Experiences from ten years of incident reporting in health care: a qualitative study among department managers and coordinators

Is It Still Time for Safety Walkaround? Pilot Project Proposing a New Model and a Review of the Methodology

Background and Objectives: Healthcare facilities are complex systems due to the interaction between different factors (human, environmental, management, and technological). As complexity increases, it is known that the possibility of error increases; therefore, it becomes essential to be able to analyze the processes that occur within these contexts to prevent their occurrence, which is the task of risk management. For this purpose, in this feasibility study, we chose to evaluate the application of a new safety walkaround (SWA) model. Materials and Methods: A multidisciplinary working group made up of experts was established and then the subsequent phases of the activity were divided into three stages, namely the initial meeting, the operational phase, and the final meeting, to investigate knowledge regarding patient safety before and subsequently through visits to the department: the correct compilation of the medical record, adherence to evidence-based medicine (EBM) practices, the overall health and the degree of burnout of the various healthcare professionals, as well as the perception of empathy of staff by patients. Results: This working group chose to start this pilot project in the vascular surgery ward, demonstrating the ability of the tool used to capture the different aspects it set out to collect. In detail, the new version of SWA proposed in this work has made it possible to identify risk situations and system vulnerabilities that have allowed the introduction of corrective tools; detect adherence to existing company procedures, reschedule training on these specific topics after reviewing, and possibly update the same procedures; record the patient experience about the doctor-patient relationship and communication to hypothesize thematic courses on the subject; evaluate workers' perception of their health conditions about work, and above all reassure operators that their well-being is in the interest of the management of the healthcare company, which is maintained. Conclusions: Therefore, the outcome of the present study demonstrates the versatility and ever-present usefulness of the SWA tool.

Patient Safety Incidents in Primary Care: Comparing APEAS-2007 (Spanish Patient Safety Adverse Events Study in Primary Care) with Data from a Health Area in Catalonia (Spain) in 2019

The initial APEAS study, conducted in June 2007, examined adverse events (AEs) in Spanish Primary Healthcare (PHC). Since then, significant changes have occurred in healthcare systems. To evaluate these changes, a study was conducted in the Camp de Tarragona PHC region (CTPHC) in June 2019. This cross-sectional study aimed to identify AEs in 20 PHC centres in Camp de Tarragona. Data collection used an online questionnaire adapted from APEAS-2007, and a comparative statistical analysis between APEAS-2007 and CTPHC-2019 was performed. The results revealed an increase in nursing notifications and a decrease in notifications from family doctors. Furthermore, fewer AEs were reported overall, particularly in medication-related incidents and healthcare-associated infections, with an increase noted in no-harm incidents. However, AEs related to worsened clinical outcomes, communication issues, care management, and administrative errors increased. Concerning severity, there was a decrease in severe AEs, coupled with an increase in moderate AEs. Despite family doctors perceiving a reduction in medication-related incidents, the overall preventability of AEs remained unchanged. In conclusion, the reporting patterns, nature, and causal factors of AEs in Spanish PHC have evolved over time. While there has been a decrease in medication-related incidents and severe AEs, challenges persist in communication, care management, and clinical outcomes. Although professionals reported reduced severity, the perception of preventability remains an area that requires attention.

Staff Experiences in Managing Incidents in Nursing Homes: A Descriptive Qualitative Study

Introduction

Adverse incidents in nursing home (NH) may occur as the result of inadequate monitoring for signs of unobservable initial complications, medical errors, improper nursing interventions, lack of communication, and inadequate reporting.

Purpose

This study explores incident types, causes, handling, and documentation in Indonesian NHs through a qualitative approach.

Patients and Methods

In-depth interviews were conducted with 23 NH staff members, including managers, nurses, and support staff.

Results

Five themes and 17 sub-themes emerged, with falls and resident-to-resident abuse as common adverse incidents. Causes included older adults' conditions, environment, and misunderstanding. Follow-up action included first aid, hospital referrals, and assertive communication. Adverse incidents were actively reported through verbal and written reports or WhatsApp groups. Reports and documentation remain unstructured, however, as there were no standard operating procedures regarding incident reporting, documentation, and the types of adverse incidents that staff should report.

Conclusion

Improvements in management, documentation, and reporting adverse incidents are highlighted in this research. Practitioners, nurses, and social workers should develop guidelines for handling, reporting, and documenting adverse incidents in NHs.

Analysis of health care professionals' incident reports on medical devices in Croatia

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.

Learning from experience: a qualitative study of surgeons' perspectives on reporting and dealing with serious adverse events

INTRODUCTION

In surgery, serious adverse events have effects on the patient journey, the patient outcome and may constitute a burden to the surgeon involved. This study aims to investigate facilitators and barriers to transparency around, reporting of and learning from serious adverse events among surgeons.

