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Forrest C, O'Sullivan MJ, Ryan M, O'Tuathaigh C, Browne TJ, Rock K, O'Leary MJ, Madden D, O'Reilly S. Patients' and doctors' views and experiences of the patient safety trajectory of breast cancer care. Breast 2024; 75:103699. [PMID: 38460442 PMCID: PMC10943021 DOI: 10.1016/j.breast.2024.103699] [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: 01/28/2024] [Accepted: 02/23/2024] [Indexed: 03/11/2024] Open
Abstract
INTRODUCTION Successful breast cancer outcomes can be jeopardised by adverse events. Understanding and integrating patients' and doctors' perspectives into care trajectories could improve patient safety. This study assessed their views on, and experiences of, medical error and patient safety. METHODS A cross-sectional, quantitative 20-40 item questionnaire for patients attending Cork University Hospital Cancer Centre and breast cancer doctors in the Republic of Ireland was developed. Domains included demographics, medical error experience, patient safety opinions and concerns. RESULTS 184 patients and 116 doctors completed the survey. Of the doctors, 41.4% felt patient safety had deteriorated over the previous five years and 54.3% felt patient safety measures were inadequate compared to 13.0% and 27.7% of patients respectively. Of the 30 patients who experienced medical errors/negligence claims, 18 reported permanent or long-term physical and emotional effects. Forty-two of 48 (87.5%) doctors who experienced medical errors/negligence claims reported emotional health impacts. Almost half of doctors involved in negligence claims considered early retirement. Forty-four patients and 154 doctors didn't experience errors but reported their patient safety concerns. Doctors were more concerned about communication and administrative errors, staffing and organisational factors compared to patients. Multiple barriers to error reporting were highlighted. CONCLUSION This is the first study to assess patients' and doctors' patient safety views and medical error/negligence claims experiences in breast cancer care in Ireland. Experience of medical error/negligence claims had long-lasting implications for both groups. Doctors were concerned about a multitude of errors and causative factors. Failure to embed these findings is a missed opportunity to improve safety.
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Affiliation(s)
- Clara Forrest
- Academic Track Intern Programme, Intern Network Executive, School of Medicine, University College Cork, Cork, Ireland.
| | - Martin J O'Sullivan
- Department of Surgery, Cork University Hospital, Wilton, Cork, Ireland; Cancer Research@UCC, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Max Ryan
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland
| | - Colm O'Tuathaigh
- Medical Education Unit, School of Medicine, University College Cork, Cork, Ireland
| | - Tara Jane Browne
- Department of Histopathology, Cork University Hospital, Wilton, Cork, Ireland
| | - Kathy Rock
- Cancer Research@UCC, College of Medicine and Health, University College Cork, Cork, Ireland; Department of Radiation Oncology, Cork University Hospital, Wilton, Cork, Ireland
| | - Mary Jane O'Leary
- Department of Palliative Medicine, Marymount University Hospice and Hospital, Bishopstown, Cork, Ireland
| | | | - Seamus O'Reilly
- Cancer Research@UCC, College of Medicine and Health, University College Cork, Cork, Ireland; Department of Medical Oncology, Cork University Hospital, Wilton, Cork, Ireland
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Gampetro PJ, Nickum A, Schultz CM. Perceptions of U.S. and U.K. Incident Reporting Systems: A Scoping Review. J Patient Saf 2024:01209203-990000000-00218. [PMID: 38682884 DOI: 10.1097/pts.0000000000001231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
OBJECTIVE The aim of the study is to evaluate the extent, range, and nature of the literature that concerns healthcare providers' perceptions following the use of incident reporting systems (IRSs) in the United States (U.S.) and the United Kingdom (U.K.). Literature was compared describing providers' perceptions of reporting patient safety incidents using IRSs from healthcare systems built on public, private, for-profit, or nonprofit insurers in the U.S., with providers' perceptions using an IRS within a universal government supported healthcare system in the U.K. METHODS This scoping review searched literature from 4 electronic databases, producing 4863 articles between January 2010 to March 2023. RESULTS Eleven U.S. and 8 U.K. articles met the inclusion criteria. Providers described system and individual barriers when using IRSs. The U.S. providers described more concerns regarding individual barriers (fear of punitive response or retaliation, feel incapable or shamed, unsure of what constitutes a patient safety incident, and concerned about litigation) than providers in the U.K. Both countries had similar responses regarding system barriers, except for U.K. providers who were more concerned than the U.S. about damage to professional culture. Providers in both countries believed incident reporting was ineffective and time consuming with hospital leaders seldom acknowledging or integrating improvement measures based on reported incidents. CONCLUSIONS Sustainable improvements in patient care must be driven by hospital leadership who create just cultures where reporting of safety concerns is encouraged and respected within nonpunitive milieus.
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Affiliation(s)
- Pamela J Gampetro
- From the University of Illinois Chicago, College of Nursing, Chicago, Illinois
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Marsch A, Khodosh R, Porter M, Raad J, Samimi S, Schultz B, Strowd LC, Vera L, Wong E, Smith GP. Implementing patient safety and quality improvement in dermatology. Part 1: Patient safety science. J Am Acad Dermatol 2023; 89:641-654. [PMID: 35143912 DOI: 10.1016/j.jaad.2022.01.049] [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: 08/30/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 11/23/2022]
Abstract
Patient safety (PS) and quality improvement (QI) have gained momentum over the last decade and are becoming more integrated into medical training, physician reimbursement, maintenance of certification, and practice improvement initiatives. While PS and QI are often lumped together, they differ in that PS is focused on preventing adverse events while QI is focused on continuous improvements to improve outcomes. The pillars of health care as defined by the 1999 Institute of Medicine report "To Err is Human: Building a Safer Health System" are safety, timeliness, effectiveness, efficiency, equity, and patient-centered care. Implementing a safety culture is dependent on all levels of the health care system. Part 1 of this CME will provide dermatologists with an overview of how PS fits into our current health care system and will include a focus on basic QI/PS terminology, principles, and processes. This article also outlines systems for the reporting of medical errors and sentinel events and the steps involved in a root cause analysis.
