified, and unqualified. The completeness of data in critical fields was assessed. For each report, the type and city of the reporter, and medical device risk class were extracted to calculate the frequency of report occurrence per risk class and outcomes for reportable reports. RESULTS The number of reports received from health care professionals was low; the highest number of reports in a year was 17. The majority of reports were deemed as unqualified (61.18%) and only 4.71% as excellent. Still, 67.65% of incident reports importantly affected the manufacturer's post-market surveillance, either as added information that contributes to risk monitoring or directly triggering a field safety corrective action. CONCLUSION The number of total reports and reports per year shows extensive underreporting in Croatia, and the quality of the provided reports is insufficient.
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Affiliation(s)
- Antonela Šimunović
- Antonela Šimunović, Croatian Agency for Medicinal Products and Medical Devices, Ksaverska cesta 4, 10000 Zagreb, Croatia,
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Sapkota B, Palaian S, Shrestha S, Ibrahim MIM. Materiovigilance in Perspective: Understanding Its Concept and Practice in the Global Healthcare System. Ther Innov Regul Sci 2023; 57:886-898. [PMID: 37106236 PMCID: PMC10139667 DOI: 10.1007/s43441-023-00514-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/21/2023] [Indexed: 04/29/2023]
Abstract
Materiovigilance (Mv) has the same purpose and approach in ensuring patient safety as pharmacovigilance but deals with medical devices associated with adverse events (MDAEs) and their monitoring. Mv has been instrumental in recalling many defective or malfunctioning devices based on their safety data. All MDAEs, such as critical or non-critical, known, or unknown, those with inadequate or incomplete specifications, and frequent or rare events should be reported and evaluated. Mv helps to improve medical devices' design and efficiency profile and avoid device-related complications and associated failures. It alerts consumers and health professionals regarding counterfeit or substandard devices. Common events reported through Mv are device breakage and malfunction, entry- and exit-site infections, organ perforations or injuries, need for surgery and even death, and life cycle assessment of devices. Health authorities globally have developed reporting frameworks with timeframes for MDAEs, such as MedWatch in the USA, MedSafe in New Zealand, and others. Health professionals and consumers need to be made aware of the significance of Mv in ensuring the safe use of medical devices and getting familiar with the reporting procedures and action plans in case of a device-induced adverse event.
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Affiliation(s)
- Binaya Sapkota
- Faculty of Health Sciences, Nobel College, Sinamangal, Kathmandu, Nepal
- Jeffrey Sachs Center On Sustainable Development, Sunway University, Sunway, Selangor Malaysia
| | - Subish Palaian
- Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emirates
| | - Sunil Shrestha
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, 47500 Sunway, Selangor Malaysia
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Falcone ML, Van Stee SK, Tokac U, Fish AF. Adverse Event Reporting Priorities: An Integrative Review. J Patient Saf 2022; 18:e727-e740. [PMID: 35617598 DOI: 10.1097/pts.0000000000000945] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Adverse events remain the third leading cause of death in hospitals today, after heart disease and cancer. However, adverse events remain underreported. The purpose of this integrative review is to synthesize adverse event reporting priorities in acute care hospitals from quantitative, qualitative, and mixed-methods research articles. METHODS A comprehensive review of articles was conducted using nursing, medicine, and communication databases between January 1, 1999, and May 3, 2021. The literature was described using standard reporting criteria. RESULTS Twenty-nine studies met the eligibility criteria. Four key priorities emerged: understanding and reducing barriers, improving perceptions of adverse event reporting within healthcare hierarchies, improving organizational culture, and improving outcomes measurement. CONCLUSIONS A paucity of literature on adverse event reporting within acute care hospital settings was found. Perceptions of fear of blaming and retaliation, lack of feedback, and comfort level of challenging someone more powerful present the greatest barriers to adverse event reporting. Based on qualitative studies, obtaining trusting relationships and sustaining that trust, especially in hierarchical healthcare systems, are difficult to achieve. Given that patient safety training is a common strategy clinically to improve organizational culture, only 4 published articles examined its effectiveness. Further research in acute care hospitals is needed on all 4 key priorities. The findings of this review may ultimately be used by clinicians and researchers to reduce adverse events and develop future research questions.