METHODS

Based on a qualitative study design, we recruited 15 surgeons (4 females and 11 males) with 4 different surgical subspecialties from four Norwegian university hospitals. The participants underwent individual semistructured interviews and data were analysed according to principles of inductive qualitative content analysis.

RESULTS AND DISCUSSION

We identified four overarching themes. All surgeons reported having experienced serious adverse events, describing these as part of 'the nature of surgery'. Most surgeons reported that established strategies failed to combine facilitation of learning with taking care of the involved surgeons. Transparency about serious adverse events was by some felt as an extra burden, fearing that openness on technical-related errors could affect their future career negatively. Positive implications of transparency were linked with factors such as minimising the surgeon's feeling of personal burden with positive impact on individual and collective learning. A lack of facilitation of individual and structural transparency factors could entail 'collateral damage'. Our participants suggested that both the younger generation of surgeons in general, and the increasing number of women in surgical professions, might contribute to 'maturing' the culture of transparency.

CONCLUSION AND IMPLICATIONS

This study suggests that transparency associated with serious adverse events is hampered by concerns at both personal and professional levels among surgeons. These results emphasise the importance of improved systemic learning and the need for structural changes; it is crucial to increase the focus on education and training curriculums and offer advice on coping strategies and establish arenas for safe discussions after serious adverse events.

The effect of refresher training on fact description in medical incident report writing in the Japanese language

To maintain the effectiveness of the training (1st-Training Session: 1st-TS) to accurate describe facts in the medical incident reports (IRs) in Japanese, a refresher TS was designed and its effectiveness was examined. First, textual analysis showed that IRs' accuracy significantly decreased six months after the 1st-TS. Based on this result, the refresher TS was designed and conducted with 64 residents. To verify the refresher TS' effectiveness, IRs after the 1st-TS, six months later, and after the refresher TS were compared via text analysis. The results showed that the refresher TS restored the description rate of patient's background, safety check procedures, original work procedures, information on equipment used, reporter's actions, and post-incident response. The questionnaire was also administered and showed that the refresher TS contributed to residents' motivation to learn about IRs. In conclusion, the refresher TS contributed to sustaining the effect of the 1st-TS on accurately describing IRs.

Barriers and facilitators to improving patient safety learning systems: a systematic review of qualitative studies and meta-synthesis

BACKGROUND

The implementation and continuous improvement of patient safety learning systems (PSLS) is a principal strategy for mitigating preventable harm to patients. Although substantial efforts have sought to improve these systems, there is a need to more comprehensively understand critical success factors. This study aims to summarise the barriers and facilitators perceived by hospital staff and physicians to influence the reporting, analysis, learning and feedback within PSLS in hospitals.

METHODS

We performed a systematic review and meta-synthesis by searching MEDLINE (Ovid), EMBASE (Ovid), CINAHL, Scopus and Web of Science. We included English-language manuscripts of qualitative studies evaluating effectiveness of the PSLS and excluded studies evaluating specific individual adverse events, such as systems for tracking only medication side effects, for example. We followed the Joanna Briggs Institute methodology for qualitative systematic reviews.

RESULTS

We extracted data from 22 studies, after screening 2475 for inclusion/exclusion criteria. The included studies focused on reporting aspects of the PSLS, however, there were important barriers and facilitators across the analysis, learning and feedback phases. We identified the following barriers for effective use of PSLS: inadequate organisational support with shortage of resources, lack of training, weak safety culture, lack of accountability, defective policies, blame and a punitive environment, complex system, lack of experience and lack of feedback. We identified the following enabling factors: continuous training, a balance between accountability and responsibility, leaders as role models, anonymous reporting, user-friendly systems, well-structured analysis teams, tangible improvement.

CONCLUSION

Multiple barriers and facilitators to uptake of PSLS exist. These factors should be considered by decision makers seeking to enhance the impact of PSLS.

ETHICS AND DISSEMINATION

No formal ethical approval or consent were required as no primary data were collected.

Utilization of ChatGPT in Medical Education: Applications and Implications for Curriculum Enhancement

Background

The integration of artificial intelligence (AI) into medical education has sparked a paradigm shift in pedagogical approaches, reshaping the way medical knowledge is accessed, processed, and applied. Medical education is a dynamic field that demands continuous adaptation to the evolving healthcare landscape. ChatGPT, an advanced AI language model, with its natural language understanding and generation capabilities, offers a multifaceted toolset that enhances various aspects of medical education.

Objective

The objective of this paper is to explore how ChatGPT, an advanced AI language model, is transforming medical education by serving as a dynamic information resource and driving curriculum reform. It aims to highlight the multifaceted uses of ChatGPT and its potential to reshape the pedagogical landscape in medical education.

Methods

PubMed, Scopus, Web of Science, ERIC, and Google Scholar databases were searched to assess the literature that met the study objectives from 2019 to August 2023 with explicit inclusion and exclusion criteria.