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Affiliation(s)
- Amanda Marsch
- University of California, San Diego Medical Center, San Diego, California
| | - Rita Khodosh
- Department of Dermatology, University of Massachusetts, Boston, Massachusetts
| | - Martina Porter
- Department of Dermatology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Jason Raad
- American Academy of Dermatology, Rosemont, Illinois
| | - Sara Samimi
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Brittney Schultz
- Department of Dermatology, University of Minnesota, Minneapolis, Minnesota
| | | | - Laura Vera
- American Academy of Dermatology, Rosemont, Illinois
| | - Emily Wong
- San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas
| | - Gideon P Smith
- Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts.
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Yamashita H, Okawa Y, Masuyama S. Signage-associated improvement in hand hygiene compliance: a low cost strategy. Infect Prev Pract 2022; 4:100225. [PMID: 35757785 PMCID: PMC9218831 DOI: 10.1016/j.infpip.2022.100225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/25/2022] [Indexed: 11/15/2022] Open
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Akiyama N, Koeda K, Uozumi R, Takahashi F, Ogasawara K. Implementing an Intervention to Improve Physicians’ Incident Reporting in the Hospital Setting: A Pilot Study. PATIENT SAFETY 2022. [DOI: 10.33940/culture/2022.3.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objectives: To improve patient safety, information regarding errors must be collected. This practice constitutes one of the strategies that hospital managers use to understand the types of errors that occur at their hospitals. This pilot study aimed to evaluate an intervention designed to improve error reporting percentage among physicians.
Methods: The study was conducted at University Hospital A, where data were collected from April 2017 to March 2019. The intervention began in April 2018 and involved the following steps: receiving support and appropriate feedback from the hospital administrator, defining reporting standards, improving the incident reporting system, and having the hospital administrators set clear goals and begin a visualized feedback process. Physicians were the main target for these steps in this study.
Results: The percentage of reports submitted by physicians relative to nonphysicians increased from fiscal year (FY) 2017 to FY 2018, with the largest monthly increase within 2018 occurring in November. Physician reporting was higher in FY 2018 than in FY 2017, with the greatest difference observed for December of the respective FYs (p < 0.001, analyzed using Fisher’s exact test). The percentage of reports submitted by physicians increased by 2.6% (95% confidence interval [CI]: 1.7, 3.5) from FY 2017 to FY 2018, raising the percentage to 9%.
Conclusions: Based on these results, it can be said that the intervention effectively increased incident reporting among not only physicians but also nonphysician staff members. In this regard, reporting barriers were broken when hospital administrators encouraged staff to submit incident reports. Active feedback by hospital administrators—the executive class of the hospital—may encourage not only physicians, but also staff members to submit incident reports, thus effectively removing reporting barriers.
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Gampetro PJ, Segvich JP, Hughes AM, Kanich C, Schlaeger JM, McFarlin BL. Associations between safety outcomes and communication practices among pediatric nurses in the United States. J Pediatr Nurs 2022; 63:20-27. [PMID: 34942469 DOI: 10.1016/j.pedn.2021.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To gain a deeper understanding of RNs communication related to patient safety. RESEARCH AIMS To determine: (1) the associations between the communication of registered nurses (RNs) within their health care teams and the frequency that they reported safety events; (2) the associations between RNs' communication within their health care teams and their perceptions of safety within the hospital unit; and (3) whether RNs' communication had improved from 2016 to 2018. THEORETICAL FRAMEWORK AND METHODS We used the United Kingdom's Safety Culture model as the theoretical framework for this study. Our secondary data analysis from the Agency for Healthcare Research and Quality's Hospital Survey on Patient Safety Culture included 2016 (n = 5298) and 2018 (n = 3476) using multiple regression models to determine associations between responses for Communication Openness and Feedback & Communication About Error, and outcome responses for Frequency of Events Reported and Overall Perceptions of Safety. RESULTS Our findings were: 1). In both 2016 and 2018 datasets, Feedback About Error had a greater impact on Reporting Frequency than Open Communication; 2). Feedback About Error had a greater impact on Safety Perceptions than Open Communication; 3). Open Communication and Feedback About Error and their associations with Reporting Frequency and Safety Perceptions showed little change; and, 4). The proportion of variance was low, indicating factors other than Open Communication and Feedback About Error were involved with Reporting Frequency and Safety Perceptions. CONCLUSION Pediatric RNs' communication, reporting, and perceptions of patient safety have not improved. (245 words).
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Affiliation(s)
- Pamela J Gampetro
- University of Illinois Chicago, College of Nursing, Department of Human Development Nursing Science, 845 S. Damen Avenue, Chicago, IL 60612, United States.
| | - John P Segvich
- Statistical Consultant, 14524 Kolin Avenue, Midlothian, IL 60445, United States
| | - Ashley M Hughes
- University of Illinois Chicago, College of Applied Health Sciences, Department of Biomedical & Health Information Sciences, Director, Systems-based Approach for Enhancing Teamwork (SAFE-T) lab, 1919 W. Taylor Street, Chicago, IL 60612, United States.
| | - Chris Kanich
- University of Illinois Chicago, College of Engineering, Department of Computer Science, 851 S. Morgan Street, Chicago, IL 60607, United States.
| | - Judith M Schlaeger
- University of Illinois Chicago, College of Nursing, Department of Human Development Nursing Science, 845 S. Damen Avenue, Chicago, IL 60612, United States.
| | - Barbara L McFarlin
- University of Illinois Chicago, College of Nursing, Department of Human Development Nursing Science, 845 S. Damen Avenue, Chicago, IL 60612, United States.