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Affiliation(s)
| | - Stephanie K Van Stee
- Department of Communication and Media, University of Missouri-St Louis, St Louis, Missouri
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Sivagourounadin K, Rajendran P, Ravichandran M. Knowledge, Attitude, and Practice of Materiovigilance among Nurses at a Tertiary Care Hospital in South India: A Cross-Sectional Study. J Pharm Bioallied Sci 2022; 14:162-167. [PMID: 36506730 PMCID: PMC9728064 DOI: 10.4103/jpbs.jpbs_274_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/19/2021] [Accepted: 04/19/2021] [Indexed: 12/15/2022] Open
Abstract
Background and Objective Inadequate knowledge and underreporting of medical device-associated adverse events (MDAEs) were observed among health-care professionals (HCPs) in studies carried out in other countries. In India, HCP's knowledge, attitude, and practice (KAP) regarding materiovigilance have not been explored extensively. Hence, the present study was carried out to assess KAP of materiovigilance among nurses working in a tertiary care teaching hospital in South India. Materials and Methods This is a descriptive, cross-sectional study conducted among nurses. A self-administered, validated questionnaire was distributed to 420 nurses. Data were analyzed using the Statistical Package for the Social Sciences software version 21.0. Kruskal-Wallis test was used to compare KAP score of materiovigilance among the study participants. Results A total of 400 (95.2%) responses were received. About 65.7% (n = 263) of nurses were having adequate knowledge about the various aspects of materiovigilance and 80.5% (n = 322) of nurses had a positive attitude toward MDAE reporting. However, only 18 (4.5%) of nurses have reported about MDAEs. Further, factors such as uncertainty on how to report a MDAE and concerns about their legal issues significantly led to underreporting of MDAEs. Conclusion The transition of adequate knowledge and positive attitude to good practice of MDAE reporting was lacking among the study participants. Hence, with due consideration of these deficits and the various factors influencing MDAE reporting, it is necessary to conduct periodical workshops and training sessions for HCPs to enhance their spontaneous reporting of MDAEs.
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Affiliation(s)
- Kiruthika Sivagourounadin
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Karaikal (JIPMER Karaikal), Puducherry, India,Address for correspondence: Dr. Kiruthika Sivagourounadin, Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Karaikal (JIPMER Karaikal), Puducherry - 605 107, India. E-mail:
| | - Priyadharsini Rajendran
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Mirunalini Ravichandran
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Porte PJ, Smits M, Verweij LM, de Bruijne MC, van der Vleuten CPM, Wagner C. The Incidence and Nature of Adverse Medical Device Events in Dutch Hospitals: A Retrospective Patient Record Review Study. J Patient Saf 2021; 17:e1719-e1725. [PMID: 32168269 DOI: 10.1097/pts.0000000000000620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Despite widespread use of medical devices and their increasing complexity, their contribution to unintended injury caused by healthcare (adverse events, AEs) remains relatively understudied. The aim of this study was to gain insight in the incidence and types of AEs involving medical devices (AMDEs). METHODS Data from two patient record studies for the identification of AEs were used. Identification of AMDEs was part of these studies. Patient records of 6894 admissions of a random sample of 20 hospitals in 2011/2012 and 19 hospitals in 2015/2016 were reviewed for AMDEs by trained nurses and physicians. RESULTS In 98.7% of the admissions, a medical device was used. Adverse events involving medical devices were present in 2.8% of the admissions, with 24% of the AMDEs being potentially preventable. Of all AEs, in 40%, medical devices were involved. Of all potentially preventable AEs, in 44%, medical devices were involved. Implants were most often involved in potentially preventable AMDEs. CONCLUSIONS Medical devices are substantially involved in potentially preventable AEs in hospitals. Research into AMDEs is of great importance because of the increasing use and complexity of medical devices. Based on patient records, most improvements could be made for placement of implants and prevention of infections related to medical devices. Safety and safe use of medical devices should be a subject of attention and further research.