Results

The results demonstrate that ChatGPT's applications in medical education are diverse and encompass real-time curriculum adaptation, personalized learning, and collaborative learning. Its capacity to provide immediate and contextually relevant information has the potential to enhance the quality of medical education significantly.

Conclusion

ChatGPT's integration into medical education represents a transformative shift in educational approaches. It offers a wide range of capabilities, from serving as a repository of medical knowledge to facilitating collaborative learning. As medical education continues to evolve, ChatGPT emerges as a powerful tool that can reshape pedagogy and drive meaningful curriculum reform to meet the needs of modern healthcare practice.ChatGPT emerges as a transformative tool that holds the potential to reshape the landscape of medical pedagogy and drive meaningful curriculum reform.

Assessing the healthcare quality issues for digital incident reporting in Sweden: Incident reports analysis

Objective

This study explored healthcare quality issues affecting the reporting and investigation levels of digital incident reporting systems.

Methods

A total of 38 health information technology-related incident reports (free-text narratives) were collected from one of Sweden's national incident reporting repositories. The incidents were analysed using an existing framework, i.e., the Health Information Technology Classification System, to identify the types of issues and consequences. The framework was applied in two fields, 'event description' by the reporters and 'manufacturer's measures', to assess the quality of reporting incidents by the reporters. Additionally, the contributing factors, i.e., either human or technical factors for both fields, were identified to evaluate the quality of the reported incidents.

Results

Five types of issues were identified and changes made between before-and-after investigations: Machine to software-related issues (n  =  8), machine to use-related issues (n  =  5), software to software-related issues (n  =  5), use to software-related issues (n  =  4) and use to use-related issues (n  =  1). Over two-thirds (n  =  15) of the incidents demonstrated a change in the contributing factors after the investigation. Only four incidents were identified as altering the consequences after the investigation.

Conclusion

This study shed some light on the issues of incident reporting and the gap between the reporting and investigation levels. Facilitating sufficient staff training sessions, agreeing on common terms for health information technology systems, refining the existing classifications systems, enforcing mini-root cause analysis, and ensuring unit-based local reporting and standard national reporting may help bridge the gap between reporting and investigation levels in digital incident reporting.

Electronic On-line Incident Reporting System (IRS) as a Tool for Risk Assessment in Radiation Therapy

Background

Radiotherapy is one of the primary treatment options in cancer management, together with surgery and chemotherapy. Radiation therapy is technologically complex discipline involving professionals with various specialties, and using high energy radiation in treatment of wide range of different cancer types. Technical complexity, increasing number of patients, large workload, and delivery of radiation therapy treatment with lack of human, technical and financial resources in low and middle income countries creates environment with great potential to develop incidents. Emerging need of modern radiation therapy is to develop preventive approach to risk management i to improve the patient safety.

Objective

The objective of this research is to identify and assess risk associated with radiation therapy practice in Bosnia and Herzegovina.

Methods

An anonymous, voluntary electronic on-line radiation therapy incident reporting system (IRS) was created. IRS consists of four sections containing questions about working environment, incident occurrence, root causes and contributing factors, and incident severity assessment. Data collected using IRS were used to create taxonomy of incidents in radiation therapy. Risk assessment was made using Risk Matrix method. Research was made using the data collected from first 60 incidents reported to IRS.

Results

Based on probability and frequency of incident occurrence and severity of consequences, it was assessed that 41.7% of incidents had low risk level (L), 50% of incidents had moderate risk level (M), and 8.3% of incidents had high risk level (H). Radiation therapy risk profile based on risk assessment results clearly shows that incidents with low frequency, low occurrence probability, but high consequences severity level have highest level of risk.

Conclusion

The results of this research confirm that the electronic on-line radiation therapy IRS allows the identification and classification of the most significant risk factors in radiotherapy and prevention of serious incidents occurrence.

Training residents in medical incident report writing to improve incident investigation quality and efficiency enables accurate fact gathering

We assessed whether training on writing readable and accurate medical incident reports (IRs) improves the quality of fact description. In this training, 124 residents created fictional IRs. We provided tips, including using When, Where, Who, What, Why, How. We compared the fictional IRs with and without tips, and the trainees' and non-trainees' IRs submitted in the first five months after training. Results indicated that the subject words in IRs were more clarified and the readability was improved. The fictional IRs using tips were more accurate, with increased descriptions of the patient's background, reporter's actions, team members' actions and conversations, safety check procedures, result of the error, and post-incident response. The reporter's actions, work procedures, and environment were more clarified in the trainees' IRs than in the non-trainees' IRs. This training may help analysts comprehend the sequence of and underlying factors for reporter's actions based on IRs.

