Database design to ensure anonymous study of medical errors: a report from the ASIPS Collaborative

Determinants of out-of-hours service users' potentially inappropriate referral or non-referral to an emergency department: a retrospective cohort study in a local health authority, Veneto Region, Italy

BACKGROUND

A growing presence of inappropriate patients has been recognised as one of the main factors influencing emergency department (ED) overcrowding, which is a very widespread problem all over the world. On the other hand, out-of-hours (OOH) physicians must avoid delaying the diagnostic and therapeutic course of patients with urgent medical conditions. The aim of this study was to analyse the appropriateness of patient management by OOH services, in terms of their potentially inappropriate referral or non-referral of non-emergency cases to the ED.

METHODS

This was an observational retrospective cohort study based on data collected in 2011 by the local health authority No. 4 in the Veneto Region (Italy). After distinguishing between patients contacting the OOH service who were or were not referred to the ED, and checking for patients actually presenting to the ED within 24 hours thereafter, these patients' medical management was judged as potentially appropriate or inappropriate.

RESULTS

The analysis considered 22 662 OOH service contacts recorded in 2011. The cases of potentially inappropriate non-referral to the ED were 392 (1.7% of all contacts), as opposed to 1207 potentially inappropriate referrals (5.3% of all contacts). Age, nationality, type of disease and type of intervention by the OOH service were the main variables associated with the appropriateness of patient management.

CONCLUSIONS

These findings may be useful for pinpointing the factors associated with a potentially inappropriate patient management by OOH services and thus contribute to improving the deployment of healthcare and the quality of care delivered by OOH services.

International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process

BACKGROUND

Patient safety incident reporting systems (PSRS) have been established for over a decade, but uncertainty remains regarding the role that they can and ought to play in quantifying healthcare-related harm and improving care.

OBJECTIVE

To establish international, expert consensus on the purpose of PSRS regarding monitoring and learning from incidents and developing recommendations for their future role.

METHODS

After a scoping review of the literature, semi-structured interviews with experts in PSRS were conducted. Based on these findings, a survey-based questionnaire was developed and subsequently completed by a larger expert panel. Using a Delphi approach, consensus was reached regarding the ideal role of PSRSs. Recommendations for best practice were devised.

RESULTS

Forty recommendations emerged from the Delphi procedure on the role and use of PSRS. Experts agreed reporting system should not be used as an epidemiological tool to monitor the rate of harm over time or to appraise the relative safety of hospitals. They agreed reporting is a valuable mechanism for identifying organisational safety needs. The benefit of a national system was clear with respect to medication error, device failures, hospital-acquired infections and never events as these problems often require solutions at a national level. Experts recommended training for senior healthcare professionals in incident investigation. Consensus recommendation was for hospitals to take responsibility for creating safety solutions locally that could be shared nationally.

CONCLUSIONS

We obtained reasonable consensus among experts on aims and specifications of PSRS. This information can be used to reflect on existing and future PSRS, and their role within the wider patient safety landscape. The role of PSRS as instruments for learning needs to be elaborated and developed further internationally.

Improving Pediatric Adverse Drug Event Reporting through Clinical Pharmacy Services

OBJECTIVES

The purpose of this study was to summarize adverse drug event (ADE) reporting and to characterize the type of healthcare practitioners involved in reporting over a 10-year period at a 120-bed university-affiliated children's hospital.

METHODS

The University of Virginia Children's Hospital ADE database was analyzed for records involving pediatric patients. Data from patients <18 years of age who were admitted to the University of Virginia Children's Hospital between January 1, 2000, and December 31, 2009, were analyzed. Data collected included drug name and therapeutic class of the suspected causative agent, description of the event, severity, causality, outcome, and the type of healthcare practitioner reporting the event.

RESULTS

A total of 863 ADEs were reported over the 10-year period. The 5 most common types reported were extravasation injury (10%), rash (8%), hypotension (5%), pruritus (5%), and renal failure (3%). A total of 196 (21%) cases were categorized as mild, 436 (47%) cases as moderate, and 296 (32%) cases as severe. Further characterization of extravasations was performed to identify trends relating to potential causes. In 45 (57%) reports, parenteral nutrition was identified as the causative agent. Full recovery was documented in 21 (47%) extravasations. Of the total events reported, 83% were reported by pharmacists, 16% by nurses, and <1% by other healthcare practitioners.

CONCLUSIONS

Results of this study are consistent with those of previous studies involving ADE reporting in children's hospitals. This consistency is due in part to system design and use of unit-based pharmacists as the primary reporters.

A review of medical error reporting system design considerations and a proposed cross-level systems research framework

OBJECTIVE

To review the literature on medical error reporting systems, identify gaps in the literature, and present an integrative cross-level systems model of reporting to address the gaps and to serve as a framework for understanding and guiding reporting system design and research.

BACKGROUND

Medical errors are thought to be a leading cause of death among adults in the United States. However, no review exists summarizing what is known about the barriers and facilitators for successful reporting systems, and no integrated model exists to guide further research into and development of medical error reporting systems.