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Bottet B, Rivera C, Dahan M, Falcoz PE, Jaillard S, Baste JM, Seguin-Givelet A, de la Tour RB, Bellenot F, Rind A, Gossot D, Thomas PA, D’Journo XB. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6584014. [PMID: 35543477 PMCID: PMC9419675 DOI: 10.1093/icvts/ivac129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/10/2022] [Accepted: 05/04/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Benjamin Bottet
- Department of General and Thoracic Surgery, Rouen University Hospital, Rouen, France
| | - Caroline Rivera
- Department of Thoracic Surgery, Bayonne Hospital, Bayonne, France
| | - Marcel Dahan
- Department of Thoracic Surgery, Larrey Hospital, CHU Toulouse, Toulouse, France
| | | | - Sophie Jaillard
- Department of Thoracic surgery, Hopital Privé le Bois, Lille, France
| | - Jean-Marc Baste
- Department of General and Thoracic Surgery, Rouen University Hospital, Rouen, France
| | - Agathe Seguin-Givelet
- Department of Thoracic Surgery, Curie-Montsouris Thorax Institute, Institut Mutualiste Montsouris, Paris, France
- Paris 13 University, Sorbonne Paris Cité, Faculty of Medecine SMBH, Bobigny, France
| | | | | | - Alain Rind
- Organisme d’Accréditation (OA)-CTCV, SFCTCV, Paris, France
| | - Dominique Gossot
- Department of Thoracic Surgery, Curie-Montsouris Thorax Institute, Institut Mutualiste Montsouris, Paris, France
| | - Pascal-Alexandre Thomas
- Department of Thoracic Surgery, Hopital Nord-APHM, Aix-Marseille University, Marseille, France
| | - Xavier Benoit D’Journo
- Department of Thoracic Surgery, Hopital Nord-APHM, Aix-Marseille University, Marseille, France
- Corresponding author. Department of Thoracic Surgery, Hopital Nord-APHM, Aix-Marseille University, Chemin des Bourrely, 13015 Marseille, France. Tel: +33-4-91-96-60-01; fax: +33-4-91-96-60-04; e-mail: (X.B. D’Journo)
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Stuhr D, Zhou Y, Pham H, Xiong JP, Liu S, Mechalakos JG, Berry SL. Automated Plan Checking Software Demonstrates Continuous and Sustained Improvements in Safety and Quality: A 3-year Longitudinal Analysis. Pract Radiat Oncol 2022; 12:163-169. [PMID: 34670137 PMCID: PMC8901531 DOI: 10.1016/j.prro.2021.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/25/2021] [Accepted: 09/27/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE This study aimed to perform a longitudinal analysis of the performance of our automated plan checking software by retrospectively evaluating the number of errors identified in plans delivered to patients in 3, month-long, data collection periods between 2017 and 2020. METHODS AND MATERIALS Eleven automated checks were retrospectively run on 1169 external beam radiation therapy treatment plans identified as meeting the following criteria: planning target volume-based multifield photon plans receiving a status of treatment approved in March 2017, March 2018, or March 2020. The number of passes (true positives) and flags were recorded. Flags were subcategorized into false negatives, false negatives due to naming conventions, and true negatives. In addition, 2 × 2 contingency tables using a 2-tailed Fisher's exact test were used to determine whether there were nonrandom associations between the output of the automated plan checking software and whether the check was manual or automated at the original time of treatment approval. RESULTS A statistically significant decrease in flags between the pre- and postautomation data sets was observed for 4 contour-based checks, namely adjacent structures overlap, empty structures and missing slices, overlap between body and couch, and laterality, as well as a check that determined whether the plan's global maximum dose was within the planning target volume. A review of the origins of false negatives was fed back into the design of the checks to improve the reliability of the system and help avoid warning fatigue. CONCLUSIONS Periodic and longitudinal review of the performance of automated software was essential for monitoring and understanding its impact on error rates, as well as for optimization of the tool to adapt to regular changes of clinical practice. The automated plan checking software has demonstrated continuous contributions to the safe and effective delivery of external beam radiation therapy to our patient population, an impact that extends beyond its initial implementation and deployment.
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Affiliation(s)
| | | | | | | | | | | | - Sean L Berry
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York.
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Müller BS, Singer J, Stamm G, Pirl L, Borowski M, Hertlein T, Rerich E, Trinkl S, Wucherer M, Ammon J. Handling of Incidents in the Clinical Application of Ionizing Radiation in Diagnostic and Interventional Radiology - a Multi-center Study. ROFO-FORTSCHR RONTG 2021; 194:400-408. [PMID: 34933352 DOI: 10.1055/a-1665-6988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE According to the German legislation and regulation of radiation protection, i. e. Strahlenschutzgesetz und Strahlenschutzverordnung (StrlSchG and StrlSchV), which came into force on 31st December 2018, significant unintended or accidential exposures have to be reported to the competent authority. Furthermore, facilities have to implement measures to prevent and to recognize unintended or accidental exposures as well as to reduce their consequences. We developed a process to register incidents and tested its application in the framework of a multi-center-study. MATERIALS AND METHODS Over a period of 12 months, 16 institutions for x-ray diagnostics and interventions, documented their incidents. Documentation of the incidents was conducted using the software CIRSrad, which was developed, released for testing purposes and implemented in the frame of the study. Reporting criteria of the project were selected to be more sensitive compared to the legal criteria specifying "significant incidents". Reported incidents were evaluated after four, eight, and twelve months. Finally, all participating institutions were interviewed on their experience with the software and the correlated effort. RESULTS The rate of reported incidents varied between institutions as well as between modalities. The majority of incidents were reported in conventional x-ray imaging, followed by computed tomography and therapeutic interventions. Incidents were attributed to several different causes, amongst others to the technical setup and patient positioning (19 %) and patient movement or insufficient cooperativeness of the patient (18 %). Most incidents were below corresponding thresholds stated in StrlSchV. The workload for documenting the incidents was rated as appropriate. CONCLUSION It is possible to monitor and handle incidents complient with legal requirements with an acceptable effort. The number of reported incidents can be increased by frequent trainings on the detection and the processing workflow, on the software and legal regulation as well as by a transparent error handling within the institution. KEY POINTS · The software CIRSrad was developed to enable the present study and as prototype platform for a future radiological incident management system.. · 586 exceedances of thresholds were recorded by 16 facilities in a period of one year.. · Frequent trainings of all users increase the number of reported cases.. CITATION FORMAT · Müller BS, Singer J, Stamm G et al. Handling of Incidents in the Clinical Application of Ionizing Radiation in Diagnostic and Interventional Radiology - a Multi-center Study. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1665-6988.