Monitoring Preventable Adverse Events and Near Misses: Number and Type Identified Differ Depending on Method Used

OBJECTIVES

This study aimed to investigate how many preventable adverse events (PAEs) and near misses are identified through the methods structured record review, Web-based incident reporting (IR), and daily safety briefings, and to distinguish the type of events identified by each method.

METHODS

One year of retrospective data from 2017 were collected from one patient cohort in a 422-bed acute care hospital. Preventable adverse events and near misses were collected from the hospital's existing resources and presented descriptively as number per 1000 patient-days.

RESULTS

The structured record review identified 19.9 PAEs; the IR system, 3.4 PAEs; and daily safety briefings, 5.4 PAEs per 1000 patient-days. The most common PAEs identified by the record review method were drug-related PAEs, pressure ulcers, and hospital-acquired infections. The most common PAEs identified by the IR system and daily safety briefings were fall injury and pressure ulcers, followed by skin/superficial vessel injuries for the IR system and hospital-acquired infections for the daily safety briefings. Incident reporting and daily safety briefings identified 7.8 and 31.9 near misses per 1000 patient-days, respectively. The most common near misses were related to how care is organized.

CONCLUSIONS

The different methods identified different amounts and types of PAEs and near misses. The study supports that health care organizations should adopt multiple methods to get a comprehensive review of the number and type of events occurring in their setting. Daily safety briefings seem to be a particularly suitable method for assessing an organization's inherent security and may foster a nonpunitive culture.

Adverse Event Reporting Priorities: An Integrative Review

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.

Perceptions and knowledge of nurses on incident reporting systems: Exploratory study in three Northeastern Italian Departments

Reporting of adverse clinical events (IRs) is believed to be an effective methodology for optimizing health care safety, however, only 1%-3% of incidents are reported by healthcare professionals, lack of information resulting from errors/adverse events/near misses limits the development of safety and improvement measures. This study aimed to identify barrier factors/incentives to report adverse events and find possible improvement strategies and possible correlations between the population under examination and the willingness to report through Incident Reporting. An ad hoc questionnaire was used and administered to 122 nurses belonging to three different departments of an Italian hospital. The frequency with which improvement interventions are noted following an IR report (p = 0.014) and the support received from their managers (p = 0.014) in reporting are among the factors that can have the greatest impact on the use of IR among the respondents. The no-blame policies and the attention that nursing managers place on clinical risk management can influence the culture of safety among nurses. Involving nurse managers in the dissemination of the IR can represent a possible strategy to be undertaken by corporate clinical risk managers in order to increase the culture of safety among nurses.

How do healthcare practitioners use incident data to improve patient safety in Japan? A qualitative study

BACKGROUND

Patient incident reporting systems have been widely used for ensuring safety and improving quality in care settings in many countries. However, little is known about the way in which incident data are used by frontline clinical staff. Furthermore, while the use of a systems perspective has been reported as an effective way of learning from incident data in a multidisciplinary team, the level of adaptability of this perspective to a different cultural context has not been widely explored. The primary aim of the study, therefore, was to investigate how healthcare practitioners in Japan perceive the reporting systems and utilize a systems perspective in learning from incident data in acute care and mental health settings.

METHODS

A non-experimental, descriptive and exploratory research design was adopted with the following two data-collection methods: 1) Sixty-one semi-structured interviews with frontline staff in two hospitals; and 2) Non-participatory observations of thirty-seven regular incident review meetings. The two hospitals in the Greater Tokyo area which were invited to take part were: 1) a not-for-profit, privately-run, acute care hospital with approximately 500 beds; and 2) a publicly-run mental health hospital with 200 beds.

RESULTS

While the majority of staff acknowledge the positive impacts of the reporting systems on safety, the observation data found that little consideration was given to systems aspects during formal meetings. The meetings were primarily a place for the exchange of practical information, as opposed to in-depth discussions regarding causes of incidents and corrective measures. Learning from incident data was influenced by four factors: professional boundaries; dealing with a psychological burden; leadership and educational approach; and compatibility of patient safety with patient-centered care.

CONCLUSIONS

Healthcare organizations are highly complex, comprising of many professional boundaries and risk perceptions, and various communication styles. In order to establish an optimum method of individual and organizational learning and effective safety management, a fine balance has to be struck between respect for professional expertise in a local team and centralized safety oversight with a strong focus on systems. Further research needs to examine culturally-sensitive organizational and professional dynamics, including leader-follower relationships and the impact of resource constraints.

Enhancement of infection prevention case review process to optimize learning from defects

Hospitals continue to struggle with preventable healthcare-associated infections. Whereas the focus is generally on proactive prevention processes, performing retrospective case reviews of infections can identify opportunities for quality improvement and maximize learning from defects. This brief article provides practical information for structuring the case review process using readily available health system platforms. Using a structured approach for case reviews can help identify trends and opportunities for improvement.