METHOD

Relevant literature was identified using online databases; references in relevant articles were searched for additional relevant articles.

RESULTS

The literature review identified components of medical error reporting systems, error reporting system design choices, barriers and incentives for reporting, and suggestions for successful reporting system design. Little theory was found to guide the published research. An integrative cross-level model of medical error reporting system design was developed and is proposed as a framework for understanding the medical error reporting literature, addressing existing limitations, and guiding future design and research.

CONCLUSION

The medical error reporting research provides some guidance for designing and implementing successful reporting systems. The proposed cross-level systems model provides a way to understand this existing research. However, additional research is needed on reporting and related safety actions. The proposed model provides a framework for such future research.

APPLICATION

This work can be used to guide the design, implementation, and study of medical error reporting systems.

Stopping the error cascade: a report on ameliorators from the ASIPS collaborative

OBJECTIVE

To present a novel examination of how error cascades are stopped (ameliorated) before they affect patients.

DESIGN

Qualitative analysis of reported errors in primary care.

SETTING

Over a three-year period, clinicians and staff in two practice-based research networks voluntarily reported medical errors to a primary care patient safety reporting system, Applied Strategies for Improving Patient Safety (ASIPS). The authors found a number of reports where the error was corrected before it had an adverse impact on the patient.

RESULTS

Of 754 codeable reported events, 60 were classified as ameliorated events. In these events, a participant stopped the progression of the event before it reached or affected the patient. Ameliorators included doctors, nurses, pharmacists, diagnostic laboratories and office staff. Additionally, patients or family members may be ameliorators by recognising the error and taking action. Ameliorating an event after an initial error requires an opportunity to catch the error by systems, chance or attentiveness. Correcting the error before it affects the patient requires action either directed by protocols and systems or by vigilance, power to change course and perseverance on the part of the ameliorator.

CONCLUSION

Despite numerous individual and systematic methods to prevent errors, a system to prevent all potential errors is not feasible. However, a more pervasive culture of safety that builds on simple acts in addition to more costly and complex electronic systems may improve patient outcomes. Medical staff and patients who are encouraged to be vigilant, ask questions and seek solutions may correct otherwise inevitable wrongs.

Toward a theoretical approach to medical error reporting system research and design

The release of the Institute of Medicine (Kohn et al., 2000) report "To Err is Human", brought attention to the problem of medical errors, which led to a concerted effort to study and design medical error reporting systems for the purpose of capturing and analyzing error data so that safety interventions could be designed. However, to make real gains in the efficacy of medical error or event reporting systems, it is necessary to begin developing a theory of reporting systems adoption and use and to understand how existing theories may play a role in explaining adoption and use. This paper presents the results of a 9-month study exploring the barriers and facilitators for the design of a statewide medical error reporting system and discusses how several existing theories of technology acceptance, adoption and implementation fit with many of the results. In addition we present an integrated theoretical model of medical error reporting system design and implementation.

Multiple user considerations and their implications in medical error reporting system design

OBJECTIVE

The study examined the differences between physicians and clinical assistants in their preferences for a statewide medical error reporting system.

BACKGROUND

Medical error reporting systems have been proposed as a means for studying the causes of medical error. Knowledge of user similarities and differences is needed for the development of design guidelines for medical error reporting systems.

METHOD

Separate focus groups composed of 8 physicians and 6 clinical assistants (physician clinical support staff) were conducted. One-hour focus group meetings were conducted via toll-free teleconference lines one to two times per month for 9 months. All conversations were audiotaped and transcribed for analysis. An inductive content analysis was conducted.

RESULTS

Eighty-six major and minor themes emerged. Differences between physicians and clinical assistants included rules and regulations governing the use of the system, the medium of reporting, and aspects of the organization that may affect reporting levels.

CONCLUSIONS

Although physicians and clinical assistants shared similar preferences and beliefs surrounding error reporting, there were differences that need to be considered if medical error reporting systems are to be effective.

APPLICATION

To successfully deploy a medical error reporting system, the system itself must be designed for the potential users. This study uncovered previously underappreciated issues that should be incorporated into the design and implementation process. Actual or potential applications of this research include the improvement of the design and implementation of medical error reporting systems to account for the needs of different types of users.

Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety

Standardized, seamless, integrated information technology in the health-care environment used with other industry tools can markedly decrease preventable errors or adverse events and increase patient safety. According to an Institute of Medicine (IOM) report released in 1999, preventable errors have caused between 44,000 and 98,000 deaths per year. Following the report, President Bill Clinton requested that the Agency of Healthcare Research and Quality, a government agency, look into the issue and fund, at the local or state level, processes that can reduce errors. Funding subsequently was made available for research that utilizes best practice tools in clinical practice to increase patient safety. The Joint Commission on Accreditation of Healthcare Organization has placed a great deal of emphasis on strategies to reduce patient identification errors. Fragmented systems tout the individual as well as enhanced safety applications. These applications, however, are related to prevention in specific conditions and in specific health-care settings. Systems are not integrated with common reference data and common terminology aggregated at a regional or national level to provide access to patient safety risks for timely interventions before errors and adverse events occur. Standardized integrated patient care information systems are not available either on a regional or on a national level. This article examines tangible options to increase patient safety through improved state-of-the-art tools that can be incorporated into the health-care system to prevent errors.