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Affiliation(s)
- Birgit Sabine Müller
- Institute of Medical Physics, Klinikum Nurnberg, Paracelsus Medical University, Nurnberg, Germany
| | - Julian Singer
- Institute of Medical Physics, Klinikum Nurnberg, Paracelsus Medical University, Nurnberg, Germany
| | - Georg Stamm
- Institute for Diagnostic and Interventional Radiology, University Medical Center Gottingen, Gottingen, Germany
| | - Lukas Pirl
- Institute for Diagnostic Radiology and Nuclear medicine, Braunschweig Municipal Hospital, Braunschweig, Germany
| | - Markus Borowski
- Institute for Diagnostic Radiology and Nuclear medicine, Braunschweig Municipal Hospital, Braunschweig, Germany
| | - Thomas Hertlein
- Institute of Medical Physics, Klinikum Nurnberg, Paracelsus Medical University, Nurnberg, Germany
| | - Eugenia Rerich
- Institute of Medical Physics, Klinikum Nurnberg, Paracelsus Medical University, Nurnberg, Germany.,Medizinphysik-Experten für sonstige Einrichtungen, Charite University Hospital Berlin, Germany
| | - Sebastian Trinkl
- External and Internal Dosimetry, Biokinetics, Federal Office for Radiation Protection Neuherberg, Germany
| | - Michael Wucherer
- Institute of Medical Physics, Klinikum Nurnberg, Paracelsus Medical University, Nurnberg, Germany
| | - Josefin Ammon
- Institute of Medical Physics, Klinikum Nurnberg, Paracelsus Medical University, Nurnberg, Germany
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Reliability of Patient-Report, Physician-Report, and Medical Record Review to Identify Hospital-Acquired Complications: A Prospective Cohort Study. Am J Med Qual 2021; 36:337-344. [PMID: 34010163 DOI: 10.1097/01.jmq.0000735460.66073.8f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This prospective study of internal medicine inpatients treated at 2 hospitals in Toronto, Canada, between September 1, 2016, and September 1, 2017, compared patient-report, physician-report, and detailed medical record review to identify specific hospital-acquired complications. Six complications were assessed: delirium, catheter-associated urinary tract infection, acute kidney injury, deep vein thrombosis/pulmonary embolism, hospital-acquired pneumonia, or fall. The study included 207 patients and physician responses were obtained for 156 (75%). Complications were identified in 28 (14%) patients by medical record review, 30 (14%) patients by patient-report, and 11 (7%) patients by physician-report. Fifty-four (26%) patients experienced a complication as identified through at least one of the 3 methods. There was little agreement between the 3 methods (Fleiss' ĸ 0.15, P < 0.001). All 3 sources agreed on the occurrence of a specific complication in only 1 patient (1%). Multiple approaches likely are needed to adequately measure hospital-acquired complications.
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Lurvey LD, Fassett MJ, Kanter MH. Self-Reported Learning (SRL), a Voluntary Incident Reporting System Experience Within a Large Health Care Organization. Jt Comm J Qual Patient Saf 2021; 47:288-295. [PMID: 33676854 DOI: 10.1016/j.jcjq.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 12/22/2020] [Accepted: 01/12/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND In aviation, significant improvements in safety have been attributed to a system of voluntary reporting of errors and hazards by pilots and other frontline personnel. Such a system is lacking in health care. METHODS A system to allow physicians to self-report their clinical care errors along with insights to prevent recurrence ("self-reported learning [SRL] system") was established in three hospitals and used for four years in one center and for two years in two others. Clinicians were educated in how to use the system and encouraged to report deviations from standard care by secure e-mail, a telephone hotline, or the institutional incident reporting system. Events were included in the SRL system only if clinicians self-reported them prior to others doing so. Submissions were analyzed for evidence of primary insight, recognition of error, and secondary insight. Physicians were surveyed afterward about their attitudes toward clinical peer review, the physician's role in errors, and the SRL program. RESULTS There were 117 SRL submissions (less than 5% of clinical peer review cases); 86 had complete information available. Of these, there was agreement among two reviewers that secondary insight was present in 52.2%, and several were novel submissions that otherwise would have not been identified. Survey response rate was 18.3%; 31.1% of respondents had never been involved in clinical peer review before, a majority had an overall favorable impression of clinical peer review, and 47.2% reported not having made "any mistakes worth reporting." CONCLUSION An SRL system modeled after the aviation reporting system elicited a low number of reports and did not decrease the number of clinical peer review reports. In a high proportion of SRL reports reporting physicians demonstrated secondary insight. Benefits to SRL reporting could be seen despite low number of self-reports.
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Sterz J, Ruesseler M, Seemann R, Münzberg M, Doepfer AK, Stange R, Mutschler M, Bouillon B, Egerth M. The acceptance of CIRS among orthopedic and trauma surgeons in Germany-Significant gap between positive perception and actual implementation in daily routine. J Orthop Surg (Hong Kong) 2020; 27:2309499019874507. [PMID: 31554465 DOI: 10.1177/2309499019874507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Medical errors are the third leading cause of death in the United States after malignant tumors and cardiovascular disease. Handling of errors becomes more and more eclectic due to the implementation of incident reporting systems and the use of checklists. Since 2015, any German hospital would have a critical incident reporting system (CIRS). The aim of this study is to discover the nationwide utilization and attitude toward CIRS of orthopedic and trauma surgeons. METHODS Between April 10, 2015 and May 22, 2015, a web-based questionnaire, which was designed by an expert team consisting of orthopedic and trauma surgeons, aeronautic human factors specialists, and psychologists (Lufthansa Aviation Training), was sent to all members of the German Society for Orthopedic and Trauma Surgery. The survey consisted of three questions regarding CIRS and its use in German hospitals. RESULTS A total of 669 orthopedic and trauma surgeons working in German hospitals completed the questionnaire. All participants rated CIRS as useful, although 71.3% of participants did not report a critical incident in the last 12 months. In that time period, only 13.4% of participating residents reported at least one incident, but 44.7% of chief physicians reported one incident within the same period. CONCLUSION The present study demonstrates that even though CIRS as a tool is positively appreciated by orthopedic and trauma surgeons working in German hospitals, many do not know about its existence at their own hospital. This can be a reason for the low number of critical incidents reported.