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Affiliation(s)
| | | | | | - Martine C de Bruijne
- From the Department of Public and Occupational Health, Amsterdam Public Health Research Institute (APH), Amsterdam UMC, VU University Medical Center, Amsterdam
| | - Cees P M van der Vleuten
- Department of Educational Development and Research, University of Maastricht, Maastricht, the Netherlands
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Tase A, Buckle P, Ni MZ, Hanna GB. Medical device error and failure reporting: Learning from the car industry. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2021. [DOI: 10.1177/25160435211008273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Improving the design of technology relies in part, on the reporting of performance failures in existing devices. Healthcare has low levels of formal reporting of performance and failure of medical equipment. This paper examines methods of reporting in the car industry and healthcare and aims to understand differences and identify opportunities for improvement within healthcare. Methods A literature search was carried out in Pubmed, Medline, Embase, Engineering Village, Scopus. NHS England and MHRA publications and guidelines were also reviewed. Focus was placed on the current system of reporting in both industries, known degree of patient harm, initiating factors, barriers, quality and methods of incident investigation and their validity. The findings were used to compare error reporting system in the two industries. Results Derivation of healthcare incident data from different sources means the full extent of patient harm is not known. For example, in 2012 there were 13,549 and 38,395 incidents reported by MHRA and NRLS (National Reporting and Learning System) respectively leading to uncertainties on the extent of the problem. The car industry emphasises the role of reporting source in ensuring data quality. Utilising some aspects of this approach might benefit healthcare reporting. These include a specific reporting system that stresses the importance of organisational learning in improving safety and recognises the limitations of root cause analysis. Conclusions Learning from reporting systems within the car industry may help the healthcare sector improve its own reporting, aiding healthcare performance.
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Abstract
The risk of medication errors with infusion pumps is well established, yet a better understanding is needed of the scenarios and factors associated with the errors. Our study explored the frequency of medication errors with infusion pumps, based on events reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) during calendar year 2018. Our study identified a total of 1,004 events involving a medication error and use of an infusion pump, which occurred at 132 different hospitals in Pennsylvania. Fortunately, a majority of medication errors did not cause patient harm or death; however, we did find that 22% of events involved a high-alert medication. Our study shows that the frequency of events varies widely across the stages of medication process and types of medication error. In a subset of our data, we manually reviewed a free-text narrative field in each event report to better understand the nature of errors. For example, we found that a majority of wrong rate errors led to medication being infused at a faster rate than intended, and user programming was the most common contributing factor. Overall, results from our study can help providers identify areas to target for risk mitigation related to medication errors and the use of infusion pumps.