Anatomic Pathology Databases and Patient Safety

Context.—The utility of anatomic pathology discrepancies has not been rigorously studied.

Objective.—To outline how databases may be used to study anatomic pathology patient safety.

Design.—The Agency for Healthcare Research and Quality funded the creation of a national anatomic pathology errors database to establish benchmarks for error frequency. The database is used to track more frequent errors and errors that result in more serious harm, in order to design quality improvement interventions intended to reduce these types of errors. In the first year of funding, 4 institutions (University of Pittsburgh, Henry Ford Hospital, University of Iowa, and Western Pennsylvania Hospital) reported cytologic-histologic correlation error data after standardizing correlation methods. Root cause analysis was performed to determine sources of error, and error reduction plans were implemented.

Participants.—Four institutions self-reported anatomic pathology error data.

Main Outcome Measures.—Frequency of cytologic-histologic correlation error, case type, cause of error (sampling or interpretation), and effect of error on patient outcome (ie, no harm, near miss, and harm).

Results.—The institutional gynecologic cytologic-histologic correlation error frequency ranged from 0.17% to 0.63%, using the denominator of all Papanicolaou tests. Based on the nongynecologic cytologic-histologic correlation data, the specimen sites with the highest discrepancy frequency (by project site) were lung (ranging from 16.5% to 62.3% of all errors) and urinary bladder (ranging from 4.4% to 25.0%). Most errors detected by the gynecologic cytologic-histologic correlation process were no-harm events (ranging from 10.7% to 43.2% by project site). Root cause analysis identified sources of error on both the clinical and pathology sides of the process, and error intervention programs are currently being implemented to improve patient safety.

Conclusions.—A multi-institutional anatomic pathology error database may be used to benchmark practices and target specific high-frequency errors or errors with high clinical impact. These error reduction programs have national import.

Applied Strategies for Improving Patient Safety: A Comprehensive Process To Improve Care in Rural and Frontier Communities

CONTEXT

Medical errors and patient safety have gained increasing attention throughout all areas of medical care. Understanding patient safety in rural settings is crucial for improving care in rural communities.

PURPOSE

To describe a system to decrease medical errors and improve care in rural and frontier primary care offices.

METHODS

Applied Strategies for Improving Patient Safety (ASIPS) was a demonstration project designed to collect and analyze medical error reports and use these reports to develop and implement interventions aimed at decreasing errors. ASIPS participants were clinicians and staff in 2 practice-based research networks: the Colorado Research Network (CaReNet) and the High Plains Research Network (HPRN). This paper describes ASIPS in HPRN.

FINDINGS

Fourteen HPRN practices with a total of 150 clinicians and staff have participated in ASIPS. Participants have submitted 128 reports. Diagnostic tests were involved in 26% of events; medication errors appeared in 20% of events. Communication errors were reported in 72%. Two learning groups developed "Principles for Process Improvement" for medication errors and diagnostic testing errors. Several safety "alerts" were issued to improve care, and 2 interventions were implemented to decrease errors.

CONCLUSIONS

A safe and secure reporting system that relies on voluntary reporting from clinicians and staff can be successfully implemented in rural primary care settings. Information from reports can be used to identify processes that can be improved.

Event reporting to a primary care patient safety reporting system: a report from the ASIPS collaborative

BACKGROUND

We examined reports to a primary care, ambulatory, patient safety reporting system to describe types of errors reported and differences between anonymous and confidential reports.

METHODS

Applied Strategies for Improving Patient Safety (ASIPS) is a demonstration project designed to collect and analyze medical error reports from clinicians and staff in 2 practice-based research networks: the Colorado Research Network (CaReNet) and the High Plains Research Network (HPRN). A major component of ASIPS is a voluntary patient safety reporting system that accepts reports of errors anonymously or confidentially. Reports are coded using a multiaxial taxonomy.

RESULTS

Two years into this project, 33 practices with a total of 475 clinicians and staff have participated in ASIPS. Participants submitted 708 reports during this time (66% using the confidential reporting form). We successfully followed up on 84% of the confidential reports of interest within the allotted 10-day time frame. We ended up with 608 relevant, codable reports. Communication problems (70.8%), diagnostic tests (47%), medication problems (35.4%), and both diagnostic tests and medications (13.6%) were the most frequently reported errors. Confidential reports were significantly more likely than anonymous reports to contain codable data.

CONCLUSION

A safe and secure reporting system that relies on voluntary reporting from clinicians and staff can be successfully implemented in primary care settings. Information from confidential reports appears to be superior to that from anonymous reports and may be more useful in understanding errors and designing interventions to improve patient safety.