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Affiliation(s)
- Jasmina Sterz
- Department for Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Miriam Ruesseler
- Department for Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Ricarda Seemann
- Center for Musculoskeletal Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Münzberg
- Department of Trauma and Orthopedic Surgery, BG-Klinik Ludwigshafen, Ludwigshafen, Germany
| | | | - Richard Stange
- Department for Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Manuel Mutschler
- Department for Orthopedic Surgery, Trauma Surgery and Sport Injuries, Kliniken der Stadt Köln, Cologne, Germany
| | - Bertil Bouillon
- Department for Orthopedic Surgery, Trauma Surgery and Sport Injuries, Kliniken der Stadt Köln, Cologne, Germany
| | - Martin Egerth
- Department of Human Factors Training, Lufthansa Aviation Training, Berlin, Germany
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Röhsig V, Lorenzini E, Mutlaq MFP, Maestri RN, de Souza AB, Alves BM, Wendt G, Borges BG, Oliveira D. Near-miss analysis in a large hospital in southern Brazil: A 5-year retrospective study. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2020; 31:247-258. [PMID: 32568118 DOI: 10.3233/jrs-194050] [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: 11/15/2022]
Abstract
BACKGROUND Near-miss analysis is an effective method for preventing serious adverse events, including never events such as wrong-site surgery. OBJECTIVE To analyze all near-miss incidents reported in a large general hospital in southern Brazil between January 2013 and August 2017. METHOD We performed a descriptive retrospective study of near-miss incidents recorded in the hospital's electronic reporting system in a large non-profit hospital (497 beds). The results are expressed as absolute (n) and relative frequencies (%). Pearson's chi-square test, Fisher's exact test (Monte Carlo simulation) and linear regression were used. RESULTS A total of 12,939 near-miss incidents were recorded during the study period, with linear growth in the number of reports. Near-miss incidents were most frequent for medication, followed by processes unspecified in the International Classification for Patient Safety framework, followed by information control (patient chart and fluid balance data), followed by venous/vascular puncture. The highest prevalence of reports was observed in inpatient wards, in adult, pediatric, and neonatal intensive care units, and in the surgical center/post-anesthesia care unit. Pharmacists and nursing personnel recorded most of the reports during the day shift. CONCLUSION The most frequent categories of near-miss incidents were medication processes, other institutional protocols, information control issues, and venous/vascular puncture. The significant number of reported near-miss incidents reflects good adherence to the reporting system.
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Affiliation(s)
| | - Elisiane Lorenzini
- Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
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Noureldin M, Noureldin MA. Reporting frequency of three near-miss error types among hospital pharmacists and associations with hospital pharmacists' perceptions of their work environment. Res Social Adm Pharm 2020; 17:381-387. [PMID: 32247681 DOI: 10.1016/j.sapharm.2020.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 03/05/2020] [Accepted: 03/20/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Medical error reporting is one of the main strategies health care institutions utilize to evaluate and improve patient safety. Many factors can influence error reporting frequency, including work environment. The study objectives were to: 1) explore hospital pharmacists' reporting frequency of three distinct near-miss errors types and 2) examine the association between near-miss error reporting frequency and work environment perceptions, specifically pharmacists' perceptions of managers' actions to promote patient safety, teamwork, and staffing issues. METHODS Pharmacist data from the 2016 AHRQ Hospital Survey on Patient Safety Culture were analyzed. Near-miss errors included errors that occurred: 1) with no potential to harm the patient, 2) that could harm the patient, but did not, and 3) that were caught and corrected before harming the patient. Pharmacists' perceptions of the three patient safety culture domains (i.e., managers' actions to promote safety, teamwork, staffing) were assessed by calculating positive response percentages, with higher percentages indicating positive perceptions of their institutions' safety culture. Descriptive statistics and bivariate and mixed effects multivariate regression analyses were conducted. RESULTS When an error occurred, it was always reported by 32.0% of pharmacists if the error could have harmed the patient, 17.6% of pharmacists if the error had no potential to harm the patient, and 12.3% of pharmacists if it was corrected before reaching the patient. Higher near-miss error reporting frequency was significantly associated with positive perceptions related to managers' actions to promote safety, teamwork, and staffing if the error could have harmed the patient (OR 1.50; OR 1.27; OR 1.18, p < 0.05 respectively) and errors that were caught/corrected before reaching the patient (OR 1.32, OR 1.26, OR 1.07, p < 0.05 respectively). CONCLUSION Differences in reporting frequency suggests that pharmacists may prioritize near-miss error reporting based on perceived importance. A positive work environment was associated with higher near-miss error reporting rates.
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Affiliation(s)
- Marwa Noureldin
- College of Pharmacy, Natural and Health Sciences, Manchester University, 10627 Diebold Rd, Fort Wayne, Indiana, USA, 46845.
| | - Maryam A Noureldin
- Ambulatory Care Medication Safety Pharmacist, Parkview Health, 11109 Parkview Plaza Drive, Fort Wayne, Indiana, 46845, USA.
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Abstract
OBJECTIVE. The purpose of this article is to describe how establishing routine practice sessions facilitates adoption by modality operations managers of the just culture model of error management in a radiology department. CONCLUSION. Implementation of ongoing just culture training among radiology operations managers can help them approach uniformity, equity, and transparency in managing errors. Managers see the just culture method as an effective tool that helps improve the safety of patient care.