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Gagliardi AR, Ducey A, Lehoux P, Turgeon T, Ross S, Trbovich P, Easty A, Bell C, Urbach D. Factors influencing the reporting of adverse medical device events: qualitative interviews with physicians about higher risk implantable devices. BMJ Qual Saf 2017; 27:190-198. [PMID: 28768712 PMCID: PMC5867432 DOI: 10.1136/bmjqs-2017-006481] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Postmarket surveillance of medical devices is reliant on physician reporting of adverse medical device events (AMDEs). Little is known about factors that influence whether and how physicians report AMDEs, an essential step in developing behaviour change interventions. This study explored factors that influence AMDE reporting. METHODS Qualitative interviews were conducted with physicians who differed by specialties that implant cardiovascular and orthopaedic devices prone to AMDEs, geography and years in practice. Participants were asked if and how they reported AMDEs, and the influencing factors. Themes were identified inductively using constant comparative technique, and reviewed and discussed by the research team on four occasions. RESULTS Twenty-two physicians of varying specialty, region, organisation and career stage perceived AMDE reporting as unnecessary, not possible or futile due to multiple factors. Physicians viewed AMDEs as an expected part of practice that they could manage by switching to different devices or developing work-around strategies for problematic devices. Physician beliefs and behaviour were reinforced by limited healthcare system capacity and industry responsiveness. The healthcare system lacked processes and infrastructure to detect, capture, share and act on information about AMDEs, and constrained device choice through purchasing contracts. The device industry did not respond to reports of AMDEs from physicians or improve their products based on such reports. As a result, participants said they used devices that were less than ideal for a given patient, leading to suboptimal patient outcomes. CONCLUSIONS There may be little point in solely educating or incentivising individual physicians to report AMDEs unless environmental conditions are conducive to doing so. Future research should explore policies that govern AMDEs and investigate how to design and implement postmarket surveillance systems.
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Affiliation(s)
- Anna R Gagliardi
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
| | - Ariel Ducey
- Department of Sociology, University of Calgary, Calgary, Canada
| | - Pascale Lehoux
- Département d'administration de la santé, Université de Montréal, Montreal, Canada
| | - Thomas Turgeon
- Concordia Hip and Knee Institute, Concordia Hospital, Winnipeg, Canada
| | - Sue Ross
- Women & Children's Health Research Institute, University of Alberta, Edmonton, Canada
| | - Patricia Trbovich
- Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
| | - Anthony Easty
- Institute of Biomaterials & Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Chaim Bell
- Division of General Internal Medicine, Sinai Health System, Toronto, Canada
| | - David Urbach
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
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Hong S, Li Q. The reasons for Chinese nursing staff to report adverse events: a questionnaire survey. J Nurs Manag 2017; 25:231-239. [PMID: 28244248 DOI: 10.1111/jonm.12461] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Su Hong
- The 2 Affiliated Hospital & College of Nursing; Harbin Medical University; Harbin China
| | - QiuJie Li
- The 2 Affiliated Hospital & College of Nursing; Harbin Medical University; Harbin China
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Chen LC, Wang LH, Redley B, Hsieh YH, Chu TL, Han CY. A Study on the Reporting Intention of Medical Incidents: A Nursing Perspective. Clin Nurs Res 2017; 27:560-578. [DOI: 10.1177/1054773817692179] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Medical incidents threaten patients’ lives and health, increase medical costs, and can lead to medical disputes. A high proportion of medical incidents are not reported. The aim of this study was to explore the factors influencing nurses’ reporting of medical incidents. The cross-sectional survey design used a self-administered 47-item questionnaire to survey 835 nurses in three hospitals in Taiwan between January and December 2014. The intention among nurses to report medical incidents was high (3.86/5); nurses’ intention to report medical incidents was positively correlated ( r = .34, p < .0001) with their attitude about reporting, awareness of reporting ( r = .37, p < .0001), and support from interested parties ( r = .12, p = .001), and was negatively correlated with positive incentives ( r = -.14, p < .0001) and negative incentives ( r = .29, p < .0001). Nurses’ awareness and a supportive work environment affect nurses’ willingness to voluntarily report medical incidents; hence, they are critical considerations as Taiwan moves toward systems of mandatory reporting.
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Affiliation(s)
- Li-Chin Chen
- Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- Chang Gung University of Science and Technology, Taoyuan City, Taiwan
| | - Li-Hsiang Wang
- Chang Gung University of Science and Technology, Taoyuan City, Taiwan
- Chang Gung University, Taoyuan City, Taiwan
| | | | | | - Tsung-Lan Chu
- Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- Chang Gung University of Science and Technology, Taoyuan City, Taiwan
| | - Chin-Yen Han
- Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- Chang Gung University of Science and Technology, Taoyuan City, Taiwan
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