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Patterns of Incident Reporting Across Clinical Sites in a Regionally Expanding Academic Radiation Oncology Department. J Am Coll Radiol 2019; 16:915-921. [DOI: 10.1016/j.jacr.2018.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/26/2018] [Accepted: 12/05/2018] [Indexed: 11/21/2022]
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Durable Improvement in Patient Safety Culture Over 5 Years With Use of High-volume Incident Learning System. Pract Radiat Oncol 2019; 9:e407-e416. [DOI: 10.1016/j.prro.2019.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/02/2019] [Accepted: 02/07/2019] [Indexed: 11/23/2022]
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Szymusiak J, Walk TJ, Benson M, Hamm M, Zickmund S, Gonzaga AM, Bump GM. A Qualitative Analysis of Resident Adverse Event Reporting: What's Holding Us Back. Am J Med Qual 2019; 35:155-162. [PMID: 31185725 DOI: 10.1177/1062860619853878] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study utilized focus groups of residents, who report adverse events at differing rates depending on their hospital site, to better understand barriers to residents' reporting and identify modifiable aspects of an institution's culture that could encourage resident event reporting. Focus groups included residents who rotated at 3 hospitals and represented 4 training programs. Focus groups were audio recorded and analyzed using qualitative methods. A total of 64 residents participated in 8 focus groups. Reporting behavior varied by hospital culture. Residents worried about damage to their professional relationships and lacked insight into the benefits of multiple reports of the same event or how human factors engineering can prevent errors. Residents did not understand how reporting affects litigation. Residents at other academic institutions likely experience similar barriers. This study illustrates that resident reporting is modifiable by changing hospital culture, but hospitals have only a few opportunities to mishandle reporting before resident reporting attitudes solidify.
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Affiliation(s)
- John Szymusiak
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Thomas J Walk
- University of Pittsburgh School of Medicine, Pittsburgh, PA.,VA Pittsburgh Healthcare System, Pittsburgh PA
| | - Maggie Benson
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Megan Hamm
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Susan Zickmund
- VA Salt Lake City Health Services Research and Development IDEAS 2.0 Center of Innovation, Salt Lake City, UT.,University of Utah School of Medicine, Salt Lake City, UT
| | | | - Gregory M Bump
- University of Pittsburgh School of Medicine, Pittsburgh, PA
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Adoption of an incident learning system in a regionally expanding academic radiation oncology department. Rep Pract Oncol Radiother 2019; 24:338-343. [PMID: 31194042 DOI: 10.1016/j.rpor.2019.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 02/28/2019] [Accepted: 05/18/2019] [Indexed: 11/24/2022] Open
Abstract
Aim and Background We describe a successful implementation of a departmental incident learning system (ILS) across a regionally expanding academic radiation oncology department, dovetailing with a structured integration of the safety and quality program across clinical sites. Materials and methods m Over 6 years between 2011 and 2017, a long-standing departmental ILS was deployed to 4 clinical locations beyond the primary clinical location where it had been established. We queried all events reported to the ILS during this period and analyzed trends in reporting by clinical site. The chi-square test was used to determine whether differences over time in the rate of reporting were statistically significant. We describe a synchronous development of a common safety and quality program over the same period. Results There was an overall increase in the number of event reports from each location over the time period from 2011 to 2017. The percentage increase in reported events from the first year of implementation to 2017 was 457% in site 1, 166.7% in site 2, 194.3% in site 3, 1025% in site 4, and 633.3% in site 5, with an overall increase of 677.7%. A statistically significant increase in the rate of reporting was seen from the first year of implementation to 2017 (p < 0.001 for all sites). Conclusions We observed significant increases in event reporting over a 6-year period across 5 regional sites within a large academic radiation oncology department, during which time we expanded and enhanced our safety and quality program, including regional integration. Implementing an ILS and structuring a safety and quality program together result in the successful integration of the ILS into existing departmental infrastructure.
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Gao X, Yan S, Wu W, Zhang R, Lu Y, Xiao S. Implications from China patient safety incidents reporting system. Ther Clin Risk Manag 2019; 15:259-267. [PMID: 30799925 PMCID: PMC6371930 DOI: 10.2147/tcrm.s190117] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective We aimed to explain the operational mechanism of China National Patient Safety Incidents Reporting System, analyze patterns and trends of incidents reporting, and discuss the implication of the incidents reporting to improve hospital patient safety. Design A nationwide, registry-based, observational study design. Data source The database of China National Patient Safety Incidents Reporting System. Outcome measures Outcome measures of this study included the temporal, regional, and hospital distribution of the reports, as well as the incident type, location, parties, and possible reasons for frequently occurring incidents. Results During 2012–2017, 36,498 patient safety incidents were reported. By analyzing the time trends, we found that there was a significant upward trend on incidents reporting in China. The most common type of incidents was drug-related incidents, followed by nursing-related incidents and surgery-related incidents. The three most frequent locations of incident occurrence were Patient’s Room (65.4%), Ambulatory Care Unit (8.4%), and Intensive Care Unit (7.4%). The majority of the incidents involved nurses (40.7%), followed by physicians (29.5%) and medical technologist (13.6%). About 44.4% of the incidents were attributed to the junior staff (work experience ≤5 years). In addition, incidents triggered by the senior staff (work experience >5 years) were more often associated with severe patient harm. Conclusion To strengthen the incidents reporting system and generate useful evidence through learning from incidents reporting will be important to China’s success in improving the nation’s patient safety status.
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Affiliation(s)
- Xinqiang Gao
- Department of Social Medicine and Health Management, Xiangya School of Public Health, Central South University, Changsha, Hunan Province, China,
| | - Shipeng Yan
- Department of Cancer Prevention and Control, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan Province, China
| | - Wenqiong Wu
- Department of Cancer Prevention and Control, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan Province, China
| | - Rui Zhang
- Department of Health Policy and Management, School of Public Health, Peiking University, Peiking, China
| | - Yuliang Lu
- Department of the Medical Affairs, Binzhou Medical University Hospital, Binzhou Medical University, Bingzhou, Shandong Province, China
| | - Shuiyuan Xiao
- Department of Social Medicine and Health Management, Xiangya School of Public Health, Central South University, Changsha, Hunan Province, China,
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Real-time management of incident learning reports in a radiation oncology department. Pract Radiat Oncol 2018; 8:e337-e345. [DOI: 10.1016/j.prro.2018.04.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 04/08/2018] [Accepted: 04/26/2018] [Indexed: 11/17/2022]
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Ford EC, Evans SB. Incident learning in radiation oncology: A review. Med Phys 2018; 45:e100-e119. [PMID: 29419944 DOI: 10.1002/mp.12800] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 12/17/2017] [Accepted: 01/03/2018] [Indexed: 11/06/2022] Open
Abstract
Incident learning is a key component for maintaining safety and quality in healthcare. Its use is well established and supported by professional society recommendations, regulations and accreditation, and objective evidence. There is an active interest in incident learning systems (ILS) in radiation oncology, with over 40 publications since 2010. This article is intended as a comprehensive topic review of ILS in radiation oncology, including history and summary of existing literature, nomenclature and categorization schemas, operational aspects of ILS at the institutional level including event handling and root cause analysis, and national and international ILS for shared learning. Core principles of patient safety in the context of ILS are discussed, including the systems view of error, culture of safety, and contributing factors such as cognitive bias. Finally, the topics of medical error disclosure and second victim syndrome are discussed. In spite of the rapid progress and understanding of ILS, challenges remain in applying ILS to the radiation oncology context. This comprehensive review may serve as a springboard for further work.
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Affiliation(s)
- Eric C Ford
- Department of Radiation Oncology, University of Washington, Seattle, WA, 98195, USA
| | - Suzanne B Evans
- Department of Radiation Oncology, Yale University, New Haven, CT, 06510, USA
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First fruits of the RO-ILS system: Are we learning anything new? Pract Radiat Oncol 2018; 8:133-135. [PMID: 29373303 DOI: 10.1016/j.prro.2017.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 11/22/2017] [Indexed: 11/23/2022]
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Jämsä JO, Palojoki SH, Lehtonen L, Tapper AM. Differences between serious and nonserious patient safety incidents in the largest hospital district in Finland. J Healthc Risk Manag 2018; 38:27-35. [PMID: 29319925 DOI: 10.1002/jhrm.21310] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To determine if and in what ways serious patient safety incidents differ from nonserious patient safety incidents. METHODS Statistical analysis was performed on patient safety incident reports that were reported in 2015 in Finland's largest hospital district (Helsinki and Uusimaa, HUS). Reports were divided into two groups: nonserious incidents and serious incidents. Differences between groups were studied from several types of categorically divided information. RESULTS Of the total number of reports (15,863), 1% were serious incidents (175). Serious and nonserious incidents differed significantly from each other. Serious incidents concerning laboratory, imaging, or medical equipment were more common. On the other hand, incidents concerning medication, infusion, and blood transfusion were less frequent. In serious incidents, the proportion of doctors reporting was greater, and contributing factors were better recognized, the most common being working of procedures. CONCLUSIONS In the future, special attention should be given to the particular aspects of serious patient safety incidents, such as safe use of medical equipment, training, and handling of procedures. Root cause analysis is an effective way to handle serious incidents and enables the prevention of their reoccurrence. However, a systematic follow-up of the root cause analysis should be developed.
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Affiliation(s)
| | | | - Lasse Lehtonen
- Helsinki and Uusimaa University Hospital District (Finland); University of Helsinki, Helsinki, Finland
| | - Anna-Maija Tapper
- Hyvinkää Hospital at Helsinki and Uusimaa University Hospital District (Hyvinkää, Finland); University of Helsinki, Helsinki, Finland
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Hamilton EC, Pham DH, Minzenmayer AN, Austin MT, Lally KP, Tsao K, Kawaguchi AL. Are we missing the near misses in the OR?-underreporting of safety incidents in pediatric surgery. J Surg Res 2017; 221:336-342. [PMID: 29229148 DOI: 10.1016/j.jss.2017.08.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/28/2017] [Accepted: 08/01/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Electronic hospital variance reporting systems used to report near misses and adverse events are plagued by underreporting. The purpose of this study is to prospectively evaluate directly observed variances that occur in our pediatric operating room and to correlate these with the two established variance reporting systems in our hospital. MATERIALS AND METHODS Trained individuals directly observed pediatric perioperative patient care for 6 wk to identify near misses and adverse events. These direct observations were compared to the established handwritten perioperative variance cards and the electronic hospital variance reporting system. All observations were analyzed and categorized into an additional six safety domains and five variance categories. The chi-square test was used, and P-values < 0.05 were considered statistically significant. RESULTS Out of 830 surgical cases, 211 were audited by the safety observers. During this period, 137 (64%) near misses were identified by direct observation, while 57 (7%) handwritten and 8 (1%) electronic variance were reported. Only 1 of 137 observed events was reported in the handwritten variance system. Five directly observed adverse events were not reported in either of the two variance reporting systems. Safety observers were more likely to recognize time-out and equipment variances (P < 0.001). Both variance reporting systems and direct observation identified numerous policy and process issues. CONCLUSIONS Despite multiple reporting systems, near misses and adverse events remain underreported. Identifying near misses may help address system and process issues before an adverse event occurs. Efforts need to be made to lessen barriers to reporting in order to improve patient safety.
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Affiliation(s)
- Emma C Hamilton
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Dean H Pham
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Andrew N Minzenmayer
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Mary T Austin
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas
| | - Akemi L Kawaguchi
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
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Deraniyagala R, Liu C, Mittauer K, Greenwalt J, Morris CG, Yeung AR. Implementing an Electronic Event-Reporting System in a Radiation Oncology Department: The Effect on Safety Culture and Near-Miss Prevention. J Am Coll Radiol 2016; 12:1191-5. [PMID: 26541132 DOI: 10.1016/j.jacr.2015.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 04/20/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE We implemented an electronic event-reporting system to investigate its effect on quality improvement in our department. METHODS We developed an event-reporting program that launched in October 2012; data analysis was performed in January 2014. Events were logged by the radiation oncology staff and reviewed by our quality and safety committee on a biweekly basis. To measure the efficacy of the new program, and change in safety culture, a Likert-scale survey was administered before, and three months after, implementation of the event-reporting system. RESULTS A total of 194 events were logged into the new system during a 15-month period (approximately 13 events per month), compared with 93 events in an 18-month period (approximately five events per month) before the program was launched. The average number of events reported by radiation therapists increased from 0.9 per month to 8.6 per month. The survey results showed a shift toward stronger agreement by staff members, in postimplementation versus preimplementation responses, when they were asked if they knew how to report an event in the department (P = .042), and if the current event-reporting system would reduce the incidence of future events (P = .032). Results showed a trend toward stronger agreement by staff members when they were asked if they felt more comfortable reporting events that they had observed (P = .093). Multiple safety action plans were implemented as a result of analysis of these events. CONCLUSIONS An electronic event-reporting system streamlines quality and safety in a radiation oncology department by increasing reported events and promoting a safety culture. A program that is widely accessible, easy to use, and can analyze data meaningfully will be the most successful.
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Affiliation(s)
- Rohan Deraniyagala
- Department of Radiation Oncology, University of Florida, Gainesville, Florida
| | - Chihray Liu
- Department of Radiation Oncology, University of Florida, Gainesville, Florida
| | - Kathryn Mittauer
- Department of Radiation Oncology, University of Florida, Gainesville, Florida
| | - Julie Greenwalt
- Department of Radiation Oncology, University of Florida, Gainesville, Florida
| | | | - Anamaria R Yeung
- Department of Radiation Oncology, University of Florida, Gainesville, Florida.
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Hill-Kayser CE, Gabriel P, Volz E, Lustig RA, Tochner Z, Hahn SM, Maity A. Factors associated with event reporting in the pediatric radiation oncology population using an electronic incident reporting system. Pract Radiat Oncol 2015. [DOI: 10.1016/j.prro.2015.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mazur L, Chera B, Mosaly P, Taylor K, Tracton G, Johnson K, Comitz E, Adams R, Pooya P, Ivy J, Rockwell J, Marks LB. The association between event learning and continuous quality improvement programs and culture of patient safety. Pract Radiat Oncol 2015; 5:286-294. [DOI: 10.1016/j.prro.2015.04.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 04/27/2015] [Accepted: 04/30/2015] [Indexed: 11/28/2022]
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Kusano AS, Nyflot MJ, Zeng J, Sponseller PA, Ermoian R, Jordan L, Carlson J, Novak A, Kane G, Ford EC. Measurable improvement in patient safety culture: A departmental experience with incident learning. Pract Radiat Oncol 2015; 5:e229-e237. [DOI: 10.1016/j.prro.2014.07.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 07/04/2014] [Accepted: 07/07/2014] [Indexed: 11/30/2022]
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Kim MK, Nam EY, Na SH, Shin MJ, Lee HS, Kim NH, Kim CJ, Song KH, Choe PG, Park WB, Bang JH, Kim ES, Park SW, Kim NJ, Oh MD, Kim HB. Discrepancy in perceptions regarding patient participation in hand hygiene between patients and health care workers. Am J Infect Control 2015; 43:510-5. [PMID: 25752956 DOI: 10.1016/j.ajic.2015.01.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 01/13/2015] [Accepted: 01/14/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patient participation in hand hygiene programs is regarded as an important component of hand hygiene improvement, but the feasibility of the program is still largely unknown. We examined the perceptions of patients/families and health care workers (HCWs) with regard to patient participation in hand hygiene. METHODS A cross-sectional survey of patients/families as well as physicians and nurses was performed using an anonymous, self-administered questionnaire in a 1,000-bed teaching hospital in South Korea. RESULTS A total of 152 physicians, 387 nurses, and 334 patients/families completed the survey. The overall response rate was 84%, 85%, and more than 60% among physicians, nurses, and patients/families, respectively. Whereas 75% of patients/families wished to ask HCWs to clean their hands if they did not do so themselves, only 26% of physicians and 31% of nurses supported the participation of patients (P < .001). The most common reason why HCWs disagreed with patient participation was concern about negative effects on their relationship with patients (54%). Regarding the method of patient involvement, patients preferred to assess hand hygiene performance, whereas physicians preferred patients to ask directly. CONCLUSIONS There was a significant discrepancy in perceptions regarding patient participation between patients/families and HCWs. Enhanced understanding and acceptance of any new program by both patients and HCWs before its introduction are needed for successful implementation.
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Affiliation(s)
- Min-Kyung Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Division of Infectious Diseases, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Eun Young Nam
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sun Hee Na
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Myoung-Jin Shin
- Infection Control Office, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyun Sook Lee
- Department of Nursing, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Nak-Hyun Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chung-Jong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Division of Infectious Diseases, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kyoung-Ho Song
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Division of Infectious Diseases, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Pyoeng Gyun Choe
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji-Hwan Bang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eu Suk Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Division of Infectious Diseases, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sang Won Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Nam Joong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Myoung-Don Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Division of Infectious Diseases, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Infection Control Office, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
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Pawlicki T, Potters L. Research on Quality and Safety: What Are We Missing? Int J Radiat Oncol Biol Phys 2015; 91:17-9. [DOI: 10.1016/j.ijrobp.2014.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 09/06/2014] [Accepted: 09/09/2014] [Indexed: 10/24/2022]
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Evans SB. Physician participation in incident learning. J Oncol Pract 2014; 10:e358-9. [PMID: 25095824 DOI: 10.1200/jop.2014.001526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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